1
|
Maher TM, Stowasser S, Voss F, Bendstrup E, Kreuter M, Martinez FJ, Sime PJ, Stock C. Decline in forced vital capacity as a surrogate for mortality in patients with pulmonary fibrosis. Respirology 2023; 28:1147-1153. [PMID: 37646126 DOI: 10.1111/resp.14579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 08/08/2023] [Indexed: 09/01/2023]
Abstract
BACKGROUND AND OBJECTIVE Surrogate endpoints enable determination of meaningful treatment effects more efficiently than applying the endpoint of ultimate interest. We used data from trials of nintedanib in subjects with pulmonary fibrosis to assess decline in forced vital capacity (FVC) as a surrogate for mortality. METHODS Data from the nintedanib and placebo groups of trials in subjects with idiopathic pulmonary fibrosis, other forms of progressive pulmonary fibrosis, and pulmonary fibrosis due to systemic sclerosis (NCT00514683, NCT01335464, NCT01335477, NCT01979952, NCT02999178, NCT02597933) were pooled. Using joint models for longitudinal and time-to-event data, we assessed the association between decline in FVC % predicted and time to death over 52 weeks. The rate of change in FVC % predicted and the current value of FVC % predicted were modelled longitudinally and estimates applied as predictors in time-to-event models. RESULTS Among 2583 subjects with pulmonary fibrosis, both a greater rate of decline in FVC % predicted and a lower current value of FVC % predicted were associated with an increased risk of death over 52 weeks (HR 1.79 [95% CI: 1.57, 2.03] and HR 1.24 [1.17, 1.32] per 5-percentage point decrease, respectively). Associations between the rate of change in FVC % predicted and the risk of death were consistent between patients with IPF and other ILDs. CONCLUSION Data from clinical trials in subjects with pulmonary fibrosis of diverse aetiology demonstrate a strong association between decline in FVC % predicted and mortality over 52 weeks, supporting FVC decline as a surrogate for mortality in these patients.
Collapse
Affiliation(s)
- Toby M Maher
- Keck School of Medicine, University of Southern California, Los Angeles, California, USA
- Imperial College London, London, UK
| | - Susanne Stowasser
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Florian Voss
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim am Rhein, Germany
| | - Elisabeth Bendstrup
- Centre for Rare Lung Diseases, Department of Respiratory Diseases and Allergy and Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Michael Kreuter
- Center for Interstitial and Rare Lung Diseases, Pneumology and Respiratory Care Medicine, Thoraxklinik, University of Heidelberg, Member of the German Center for Lung Research, Heidelberg, Germany
| | | | - Patricia J Sime
- Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Christian Stock
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim am Rhein, Germany
| |
Collapse
|
2
|
Richeldi L, Azuma A, Cottin V, Kreuter M, Maher TM, Martinez FJ, Oldham JM, Valenzuela C, Gordat M, Liu Y, Stowasser S, Zoz DF, Wijsenbeek MS. Design of a phase III, double-blind, randomised, placebo-controlled trial of BI 1015550 in patients with idiopathic pulmonary fibrosis (FIBRONEER-IPF). BMJ Open Respir Res 2023; 10:e001563. [PMID: 37597969 PMCID: PMC10441083 DOI: 10.1136/bmjresp-2022-001563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 07/31/2023] [Indexed: 08/21/2023] Open
Abstract
IntroductionThere is an unmet need for new treatments for idiopathic pulmonary fibrosis (IPF). The oral preferential phosphodiesterase 4B inhibitor, BI 1015550, prevented a decline in forced vital capacity (FVC) in a phase II study in patients with IPF. This study design describes the subsequent pivotal phase III study of BI 1015550 in patients with IPF (FIBRONEER-IPF). METHODS AND ANALYSIS In this placebo-controlled, double-blind, phase III trial, patients are being randomised in a 1:1:1 ratio to receive 9 mg or 18 mg of BI 1015550 or placebo two times per day over at least 52 weeks, stratified by use of background antifibrotics (nintedanib/pirfenidone vs neither). The primary endpoint is the absolute change in FVC at week 52. The key secondary endpoint is a composite of time to first acute IPF exacerbation, hospitalisation due to respiratory cause or death over the duration of the trial. ETHICS AND DISSEMINATION The trial is being carried out in compliance with the ethical principles of the Declaration of Helsinki, in accordance with the International Council on Harmonisation Guideline for Good Clinical Practice and other local ethics committees. The results of the study will be disseminated at scientific congresses and in peer-reviewed publications. TRIAL REGISTRATION NUMBER NCT05321069.
