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Xiong Y, Hu JQ, Tang HL, Zhao ZX, Liu LH. Network meta-analysis of the efficacy and safety of monoclonal antibodies and traditional conventional dichotomous agents for chronic obstructive pulmonary disease. Front Med (Lausanne) 2024; 11:1334442. [PMID: 38414617 PMCID: PMC10898352 DOI: 10.3389/fmed.2024.1334442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 01/18/2024] [Indexed: 02/29/2024] Open
Abstract
Introduction Monoclonal antibodies (mAbs) against cytokines and chemokines or their receptors promise to be a potential therapeutic option to address chronic obstructive pulmonary disease (COPD). We aim to provide a comprehensive literature review of the improvement in FEV1 and safety when comparing mAbs with conventional dichotomous agents. Methods We systematically searched 3 electronic databases (PubMed, EMBASE, and CENTRAL) up to August 1, 2023 to collect eligible randomized controlled trials (RCTs). A frequentist network meta-analysis using a random-effects model was deployed to calculate mean differences (MD) for FEV1, relative risk (RR) of treatment-emergent adverse events (TEAEs), and estimate the surface under cumulative rankings (SUCRA). A higher SUCRA indicates a better outcome. Results This study included 23 RCTs involving a total of 20,853 patients. Overall, except for Dupilumab, mAbs did not significantly improve FEV1 compared to traditional conventional dichotomous agents. Among all the interventions included, Aclidinium bromide/Formoterol (AB/FF) (SUCRA 97.7%) ranked highest, followed by Umeclidinium/vilanterol (UMEC/VI) (SUCRA 93.5%), and Glycopyrrolate Formoterol Fumarate (GFF) (SUCRA 84.7%). Dupilumab (SUCRA 66.9%) ranked the fourth among all interventions but ranked the first among all the mAbs. Importantly, all mAbs demonstrated a good safety profile compared with placebo. Conclusion Considering the improvement in FEV1 and its safety, the development of mAbs for COPD still holds significant clinical potential. Systematic review registration PROSPERO, CRD42023452714.
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Affiliation(s)
- Yu Xiong
- Institute of Materia Medica, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- Department of Pharmacy, China-Japan Friendship Hospital, Beijing, China
- Clinical Trial Research Center, China-Japan Friendship Hospital, Beijing, China
| | - Jia-Qiang Hu
- Personalized Drug Therapy Key Laboratory of Sichuan Province, Department of Pharmacy, Sichuan Provincial People's Hospital, School of Medicine University of Electronic Science and Technology of China, Chengdu, Sichuan, China
| | - Hui-Lin Tang
- Department of Pharmaceutical Outcomes and Policy, University of Florida College of Pharmacy, Gainesville, FL, United States
| | - Zhi-Xia Zhao
- Department of Pharmacy, China-Japan Friendship Hospital, Beijing, China
- Clinical Trial Research Center, China-Japan Friendship Hospital, Beijing, China
| | - Li-Hong Liu
- Department of Pharmacy, China-Japan Friendship Hospital, Beijing, China
- Clinical Trial Research Center, China-Japan Friendship Hospital, Beijing, China
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Sun Y, Molins E, Daoud SZ, Trivedi R, Stewart C, Lamarca R, Bharali P, Garcia-Gil E. Efficacy and safety of aclidinium/formoterol versus monotherapies and aclidinium versus placebo in Chinese and other Asian patients with moderate-to-severe COPD: The AVANT Phase 3 study. Respir Med 2023; 218:107393. [PMID: 37640273 DOI: 10.1016/j.rmed.2023.107393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 08/01/2023] [Accepted: 08/19/2023] [Indexed: 08/31/2023]
Abstract
AVANT was a Phase 3, 24-week, randomized, parallel-group, double-blind, double-dummy, placebo-controlled study to assess the efficacy and safety of aclidinium/formoterol 400 μg/12 μg combination vs monotherapies and aclidinium vs placebo (1:1:1:1) in Asian patients (∼70% of whom were Chinese) with moderate-to-severe stable chronic obstructive pulmonary disease. Endpoints were analyzed hierarchically to incorporate type I error control. At Week 24, aclidinium/formoterol demonstrated improvements from baseline in 1-h morning post-dose forced expiratory volume in 1 s (FEV1) vs aclidinium (least squares [LS] mean 92 mL; 95% confidence interval [CI] 60, 124 mL; p < 0.001), and in trough FEV1 vs formoterol (LS mean 85 mL; 95% CI 53, 117 mL; p < 0.001). Furthermore, aclidinium provided improvements in trough FEV1 vs placebo (LS mean 134 mL; 95% CI 103, 166 mL; p < 0.001). There was an improvement in transition dyspnea index focal score at Week 24 for aclidinium/formoterol vs placebo (LS mean 0.8; 95% CI 0.2, 1.3; p = 0.005) but not for aclidinium vs placebo (LS mean 0.4; 95% CI -0.1, 1.0; p = 0.132). Improvements in St George's Respiratory Questionnaire total scores occurred for aclidinium/formoterol vs placebo (LS mean -4.0; 95% CI -6.7, -1.4; p = 0.003) and aclidinium vs placebo (LS mean -2.9; 95% CI -5.5, -0.3; p = 0.031). Aclidinium/formoterol and aclidinium were well tolerated and safety findings were consistent with known profiles; rates of treatment-emergent adverse events (AEs) (aclidinium/formoterol: 54.8%; aclidinium: 47.4%; placebo: 53.9%), serious AEs (7.2, 7.9, and 7.8%, respectively), and AEs leading to discontinuation of study medication (2.3, 1.5, and 2.2%, respectively) were similar between groups.
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Affiliation(s)
- Yongchang Sun
- Department of Respiratory and Critical Care Medicine, Peking University Third Hospital, Beijing, China
| | - Eduard Molins
- Late Respiratory & Immunology, BioPharmaceuticals R&D, AstraZeneca, Barcelona, Spain
| | - Sami Z Daoud
- Late Respiratory & Immunology, BioPharmaceuticals R&D, Gaithersburg, MD, USA.
| | - Roopa Trivedi
- Late Respiratory & Immunology, BioPharmaceuticals R&D, Durham, NC, USA
| | | | - Rosa Lamarca
- Late Respiratory & Immunology, BioPharmaceuticals R&D, AstraZeneca, Barcelona, Spain
| | - Pranob Bharali
- Late Respiratory & Immunology, BioPharmaceuticals R&D, AstraZeneca Pvt. Ltd, Bangalore, India
| | - Esther Garcia-Gil
- Late Respiratory & Immunology, BioPharmaceuticals R&D, AstraZeneca, Barcelona, Spain
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Manzetti GM, Ora J, Sepiacci A, Cazzola M, Rogliani P, Calzetta L. Clinically Important Deterioration (CID) and Ageing in COPD: A Systematic Review and Meta-Regression Analysis According to PRISMA Statement. Int J Chron Obstruct Pulmon Dis 2023; 18:2225-2243. [PMID: 37841747 PMCID: PMC10576506 DOI: 10.2147/copd.s396945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 10/01/2023] [Indexed: 10/17/2023] Open
Abstract
Purpose Clinically important deterioration (CID) is a composite endpoint developed to quantify the impact of pharmacological treatment in clinical trials for Chronic Obstructive Pulmonary Disease (COPD), also showing a prognostic value. CID is defined as any of the following condition: forced expiratory volume in 1 s decrease ≥100 mL from baseline, and/or St. George's Respiratory Questionnaire total score increase ≥4-unit from baseline, and/or the occurrence of a moderate-to-severe exacerbation of COPD. Although most COPD patients experience a clinical worsening as they get older, to date, no specific studies assessed the correlation between ageing and CID in COPD. Therefore, the aim of this study was to investigate the impact of ageing on CID in COPD patients. Patients and Methods Data obtained from 55219 COPD patients were extracted from 17 papers, mostly post-hoc analyses. A pairwise meta-analysis and a meta-regression analysis were performed according to PRISMA-P guidelines to quantify the impact of pharmacological therapy on CID and to determine whether ageing might modulate the risk of CID in COPD patients. Results Inhaled treatments resulted generally effective in reducing the risk of CID in COPD (relative risk: 0.81, 95% confidence interval 0.79-0.84; P < 0.001). The meta-regression analysis indicated a trend toward significance (P = 0.063) in the linear relationship between age and the risk of CID. Of note, age significantly (P < 0.05) increased the risk of CID when associated with lower post-bronchodilator FEV1. These results were not affected by a significant risk of bias. Conclusion This quantitative synthesis suggests that inhaled therapy is effective in reducing the risk of CID in COPD, although such a protective effect may be affected in older patients with impaired lung function. Further studies specifically designed on CID in COPD are needed to confirm these results.
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Affiliation(s)
- Gian Marco Manzetti
- Department of Experimental Medicine, Unit of Respiratory Medicine, University of Rome “Tor Vergata”, Rome, Italy
| | - Josuel Ora
- Department of Experimental Medicine, Unit of Respiratory Medicine, University of Rome “Tor Vergata”, Rome, Italy
| | - Arianna Sepiacci
- Department of Experimental Medicine, Unit of Respiratory Medicine, University of Rome “Tor Vergata”, Rome, Italy
| | - Mario Cazzola
- Department of Experimental Medicine, Unit of Respiratory Medicine, University of Rome “Tor Vergata”, Rome, Italy
| | - Paola Rogliani
- Department of Experimental Medicine, Unit of Respiratory Medicine, University of Rome “Tor Vergata”, Rome, Italy
| | - Luigino Calzetta
- Department of Medicine and Surgery, Respiratory Disease and Lung Function Unit, University of Parma, Parma, Italy
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Yang M, Li Y, Jiang Y, Guo S, He JQ, Sin DD. Combination therapy with long-acting bronchodilators and the risk of major adverse cardiovascular events in patients with COPD: a systematic review and meta-analysis. Eur Respir J 2023; 61:2200302. [PMID: 36137586 DOI: 10.1183/13993003.00302-2022] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 09/07/2022] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Accumulated high-quality data from randomised controlled trials (RCTs) indicate that long-acting muscarinic antagonist (LAMA)/long-acting β2 agonist (LABA) combination therapy significantly improves clinical symptoms and health status in patients with chronic obstructive pulmonary disease (COPD) and reduces exacerbation risk. However, there is a growing concern that LAMA/LABA therapy may increase the risk of cardiovascular disease in patients with COPD. The aim of this paper is to determine whether the use of LAMA/LABA combination therapy modifies the risk of cardiovascular disease in patients with COPD. METHODS Two reviewers independently searched Embase, PubMed and Cochrane Library to identify relevant RCTs of LAMA/LABA or LABA/LAMA/inhaled corticosteroids (ICS) for the management of patients with COPD that reported on cardiovascular end-points. The primary outcome was major adverse cardiovascular events (MACE), which was a composite of cardiovascular death, myocardial infarction or stroke. RESULTS A total of 51 RCTs enrolling 91 021 subjects were analysed. Both dual LAMA/LABA (1.6% versus 1.3%; relative risk 1.42, 95% CI 1.11-1.81) and triple therapy (1.6% versus 1.4%; relative risk 1.29, 95% CI 1.03-1.61) significantly increased the risk of MACE compared with ICS/LABA. The excess risk was most evident in RCTs in which the average underlying baseline risk for MACE was >1% per year. Compared with LAMA only, LABA only or placebo, dual LAMA/LABA therapy did not significantly increase the risk of MACE, though these comparisons may have lacked sufficient statistical power. CONCLUSION Compared with ICS/LABA, dual LAMA/LABA or triple therapy increases cardiovascular risk in patients with COPD. This should be considered in the context of the incremental benefits of these therapies for symptoms and exacerbation rates in patients with COPD, especially in those with a MACE risk of >1% per year.
