POS1130 A RANDOMISED CONTROLLED STUDY OF POLYACRYLAMIDE HYDROGEL VS. HYALURONIC ACID IN KNEE OSTEOARTHRITIS: RESULTS AT 12-MONTHS

Background

Polyacrylamide hydrogel (iPAAG), manufactured by Contura International, is CE marked for the symptomatic treatment of patients with knee osteoarthritis (OA).

iPAAG fulfils an unmet clinical need for an effective, long-acting, safe and minimally invasive treatment that may postpone and potentially prevent knee surgery for those with OA.

Objectives

To compare the effectiveness of single intra-articular injections of iPAAG and hyaluronic acid (HA) in participants with moderate to severe knee OA.

To compare the effectiveness of iPAAG and HA in subgroups based on age, BMI or Kellgren-Lawrence (KL) grade at baseline by assessing changes from baseline in transformed WOMAC pain subscale scores.

Methods

This prospective, double-blind study (NCT04045431) randomized 239 participants to receive a single intra-articular injection of either 6 mL iPAAG (n=119) or 6 mL HA (n=120). The study was approved by the Capital Region’s Committee on Health Research Ethics. All participants provided informed consent prior to study activities.

Outcomes included changes in the WOMAC pain, stiffness and function subscales and Patient Global Assessment of disease impact (PGA) at 52 weeks. All statistical analyses were based on the ITT principle using a mixed model for repeated measurement with a restricted maximum likelihood-based approach. The estimated mean treatment difference based on this model was reported with 95 % CI and p-value.

Results

Demographic and baseline characteristics were similar between treatment groups with an average age at treatment of approximately 67 years (range 31 – 90 years) and slightly more females (53%) than males.

There was a clinically relevant decrease in WOMAC pain subscale score from baseline to 52 weeks in both groups (Figure 1). There were also clinically relevant decreases in the WOMAC stiffness subscale and physical function subscale and PGA in both groups. Treatment differences in favor of iPAAG compared to HA, were measured for the 3 WOMAC subscales and PGA. However, none of these differences reached statistical significance.

Figure 1.

Mean plot of transformed WOMAC pain subscale (0-100) – ITT analysis set

The treatment difference in favor of iPAAG compared to HA for the WOMAC pain subscale score was statistically significant in the subgroup with age at baseline <70 years but did not reach statistical significance in the subgroup with age at baseline ≥70 years.

The treatment difference in favor of IPAAG compared to HA for the WOMAC pain subscale score was statistically significant in the subgroup with normal BMI but did not reach statistical significance in the subgroups with overweight or obese BMI.

The treatment difference in favor of IPAAG compared to HA for the WOMAC pain subscale score was statistically significant in the subgroup with KL grade 2 or 3. In the subgroup with KL grade 4, a treatment difference in favor of HA was not statistically significant.

Table 1.

Change from baseline in transformed (0-100) WOMAC pain subscale at week 52

LSMean (95% CI)Treatment difference (95% CI)p-valueOverall  HA-13.3 (-16.7; -10.0)  iPAAG-17.9 (-21.3; -14.6)4.6 (-0.1; 9.4)0.0572Age <70 years  HA-14.0 (-18.3; -9.6)0.0195  iPAAG-21.3 (-25.5; -17.0)7.3 (1.2; 13.4)Age ≥ 70 years  HA-12.5 (-17.6; -7.4)0.7970  iPAAG-13.4 (-18.7; -8.2)1.0 (-6.3; 8.2)BMI normal  HA-13.5 (-18.1; -8.9)0.0110  iPAAG-17.5 (-22.2; -12.9)10.9 (2.6; 19.1)BMI overweight  HA-14.3 (-19.5; -9.2)0.6114  iPAAG-16.1 (-21.0; -11.3)1.8 (-5.3; 8.9)BMI obese  HA-14.5 (-22.7; -6.2)0.5565  iPAAG-17.8 (-25.6; -10.0)3.3 (-8.0; 14.7)KL grade 2 or 3  HA-13.4 (-17.0; -9.7)0.0332  iPAAG-18.9 (-22.5; -15.4)5.6 (0.5; 10.7)KL grade 4)  HA-13.1 (-21.9; -4.3)0.6757  iPAAG-10.3 (-20.6; 0.0)-2.8 (-16.4; 10.8)

Conclusion

At 52 weeks after treatment, the effectiveness of iPAAG was numerically superior to HA but not statistically significantly different.