Collapse
Affiliation(s)
- Luca Richeldi
- Unità Operativa Complessa di Pneumologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Arata Azuma
- Pulmonary Medicine and Oncology, Nippon Medical School, Tokyo, Japan
- Respiratory Medicine and Clinical Research Centre, Meisei Hospital, Saitama, Japan
| | - Vincent Cottin
- Hôpital Louis Pradel, Centre Coordonnateur National de référence des Maladies Pulmonaires Rares, Hospices Civils de Lyon, UMR754, INRAE, Université Claude Bernard Lyon 1, Member of ERN-LUNG, Lyon, France
| | - Michael Kreuter
- Centre for Interstitial and Rare Lung Diseases, Department of Pneumology, Thoraxklinik, University of Heidelberg, German Center for Lung Research, Heidelberg, Germany
- Department of Pneumology, RKH Clinic Ludwigsburg, Ludwigsburg, Germany
| | - Toby M Maher
- Department of Pulmonary, Critical Care and Sleep Medicine, USC Keck School of Medicine, Los Angeles, California, USA
- Section of Inflammation, Repair and Development, National Heart and Lung Institute, Imperial College London, London, UK
| | | | - Justin M Oldham
- Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Claudia Valenzuela
- ILD Unit, Pulmonology Department, Hospital Universitario de la Princesa, Universidad Autónoma de Madrid, Madrid, Spain
| | - Maud Gordat
- Clinical Development & Operation Department, Boehringer Ingelheim, Reims, France
| | - Yi Liu
- Department of Biostatistics and Data Sciences, Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, Connecticut, USA
| | - Susanne Stowasser
- TA Inflammation Med, Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Donald F Zoz
- Global Clinical Development and Medical Affairs, Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, Connecticut, USA
| | - Marlies S Wijsenbeek
- Centre for Interstitial Lung Diseases and Sarcoidosis, Department of Respiratory Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| |
Collapse
|
3
|
Deterding R, Young LR, DeBoer EM, Warburton D, Cunningham S, Schwerk N, Flaherty KR, Brown KK, Dumistracel M, Erhardt E, Bertulis J, Gahlemann M, Stowasser S, Griese M. Nintedanib in children and adolescents with fibrosing interstitial lung diseases. Eur Respir J 2023; 61:13993003.01512-2022. [PMID: 36041751 PMCID: PMC9892863 DOI: 10.1183/13993003.01512-2022] [Citation(s) in RCA: 21] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 08/25/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Childhood interstitial lung disease (ILD) comprises a spectrum of rare ILDs affecting infants, children and adolescents. Nintedanib is a licensed treatment for pulmonary fibrosis in adults. The primary objectives of the InPedILD trial were to determine the dose-exposure and safety of nintedanib in children and adolescents with fibrosing ILD. METHODS Patients aged 6-17 years with fibrosing ILD on high-resolution computed tomography and clinically significant disease were randomised 2:1 to receive nintedanib or placebo for 24 weeks and then open-label nintedanib. Dosing was based on weight-dependent allometric scaling. Co-primary end-points were the area under the plasma concentration-time curve at steady state (AUCτ,ss) at weeks 2 and 26 and the proportion of patients with treatment-emergent adverse events at week 24. RESULTS 26 patients received nintedanib and 13 patients received placebo. The geometric mean (geometric coefficient of variation) AUCτ,ss for nintedanib was 175 µg·h·L-1 (85.1%) in patients aged 6-11 years and 160 µg·h·L-1 (82.7%) in patients aged 12-17 years. In the double-blind period, adverse events were reported in 84.6% of patients in each treatment group. Two patients discontinued nintedanib due to adverse events. Diarrhoea was reported in 38.5% and 15.4% of the nintedanib and placebo groups, respectively. Adjusted mean±se changes in percentage predicted forced vital capacity at week 24 were 0.3±1.3% in the nintedanib group and -0.9±1.8% in the placebo group. CONCLUSIONS In children and adolescents with fibrosing ILD, a weight-based dosing regimen resulted in exposure to nintedanib similar to adults and an acceptable safety profile. These data provide a scientific basis for the use of nintedanib in this patient population.
Collapse
Affiliation(s)
- Robin Deterding
- Section of Pediatric Pulmonary and Sleep Medicine, Department of Pediatrics, University of Colorado Denver, Denver, CO, USA
- The Children's Hospital Colorado, Aurora, CO, USA
- These two authors contributed equally
| | - Lisa R. Young
- Division of Pulmonary and Sleep Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- These two authors contributed equally
| | - Emily M. DeBoer
- Section of Pediatric Pulmonary and Sleep Medicine, Department of Pediatrics, University of Colorado Denver, Denver, CO, USA
- The Children's Hospital Colorado, Aurora, CO, USA
| | - David Warburton
- Children's Hospital Los Angeles, Los Angeles, CA, USA
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Steven Cunningham
- Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
| | - Nicolaus Schwerk
- Clinic for Pediatric Pulmonology, Allergology and Neonatology, Hannover Medical School, Hannover, Germany
| | - Kevin R. Flaherty
- Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Kevin K. Brown
- Department of Medicine, National Jewish Health, Denver, CO, USA
| | | | - Elvira Erhardt
- Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach, Germany
| | - Julia Bertulis
- Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach, Germany
| | | | - Susanne Stowasser
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Matthias Griese
- Hauner Children's Hospital, Ludwig Maximilians University, German Center for Lung Research (DZL), Munich, Germany
| |
Collapse
|
4
|
Richeldi L, Azuma A, Cottin V, Hesslinger C, Stowasser S, Valenzuela C, Wijsenbeek MS, Zoz DF, Voss F, Maher TM. Plain language summary: Clinical study of BI 1015550 as a potential treatment for idiopathic pulmonary fibrosis. J Comp Eff Res 2022; 12:e220142. [PMID: 36537726 PMCID: PMC10288937 DOI: 10.2217/cer-2022-0142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 10/27/2022] [Indexed: 12/24/2022] Open
Abstract
WHAT IS THIS SUMMARY ABOUT? This plain language summary describes the main findings from a trial in people with idiopathic pulmonary fibrosis (also called IPF) that was recently published in the New England Journal of Medicine. IPF is a rare disease, where the lungs become more and more scarred, with breathing and oxygen uptake becoming increasingly difficult. This trial looked at the medication BI 1015550 as a potential treatment for IPF. It compared BI 1015550 to placebo (a dummy drug that does not contain any active ingredients) to investigate the effectiveness of the drug in treating people with IPF. The study also looked at the additional medical issues (referred to as adverse events) reported during the study. Some participants took approved treatments to reduce scarring (nintedanib or pirfenidone), and some did not. WHAT WERE THE RESULTS? Overall, 147 people with IPF from 22 countries took part in the trial. The results showed that BI 1015550 prevented lung function from decreasing in people with IPF. There was no difference in the percentage of patients with medical issues rated as severe by the study physician with BI 1015550 or placebo. However, more people treated with BI 1015550 had diarrhoea. Among those treated with BI 1015550, 13 participants stopped their treatment due to medical issues, whereas treatment was not stopped due to medical issues for any participants treated with placebo. WHAT DO THE RESULTS MEAN? These results provide evidence that BI 1015550 prevents lung function from worsening in people with IPF. Further clinical studies will be conducted in the future to test BI 1015550 in a larger group of people with IPF and other forms of lung scarring that get worse over time, and for a longer time period.