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Affiliation(s)
- Mingjin Yang
- Dept of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Mingjin Yang, Yishi Li and Youfan Jiang are joint first authors
| | - Yishi Li
- Dept of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Mingjin Yang, Yishi Li and Youfan Jiang are joint first authors
| | - Youfan Jiang
- Dept of Respiratory and Critical Care Medicine, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Mingjin Yang, Yishi Li and Youfan Jiang are joint first authors
| | - Shuliang Guo
- Dept of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Shuliang Guo, Jian-Qing He and Don D. Sin contributed equally to this article as lead authors and supervised the work
| | - Jian-Qing He
- Dept of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China
- Shuliang Guo, Jian-Qing He and Don D. Sin contributed equally to this article as lead authors and supervised the work
| | - Don D Sin
- Division of Respiratory Medicine, Dept of Medicine, University of British Columbia, Vancouver, BC, Canada
- Centre for Heart Lung Innovation, University of British Columbia, St. Paul's Hospital, Vancouver, BC, Canada
- Shuliang Guo, Jian-Qing He and Don D. Sin contributed equally to this article as lead authors and supervised the work
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Salvi S, Kumar A, Agrawal S, Leuva A, Shukla VK, Deshpande SV, Balamurugan S, Singh A, Tikkiwal S, Gupta SK, Singh BP, Lopez M, Sawant S, Vaidya A, Gogtay J. Efficacy and safety of glycopyrronium/formoterol delivered via a dry powder inhaler in patients with moderate to severe chronic obstructive pulmonary disease: Results from a multi-centre, open-label, randomised study. Lung India 2022; 39:408-416. [PMID: 36629200 PMCID: PMC9623852 DOI: 10.4103/lungindia.lungindia_92_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 05/05/2022] [Accepted: 05/06/2022] [Indexed: 01/14/2023] Open
Abstract
Background We designed this randomised, open-label, parallel group, multi-centre study to investigate the efficacy and safety of glycopyrronium/formoterol, a long-acting muscarinic antagonist/long-acting β2-agonist fixed dose combination, delivered through a dry powder inhaler (DPI) in patients with chronic obstructive pulmonary disease (COPD). Material and Methods We randomised (1:1) patients with moderate to severe COPD (N = 356) to receive glycopyrronium 25 μg/formoterol 12 μg via DPI twice daily (GF-DPI) or glycopyrronium 50 μg monotherapy via DPI once daily (G-DPI). The primary study endpoint was the mean change from the baseline in pre-dose trough-forced expiratory volume in one second (FEV1) at 12 weeks. Results At week 12, the mean increase from the baseline in pre-dose trough FEV1 was higher in the GF-DPI group (120 ml) than in the G-DPI (60 ml) group. The mean difference (MD) between treatment groups was 0.06 L (95% CI: 0.00-0.12 L, P < 0.0001 for non-inferiority). At week 12, the mean pre-dose forced vital capacity (FVC), 1 hour post-dose FEV1, and post-dose FVC increased significantly from the baseline only in the GF-DPI group (p < 0.0001). The reduction in the COPD assessment test score was greater in the GF-DPI group (p = 0.0379). The average daily number of puffs of rescue medication and the reduction in mean modified Medical Research Council scale, COPD, and Asthma Sleep Impact Scale score at week 12 were similar between groups (p > 0.05). Overall, 35 adverse events and two serious adverse events unrelated to study drugs were reported. Both groups had similar results for overall drug safety. Conclusion The results demonstrate efficacy and safety of GF-DPI in Indian patients with moderate to severe COPD. Treatment with GF-DPI significantly improved the lung function and quality of life and was well tolerated.
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Affiliation(s)
- Sundeep Salvi
- Department of Pulmonology, Pulmocare Research and Education Faith Centre, Pune, Maharashtra, India
| | - Anand Kumar
- Department of Pulmonology, GSVM Medical College, Kanpur, Uttar Pradesh, India
| | - Sumit Agrawal
- Department of Pulmonology, Oyster and Pearl Hospital, Pune, Maharashtra, India
| | - Amritlal Leuva
- Department of Chest and TB, Shree Sayaji General Hospital and Government Medical College, Vadodara, Gujarat, India
| | - Vineet Kumar Shukla
- Department of Pulmonology, KRM Hospital and Research Centre, Lucknow, Uttar Pradesh, India
| | - Shrikant Vishnu Deshpande
- Department of General Medicine, Dr. Deshpande’s Ashirwad Hospital and Research Center, Ulhasnagar, Maharashtra, India
| | - Santhalingam Balamurugan
- Department of Pulmonology, Sri Muthukumaran Medical College Hospital and Research Institute, Chennai, Tamil Nadu, India
| | - Ajit Singh
- Department of Pulmonology, SMS Hospital and Medical College, Jaipur, Rajasthan, India
| | - Sharad Tikkiwal
- Department of Pulmonology, Asthma Bhawan, Jaipur, Rajasthan, India
| | - Sandeep K. Gupta
- Department of Medicine, M.V. Hospital and Research Center, Lucknow, Uttar Pradesh, India
| | - Bhanu Pratap Singh
- Department of Pulmonary Medicine, Miland Healthcare, Lucknow, Uttar Pradesh, India
| | - Meena Lopez
- Department of Medical Affairs, Cipla Ltd., Mumbai, Maharashtra, India
| | - Sandesh Sawant
- Department of Medical Affairs, Cipla Ltd., Mumbai, Maharashtra, India
| | - Abhijit Vaidya
- Department of Medical Affairs, Cipla Ltd., Mumbai, Maharashtra, India
| | - Jaideep Gogtay
- Department of Medical Affairs, Cipla Ltd., Mumbai, Maharashtra, India
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Wang L, Gu W, Zhang X, Fu S, Zhang D, Guan X, Li H, Ma A. How the cost-effectiveness results change in the China health policy environment: an economic evaluation of glycopyrrolate/formoterol for the treatment of COPD. J Med Econ 2022; 25:356-366. [PMID: 35184671 DOI: 10.1080/13696998.2022.2043633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To investigate the cost-effectiveness of glycopyrrolate/formoterol compared with tiotropium bromide for the treatment of moderate-to-severe COPD in China and discuss the influence of healthcare policies on the economic evaluation. METHODS A Markov model with seven disease states was built to evaluate the lifetime cost-effectiveness of glycopyrrolate/formoterol from the perspective of the Chinese healthcare sector. Drug prices both before and after the negotiation were applied to discuss the influence on the economic evaluation results. Exacerbation and adverse event were included in each cycle. The improvement of forced expiratory volume in 1 second (FEV1) and incidence rate of exacerbation were derived from pooled PINNACLE analysis. Mortality rates from Chinese life tables were adjusted using hazard ratios. Direct medical costs were modeled in accordance with the perspective chosen. Health resource utilization were derived from previous studies and expert's opinions. Life-years gained, quality-adjusted life years (QALYs), and incidence of exacerbation were simulated as the health outcomes. One-way sensitivity analysis and probability analysis were conducted to explore the robustness of the base case results. Several scenario analyses were also designed. RESULTS Glycopyrrolate/formoterol generated an additional 0.0063 LYs and 0.0032 QALYs with lower lifetime costs compared with tiotropium (CNY 27,854 vs. CNY 33,189) and was proved to be the dominant strategy in the base case analysis. The one-way sensitivity analysis confirmed the robustness of the base case results. The probabilities of glycopyrrolate/formoterol being cost-effective were 96.5, 95.7, and 93.0% when CNY 72,000 (1 time GDP per capital), CNY 108,000, and CNY 216,000 were used as thresholds, respectively. Compared with the scenario where price before negotiation was used, the cost-effectiveness based on current price was significantly increased. CONCLUSION Glycopyrrolate/formoterol was demonstrated to be a clinically and cost-effective treatment for moderate-to-severe COPD in China using the latest price. The negotiation policy could increase the cost-effectiveness and benefit the patients.
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Affiliation(s)
- Luying Wang
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, China
| | - Weili Gu
- The First Affiliated Hospital of Guangzhou Medical University, State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, Guangzhou, China
| | - Xiao Zhang
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, China
| | - Shihui Fu
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, China
| | - Donger Zhang
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, China
| | - Xin Guan
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, China
| | - Hongchao Li
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, China
| | - Aixia Ma
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, China
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Gong Y, Lv Y, Liu H, Zheng Q, Li L. Quantitative analysis of efficacy and safety of LABA/LAMA fixed-dose combinations in the treatment of stable COPD. Ther Adv Respir Dis 2022; 16:17534666211066068. [PMID: 35001708 PMCID: PMC8743917 DOI: 10.1177/17534666211066068] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 11/11/2021] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE This study aimed to quantitatively compare the efficacy and safety of long-acting β2-agonist (LABA)/long-acting muscarinic antagonist (LAMA) fixed-dose combinations (FDCs) for the treatment of stable chronic obstructive pulmonary disease (COPD), especially in terms of their loss of efficacy in lung function. METHODS Randomized controlled clinical trials of LABA/LAMA FDCs for the treatment of stable COPD were comprehensively searched for in public databases. Pharmacodynamic models were established to describe the time course of the primary outcome [trough forced expiratory volume in the first second (FEV1)]. Secondary outcomes [COPD exacerbations, St. George's Respiratory Questionnaire (SGRQ), Transition Dyspnoea Index (TDI), and rescue medication use] and safety outcomes [mortality, serious adverse events (SAEs), and withdrawals due to adverse events (AEs)] were also compared via a meta-analysis. RESULTS A total of 22 studies involving 16,486 participants were included in this study. The results showed that in terms of primary outcome (change from baseline in trough FEV1), the efficacy of vilanterol/umeclidinium was the highest, while the efficacy of formoterol/aclidinium was the lowest, with a maximum effect value (Emax) of 0.185 L [95% confidence interval (CI): 0.173-0.197 L] and 0.119 L (95% CI: 0.103-0.135 L), respectively. The efficacy of other drugs, such as formoterol/glycopyrronium, indacaterol/glycopyrronium, and olodaterol/tiotropium, were comparable, and their Emax values were 0.150-0.177 L. Except for vilanterol/umeclidinium, the other four LABA/LAMA FDCs showed a certain degree of loss of efficacy. Compared with the efficacy at 2 days, the trough FEV1 (L) relative to baseline at 24 weeks decreased by 0.029-0.041 L. In terms of secondary outcomes, the efficacy of different LABA/LAMA FDCs was similar in TDI and rescue medication use. However, formoterol/aclidinium was better in preventing the COPD exacerbations, while vilanterol/umeclidinium was the best in terms of SGRQ. In addition, different LABA/LAMA FDCs and placebo had similar safety outcomes. CONCLUSION The present findings may provide necessary quantitative information for COPD medication guidelines.