In subgroups of participants with normal BMI, participants <70 years old or participants with KL grade 2 or 3 iPAAG performed statistically significantly better than HA at 52 weeks after treatment.

Disclosure of Interests

None declared

The initial validation of a novel outcome measure in severe burns- the Persistent Organ Dysfunction +Death: Results from a multicenter evaluation

INTRODUCTION

A need exists to improve the efficiency of clinical trials in burn care. The objective of this study was to validate "Persistent Organ Dysfunction" plus death as endpoint in burn patients and to demonstrate its statistical efficiency.

METHODS

This secondary outcome analysis of a dataset from a prospective international multicenter RCT (RE-ENERGIZE) included patients with burned total body surface area >20% and a 6-month follow-up. Persistent organ dysfunction was defined as persistence of organ dysfunction with life-supportiing technologies and ICU care.

RESULTS

In the 539 included patients, the prevalence of 0p p+ pdeath was 40% at day 14 and of 27% at day 28. At both timepoints, survivors with POD (vs. survivors without POD) had a higher mortality rate, longer ICU- and hospital-stays, and a reduced quality of life. POD + death as an endpoint could result in reduced sample size requirements for clinical trials. Detecting a 25% relative risk reduction in 28-day mortality would require a sample size of 4492 patients, whereas 1236 patients would be required were 28-day POD + death used.

CONCLUSIONS

POD + death represents a promising composite outcome measure that may reduce the sample size requirements of clinical trials in severe burns patients. Further validation in larger clinical trials is warranted.

STUDY TYPE

Prospective cohort study, level of evidence: II.

Abediterol (LAS100977), a novel long-acting β2-agonist: efficacy, safety and tolerability in persistent asthma

BACKGROUND

Abediterol (LAS100977) is a novel, long-acting β2-agonist, in development for the once-daily treatment of asthma in combination with mometasone. Here we report the results of a Phase IIa trial of single doses of abediterol added to ongoing maintenance therapy (inhaled corticosteroids) in patients with persistent mild-to-moderate asthma.

METHODS

This was a randomised, double-blind, placebo- and active-comparator-controlled, five-way crossover study. Male patients (18-70 years) with a clinical diagnosis of persistent asthma received abediterol (5, 10 and 25 μg), salmeterol and placebo, on top of ongoing maintenance therapy. Lung function was determined using spirometry and whole body plethysmography. The primary efficacy endpoint was change from baseline in trough forced expiratory volume in 1 s (FEV1) after a single dose.

RESULTS

All three abediterol doses induced statistically significant increases in trough FEV1 vs placebo and salmeterol. Improvements in other lung function parameters were also statistically significantly greater with all abediterol doses vs both placebo (p < 0.0001) and salmeterol (p < 0.05) than the first assessment at 5 min post-dose. These improvements were sustained to 36 h post-dose. The profile of treatment-emergent adverse events judged as related to abediterol was consistent with that seen after adrenergic stimulation and occurred exclusively in patients who received abediterol 10 μg or 25 μg.

CONCLUSIONS

This first-in-patient study revealed the potent, rapid and long-acting bronchodilatory effect of abediterol in patients with persistent mild-to-moderate asthma together with an overall good safety and tolerability profile. Further studies are now underway to establish the optimal efficacy-safety-tolerability profile for this compound.

Antiinflammatory properties of ambroxol

Ambroxol is frequently used as mucolytic agent in respiratory diseases associated with increased mucus production like acute or chronic bronchitis. Further, ambroxol is used topically (lozenges) for the treatment of sore throat and pharyngitis associated with common cold. In addition to the effects of ambroxol on mucus regulation and local anaesthetic effects, a wide range of pharmacological antiinflammatory properties of ambroxol have been described in vitro and in vivo, including inhibition or scavenging of oxidative and nitro?sative stress, increase of local defense molecules involved in respiratory virus replication, reduction of proinflammatory cytokines and arachidonic acid meta?bolites, inflammatory cell chemotaxis, and lipid peroxidation of tissues. The present review summarizes the antiinflammatory effects of ambroxol and relates these properties to results from controlled clinical trials in targeted diseases such as chronic bronchitis, chronic obstructive pulmonary disease and sore throat.