Collapse
Affiliation(s)
- Luca Richeldi
- Unità Operativa Complessa di Pneumologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Arata Azuma
- Pulmonary Medicine & Oncology, Nippon Medical School, Tokyo, Japan
| | - Vincent Cottin
- Hôpital Louis Pradel, Centre Coordonnateur National de Référence des Maladies Pulmonaires Rares, Hospices Civils de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Christian Hesslinger
- Translational Medicine + Clinical Pharmacology, Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach, Germany
| | - Susanne Stowasser
- TA Inflammation Med, Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Claudia Valenzuela
- ILD Unit, Pulmonology Department, Hospital Universitario de la Princesa, University Autonoma de Madrid, Madrid, Spain
| | - Marlies S Wijsenbeek
- Department of Respiratory Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Donald F Zoz
- Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, CT, USA
| | - Florian Voss
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim am Rhein, Germany
| | | |
Collapse
|
5
|
Assassi S, Distler O, Allanore Y, Ogura T, Varga J, Vettori S, Crestani B, Voss F, Alves M, Stowasser S, Maher TM. Effect of Nintedanib on Progression of Systemic Sclerosis-Associated Interstitial Lung Disease Over 100 Weeks: Data From a Randomized Controlled Trial. ACR Open Rheumatol 2022; 4:837-844. [PMID: 35852465 PMCID: PMC9555199 DOI: 10.1002/acr2.11483] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 06/13/2022] [Accepted: 06/16/2022] [Indexed: 11/10/2022] Open
Abstract
Objective In the SENSCIS trial, participants with systemic sclerosis‐associated interstitial lung disease (SSc‐ILD) were randomized to receive nintedanib or placebo until the last participant reached week 52 but for 100 weeks or less. Nintedanib reduced the rate of decline in forced vital capacity (FVC) (ml/year) over 52 weeks by 44% (41 ml [95% confidence interval (95% CI): 2.9‐79.0]) versus placebo. We investigated the effect of nintedanib over the whole SENSCIS trial. Methods The annual rate of decline in FVC (ml/year) over the whole trial was assessed descriptively using 1) on‐treatment data plus off‐treatment data from participants who prematurely discontinued treatment (intent‐to‐treat analysis) and 2) only on‐treatment data to assess the effect of nintedanib in participants who remained on treatment. Results In the intent‐to‐treat analysis, the adjusted mean (SE) annual rate of decline in FVC over 100 weeks was −54.9 (11.1) and −88.8 (10.9) ml/year in the nintedanib (n = 287) and placebo (n = 288) groups, respectively (difference 34.0 ml/year [95% CI: 3.4‐64.5]). In the on‐treatment analysis, the adjusted mean (SE) annual rate of decline in FVC over 100 weeks was −55.1 (12.3) and −94.0 (11.7) ml/year in the nintedanib (n = 286) and placebo (n = 288) groups, respectively (difference 38.9 ml/year [95% CI: 5.6‐72.1]). The adverse event profile of nintedanib over 100 weeks was consistent with that observed over 52 weeks. Conclusion Nintedanib provides a sustained benefit on slowing the progression of SSc‐ILD over 100 weeks, with adverse events that are manageable for most patients.
Collapse
Affiliation(s)
| | - Oliver Distler
- University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | | | - Takashi Ogura
- Kanagawa Cardiovascular and Respiratory Centre, Yokohama, Japan
| | | | | | | | - Florian Voss
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim am Rhein, Germany
| | - Margarida Alves
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Susanne Stowasser
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Toby M Maher
- National Heart and Lung Institute, Imperial College London, London, UK, and Keck School of Medicine, University of Southern California, Los Angeles, USA
| | | |
Collapse
|
6
|
Richeldi L, Azuma A, Cottin V, Hesslinger C, Stowasser S, Valenzuela C, Wijsenbeek MS, Zoz DF, Voss F, Maher TM. Trial of a Preferential Phosphodiesterase 4B Inhibitor for Idiopathic Pulmonary Fibrosis. N Engl J Med 2022; 386:2178-2187. [PMID: 35569036 DOI: 10.1056/nejmoa2201737] [Citation(s) in RCA: 59] [Impact Index Per Article: 29.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Phosphodiesterase 4 (PDE4) inhibition is associated with antiinflammatory and antifibrotic effects that may be beneficial in patients with idiopathic pulmonary fibrosis. METHODS In this phase 2, double-blind, placebo-controlled trial, we investigated the efficacy and safety of BI 1015550, an oral preferential inhibitor of the PDE4B subtype, in patients with idiopathic pulmonary fibrosis. Patients were randomly assigned in a 2:1 ratio to receive BI 1015550 at a dose of 18 mg twice daily or placebo. The primary end point was the change from baseline in the forced vital capacity (FVC) at 12 weeks, which we analyzed with a Bayesian approach separately according to background nonuse or use of an antifibrotic agent. RESULTS A total of 147 patients were randomly assigned to receive BI 1015550 or placebo. Among patients without background antifibrotic use, the median change in the FVC was 5.7 ml (95% credible interval, -39.1 to 50.5) in the BI 1015550 group and -81.7 ml (95% credible interval, -133.5 to -44.8) in the placebo group (median difference, 88.4 ml; 95% credible interval, 29.5 to 154.2; probability that BI 1015550 was superior to placebo, 0.998). Among patients with background antifibrotic use, the median change in the FVC was 2.7 ml (95% credible interval, -32.8 to 38.2) in the BI 1015550 group and -59.2 ml (95% credible interval, -111.8 to -17.9) in the placebo group (median difference, 62.4 ml; 95% credible interval, 6.3 to 125.5; probability that BI 1015550 was superior to placebo, 0.986). A mixed model with repeated measures analysis provided results that were consistent with those of the Bayesian analysis. The most frequent adverse event was diarrhea. A total of 13 patients discontinued BI 1015550 treatment owing to adverse events. The percentages of patients with serious adverse events or severe adverse events were similar in the two trial groups. CONCLUSIONS In this placebo-controlled trial, treatment with BI 1015550, either alone or with background use of an antifibrotic agent, prevented a decrease in lung function in patients with idiopathic pulmonary fibrosis. (Funded by Boehringer Ingelheim; 1305-0013 ClinicalTrials.gov number, NCT04419506.).