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Affiliation(s)
- Yiwen Gong
- Center for Drug Clinical Evaluation, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Yinghua Lv
- Center for Drug Clinical Evaluation, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Hongxia Liu
- Center for Drug Clinical Evaluation, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Qingshan Zheng
- Center for Drug Clinical Evaluation, Shanghai University of Traditional Chinese Medicine, No. 1200 Cailun Road, Shanghai 201203, China
| | - Lujin Li
- Center for Drug Clinical Evaluation, Shanghai University of Traditional Chinese Medicine, No. 1200 Cailun Road, Shanghai 201203, China
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8
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Singh D, Hurst JR, Martinez FJ, Rabe KF, Bafadhel M, Jenkins M, Salazar D, Dorinsky P, Darken P. Predictive modeling of COPD exacerbation rates using baseline risk factors. Ther Adv Respir Dis 2022; 16:17534666221107314. [PMID: 35815359 PMCID: PMC9340368 DOI: 10.1177/17534666221107314] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Demographic and disease characteristics have been associated with the risk of
chronic obstructive pulmonary disease (COPD) exacerbations. Using previously
collected multinational clinical trial data, we developed models that use
baseline risk factors to predict an individual’s rate of moderate/severe
exacerbations in the next year on various pharmacological treatments for
COPD. Methods: Exacerbation data from 20,054 patients in the ETHOS, KRONOS, TELOS, SOPHOS,
and PINNACLE-1, PINNACLE-2, and PINNACLE-4 studies were pooled. Machine
learning was used to identify predictors of moderate/severe exacerbation
rates. Important factors were selected for generalized linear modeling,
further informed by backward variable selection. An independent test set was
held back for validation. Results: Prior exacerbations, eosinophil count, forced expiratory volume in 1 s
percent predicted, prior maintenance treatments, reliever medication use,
sex, COPD Assessment Test score, smoking status, and region were significant
predictors of exacerbation risk, with response to inhaled corticosteroids
(ICSs) increasing with higher eosinophil counts, more prior exacerbations,
or additional prior treatments. Model fit was similar in the training and
test set. Prediction metrics were ~10% better in the full model than in a
simplified model based only on eosinophil count, prior exacerbations, and
ICS use. Conclusion: These models predicting rates of moderate/severe exacerbations can be applied
to a broad range of patients with COPD in terms of airway obstruction,
eosinophil counts, exacerbation history, symptoms, and treatment history.
Understanding the relative and absolute risks related to these factors may
be useful for clinicians in evaluating the benefit: risk ratio of various
treatment decisions for individual patients. Clinical trials registered with www.clinicaltrials.gov (NCT02465567, NCT02497001,
NCT02766608, NCT02727660, NCT01854645, NCT01854658, NCT02343458,
NCT03262012, NCT02536508, and NCT01970878)
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Affiliation(s)
- Dave Singh
- Medicines Evaluation Unit, University of Manchester, Manchester University NHS Foundation Hospitals Trust, Manchester M23 9QZ, UK
| | - John R Hurst
- UCL Respiratory, University College London, London, UK
| | - Fernando J Martinez
- Joan and Sanford I. Weill Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Klaus F Rabe
- LungenClinic Grosshansdorf and Christian-Albrechts University Kiel, Airway Research Center North, Member of the German Center for Lung Research (DZL), Grosshansdorf, Germany
| | - Mona Bafadhel
- Respiratory Medicine Unit, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
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Ismaila AS, Haeussler K, Czira A, Tongbram V, Malmenäs M, Agarwal J, Nassim M, Živković-Gojović M, Shen Y, Dong X, Duarte M, Compton C, Vogelmeier CF, Halpin DMG. Comparative Efficacy of Umeclidinium/Vilanterol Versus Other Bronchodilators for the Treatment of Chronic Obstructive Pulmonary Disease: A Network Meta-Analysis. Adv Ther 2022; 39:4961-5010. [PMID: 35857184 PMCID: PMC9525347 DOI: 10.1007/s12325-022-02234-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 06/17/2022] [Indexed: 01/30/2023]
Abstract
INTRODUCTION Few randomised controlled trials (RCTs) have directly compared long-acting muscarinic antagonist/long-acting β2-agonist (LAMA/LABA) dual maintenance therapies for patients with chronic obstructive pulmonary disease (COPD). This systematic literature review and network meta-analysis (NMA) compared the efficacy of umeclidinium/vilanterol (UMEC/VI) versus other dual and mono-bronchodilator therapies in symptomatic patients with COPD. METHODS A systematic literature review (October 2015-November 2020) was performed to identify RCTs ≥ 8 weeks long in adult patients with COPD that compared LAMA/LABA combinations against any long-acting bronchodilator-containing dual therapy or monotherapy. Data extracted on changes from baseline in trough forced expiratory volume in 1 s (FEV1), St George's Respiratory Questionnaire (SGRQ) total score, Transitional Dyspnoea Index (TDI) focal score, rescue medication use and moderate/severe exacerbation rate were analysed using an NMA in a frequentist framework. The primary comparison was at 24 weeks. Fixed effects model results are presented. RESULTS The NMA included 69 full-length publications (including 10 GSK clinical study reports) reporting 49 studies. At 24 weeks, UMEC/VI provided statistically significant greater improvements in FEV1 versus all dual therapy and monotherapy comparators. UMEC/VI provided similar improvements in SGRQ total score compared with all other LAMA/LABAs, and significantly greater improvements versus UMEC 125 μg, glycopyrronium 50 μg, glycopyrronium 18 μg, tiotropium 18 μg and salmeterol 50 μg. UMEC/VI also provided significantly better outcomes versus some comparators for TDI focal score, rescue medication use, annualised moderate/severe exacerbation rate, and time to first moderate/severe exacerbation. CONCLUSION UMEC/VI provided generally better outcomes compared with LAMA or LABA monotherapies, and consistent improvements in lung function (measured by change from baseline in trough FEV1 at 24 weeks) versus dual therapies. Treatment with UMEC/VI may improve outcomes for symptomatic patients with COPD compared with alternative maintenance treatments.
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Affiliation(s)
- Afisi S. Ismaila
- R&D Global Medical, GSK, Collegeville, PA USA ,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON Canada ,Value Evidence and Outcomes, GSK, 1250 South Collegeville Road, Collegeville, PA 19426-0989 USA
| | | | | | | | | | | | | | | | | | | | - Maria Duarte
- R&D Global Medical, GSK, Brentford, Middlesex UK
| | | | - Claus F. Vogelmeier
- Department of Medicine, Pulmonary and Critical Care Medicine, University Medical Center Giessen and Marburg, Philipps-Universität Marburg, Member of the German Center for Lung Research (DZL), Marburg, Germany
| | - David M. G. Halpin
- University of Exeter Medical School, College of Medicine and Health, University of Exeter, Exeter, UK
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Zhang C, Zhang M, Wang Y, Xiong H, Huang Q, Shuai T, Liu J. Efficacy and cardiovascular safety of LAMA in patients with COPD: a systematic review and meta-analysis. J Investig Med 2021; 69:1391-1398. [PMID: 34362778 PMCID: PMC8639957 DOI: 10.1136/jim-2021-001931] [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] [Accepted: 07/13/2021] [Indexed: 12/14/2022]
Abstract
Chronic obstructive pulmonary disease (COPD) is at present the third leading cause of death in the world. Long-acting muscarinic antagonist (LAMA) is widely used as a bronchodilator in patients with COPD. However, there is controversy concerning their cardiovascular safety. This meta-analysis aims to assess the efficacy and cardiovascular safety of LAMAs versus placebo in patients with COPD. We searched Pub Med, Embase, Cochrane Library, and Web of Science to identify studies that compared LAMA with placebo in patients with COPD. Twenty-one studies involving 24,987 participants were finally included in the analysis. There was no significant difference in the incidence of all adverse events (risk ratio (RR)=1.01, 95% CI 1.00 to 1.02, I2=15.2%) and cardiovascular events (RR=0.98, 95% CI 0.88 to 1.09, I2=4.9%) in patients treated with LAMAs versus placebo. LAMAs significantly improved trough forced expiratory volume in 1 s (weighted mean difference (WMD)=0.12, 95% CI 0.10 to 0.14, I2=86.6%), Transitional Dyspnea Index (WMD=0.75, 95% CI 0.56 to 0.94, I2=0%), and St. George's Respiratory Questionnaire (WMD=‒2.50, 95% CI ‒3.32 to ‒1.69, I2=39.8%). Moreover, LAMAs significantly reduced the incidence of exacerbation in patients with COPD (RR=0.85, 95% CI 0.79 to 0.91, I2=69.9%). LAMAs are safe therapy and play a pivotal role in improving lung function, dyspnea, and health status, and reducing the exacerbation in patients with COPD.
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Affiliation(s)
- Chuchu Zhang
- Department of Intensive Care Unit, Lanzhou University First Affiliated Hospital, Lanzhou, Gansu, China
- The First Clinical Medical College of Lanzhou University, Lanzhou University, Lanzhou, Gansu, China
| | - Meng Zhang
- Department of Intensive Care Unit, Lanzhou University First Affiliated Hospital, Lanzhou, Gansu, China
- The First Clinical Medical College of Lanzhou University, Lanzhou University, Lanzhou, Gansu, China
| | - Yalei Wang
- Department of Intensive Care Unit, Lanzhou University First Affiliated Hospital, Lanzhou, Gansu, China
- The First Clinical Medical College of Lanzhou University, Lanzhou University, Lanzhou, Gansu, China
| | - Huaiyu Xiong
- Department of Intensive Care Unit, Lanzhou University First Affiliated Hospital, Lanzhou, Gansu, China
- The First Clinical Medical College of Lanzhou University, Lanzhou University, Lanzhou, Gansu, China
| | - Qiangru Huang
- Department of Intensive Care Unit, Lanzhou University First Affiliated Hospital, Lanzhou, Gansu, China
- The First Clinical Medical College of Lanzhou University, Lanzhou University, Lanzhou, Gansu, China
| | - Tiankui Shuai
- Department of Intensive Care Unit, Lanzhou University First Affiliated Hospital, Lanzhou, Gansu, China
- The First Clinical Medical College of Lanzhou University, Lanzhou University, Lanzhou, Gansu, China
| | - Jian Liu
- Department of Intensive Care Unit, Lanzhou University First Affiliated Hospital, Lanzhou, Gansu, China
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11
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Kerwin E, Dorinsky P, Patel M, Rossman K, Reisner C, Maes A, Darken P, Griffis D, Fjällbrant H. A randomized controlled trial of glycopyrrolate administered by metered dose inhaler in patients with uncontrolled asthma despite ICS/LABA treatment. J Asthma 2021; 59:1420-1432. [PMID: 34338132 DOI: 10.1080/02770903.2021.1938603] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To evaluate the efficacy and safety of three doses of glycopyrrolate metered dose inhaler (GP MDI) in patients with uncontrolled asthma despite treatment with inhaled corticosteroid/long-acting β2-agonists (ICS/LABA) with or without tiotropium, to characterize the benefit of triple therapy. METHOD This phase II/III, double-blind study randomized patients to 24 weeks' treatment with twice-daily GP MDI 36 µg, 18 µg, 9 µg, or placebo MDI (all delivered via Aerosphere inhalers), or once-daily open-label tiotropium 2.5 µg. Patients continued their own ICS/LABA regimen throughout the study. The primary endpoint was change from baseline in forced expiratory volume in 1 s (FEV1) area under the curve from 0 - 4 h (AUC0 - 4) at Week 24. Secondary endpoints included patient questionnaires to measure asthma control or symptoms. Safety was also assessed. RESULTS The primary analysis (modified intent-to-treat) population included 1066 patients. The primary study endpoint was not met (changes from baseline in FEV1 AUC0 - 4 at Week 24 were 294 mL, 284 mL, 308 mL, 240 mL, and 347 mL for GP MDI 36 µg, GP MDI 18 µg, GP MDI 9 µg, placebo, and open-label tiotropium, respectively). There were no significant differences between treatment and placebo in secondary endpoints at Week 24. Post-hoc analyses using post-bronchodilator FEV1 as the baseline measurement, or averaging values across multiple baseline visits, showed a dose-related response to GP MDI. The incidence of adverse events was low and similar across treatments. CONCLUSION Although this study did not meet its primary endpoint, post hoc analyses identified a dose-related response to GP MDI when alternative definitions of baseline FEV1 were used in the analyses.