Handle with care: targeting neutrophils in chronic obstructive pulmonary disease and severe asthma?

Neutrophils play an important role in the pathogenesis of airway inflammation in both chronic obstructive pulmonary disease (COPD) and severe asthma. Currently available drugs have only limited effects on neutrophilic airway inflammation, particularily in COPD. Therefore, great efforts are undertaken to address neutrophilic inflammation in chronic respiratory disorders, in particular COPD. This review summarizes the rationale for anti-neutrophilic treatment in COPD and asthma and gives a critical overview of current developments in drug therapy. Moreover, unanswered questions and limitations of clinical trial design and choice of outcome parameters for proof-of-concept studies with novel anti-neutrophilic drugs are discussed as well as potential safety issues.

Wirksamkeit von Tiotropiumbromid (Spiriva®) bei verschiedenen Schweregraden der chronisch-obstruktiven Lungenerkrankung (COPD)

BACKGROUND

Aim of this study was to evaluate the efficacy of inhaled Tiotropium bromide in COPD patients of different severities in pneumological practices during a three months clinical trial.

METHODS

A randomized, double blind, placebo controlled study including COPD-patients (FEV1/FVC < 70 %, FEV1 < or = 70 % predicted; age > or = 40 years; > or = 10 pack years) of different severities was performed. The efficacy of 18 microg Tiotropium bromide once daily on lung function and exacerbations over 12 weeks was evaluated by respective pulmonary function tests (spirometry) before (trough value) and 2 hours after inhalation of study medication.

RESULTS

1639 patients (1236 Tiotropium bromide, 403 placebo; FEV1 reversibility after 200 microg Ipratropium bromide + 200 microg Fenoterol: 7.9 +/- 7.5 % predicted [mean +/- sd]) were randomized. After 12 weeks of treatment Tiotropium bromide led to significant increases of trough FEV1 (23 - 24 h after last inhalation; + 79 +/- 17 ml), and 2 h after Tiotropium bromide inhalation (+ 128 +/- 19 ml) (all values vs. placebo, adjusted mean +/- se, p < 0.0001). FVC and IVC were also improved significantly. In mild COPD (FEV1 > or = 50 - 70 %) improvements were most pronounced (trough FEV1 + 113 +/- 29 ml, 2 h post-inhalation + 181 +/- 33 ml; all values vs. placebo., p < 0.0001). 14.6 % of patients treated with Tiotropium bromide had a COPD exacerbation vs. 19.9 % of patients treated with placebo (p = 0.0151). The time to first exacerbation was prolonged (p = 0.0092 vs. placebo).

CONCLUSION

Tiotropium bromide 18 microg once daily led to a persistent improvement of lung function and a reduction of exacerbations in patients with COPD of different severities.

[Novel perspectives of COPD pharmacotherapy: focus on neutrophils]

Inflammation in COPD is characterized by an increased presence and activation of airway neutrophils. However, since currently available treatment options have only limited effects on neutrophilic airway inflammation, great efforts are undertaken to develop novel therapies targeting the neutrophilic component of inflammation in COPD. The present review discusses the rationale for anti-neutrophilic treatment in COPD and provides a critical overview of recent developments in drug therapy. Moreover, open questions and limitations of clinical trials including choice of adequate outcome parameters for proof-of-concept studies with putative anti-neutrophilic drugs and potential safety issues are summarized.

Tissue engineering of cultured skin substitutes

Skin replacement has been a challenging task for surgeons ever since the introduction of skin grafts by Reverdin in 1871. Recently, skin grafting has evolved from the initial autograft and allograft preparations to biosynthetic and tissue-engineered living skin replacements. This has been fostered by the dramatically improved survival rates of major burns where the availability of autologous normal skin for grafting has become one of the limiting factors. The ideal properties of a temporary and a permanent skin substitute have been well defined. Tissue-engineered skin replacements: cultured autologous keratinocyte grafts, cultured allogeneic keratinocyte grafts, autologous/allogeneic composites, acellular biological matrices, and cellular matrices including such biological substances as fibrin sealant and various types of collagen, hyaluronic acid etc. have opened new horizons to deal with such massive skin loss. In extensive burns it has been shown that skin substitution with cultured grafts can be a life-saving measure where few alternatives exist. Future research will aim to create skin substitutes with cultured epidermis that under appropriate circumstances may provide a wound cover that could be just as durable and esthetically acceptable as conventional split-thickness skin grafts. Genetic manipulation may in addition enhance the performance of such cultured skin substitutes. If cell science, molecular biology, genetic engineering, material science and clinical expertise join their efforts to develop optimized cell culture techniques and synthetic or biological matrices then further technical advances might well lead to the production of almost skin like new tissue-engineered human skin products resembling natural human skin.