Collapse
Affiliation(s)
- Luca Richeldi
- From Unità Operativa Complessa di Pneumologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome (L.R.); Nippon Medical School, Tokyo (A.A.); Hôpital Louis Pradel, Centre National de Référence des Maladies Pulmonaires Rares, Hospices Civils de Lyon, Unité Mixte de Recherche 754 Institut National de la Recherche Agronomique and Université Claude Bernard Lyon 1, ERN-LUNG (European Reference Network on Rare Respiratory Diseases), RespiFil, OrphaLung, Lyon, France (V.C.); Translational Medicine and Clinical Pharmacology, Boehringer Ingelheim International, Biberach (C.H.), and TA Inflammation Medicine (S.S.), Boehringer Ingelheim Pharma (F.V.), Ingelheim am Rhein - both in Germany; the Interstitial Lung Disease Unit, Department of Pulmonology, Hospital Universitario de la Princesa, University Autonoma de Madrid, Madrid (C.V.); the Department of Respiratory Medicine, Erasmus Medical Center, Rotterdam, the Netherlands (M.S.W.); Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT (D.F.Z.); Keck School of Medicine, University of Southern California, Los Angeles (T.M.M.); and the National Heart and Lung Institute, Imperial College London, London (T.M.M.)
| | - Arata Azuma
- From Unità Operativa Complessa di Pneumologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome (L.R.); Nippon Medical School, Tokyo (A.A.); Hôpital Louis Pradel, Centre National de Référence des Maladies Pulmonaires Rares, Hospices Civils de Lyon, Unité Mixte de Recherche 754 Institut National de la Recherche Agronomique and Université Claude Bernard Lyon 1, ERN-LUNG (European Reference Network on Rare Respiratory Diseases), RespiFil, OrphaLung, Lyon, France (V.C.); Translational Medicine and Clinical Pharmacology, Boehringer Ingelheim International, Biberach (C.H.), and TA Inflammation Medicine (S.S.), Boehringer Ingelheim Pharma (F.V.), Ingelheim am Rhein - both in Germany; the Interstitial Lung Disease Unit, Department of Pulmonology, Hospital Universitario de la Princesa, University Autonoma de Madrid, Madrid (C.V.); the Department of Respiratory Medicine, Erasmus Medical Center, Rotterdam, the Netherlands (M.S.W.); Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT (D.F.Z.); Keck School of Medicine, University of Southern California, Los Angeles (T.M.M.); and the National Heart and Lung Institute, Imperial College London, London (T.M.M.)
| | - Vincent Cottin
- From Unità Operativa Complessa di Pneumologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome (L.R.); Nippon Medical School, Tokyo (A.A.); Hôpital Louis Pradel, Centre National de Référence des Maladies Pulmonaires Rares, Hospices Civils de Lyon, Unité Mixte de Recherche 754 Institut National de la Recherche Agronomique and Université Claude Bernard Lyon 1, ERN-LUNG (European Reference Network on Rare Respiratory Diseases), RespiFil, OrphaLung, Lyon, France (V.C.); Translational Medicine and Clinical Pharmacology, Boehringer Ingelheim International, Biberach (C.H.), and TA Inflammation Medicine (S.S.), Boehringer Ingelheim Pharma (F.V.), Ingelheim am Rhein - both in Germany; the Interstitial Lung Disease Unit, Department of Pulmonology, Hospital Universitario de la Princesa, University Autonoma de Madrid, Madrid (C.V.); the Department of Respiratory Medicine, Erasmus Medical Center, Rotterdam, the Netherlands (M.S.W.); Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT (D.F.Z.); Keck School of Medicine, University of Southern California, Los Angeles (T.M.M.); and the National Heart and Lung Institute, Imperial College London, London (T.M.M.)
| | - Christian Hesslinger
- From Unità Operativa Complessa di Pneumologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome (L.R.); Nippon Medical School, Tokyo (A.A.); Hôpital Louis Pradel, Centre National de Référence des Maladies Pulmonaires Rares, Hospices Civils de Lyon, Unité Mixte de Recherche 754 Institut National de la Recherche Agronomique and Université Claude Bernard Lyon 1, ERN-LUNG (European Reference Network on Rare Respiratory Diseases), RespiFil, OrphaLung, Lyon, France (V.C.); Translational Medicine and Clinical Pharmacology, Boehringer Ingelheim International, Biberach (C.H.), and TA Inflammation Medicine (S.S.), Boehringer Ingelheim Pharma (F.V.), Ingelheim am Rhein - both in Germany; the Interstitial Lung Disease Unit, Department of Pulmonology, Hospital Universitario de la Princesa, University Autonoma de Madrid, Madrid (C.V.); the Department of Respiratory Medicine, Erasmus Medical Center, Rotterdam, the Netherlands (M.S.W.); Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT (D.F.Z.); Keck School of Medicine, University of Southern California, Los Angeles (T.M.M.); and the National Heart and Lung Institute, Imperial College London, London (T.M.M.)