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Affiliation(s)
- Edward Kerwin
- Clinical Research Institute of Southern Oregon, Medford, OR, USA
| | - Paul Dorinsky
- BioPharmaceuticals R&D, AstraZeneca, Durham, NC, USA
| | - Mehul Patel
- BioPharmaceuticals R&D, AstraZeneca, Cambridge, UK
| | - Kimberly Rossman
- Formerly of BioPharmaceuticals R&D, AstraZeneca, Morristown, NJ, USA
| | - Colin Reisner
- Formerly of BioPharmaceuticals R&D, AstraZeneca, Morristown, NJ, USA
| | - Andrea Maes
- Formerly of Biopharmaceuticals R&D, AstraZeneca, Wilmington, DE, USA
| | - Patrick Darken
- Biopharmaceuticals R&D, AstraZeneca, Gaithersburg, MD, USA
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12
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De Backer W, De Backer J, Verlinden I, Leemans G, Van Holsbeke C, Mignot B, Jenkins M, Griffis D, Ivanov S, Fitzpatrick J, St Rose E, Martin UJ, Reisner C. Functional respiratory imaging assessment of glycopyrrolate and formoterol fumarate metered dose inhalers formulated using co-suspension delivery technology in patients with COPD. Ther Adv Respir Dis 2021; 14:1753466620916990. [PMID: 32380894 PMCID: PMC7225799 DOI: 10.1177/1753466620916990] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background: Functional respiratory imaging (FRI) is a quantitative postprocessing imaging technique used to assess changes in the respiratory system. Using FRI, we characterized the effects of the long-acting muscarinic antagonist (LAMA), glycopyrrolate metered dose inhaler (GP MDI), and the long-acting β2-agonist (LABA), formoterol fumarate metered dose inhaler (FF MDI), on airway volume and resistance in patients with moderate-to-severe chronic obstructive pulmonary disease. Methods: Patients in this phase IIIb, randomized, double-blind crossover study received twice-daily GP MDI (18 μg) and FF MDI (9.6 μg). Primary endpoints were specific (i.e. corrected for lobar volume) image-based airway volume (siVaw) and specific image-based airway resistance (siRaw), measured using FRI. Secondary and other endpoints included additional FRI, spirometry, and body plethysmography parameters. Postdose efficacy assessments were performed within 60–150 min of dosing on day 15. Results: A total of 23 patients were randomized and 19 completed both treatment periods. GP MDI and FF MDI both achieved significant improvements from baseline to day 15 in siVaw [11% (p = 0.0187) and 23% (p < 0.0001) increases, respectively] and siRaw [25% (p = 0.0219) and 44% (p < 0.0001) reductions, respectively]. Although, on average, improvements were larger for FF MDI than GP MDI, some individuals displayed greater responses with each of the two treatments. These within-patient differences increased with airway generation number. Spirometry and body plethysmography endpoints showed significant improvements from baseline in inspiratory capacity for both treatments, and numeric improvements for other endpoints. Conclusion: Both GP MDI and FF MDI significantly improved siRaw and siVaw at day 15 versus baseline. FRI endpoints demonstrated increased sensitivity relative to spirometry and body plethysmography in detecting differences between treatments in a small number of patients. Intra-patient differences in treatment response between the LAMA and the LABA provide further support for the benefit of dual bronchodilator therapies. ClinicalTrials.gov registration number: NCT02937584 The reviews of this paper are available via the supplemental material section.
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Affiliation(s)
- Wilfried De Backer
- University of Antwerp, Campus Drie Eiken, Universiteitsplein 1, Wilrijk, 2610 Antwerp, Belgium
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13
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Zysman M, Ribeiro Baptista B, Soumagne T, Marques da Silva V, Martin C, Thibault de Menonville C, Boyer L, Degano B, Morelot Panzini C, Burgel PR, Perez T, Bourdin A, Raherison C, Pégliasco H, Piperno D, Zanetti C, Morel H, Delclaux B, Delafosse C, Lorenzo A, Housset B, Chabot F, Devillier P, Deslée G, Roche N. [Pharmacological treatment optimisation in patients with stale COPD. Position of the French-language Respiratory Society. 2021 Update]. Rev Mal Respir 2021; 38:539-561. [PMID: 33985869 DOI: 10.1016/j.rmr.2021.02.070] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 02/21/2021] [Indexed: 01/19/2023]
Affiliation(s)
- M Zysman
- Université Bordeaux, centre de recherche cardiothoracique de Bordeaux, U1045, CIC 1401, 33604 Pessac, France; Service des maladies respiratoires, CHU Bordeaux, Bordeaux, France.
| | - B Ribeiro Baptista
- Université Paris-Est, UMR S955, UPEC, 94000 Créteil, France; Département de pneumologie, CHRU Nancy, université de Lorraine, Inserm, U1116, université de Lorraine, Nancy/Vandœuvre-lès-Nancy, France
| | - T Soumagne
- Service de pneumologie, oncologie thoracique et allergologie respiratoire, CHU de Besançon, Besançon, France
| | | | - C Martin
- Department of Respir Med, Cochin Hospital, Assistance publique-Hôpitaux de Paris, Paris, France; Université de Paris, Paris, France; INSERM U1016, Institut Cochin, Paris, France
| | | | - L Boyer
- Université Paris-Est, UMR S955, UPEC, 94000 Créteil, France; Département de physiologie-explorations fonctionnelles, AP-HP, hôpital Henri-Mondor, Paris, France
| | - B Degano
- Service hospitalier universitaire pneumologie physiologie, pôle thorax et vaisseaux, CHU Grenoble Alpes, Grenoble, France; Université Grenoble Alpes, Grenoble, France
| | - C Morelot Panzini
- Sorbonne Université, AP-HP, Service de Pneumologie, Médecine Intensive et Réanimation, Pitié-Salpêtrière Hospital, Paris, France
| | - P R Burgel
- Department of Respir Med, Cochin Hospital, Assistance publique-Hôpitaux de Paris, Paris, France; Université de Paris, Paris, France; INSERM U1016, Institut Cochin, Paris, France
| | - T Perez
- Service de pneumologie, CHU Lille, institut Pasteur de Lille, U1019, UMR9017, centre d'infection et d'immunité de Lille (CIIL), Lille, France
| | - A Bourdin
- PhyMedExp, University of Montpellier, INSERM U1046, CNRS UMR 9214, Montpellier, France; Department of Respiratory Diseases, University of Montpellier, CHU Montpellier, Montpellier, France
| | - C Raherison
- Service des maladies respiratoires, CHU Bordeaux, Bordeaux, France; Bordeaux Population Health Research Center, université Bordeaux, INSERM, Team EPICENE, UMR 1219, Bordeaux, France
| | - H Pégliasco
- Service de pneumologie, hôpital européen, Marseille, France
| | | | - C Zanetti
- Cabinet de pneumologie, 62300 Lens, France
| | - H Morel
- Service de pneumologie d'allergologie et d'oncologie thoracique, CHR d'Orléans, 45067 Orléans, France
| | - B Delclaux
- Service de pneumologie, centre hospitalier de Troyes, 10003 Troyes, France
| | - C Delafosse
- Centre hospitaliser Simone-Veil, 95602 Eaubonne, France
| | - A Lorenzo
- Médecine Sorbonne université, département de médecine générale, Paris, France
| | - B Housset
- Département de pneumologie, CHI de Créteil, University Paris Est Créteil, Créteil, France
| | - F Chabot
- Département de pneumologie, CHRU Nancy, université de Lorraine, Inserm, U1116, université de Lorraine, Nancy/Vandœuvre-lès-Nancy, France
| | - P Devillier
- Department of Airway Diseases, VIM-Suresnes, UMR0892, Foch Hospital, Paris-Saclay University, Suresnes, France
| | - G Deslée
- Service de pneumologie, Inserm U1250, CHU Reims, université Reims Champagne Ardenne, Reims, France
| | - N Roche
- Department of Respir Med, Cochin Hospital, Assistance publique-Hôpitaux de Paris, Paris, France; Université de Paris, Paris, France; INSERM U1016, Institut Cochin, Paris, France
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14
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Usmani OS, Roche N, Jenkins M, Stjepanovic N, Mack P, De Backer W. Consistent Pulmonary Drug Delivery with Whole Lung Deposition Using the Aerosphere Inhaler: A Review of the Evidence. Int J Chron Obstruct Pulmon Dis 2021; 16:113-124. [PMID: 33500616 PMCID: PMC7822085 DOI: 10.2147/copd.s274846] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 11/24/2020] [Indexed: 11/23/2022] Open
Abstract
Metered dose inhalers (MDIs) are one of the most common device types for delivering inhaled therapies. However, there are several technical challenges in development and drug delivery of these medications. In particular, suspension-based MDIs are susceptible to suspension heterogeneity, in vitro drug–drug interactions, and patient handling errors, which may all affect drug delivery. To overcome these challenges, new formulation approaches are required. The AerosphereTM inhaler, formulated using co-suspension delivery technology, combines drug crystals with porous phospholipid particles to create stable, homogenous suspensions that dissolve once they reach the airways. Two combination therapies using this technology have been developed for the treatment of COPD: glycopyrrolate/formoterol fumarate (GFF MDI; dual combination) and budesonide/glycopyrrolate/formoterol fumarate (BGF MDI; triple combination). Here, we review the evidence with a focus on studies assessing dose delivery, lung deposition, and effects on airway geometry. In vitro assessments have demonstrated that the Aerosphere inhaler provides consistent dose delivery, even in the presence of simulated patient handling errors. Combination therapies delivered with this technology also show a consistent fine particle fraction (FPF) and an optimal particle size distribution for delivery to the central and peripheral airways even when multiple drugs are delivered via the same inhaler. Studies using gamma scintigraphy and functional respiratory imaging have demonstrated that GFF MDI is effectively deposited in the central and peripheral airways, and provides clinically meaningful benefits on airway volume and resistance throughout the lung. Overall, studies suggest that the Aerosphere inhaler, formulated using co-suspension delivery technology, may offer advantages over traditional formulations, including consistent delivery of multiple components across patient handling conditions, optimal particle size and FPF, and effective delivery to the central and peripheral airways. Future studies may provide additional evidence to further characterize the clinical benefits of these technical improvements in MDI drug delivery.