Saisonale Schwankungen des Serum-IgE-Spiegels und deren mögliche Bedeutung für die Berechnung der therapeutischen Dosis von Omalizumab (rhuMab-E25, anti-IgE)

BACKGROUND

The anti-IgE antibody Omalizumab has been approved for the treatment of perennial allergic asthma. Dosing of omalizumab is adjusted according to total IgE levels and body weight, and a near complete suppression of free IgE is deemed to be necessary for optimal efficacy. Many asthmatics, however, have additional sensitisations against seasonal allergens, e. g. pollen, and seasonal exposure may increase total and specific IgE levels ("boost"), thus leading to an imbalance between IgE levels and omalizumab with possible impact on therapeutic outcome.

METHODS

We studied serum total and specific (timothy grass) IgE levels in 17 patients with seasonal allergic rhinitis and/or asthma prior to and during the grass pollen season. Based on total IgE levels, we then calculated hypothetical doses of omalizumab required for treatment at each time point.

RESULTS

During the pollen season, total IgE increased significantly from a pre-seasonal mean of 89 (50 - 178) kU/l (geom. mean with 95 % confidence interval) to 126 (63 - 251) kU/l (p = 0.0006). Accordingly, specific IgE increased from 11 (6.3 - 19) kU/l to 15.1 (8.3 - 29) kU/l (p = 0.0013). Calculated doses of omalizumab based on pre-seasonal IgE levels were: no dosing (IgE < 30 kU/l): n = 2; 150 mg 4-weekly: n = 7; 300 mg 4-weekly: n = 2; 225 mg 2-weekly: n = 4; 300 mg 2-weekly: n = 1; 375 mg 2-weekly: n = 1. Based on seasonal IgE levels, doses of omalizumab would have changed in 5/17 patients requiring the next possible dosing step. Of these, two patients would have fallen out of the current dosing scheme.

CONCLUSIONS

A seasonal increase of serum total and specific IgE can be observed in patients with pollen allergy, although this increase would have no impact on omalizumab doses in the majority of patient. Individual variations, however, can be large and necessitate a dose correction. Therefore, therapeutic monitoring of free IgE levels during anti-IgE treatment appears as desirable tool.

Stability of glutathione in induced sputum: impact of freezing

BACKGROUND

Oxidative stress has repeatedly been linked to the pathogenesis of pulmonary disorders like asthma and chronic obstructive pulmonary disease. Measuring glutathione (GSH) in induced sputum (IS) offers a noninvasive tool to study oxidative stress in airway diseases.

OBJECTIVES

This study assessed the stability of GSH in sputum supernatant under varying conditions.

METHODS

GSH in IS of 14 (7 healthy, 4 chronic obstructive pulmonary disease, 3 allergic rhinitis) nonsmoking subjects was quantified spectrophotometrically. The stability of GSH in supernatant was analyzed over 24 h under different ambient conditions (room temperature and cooling at 4 degrees C). Reproducibility of GSH measurements in immediately processed and frozen supernatant (+72 h) was expressed by intraclass correlation coefficient (R(i)) and coefficient of repeatability (CR).

RESULTS

GSH recovery in supernatant decreased in a time- and temperature-dependent manner. Samples stored at 4 degrees C and room temperature showed a rapid decline of stability after 2 h. Mean GSH concentrations in IS after freezing (-20 degrees C) and thawing after 72 h were not significantly different from GSH values measured immediately after processing of the samples (immediate processing: 17.9 +/- 13.9 microM; 72 h freezing: 16.4 +/- 12.9 microM, p = 0.2). The reproducibility between immediately processed and frozen samples was excellent (R(i) = 0.97; CR = 5.7 microM).

CONCLUSIONS

Storage of sputum supernatant at room temperature or 4 degrees C leads to a rapid decline of GSH recovery compared with baseline values. Immediate freezing of samples is a suitable and valid alternative to rapid processing and allows collection and shipment of samples for subsequent analysis.