| | - Susanne Stowasser
- From Unità Operativa Complessa di Pneumologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome (L.R.); Nippon Medical School, Tokyo (A.A.); Hôpital Louis Pradel, Centre National de Référence des Maladies Pulmonaires Rares, Hospices Civils de Lyon, Unité Mixte de Recherche 754 Institut National de la Recherche Agronomique and Université Claude Bernard Lyon 1, ERN-LUNG (European Reference Network on Rare Respiratory Diseases), RespiFil, OrphaLung, Lyon, France (V.C.); Translational Medicine and Clinical Pharmacology, Boehringer Ingelheim International, Biberach (C.H.), and TA Inflammation Medicine (S.S.), Boehringer Ingelheim Pharma (F.V.), Ingelheim am Rhein - both in Germany; the Interstitial Lung Disease Unit, Department of Pulmonology, Hospital Universitario de la Princesa, University Autonoma de Madrid, Madrid (C.V.); the Department of Respiratory Medicine, Erasmus Medical Center, Rotterdam, the Netherlands (M.S.W.); Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT (D.F.Z.); Keck School of Medicine, University of Southern California, Los Angeles (T.M.M.); and the National Heart and Lung Institute, Imperial College London, London (T.M.M.)
| | - Claudia Valenzuela
- From Unità Operativa Complessa di Pneumologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome (L.R.); Nippon Medical School, Tokyo (A.A.); Hôpital Louis Pradel, Centre National de Référence des Maladies Pulmonaires Rares, Hospices Civils de Lyon, Unité Mixte de Recherche 754 Institut National de la Recherche Agronomique and Université Claude Bernard Lyon 1, ERN-LUNG (European Reference Network on Rare Respiratory Diseases), RespiFil, OrphaLung, Lyon, France (V.C.); Translational Medicine and Clinical Pharmacology, Boehringer Ingelheim International, Biberach (C.H.), and TA Inflammation Medicine (S.S.), Boehringer Ingelheim Pharma (F.V.), Ingelheim am Rhein - both in Germany; the Interstitial Lung Disease Unit, Department of Pulmonology, Hospital Universitario de la Princesa, University Autonoma de Madrid, Madrid (C.V.); the Department of Respiratory Medicine, Erasmus Medical Center, Rotterdam, the Netherlands (M.S.W.); Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT (D.F.Z.); Keck School of Medicine, University of Southern California, Los Angeles (T.M.M.); and the National Heart and Lung Institute, Imperial College London, London (T.M.M.)
| | - Marlies S Wijsenbeek
- From Unità Operativa Complessa di Pneumologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome (L.R.); Nippon Medical School, Tokyo (A.A.); Hôpital Louis Pradel, Centre National de Référence des Maladies Pulmonaires Rares, Hospices Civils de Lyon, Unité Mixte de Recherche 754 Institut National de la Recherche Agronomique and Université Claude Bernard Lyon 1, ERN-LUNG (European Reference Network on Rare Respiratory Diseases), RespiFil, OrphaLung, Lyon, France (V.C.); Translational Medicine and Clinical Pharmacology, Boehringer Ingelheim International, Biberach (C.H.), and TA Inflammation Medicine (S.S.), Boehringer Ingelheim Pharma (F.V.), Ingelheim am Rhein - both in Germany; the Interstitial Lung Disease Unit, Department of Pulmonology, Hospital Universitario de la Princesa, University Autonoma de Madrid, Madrid (C.V.); the Department of Respiratory Medicine, Erasmus Medical Center, Rotterdam, the Netherlands (M.S.W.); Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT (D.F.Z.); Keck School of Medicine, University of Southern California, Los Angeles (T.M.M.); and the National Heart and Lung Institute, Imperial College London, London (T.M.M.)
| | - Donald F Zoz
- From Unità Operativa Complessa di Pneumologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome (L.R.); Nippon Medical School, Tokyo (A.A.); Hôpital Louis Pradel, Centre National de Référence des Maladies Pulmonaires Rares, Hospices Civils de Lyon, Unité Mixte de Recherche 754 Institut National de la Recherche Agronomique and Université Claude Bernard Lyon 1, ERN-LUNG (European Reference Network on Rare Respiratory Diseases), RespiFil, OrphaLung, Lyon, France (V.C.); Translational Medicine and Clinical Pharmacology, Boehringer Ingelheim International, Biberach (C.H.), and TA Inflammation Medicine (S.S.), Boehringer Ingelheim Pharma (F.V.), Ingelheim am Rhein - both in Germany; the Interstitial Lung Disease Unit, Department of Pulmonology, Hospital Universitario de la Princesa, University Autonoma de Madrid, Madrid (C.V.); the Department of Respiratory Medicine, Erasmus Medical Center, Rotterdam, the Netherlands (M.S.W.); Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT (D.F.Z.); Keck School of Medicine, University of Southern California, Los Angeles (T.M.M.); and the National Heart and Lung Institute, Imperial College London, London (T.M.M.)
| | - Florian Voss
- From Unità Operativa Complessa di Pneumologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome (L.R.); Nippon Medical School, Tokyo (A.A.); Hôpital Louis Pradel, Centre National de Référence des Maladies Pulmonaires Rares, Hospices Civils de Lyon, Unité Mixte de Recherche 754 Institut National de la Recherche Agronomique and Université Claude Bernard Lyon 1, ERN-LUNG (European Reference Network on Rare Respiratory Diseases), RespiFil, OrphaLung, Lyon, France (V.C.); Translational Medicine and Clinical Pharmacology, Boehringer Ingelheim International, Biberach (C.H.), and TA Inflammation Medicine (S.S.), Boehringer Ingelheim Pharma (F.V.), Ingelheim am Rhein - both in Germany; the Interstitial Lung Disease Unit, Department of Pulmonology, Hospital Universitario de la Princesa, University Autonoma de Madrid, Madrid (C.V.); the Department of Respiratory Medicine, Erasmus Medical Center, Rotterdam, the Netherlands (M.S.W.); Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT (D.F.Z.); Keck School of Medicine, University of Southern California, Los Angeles (T.M.M.); and the National Heart and Lung Institute, Imperial College London, London (T.M.M.)