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Affiliation(s)
- Omar S Usmani
- National Heart and Lung Institute (NHLI), Imperial College London, and Royal Brompton Hospital, London, UK
| | - Nicolas Roche
- Respiratory Medicine, Cochin Hospital, University Paris Descartes, Paris, France
| | | | | | | | - Wilfried De Backer
- Department of Pulmonary Medicine, Faculty of Medicine, University of Antwerp, Antwerp, Belgium
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15
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Tashkin DP. Formoterol for the Treatment of Chronic Obstructive Pulmonary Disease. Int J Chron Obstruct Pulmon Dis 2020; 15:3105-3122. [PMID: 33273813 PMCID: PMC7708267 DOI: 10.2147/copd.s273497] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 10/26/2020] [Indexed: 11/23/2022] Open
Abstract
Bronchodilators, including long-acting β2-agonists and long-acting muscarinic antagonists, are the mainstay for treatment of patients with chronic obstructive pulmonary disease (COPD) to prevent exacerbations or reduce symptoms. Formoterol is a highly selective and potent β2-agonist that relaxes airway smooth muscle to significantly improve lung function. Inhaled formoterol works within 5 minutes of administration and provides improvements in spirometry measurements over 12 hours. The lipophilicity of formoterol allows it to form a depot within the smooth muscle to provide a prolonged duration of action. Following therapeutic doses, plasma concentrations are very low or undetectable. Determination of the pharmacokinetics of formoterol following high-dose administration to healthy volunteers revealed that the drug was rapidly absorbed and excreted unchanged in the urine with a half-life of 10 hours. Inhaled formoterol, as monotherapy or in combination with other agents, is an effective and safe treatment option for patients with moderate to severe COPD. Clinical studies have demonstrated improvements in lung function and COPD symptoms, particularly dyspnea; reductions in the risk of exacerbations; and improvement in patients' health status. The adverse event profile of inhaled formoterol is similar to that of placebo, with few adverse cardiovascular events. Formoterol is a valuable bronchodilator used in the maintenance treatment of COPD. This review describes the mechanism of action, pharmacodynamics, and pharmacokinetics of inhaled formoterol. It also reviews the results of large, randomized, controlled clinical trials that evaluated the use of formoterol as monotherapy and in combination with inhaled corticosteroids, long-acting muscarinic antagonists, and triple therapy regimens in the treatment of patients with moderate to severe COPD.
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Affiliation(s)
- Donald P Tashkin
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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16
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Anzueto A, Kaplan A. Dual bronchodilators in chronic obstructive pulmonary disease: Evidence from randomized controlled trials and real-world studies. RESPIRATORY MEDICINE: X 2020. [DOI: 10.1016/j.yrmex.2020.100016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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17
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Grillet PE, Le Souder C, Rohou J, Cazorla O, Charriot J, Bourdin A. Glycopyrrolate and formoterol fumarate for the treatment of COPD. Expert Rev Respir Med 2020; 15:13-25. [PMID: 32772582 DOI: 10.1080/17476348.2020.1807946] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Long acting bronchodilators are nowadays the central treatment for management of stable COPD. Several combinations exist within the market with different formulation devices. This article reviews a recent dual combination of glycopyrronium and formoterol fumarate in an innovative pMDI-fixed dual combination, Bevespi® Aerosphere. AREAS COVERED This article explored the literature to understand the place of this novel combination and unique delivery drug device in today's therapeutic arsenal. Clinical efficacy and safety have been evaluated through the different clinical trials published in public databases. EXPERT OPINION Within the fixed-dose combinations, Glycopyrrolate and formoterol fumarate offer a credible unique pMDI option to be given twice a day. LABA-LAMA offers an ICS-free alternative in COPD pharmacology which represents an important treatment option given the current debate over whether or not, maintenance triple therapy combined with ICS are benefic in the long term.
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Affiliation(s)
- Pierre-Edouard Grillet
- PhyMedExp, University of Montpellier, INSERM U1046, CNRS UMR , Montpellier, France.,Department of Respiratory Diseases, CHU Montpellier, University of Montpellier , Montpellier, France
| | - Cosette Le Souder
- Pharmacovigilance Regional Center, Medical Pharmacology and Toxicology Department, CHU Montpellier , Montpellier, France
| | - Juliette Rohou
- PhyMedExp, University of Montpellier, INSERM U1046, CNRS UMR , Montpellier, France.,Department of Respiratory Diseases, CHU Montpellier, University of Montpellier , Montpellier, France
| | | | - Jérémy Charriot
- Department of Respiratory Diseases, CHU Montpellier, University of Montpellier , Montpellier, France
| | - Arnaud Bourdin
- PhyMedExp, University of Montpellier, INSERM U1046, CNRS UMR , Montpellier, France.,Department of Respiratory Diseases, CHU Montpellier, University of Montpellier , Montpellier, France
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18
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Ethnic pharmacokinetic comparison of budesonide/glycopyrrolate/formoterol fumarate metered dose inhaler (BGF MDI) between Asian and Western healthy subjects. Pulm Pharmacol Ther 2020; 64:101976. [DOI: 10.1016/j.pupt.2020.101976] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 09/30/2020] [Accepted: 10/29/2020] [Indexed: 12/26/2022]
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19
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Efficacy and safety of glycopyrrolate/formoterol fumarate metered dose inhaler delivered using co-suspension delivery technology in Japanese patients with moderate-to-very severe chronic obstructive pulmonary disease. Respir Investig 2020; 59:135-144. [PMID: 32917556 DOI: 10.1016/j.resinv.2020.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 06/12/2020] [Accepted: 06/28/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND PINNACLE-4 evaluated the efficacy and safety of the long-acting muscarinic antagonist/long-acting β2-agonist fixed-dose combination glycopyrrolate/formoterol fumarate metered dose inhaler (GFF MDI) in patients from Asia, Europe, and the USA with moderate-to-very severe chronic obstructive pulmonary disease (COPD). This pre-specified analysis included Japanese patients in PINNACLE-4. METHODS In this double-blind randomized study (NCT02343458), patients received GFF MDI (18/9.6 μg), glycopyrrolate (GP) MDI (18 μg), formoterol fumarate (FF) MDI (9.6 μg), or placebo MDI twice daily for 24 weeks. The primary endpoint was change from baseline in morning pre-dose trough forced expiratory volume in 1 s (FEV1) over Weeks 12-24. Secondary lung function endpoints, patient-reported outcomes, and safety were assessed. The Japanese subpopulation (n = 150) analyses were exploratory. RESULTS GFF MDI improved change from baseline in morning pre-dose trough FEV1 over Weeks 12-24 versus GP MDI, FF MDI, and placebo MDI (least squares mean [LSM] differences [95% confidence interval]: 69 [8-131], 60 [-1 to 121], and 275 [180-370] mL, respectively). GFF MDI numerically improved Transition Dyspnea Index focal score and change from baseline in St George's Respiratory Questionnaire total score versus placebo MDI (LSM differences 0.19 and -3.78, respectively). Treatment-related adverse events occurred in ≤4.5% of patients in any treatment group. CONCLUSIONS GFF MDI improved lung function versus monocomponents and placebo MDI in the Japan subpopulation of PINNACLE-4. The efficacy and safety results were generally consistent with those of the global study population, supporting the use of GFF MDI in Japanese patients with moderate-to-very severe COPD.
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Martinez FJ, Lipworth BJ, Rabe KF, Collier DJ, Ferguson GT, Sethi S, Feldman GJ, O'Brien G, Jenkins M, Reisner C. Benefits of glycopyrrolate/formoterol fumarate metered dose inhaler (GFF MDI) in improving lung function and reducing exacerbations in patients with moderate-to-very severe COPD: a pooled analysis of the PINNACLE studies. Respir Res 2020; 21:128. [PMID: 32450869 PMCID: PMC7249639 DOI: 10.1186/s12931-020-01388-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 05/05/2020] [Indexed: 01/18/2023] Open
Abstract
Background The Phase III PINNACLE studies assessed the efficacy and safety of glycopyrrolate/formoterol fumarate metered dose inhaler (GFF MDI), a dual long-acting bronchodilator for chronic obstructive pulmonary disease (COPD). Here we present a pre-specified pooled analysis of PINNACLE-1, PINNACLE-2, and PINNACLE-4. Methods PINNACLE-1, -2, and -4 were multicenter, double-blind, randomized controlled trials that enrolled patients with moderate-to-very severe COPD, with no requirement for exacerbation history or a high symptom burden. Patients received GFF MDI 18/9.6 μg, glycopyrrolate (GP) MDI 18 μg, formoterol fumarate (FF) MDI 9.6 μg, or placebo MDI, twice-daily for 24 weeks. The primary endpoint of the pooled analysis was the change from baseline in morning pre-dose trough forced expiratory volume in 1 s (FEV1) at week 24. Secondary endpoints included COPD exacerbations and clinically important deterioration (CID). Adverse events were also assessed. Results The pooled intent-to-treat population included 4983 patients; of these, 61.9% had a COPD assessment test (CAT) score ≥15, and 25.0% had experienced ≥1 moderate/severe exacerbation in the past year. At week 24, GFF MDI improved morning pre-dose trough FEV1 versus GP MDI (least squares mean [LSM] difference [95% confidence interval (CI)]: 59 mL [43, 75]), FF MDI (65 mL [48, 81]), and placebo MDI (146 mL [125, 166]); all p < 0.0001. GFF MDI reduced the risk of a moderate/severe exacerbation by 18% (p = 0.0168), 15% (p = 0.0628), and 28% (p = 0.0012) compared with GP MDI, FF MDI, and placebo MDI, respectively. In general, exacerbation risk reduction with GFF MDI versus comparators was greater in subgroups of symptomatic patients (CAT ≥15) and those who had an exacerbation history, than in the pooled intent-to-treat population. The risk of CID was also lower with GFF MDI versus GP MDI (23% decrease), FF MDI (17%), and placebo MDI (49%); all p < 0.0001. All treatments were well tolerated, with no unexpected safety signals. Conclusions This pooled analysis of the PINNACLE studies demonstrated that GFF MDI improved lung function and reduced the risk of exacerbations compared with monocomponents and placebo in patients with COPD. Exacerbation reductions with GFF MDI versus comparators were generally greater in patients with higher symptom burden and those with exacerbation history. Trial registration ClinicalTrials.gov NCT01854645, NCT01854658, and NCT02343458. Registered 13 May 2013 (NCT01854645, NCT01854658) and 6 January 2015 (NCT02343458).
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Affiliation(s)
- Fernando J Martinez
- Weill Cornell Medical College, New York-Presbyterian Hospital/Weill Cornell Medical Center, 525 E 68th St, Room M-522, Box 130, New York, NY, 10065, USA.
| | - Brian J Lipworth
- Scottish Centre for Respiratory Research, Ninewells Hospital, University of Dundee, Dundee, Scotland, UK
| | - Klaus F Rabe
- LungenClinic Grosshansdorf and Christian-Albrechts University Kiel, Airway Research Center North, Member of the German Center for Lung Research (DZL), Kiel, Germany
| | - David J Collier
- William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Gary T Ferguson
- Pulmonary Research Institute of Southeast Michigan, Farmington Hills, MI, USA
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Koarai A, Sugiura H, Yamada M, Ichikawa T, Fujino N, Kawayama T, Ichinose M. Treatment with LABA versus LAMA for stable COPD: a systematic review and meta-analysis. BMC Pulm Med 2020; 20:111. [PMID: 32349720 PMCID: PMC7191827 DOI: 10.1186/s12890-020-1152-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 04/16/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Inhaled bronchodilators including long-acting beta-agonist (LABA) and long-acting muscarinic antagonist (LAMA) play a central role in the treatment of stable chronic obstructive pulmonary disease (COPD). However, it is still unclear whether LABA or LAMA should be used for the initial treatment. Therefore, we conducted a systematic review and meta-analysis to evaluate the efficacy and safety of LABA versus LAMA in patients with stable COPD. METHODS We searched relevant randomized control trials (RCTs) with a period of treatment of at least 12 weeks and analyzed the exacerbations, quality of life, dyspnea score, lung function and adverse events as the outcomes of interest. RESULTS We carefully excluded unblinded data and identified a total of 19 RCTs (N = 28,211). LAMA significantly decreased the exacerbations compared to LABA (OR 0.85, 95% CI 0.74 to 0.98; P = 0.02). In St George's Respiratory Questionnaire and transitional dyspnoea index score, there were no differences between LABA and LAMA treatment. Compared to LABA, there was a small but significant increase in the trough FEV1 after LAMA treatment (Mean difference 0.02, 95% CI 0.01 to 0.03, P = 0.0006). In the safety components, there was no difference in the serious adverse events between LABA and LAMA. However, LAMA showed a significantly lower incidence of total adverse events compared to LABA (OR 0.92, 95% CI 0.86 to 0.98; P = 0.02). CONCLUSION Treatment with LAMA in stable COPD provided a significantly lower incidence of exacerbation and non-serious adverse events, and a higher trough FEV1 compared to LABA. TRIAL REGISTRATION (PROSPERO: CRD42019144764).
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Affiliation(s)
- Akira Koarai
- Department of Respiratory Medicine, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574 Japan
| | - Hisatoshi Sugiura
- Department of Respiratory Medicine, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574 Japan
| | - Mitsuhiro Yamada
- Department of Respiratory Medicine, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574 Japan
| | - Tomohiro Ichikawa
- Department of Respiratory Medicine, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574 Japan
| | - Naoya Fujino
- Department of Respiratory Medicine, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574 Japan
| | - Tomotaka Kawayama
- Division of Respirology, Neurology and Rheumatology, Department of Medicine, Kurume University School of Medicine, 67 Asahi-machi, Kurume, 830-0011 Japan
| | - Masakazu Ichinose
- Department of Respiratory Medicine, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574 Japan
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Ding B, Kallenbach L, Slipski L, Wilk A, O’Brien D, Guranlioglu D. Patient Characteristics and Healthcare Resource Utilization Among Patients with COPD New to LAMA/LABA Fixed-Dose Combination Treatment in US-Based Real-World Practice. Int J Chron Obstruct Pulmon Dis 2020; 15:775-786. [PMID: 32346288 PMCID: PMC7169942 DOI: 10.2147/copd.s238408] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Accepted: 03/21/2020] [Indexed: 11/23/2022] Open
Abstract
Introduction This retrospective, observational cohort study utilized an integrated dataset from an electronic health records system and a claims database to describe demographic and clinical characteristics, healthcare resource utilization (HCRU), and treatment patterns in COPD patients initiating long-acting muscarinic antagonist (LAMA)/long-acting β2-agonist (LABA) fixed-dose combination (FDC) treatment in the USA. Methods Patients were aged ≥40 years and had a COPD diagnosis (Practice Fusion system) and ≥1 prescription of LAMA/LABA FDC therapy, with an index date (first prescription) 1 May 2014-31 December 2017. For the HCRU analysis, patients had ≥2 claims from the Symphony Health database within 12 months before index. All analyses of outcomes relating to demographic and clinical characteristics, HCRU, and treatment patterns were descriptive. Results Patients initiating LAMA/LABA FDCs (n=8224) had a mean age of 67.9 years, 52.8% were female, and mean BMI was 29.2 kg/m2. The most common comorbidities were cardiovascular disease (74.3%), hypertension (64.0%), and hyperlipidemia (45.6%). In the 12 months prior to index, 53.1% of patients had used inhaled therapy: 23.4% short-acting therapy only, 16.7% short-acting and maintenance therapy, and 13.1% maintenance therapy only. Amongst users of inhaled therapies, the pMDI was the most frequently used device (64.3%, n=2812/4370). Of 7050 patients included in the HCRU analysis, 79.8% had COPD-related costs; mean cost/patient was $4174. Mean COPD-related costs per patient for moderate and severe exacerbations were $910 and $23,208, respectively. Per-patient costs included $23,032 for inpatient visits, $2358 for emergency visits, $4432 for outpatient visits, and $1989 for pharmacy claims. Conclusion This observational study is the first to describe the real-world demographic and clinical characteristics and HCRU of patients initiating LAMA/LABA FDC treatment in the USA. Patients were generally elderly and overweight, with comorbidities of CVD, hypertension, and hyperlipidemia. Inpatient visits were the largest contributor to COPD-related costs per patient in the year prior to initiation of LAMA/LABA FDCs.
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Affiliation(s)
- Bo Ding
- AstraZeneca, Gothenburg, Sweden
| | | | | | - Alan Wilk
- Practice Fusion, San Francisco, CA, USA
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Wang C, Yang T, Kang J, Chen R, Zhao L, He H, Assam PN, Su R, Bourne E, Ballal S, DeAngelis K, Dorinsky P. Efficacy and Safety of Budesonide/Glycopyrrolate/Formoterol Fumarate Metered Dose Inhaler in Chinese Patients with COPD: A Subgroup Analysis of KRONOS. Adv Ther 2020; 37:1591-1607. [PMID: 32152869 PMCID: PMC7140742 DOI: 10.1007/s12325-020-01266-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Indexed: 12/30/2022]
Abstract
INTRODUCTION This pre-specified subgroup analysis evaluated the efficacy and safety of budesonide/glycopyrrolate/formoterol fumarate metered dose inhaler (BGF MDI) triple therapy versus corresponding dual therapies in the China subgroup of the phase III, double-blind KRONOS study in patients with moderate to very severe chronic obstructive pulmonary disease (COPD). METHODS Patients were randomized 2:2:1:1 to BGF MDI 320/18/9.6 μg, glycopyrrolate/formoterol fumarate (GFF) MDI 18/9.6 μg, budesonide/formoterol fumarate (BFF) MDI 320/9.6 μg, or budesonide/formoterol fumarate dry powder inhaler (BUD/FORM DPI) 400/12 μg twice daily for 24 weeks. The primary endpoint was change from baseline in morning pre-dose trough forced expiratory volume in 1 s (FEV1) over weeks 12-24. Secondary endpoints included symptoms, health-related quality of life, and safety. Rate of moderate/severe COPD exacerbations was an additional efficacy endpoint. RESULTS In the China subgroup (n = 432; 22.7% of the KRONOS population), BGF MDI demonstrated nominally significant improvements in the primary endpoint versus BFF MDI (least squares mean (LSM) difference 68 mL; P = 0.0035) and BUD/FORM DPI (LSM difference 78 mL; P = 0.0010) but not GFF MDI (LSM difference - 4 mL; P = 0.8316). BGF MDI demonstrated at least numerical improvements versus comparators in secondary lung function and symptom endpoints. BGF MDI reduced the rate of moderate/severe COPD exacerbations versus GFF MDI (rate ratio 0.41; P = 0.0030), with numerical benefits versus BFF MDI and BUD/FORM DPI. All treatments were well tolerated. CONCLUSIONS Results demonstrated that BGF MDI showed benefits on lung function (vs inhaled corticosteroid/long-acting β2-agonist), as well as symptoms and exacerbations relative to dual therapies. Findings support BGF MDI use in Chinese patients with moderate to very severe COPD. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov NCT02497001.
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Affiliation(s)
- Chen Wang
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, No. 2, East Yinghua Street, Chaoyang District, Beijing, 100029, China.
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China.
- National Clinical Research Center for Respiratory Diseases, Beijing, China.
- Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
- Department of Respiratory Medicine, Capital Medical University, Beijing, China.
| | - Ting Yang
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, No. 2, East Yinghua Street, Chaoyang District, Beijing, 100029, China
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China
- National Clinical Research Center for Respiratory Diseases, Beijing, China
- Department of Respiratory Medicine, Capital Medical University, Beijing, China
| | - Jian Kang
- The First Hospital of China Medical University, Shenyang, China
| | - Rongchang Chen
- The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Li Zhao
- Shengjing Hospital of China Medical University, Shenyang, China
| | - Huijie He
- The First Affiliated Hospital of Baotou Medical College, Inner Mongolia University of Science and Technology, Baotou, Inner Mongolia, China
| | | | - Rong Su
- AstraZeneca, Shanghai, China
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Zheng J, Xu JF, Jenkins M, Assam PN, Wang L, Lipworth BJ. Glycopyrrolate/formoterol fumarate metered dose inhaler for maintenance-naïve patients with chronic obstructive pulmonary disease: a post-hoc analysis of the randomized PINNACLE trials. Respir Res 2020; 21:69. [PMID: 32164675 PMCID: PMC7068860 DOI: 10.1186/s12931-020-1332-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Accepted: 03/02/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Glycopyrrolate (GP)/formoterol fumarate (FF; GFF) metered dose inhaler is a fixed-dose combination dual bronchodilator for patients with chronic obstructive pulmonary disease (COPD); however, whether the efficacy in patients without current maintenance treatment is consistent with currently maintenance-treated patients is unclear. METHODS Data from patients who were not maintenance-treated at screening (NMT) (n = 1943) and patients who were maintenance-treated at screening (MT) patients (n = 3040) receiving GFF, FF, GP, or placebo were pooled from the Phase III PINNACLE studies (NCT01854645, NCT01854658, NCT02343458) for post-hoc analysis. MT patients had received long-acting bronchodilators and/or inhaled corticosteroids in the 30 days prior to screening, and/or prior to randomization. NMT patients had received short-acting bronchodilators or no treatment. Outcomes included forced expiratory volume over 1 s (FEV1), clinically important deterioration (CID), rescue medication use, and safety. RESULTS GFF provided significant lung function improvements at Week 24 versus placebo, GP, and FF for NMT patients, with pre-dose trough FEV1 treatment differences of 152 (117-188) mL, 73 (45-100) mL, and 56 (29-84) mL, respectively (least squares mean change from baseline versus comparators [95% CI]; all P < 0.0001). GFF reduced the risk of CID by 17-43% in NMT (P ≤ 0.0157) and 18-52% (P ≤ 0.0012) in MT patients compared with monotherapy and placebo, and reduced rescue medication use by 1.5 puffs/day over 24 weeks for both cohorts. Safety profiles for all cohorts were consistent with each other and the parent studies. CONCLUSIONS NMT patients achieved better lung function with GFF versus monotherapy and placebo, without increased safety risk. Dual bronchodilator therapy may offer better outcomes than monotherapy for COPD patients when administered as first-line treatment.