| | - Toby M Maher
- From Unità Operativa Complessa di Pneumologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome (L.R.); Nippon Medical School, Tokyo (A.A.); Hôpital Louis Pradel, Centre National de Référence des Maladies Pulmonaires Rares, Hospices Civils de Lyon, Unité Mixte de Recherche 754 Institut National de la Recherche Agronomique and Université Claude Bernard Lyon 1, ERN-LUNG (European Reference Network on Rare Respiratory Diseases), RespiFil, OrphaLung, Lyon, France (V.C.); Translational Medicine and Clinical Pharmacology, Boehringer Ingelheim International, Biberach (C.H.), and TA Inflammation Medicine (S.S.), Boehringer Ingelheim Pharma (F.V.), Ingelheim am Rhein - both in Germany; the Interstitial Lung Disease Unit, Department of Pulmonology, Hospital Universitario de la Princesa, University Autonoma de Madrid, Madrid (C.V.); the Department of Respiratory Medicine, Erasmus Medical Center, Rotterdam, the Netherlands (M.S.W.); Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT (D.F.Z.); Keck School of Medicine, University of Southern California, Los Angeles (T.M.M.); and the National Heart and Lung Institute, Imperial College London, London (T.M.M.)
| |
Collapse
|
7
|
Matteson EL, Kelly C, Distler JHW, Hoffmann-Vold AM, Seibold JR, Mittoo S, Dellaripa PF, Aringer M, Pope J, Distler O, James A, Schlenker-Herceg R, Stowasser S, Quaresma M, Flaherty KR. Nintedanib in Patients With Autoimmune Disease-Related Progressive Fibrosing Interstitial Lung Diseases: Subgroup Analysis of the INBUILD Trial. Arthritis Rheumatol 2022; 74:1039-1047. [PMID: 35199968 PMCID: PMC9321107 DOI: 10.1002/art.42075] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 11/26/2021] [Accepted: 01/21/2022] [Indexed: 11/18/2022]
Abstract
Objective To analyze the efficacy and safety of nintedanib in patients with fibrosing autoimmune disease–related interstitial lung diseases (ILDs) with a progressive phenotype. Methods The INBUILD trial enrolled patients with a fibrosing ILD other than idiopathic pulmonary fibrosis, with diffuse fibrosing lung disease of >10% extent on high‐resolution computed tomography, forced vital capacity percent predicted (FVC%) ≥45%, and diffusing capacity of the lungs for carbon monoxide percent predicted ≥30% to <80%. Patients fulfilled protocol‐defined criteria for progression of ILD within the 24 months before screening, despite management deemed appropriate in clinical practice. Subjects were randomized to receive nintedanib or placebo. We assessed the rate of decline in FVC (ml/year) and adverse events (AEs) over 52 weeks in the subgroup with autoimmune disease–related ILDs. Results Among 170 patients with autoimmune disease–related ILDs, the rate of decline in FVC over 52 weeks was −75.9 ml/year with nintedanib versus −178.6 ml/year with placebo (difference 102.7 ml/year [95% confidence interval 23.2, 182.2]; nominal P = 0.012). No heterogeneity was detected in the effect of nintedanib versus placebo across subgroups based on ILD diagnosis (P = 0.91). The most frequent AE was diarrhea, reported in 63.4% and 27.3% of subjects in the nintedanib and placebo groups, respectively. AEs led to permanent discontinuation of trial drug in 17.1% and 10.2% of subjects in the nintedanib and placebo groups, respectively. Conclusion In the INBUILD trial, nintedanib slowed the rate of decline in FVC in patients with progressive fibrosing autoimmune disease–related ILDs, with AEs that were manageable for most patients. Video Abstract
Collapse
Affiliation(s)
- Eric L Matteson
- Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Clive Kelly
- Newcastle University, Newcastle-upon-Tyne, UK
| | - Jörg H W Distler
- Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
| | | | | | | | | | | | - Janet Pope
- University of Western Ontario, London, Ontario, Canada
| | | | | | | | - Susanne Stowasser
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Manuel Quaresma
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | | | | |
Collapse
|
8
|
Bonella F, Cottin V, Valenzuela C, Wijsenbeek M, Voss F, Rohr KB, Stowasser S, Maher TM. Meta-Analysis of Effect of Nintedanib on Reducing FVC Decline Across Interstitial Lung Diseases. Adv Ther 2022; 39:3392-3402. [PMID: 35576048 PMCID: PMC9239974 DOI: 10.1007/s12325-022-02145-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 03/24/2022] [Indexed: 11/30/2022]
Abstract
Introduction The effect of nintedanib on slowing the rate of decline in forced vital capacity (FVC) has been investigated in randomized placebo-controlled trials in subjects with idiopathic pulmonary fibrosis (IPF), other progressive fibrosing interstitial lung diseases (ILDs), and ILD associated with systemic sclerosis (SSc-ILD). We assessed the consistency of the effect of nintedanib on the rate of decline in FVC over 52 weeks across four placebo-controlled phase III trials. Methods We used data on FVC decline from the INPULSIS-1 and INPULSIS-2 trials in subjects with IPF, the INBUILD trial in subjects with progressing fibrosing ILDs other than IPF, and the SENSCIS trial in subjects with SSc-ILD. In each trial, the primary endpoint was the annual rate of decline in FVC (mL/year) assessed over 52 weeks. We performed fixed effect and random effects meta-analyses based on the relative treatment effect of nintedanib versus placebo on the rate of decline in FVC (mL/year) over 52 weeks. Heterogeneity of the relative treatment effect of nintedanib across populations was assessed using the I2 statistic, τ2 and corresponding p value from a Q test for heterogeneity. Results The combined analysis comprised 1257 subjects treated with nintedanib and 1042 subjects who received placebo. Nintedanib reduced the rate of decline in FVC (mL/year) over 52 weeks by 51.0% (95% CI 39.1, 63.0) compared with placebo. The relative effect (95% CI) was the same using the fixed effect and random effects models. There was no evidence of heterogeneity in the relative treatment effect of nintedanib across the populations studied (I2 = 0%, τ2 = 0, p = 0.93). Conclusions A meta-analysis of data from four placebo-controlled trials demonstrated that nintedanib approximately halved the rate of decline in FVC over 52 weeks across subjects with different forms of pulmonary fibrosis, with no evidence of heterogeneity in its relative treatment effect across patient populations. Graphical abstract ![]()
Collapse
Affiliation(s)
- Francesco Bonella
- Interstitial and Rare Lung Disease Unit, Pneumology Department, Ruhrlandklinik, Duisburg-Essen University, Essen, Germany.