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Affiliation(s)
- Jinping Zheng
- State Key Laboratory of Respiratory Disease, National Clinical Research Center of Respiratory Disease, Guangzhou Institute of Respiratory Health, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Jin-Fu Xu
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Martin Jenkins
- Global Medicines Development, AstraZeneca, Central Cambridge, UK
| | | | - Lijiao Wang
- Medical Affairs, AstraZeneca, Shanghai, China
| | - Brian J Lipworth
- Scottish Centre for Respiratory Research, Ninewells Hospital, University of Dundee, Dundee, DD1 9SY, Scotland, UK.
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Chen R, Zhong N, Wang HY, Zhao L, Mei X, Qin Z, Huang J, Assam PN, Maes A, Siddiqui S, Martin UJ, Reisner C. Efficacy And Safety Of Glycopyrrolate/Formoterol Fumarate Metered Dose Inhaler (GFF MDI) Formulated Using Co-Suspension Delivery Technology In Chinese Patients With COPD. Int J Chron Obstruct Pulmon Dis 2020; 15:43-56. [PMID: 32021143 PMCID: PMC6956867 DOI: 10.2147/copd.s223638] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 10/30/2019] [Indexed: 12/03/2022] Open
Abstract
Background Glycopyrrolate/formoterol fumarate metered dose inhaler (GFF MDI) is a long-acting muscarinic antagonist/long-acting β2-agonist fixed-dose combination therapy delivered by MDI, formulated using innovative co-suspension delivery technology. The PINNACLE-4 study evaluated the efficacy and safety of GFF MDI in patients with moderate-to-very severe chronic obstructive pulmonary disease (COPD) from Asia, Europe, and the USA. This article presents the results from the China subpopulation of PINNACLE-4. Methods In this randomized, double-blind, placebo-controlled, parallel-group Phase III study (NCT02343458), patients received GFF MDI 18/9.6 µg, glycopyrrolate (GP) MDI 18 µg, formoterol fumarate (FF) MDI 9.6 µg, or placebo MDI (all twice daily) for 24 weeks. The primary endpoint was change from baseline in morning pre-dose trough forced expiratory volume in 1 second at Week 24. Secondary lung function endpoints and patient-reported outcome measures were also assessed. Safety was monitored throughout the study. Results Overall, 466 patients from China were included in the intent-to-treat population (mean age 63.6 years, 95.7% male). Treatment with GFF MDI improved the primary endpoint compared to GP MDI, FF MDI, and placebo MDI (least squares mean differences: 98, 104, and 173 mL, respectively; all P≤0.0001). GFF MDI also improved daily total symptom scores and time to first clinically important deterioration versus monocomponents and placebo MDI, and Transition Dyspnea Index focal score versus placebo MDI. Rates of treatment-emergent adverse events were similar across the active treatment groups and slightly higher in the placebo MDI group. Conclusion GFF MDI improved lung function and daily symptoms versus monocomponents and placebo MDI and improved dyspnea versus placebo MDI. All treatments were well tolerated with no unexpected safety findings. Efficacy and safety results were generally consistent with the global PINNACLE-4 population, supporting the use of GFF MDI in patients with COPD from China.
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Affiliation(s)
- Rongchang Chen
- Shenzhen Institute of Respiratory Diseases, Shenzhen People's Hospital, Shenzhen, Guangdong, People's Republic of China
| | - Nanshan Zhong
- Guangzhou Institute of Respiratory Health, State Key Laboratory of Respiratory Diseases, National Clinical Research Centre for Respiratory Diseases, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, People's Republic of China
| | - Hao-Yan Wang
- Beijing Friendship Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Li Zhao
- Sheng Jing Hospital of China Medical University, Shenyang, Liaoning, People's Republic of China
| | - Xiaodong Mei
- Anhui Provincial Hospital, Hefei, Anhui, People's Republic of China
| | - Zhiqiang Qin
- The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning City, Guangxi Zhuang Autonomous Region, People's Republic of China
| | - Juan Huang
- Formerly of AstraZeneca, Shanghai, People's Republic of China
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Martinez FJ, Rabe KF, Lipworth BJ, Arora S, Jenkins M, Martin UJ, Reisner C. Glycopyrrolate/Formoterol Fumarate Metered Dose Inhaler Improves Lung Function versus Monotherapies in GOLD Category A Patients with COPD: Pooled Data from the Phase III PINNACLE Studies. Int J Chron Obstruct Pulmon Dis 2020; 15:99-106. [PMID: 32021148 PMCID: PMC6957003 DOI: 10.2147/copd.s229794] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 12/02/2019] [Indexed: 11/23/2022] Open
Abstract
Background The Global Initiative for Chronic Obstructive Lung Disease (GOLD) recommends a short-acting bronchodilator or single long-acting bronchodilator as an initial pharmacological treatment for GOLD category A patients with COPD. We pooled data from the PINNACLE-1, -2, and -4 studies to evaluate the efficacy and safety of the dual bronchodilator fixed-dose combination glycopyrrolate/formoterol fumarate metered dose inhaler (GFF MDI), formulated using co-suspension delivery technology, in GOLD category A patients with moderate-to-very severe COPD. Materials and Methods PINNACLE-1, -2, and -4 were Phase III, randomized, double-blind, parallel-group, multicenter studies (NCT01854645, NCT01854658, and NCT02343458). Patients received 24 weeks' treatment with GFF MDI 18/9.6 µg, glycopyrrolate (GP) MDI 18 µg, formoterol fumarate (FF) MDI 9.6 µg, or placebo MDI twice daily. GOLD category A patients were identified based on a COPD Assessment Test score of <10 and exacerbation history in the previous year (none/one not requiring hospitalization). Endpoints evaluated were change from baseline in morning pre-dose trough forced expiratory volume in 1 second (FEV1), peak change from baseline in FEV1 within 2 hrs post-dose, and adverse events (AEs). Results The pooled intent-to-treat population comprised 729 GOLD category A patients. GFF MDI significantly improved morning pre-dose trough FEV1 at Week 24 versus GP MDI, FF MDI, and placebo MDI (least squares mean [LSM] differences 54 mL, 62 mL, and 188 mL, respectively; all p≤0.0053), and peak FEV1 at Week 24 versus GP MDI, FF MDI, and placebo MDI (LSM differences 124 mL, 104 mL, and 307 mL, respectively; all p<0.0001). Improvements over 24 weeks were comparable to at Week 24. The AE profile of GFF MDI in GOLD category A patients was similar to monocomponents and placebo MDI. Conclusion GFF MDI significantly improved lung function versus monocomponents and placebo MDI in GOLD category A patients with moderate-to-very severe COPD, with no unexpected safety findings.
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Affiliation(s)
- Fernando J Martinez
- Joan and Sanford I. Weill Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Klaus F Rabe
- Department of Pneumonology, LungenClinic Grosshansdorf and Christian-Albrechts University Kiel, Airway Research Center North, Member of the German Center for Lung Research (DZL), Grosshansdorf, Germany
| | - Brian J Lipworth
- Division of Molecular and Clinical Medicine, Scottish Centre for Respiratory Research, Ninewells Hospital, University of Dundee, Dundee, Scotland, UK
| | | | - Martin Jenkins
- Global Medicines Development, AstraZeneca, Cambridge, UK
| | - Ubaldo J Martin
- Research and Development, AstraZeneca, Gaithersburg, MD, USA
| | - Colin Reisner
- Research and Development, AstraZeneca, Gaithersburg, MD, USA.,R&D Biopharmaceuticals, AstraZeneca, Morristown, NJ, USA
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Rogliani P, Matera MG, Ritondo BL, De Guido I, Puxeddu E, Cazzola M, Calzetta L. Efficacy and cardiovascular safety profile of dual bronchodilation therapy in chronic obstructive pulmonary disease: A bidimensional comparative analysis across fixed-dose combinations. Pulm Pharmacol Ther 2019; 59:101841. [DOI: 10.1016/j.pupt.2019.101841] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 07/21/2019] [Accepted: 09/10/2019] [Indexed: 12/12/2022]
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Maltais F, Ferguson GT, Feldman GJ, Deslee G, Bourdin A, Fjällbrant H, Siwek-Posłuszna A, Jenkins MA, Martin UJ. A Randomized, Double-Blind, Double-Dummy Study of Glycopyrrolate/Formoterol Fumarate Metered Dose Inhaler Relative to Umeclidinium/Vilanterol Dry Powder Inhaler in COPD. Adv Ther 2019; 36:2434-2449. [PMID: 31267366 DOI: 10.1007/s12325-019-01015-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Glycopyrrolate/formoterol fumarate metered dose inhaler (GFF MDI), formulated using co-suspension delivery technology, is the only approved fixed-dose combination long-acting muscarinic antagonist/long-acting β2-agonist (LAMA/LABA) delivered via MDI. Direct comparisons of GFF MDI versus other LAMA/LABAs have not previously been performed. We assessed the efficacy and safety of GFF MDI relative to umeclidinium/vilanterol dry powder inhaler (UV DPI) in patients with moderate-to-very severe chronic obstructive pulmonary disease (COPD). METHODS In this phase IIIb randomized, double-blind, double-dummy, multicenter, 24-week study, patients received GFF MDI 18/9.6 μg (equivalent to glycopyrronium/formoterol fumarate dihydrate 14.4/10 μg; two inhalations per dose, twice-daily; n = 559) or UV DPI 62.5/25 μg (one inhalation, once-daily; n = 560). Primary endpoints were change from baseline in morning pre-dose trough forced expiratory volume in 1 s (FEV1) and peak change from baseline in FEV1 within 2 h post-dose, both over 24 weeks. Additional lung function, symptom and safety endpoints were also assessed. RESULTS For the primary endpoints, GFF MDI was non-inferior to UV DPI (using a margin of - 50 mL) for peak FEV1 (least squares mean [LSM] difference - 3.4 mL, 97.5% confidence interval [CI] - 32.8, 25.9) but not for trough FEV1 (LSM difference - 87.2 mL; - 117.0, - 57.4). GFF MDI was nominally superior to UV DPI for onset of action (p < 0.0001) and was nominally non-inferior to UV DPI for all symptom endpoints (Transition Dyspnea Index focal score, Early Morning/Night-Time Symptoms COPD instrument scores, and COPD Assessment Test score). Exacerbation and safety findings were similar between groups. CONCLUSIONS Over 24 weeks of treatment, GFF MDI was non-inferior to UV DPI for peak FEV1, but not for morning pre-dose trough FEV1. GFF MDI had a faster onset of action versus UV DPI. There were no clinically meaningful differences between treatments in symptom endpoints. Both treatments were well tolerated with similar safety profiles. TRIAL REGISTRATION NCT03162055 (Clinicaltrials.gov) FUNDING: AstraZeneca.