| | - Vincent Cottin
- National Reference Center for Rare Pulmonary Diseases, Louis Pradel Hospital, Hospices Civils de Lyon, Claude Bernard University Lyon 1, UMR 754, Lyon, France
| | - Claudia Valenzuela
- Hospital Universitario de la Princesa, Universidad Autonoma de Madrid, Madrid, Spain
| | - Marlies Wijsenbeek
- Centre for Interstitial Lung Diseases and Sarcoidosis, Department of Respiratory Medicine, Erasmus MC, University Medical Centre, Rotterdam, The Netherlands
| | - Florian Voss
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim am Rhein, Germany
| | - Klaus B Rohr
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Susanne Stowasser
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Toby M Maher
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| |
Collapse
|
9
|
Brown KK, Inoue Y, Flaherty KR, Martinez FJ, Cottin V, Bonella F, Cerri S, Danoff SK, Jouneau S, Goeldner R, Schmidt M, Stowasser S, Schlenker‐Herceg R, Wells AU. Predictors of mortality in subjects with progressive fibrosing interstitial lung diseases. Respirology 2022; 27:294-300. [PMID: 35224814 PMCID: PMC9306931 DOI: 10.1111/resp.14231] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 12/13/2021] [Accepted: 02/08/2022] [Indexed: 01/15/2023]
Abstract
Background and objective Demographic and clinical variables, measured at baseline or over time, have been associated with mortality in subjects with progressive fibrosing interstitial lung diseases (ILDs). We used data from the INPULSIS trials in subjects with idiopathic pulmonary fibrosis (IPF) and the INBUILD trial in subjects with other progressive fibrosing ILDs to assess relationships between demographic/clinical variables and mortality. Methods The relationships between baseline variables and time‐varying covariates and time to death over 52 weeks were analysed using pooled data from the INPULSIS trials and, separately, the INBUILD trial using a Cox proportional hazards model. Results Over 52 weeks, 68/1061 (6.4%) and 33/663 (5.0%) subjects died in the INPULSIS and INBUILD trials, respectively. In the INPULSIS trials, a relative decline in forced vital capacity (FVC) >10% predicted within 12 months (hazard ratio [HR] 3.77) and age (HR 1.03 per 1‐year increase) were associated with increased risk of mortality, while baseline FVC % predicted (HR 0.97 per 1‐unit increase) and diffusing capacity of the lungs for carbon monoxide (DLCO) % predicted (HR 0.77 per 1‐unit increase) were associated with lower risk. In the INBUILD trial, a relative decline in FVC >10% predicted within 12 months (HR 2.60) and a usual interstitial pneumonia‐like fibrotic pattern on HRCT (HR 2.98) were associated with increased risk of mortality, while baseline DLCO % predicted (HR 0.95 per 1‐unit increase) was associated with lower risk. Conclusion These data support similarity in the course of lung injury between IPF and other progressive fibrosing ILDs and the value of FVC decline as a predictor of mortality. We assessed relationships between baseline and time‐varying factors and mortality over 52 weeks in 1061 subjects with idiopathic pulmonary fibrosis (IPF) and 663 subjects with other progressive fibrosing interstitial lung diseases (ILDs). Our findings support similarity in the course of IPF and ILD and an association between decline in forced vital capacity and mortality.
Collapse
Affiliation(s)
- Kevin K. Brown
- Department of Medicine National Jewish Health Denver Colorado USA
| | - Yoshikazu Inoue
- Clinical Research Center National Hospital Organization Kinki‐Chuo Chest Medical Center Sakai City Japan
| | - Kevin R. Flaherty
- Division of Pulmonary and Critical Care Medicine University of Michigan Ann Arbor Michigan USA
| | | | - Vincent Cottin
- National Reference Centre for Rare Pulmonary Diseases, Louis Pradel Hospital, Hospices Civils de Lyon Claude Bernard University Lyon 1 Lyon France
| | - Francesco Bonella
- Center for Interstitial and Rare Lung Diseases, Department of Pneumology, Ruhrlandklinik University Hospital University of Duisburg‐Essen Essen Germany
| | - Stefania Cerri
- Center for Rare Lung Disease Azienda Ospedaliero‐Universitaria Policlinico di Modena Modena Italy
| | | | - Stephane Jouneau
- Department of Respiratory Medicine Competences Centre for Rare Pulmonary Diseases, CHU Rennes, IRSET UMR 1085, Univ Rennes Rennes France
| | | | - Martin Schmidt
- Boehringer Ingelheim Pharma GmbH Ingelheim am Rhein Germany
| | | | | | - Athol U. Wells
- National Institute for Health Research Respiratory Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust, and National Heart and Lung Institute Imperial College London UK
| |
Collapse
|
10
|
White ES, Thomas M, Stowasser S, Tetzlaff K. Challenges for Clinical Drug Development in Pulmonary Fibrosis. Front Pharmacol 2022; 13:823085. [PMID: 35173620 PMCID: PMC8841605 DOI: 10.3389/fphar.2022.823085] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Accepted: 01/10/2022] [Indexed: 12/15/2022] Open
Abstract
Pulmonary fibrosis is a pathologic process associated with scarring of the lung interstitium. Interstitial lung diseases (ILDs) encompass a large and heterogenous group of disorders, a number of which are characterized by progressive pulmonary fibrosis that leads to respiratory failure and death. Idiopathic pulmonary fibrosis (IPF) has been described as an archetype of progressive fibrosing ILD, and the development of pirfenidone and nintedanib has been a major breakthrough in the treatment of patients with this deadly disease. Both drugs principally target scar-forming fibroblasts and have been shown to significantly slow down the accelerated decline of lung function by approximately 50%. In addition, nintedanib has been approved for patients with other progressive fibrosing ILDs and systemic sclerosis-associated ILD. However, there is still no cure for pulmonary fibrosis and no meaningful improvement of symptoms or quality of life has been shown. Advancement in research, such as the advent of single cell sequencing technology, has identified additional pathologic cell populations beyond the fibroblast which could be targeted for therapeutic purposes. The preclinical and clinical development of novel drug candidates is hampered by profound challenges such as a lack of sensitive clinical outcomes or suitable biomarkers that would provide an early indication of patient benefit. With the availability of these anti-fibrotic treatments, it has become even more difficult to demonstrate added efficacy, in particular in short-term clinical studies. Patient heterogeneity and the paucity of biomarkers of disease activity further complicate clinical development. It is conceivable that future treatment of pulmonary fibrosis will need to embrace more precision in treating the right patient at the right time, explore novel measures of efficacy, and likely combine treatment options.