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Kerwin EM, Ferguson GT, Mo M, DeAngelis K, Dorinsky P. Bone and ocular safety of budesonide/glycopyrrolate/formoterol fumarate metered dose inhaler in COPD: a 52-week randomized study. Respir Res 2019; 20:167. [PMID: 31358008 PMCID: PMC6664772 DOI: 10.1186/s12931-019-1126-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Accepted: 07/04/2019] [Indexed: 12/13/2022] Open
Abstract
Background Long-term use of inhaled corticosteroids (ICSs) has been associated with increased risk of bone and ocular comorbidities. We evaluated the effects of the triple fixed-dose combination budesonide/glycopyrrolate/formoterol fumarate metered dose inhaler (BGF MDI), formulated using co-suspension delivery technology, on bone mineral density (BMD) and ocular safety in patients with moderate-to-very severe chronic obstructive pulmonary disease (COPD). Methods In this extension study, a subset of patients from the 24-week, phase III, randomized, double-blind KRONOS study (NCT02497001) continued treatment (BGF MDI 320/18/9.6 μg, budesonide/formoterol fumarate [BFF] MDI 320/9.6 μg or glycopyrrolate/formoterol fumarate [GFF] MDI 18/9.6 μg, as a non-steroidal comparator) for an additional 28 weeks. Primary endpoints were percentage change from baseline in lumbar spine BMD and change from baseline in lens opacities classification system III posterior subcapsular cataract (P) score, both at Week 52. Adverse events were also assessed. Results In total, 456 patients were included in the safety population (53.1% male, mean age 62.8 years). Changes from baseline in lumbar spine BMD (least squares mean [LSM] range − 0.12 to 0.38%) and P score (LSM range 0.02–0.15) were small for all treatments. Both BGF MDI and BFF MDI were non-inferior to GFF MDI using margins of −2% (BMD) and 0.5 units (P score). The incidence of treatment-emergent adverse events (TEAEs) was generally similar among groups. Rates of confirmed pneumonia were low overall (2.4%) and highest in the GFF MDI group (3.4%), followed by BGF MDI (2.1%) and BFF MDI (1.1%). There were no cumulative adverse effects of treatment over time as the incidence and types of TEAEs, were generally similar in the first 24 weeks of the study and after Week 24. Conclusions In patients with COPD, both ICS-containing therapies were non-inferior to GFF MDI for the primary BMD and ophthalmological endpoints. Changes from baseline in all three treatment groups over 52 weeks were small and not clinically meaningful. All treatments were well tolerated with no new or unexpected safety findings. Trial registration ClinicalTrials.gov NCT02536508. Registered 27 August 2015. Electronic supplementary material The online version of this article (10.1186/s12931-019-1126-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Edward M Kerwin
- Clinical Research Institute of Southern Oregon, 3860 Crater Lake Avenue, Medford, OR, 97504, USA.
| | - Gary T Ferguson
- Pulmonary Research Institute of Southeast Michigan, Farmington Hills, MI, USA
| | - Mindy Mo
- Formerly of AstraZeneca, Morristown, NJ, USA
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Chen Q, Hu C, Yu H, Shen K, Assam PN, Gillen M, Liu Y, Dorinsky P. Pharmacokinetics and Tolerability of Budesonide/Glycopyrronium/Formoterol Fumarate Dihydrate and Glycopyrronium/Formoterol Fumarate Dihydrate Metered Dose Inhalers in Healthy Chinese Adults: A Randomized, Double-blind, Parallel-group Study. Clin Ther 2019; 41:897-909.e1. [PMID: 30982547 DOI: 10.1016/j.clinthera.2019.03.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Revised: 03/01/2019] [Accepted: 03/13/2019] [Indexed: 10/27/2022]
Abstract
PURPOSE The objective of this study was to assess pharmacokinetic (PK) and safety profiles of 2 fixed-dose combinations in development for the treatment of chronic obstructive pulmonary disease (COPD): budesonide/glycopyrronium/formoterol fumarate dihydrate metered-dose inhaler (BGF MDI; triple combination) and glycopyrronium/formoterol fumarate dihydrate (GFF MDI; dual combination). The PK and safety profiles of BGF MDI and GFF MDI were assessed for the first time in healthy Chinese adults after single and repeated (7-day) dosing. METHODS This Phase I, randomized, double-blind, parallel-group study was conducted at a single site in Shanghai, China. Male or female Chinese subjects, 18-45 years of age and in good general health, were randomized 1:1:1 to receive BGF MDI 320/14.4/10 μg, BGF MDI 160/14.4/10 μg, or GFF MDI 14.4/10 μg. PK parameters were assessed after a single dose (day 1) and at steady state (day 8), and included AUC0-12, Cmax, and Tmax. Tolerability was assessed using physical examination findings, adverse events reporting, 12-lead ECG, vital signs, and clinical laboratory values. FINDINGS Ninety-six subjects (mean age, 25.6 years; 83.3% male) were randomized and received treatment. All randomized subjects were included in the safety and PK populations. After single and repeated dosing, budesonide AUC0-12 and Cmax were increased dose proportionally from BGF MDI 160/14.4/10 μg to BGF MDI 320/14.4/10 μg, respectively (single dose: AUC0-12, 811.8 vs 1748 h · pg/mL; Cmax, 224.3 vs 459.3 pg/mL; repeated dosing: AUC0-12, 1250 vs 2510 h · pg/mL; Cmax, 315.4 vs 626.4 pg/mL). After single and repeated dosing, glycopyrronium AUC0-12 and Cmax were similar across all treatments (single dose: AUC0-12, 27.20-29.40 h · pg/mL; Cmax, 4.884-5.674 pg/mL; repeated dosing: AUC0-12, 69.49-77.08 h · pg/mL; Cmax, 11.30-13.12 pg/mL) and formoterol (single dose: AUC0-12, 46.49-53.58 h · pg/mL; Cmax 9.651-10.62 pg/mL; repeated dosing: AUC0-12, 81.94-85.32 h · pg/mL; Cmax, 16.13-17.71 pg/mL), suggesting that the addition of budesonide did not appreciably alter the PK properties of GFF MDI. All treatment-emergent adverse events were mild in severity and rates were similar across groups (range, 50.0%-56.3%). There were no new or unexpected findings on tolerability. IMPLICATIONS Overall, all treatments were well tolerated and PK parameters were generally comparable to those previously reported in Western and Japanese healthy subjects, suggesting that the doses of BGF MDI and GFF MDI in development globally for COPD are also appropriate for Chinese patients with COPD. ClinicalTrials.gov identifier: NCT03075267.
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Affiliation(s)
- Qian Chen
- Central Laboratory, Shanghai Xuhui District Central Hospital, Shanghai, China
| | - Chaoying Hu
- Central Laboratory, Shanghai Xuhui District Central Hospital, Shanghai, China
| | - Hui Yu
- AstraZeneca, Shanghai, China
| | | | | | | | - Yun Liu
- Central Laboratory, Shanghai Xuhui District Central Hospital, Shanghai, China
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Siddiqui MK, Shukla P, Jenkins M, Ouwens M, Guranlioglu D, Darken P, Biswas M. Systematic review and network meta-analysis of the efficacy and safety of glycopyrrolate/formoterol fumarate metered dose inhaler in comparison with other long-acting muscarinic antagonist/long-acting β 2-agonist fixed-dose combinations in COPD. Ther Adv Respir Dis 2019; 13:1753466619894502. [PMID: 31868101 PMCID: PMC6928544 DOI: 10.1177/1753466619894502] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 11/18/2019] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Dual bronchodilation with a long-acting muscarinic antagonist (LAMA)/long-acting β2-agonist (LABA) fixed-dose combination (FDC) is an established treatment strategy for chronic obstructive pulmonary disease (COPD). The relative efficacy and safety of glycopyrrolate/formoterol fumarate metered dose inhaler (GFF MDI 18/9.6 μg) in patients with moderate-to-very severe COPD, compared with other licensed LAMA/LABA FDCs, was investigated using an integrated Bayesian network meta-analysis (NMA). METHODS A systematic literature review and subsequent screening process identified randomized controlled trials of ⩾10 weeks' duration that enrolled patients aged ⩾40 years with moderate-to-very severe COPD and included at least one LAMA/LABA FDC or open LAMA + LABA treatment arm. NMAs were conducted for outcomes including change from baseline in forced expiratory volume in 1 s (FEV1), St George's Respiratory Questionnaire (SGRQ), and transition dyspnea index (TDI) parameters, annualized rate of exacerbations, use of rescue medication, adverse events, and all-cause withdrawals. Meta-regression and sensitivity analyses accounted for heterogeneity across studies. RESULTS In total, 29 studies including 34,617 patients contributed to the NMA for efficacy or safety outcomes at week 24 or exacerbations. For all LAMA/LABA FDCs with data available, significantly greater improvements in FEV1 [trough, peak, and area under the curve (AUC)0-4], SGRQ total score and TDI focal score at week 24, and annualized rate of moderate-to-severe exacerbations, were observed versus placebo. Where indirect comparisons were possible, differences between GFF MDI and other LAMA/LABA FDCs were small relative to established margins of clinical relevance, and not statistically significant. The safety and tolerability profile of GFF MDI was consistent with other LAMA/LABA FDCs and placebo. The results of the meta-regression were generally similar to the base case. CONCLUSIONS GFF MDI demonstrated comparable efficacy and safety outcomes to other LAMA/LABA FDCs. Personalization of treatment choice within the class on the basis of other factors such as patient preference may be appropriate.
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Affiliation(s)
| | | | | | | | | | | | - Mousumi Biswas
- AstraZeneca 101 Orchard Ridge Dr, Gaithersburg, MD 20878, USA
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Reisner C, Miller J, DePetrillo P, Maes A, Siddiqui S, Martin UJ. Pharmacokinetics and safety of a single dose of the novel LAMA/LABA fixed-dose combination of glycopyrronium/formoterol fumarate dihydrate metered dose inhaler, formulated using co-suspension delivery technology, in Japanese healthy subjects. Pulm Pharmacol Ther 2018; 53:33-38. [DOI: 10.1016/j.pupt.2018.09.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 08/23/2018] [Accepted: 09/10/2018] [Indexed: 12/19/2022]
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