Collapse
Affiliation(s)
- Eric S. White
- Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, CT, United States
| | - Matthew Thomas
- Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach, Germany
| | - Susanne Stowasser
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Kay Tetzlaff
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
- Department of Sports Medicine, University of Tübingen, Tübingen, Germany
- *Correspondence: Kay Tetzlaff,
| |
Collapse
|
11
|
Inoue Y, Suda T, Kitamura H, Okamoto M, Azuma A, Inase N, Kuwana M, Makino S, Nishioka Y, Ogura T, Takizawa A, Ugai H, Stowasser S, Schlenker-Herceg R, Takeuchi T. Efficacy and safety of nintedanib in Japanese patients with progressive fibrosing interstitial lung diseases: Subgroup analysis of the randomised, double-blind, placebo-controlled, phase 3 INBUILD trial. Respir Med 2021; 187:106574. [PMID: 34564020 DOI: 10.1016/j.rmed.2021.106574] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 07/28/2021] [Accepted: 08/09/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND The efficacy of nintedanib in progressive fibrosing interstitial lung diseases (ILDs) was demonstrated in the randomised, double-blind, placebo-controlled INBUILD trial. This subgroup analysis evaluated the efficacy and safety of nintedanib in the Japanese population. METHODS Patients with progressive fibrosing ILDs (evaluated by physicians within 24 months of screening) were randomised (1:1) to twice-daily 150-mg nintedanib or placebo; treatment continued until the last patient completed 52 weeks. The primary endpoint was the annual rate of decline in forced vital capacity (FVC) over 52 weeks. Time-to-first acute ILD exacerbation or death and time-to-death up until the last patient had completed the week 52 visit were evaluated. This subgroup analysis included 108 Japanese patients. RESULTS The adjusted annual rates of FVC decline (mL/year) over 52 weeks for Japanese patients were -148.31 (nintedanib) and -240.36 (placebo), adjusted difference: 92.05 (95% CI: -10.69-194.80) and for non-Japanese patients were -67.41 (nintedanib) and -177.65 (placebo), adjusted difference: 110.24 (95% CI: 64.97-155.52). No heterogeneity in treatment effect between Japanese and non-Japanese subgroups was observed (treatment-by-subgroup interaction, p = 0.75). The risks of "acute exacerbation or death" (hazard ratio, 0.30 [95% CI: 0.10-0.91]) and mortality (hazard ratio, 0.54 [95% CI: 0.14-2.11]) in Japanese patients were numerically lower for nintedanib than placebo. There were no new or unexpected safety findings. CONCLUSIONS In Japanese patients, nintedanib slowed ILD progression, evidenced by a reduction in the annual rate of decline in FVC vs placebo. The efficacy and safety of nintedanib in Japanese patients were consistent with the overall INBUILD population. CLINICALTRIALS.GOV: NCT02999178 (21-Dec-2016).
Collapse
Affiliation(s)
- Yoshikazu Inoue
- National Hospital Organization Kinki-Chuo Chest Medical Center, Clinical Research Center, Osaka, Japan.
| | - Takafumi Suda
- Hamamatsu University School of Medicine, Second Division, Department of Internal Medicine, Shizuoka, Japan.
| | - Hideya Kitamura
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Kanagawa, Japan.
| | - Masaki Okamoto
- Kurume University School of Medicine, Division of Respirology, Neurology, and Rheumatology, Fukuoka, Japan.
| | - Arata Azuma
- Department of Pulmonary Medicine and Oncology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan.
| | - Naohiko Inase
- Department of Respiratory Medicine, Hiratsuka Kyosai Hospital, Kanagawa, Japan.
| | - Masataka Kuwana
- Department of Allergy and Rheumatology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan.
| | - Shigeki Makino
- Osaka Medical and Pharmaceutical University, Mishima-Minami Hospital, Osaka, Japan.
| | - Yasuhiko Nishioka
- Department of Respiratory Medicine and Rheumatology, Graduate School of Biomedical Sciences, Tokushima University, Tokushima, Japan.
| | - Takashi Ogura
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Kanagawa, Japan.
| | | | | | | | | | - Tsutomu Takeuchi
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan.
| |
Collapse
|
12
|
Flaherty KR, Wells AU, Cottin V, Devaraj A, Inoue Y, Richeldi L, Walsh SLF, Kolb M, Koschel D, Moua T, Stowasser S, Goeldner RG, Schlenker-Herceg R, Brown KK. Nintedanib in progressive interstitial lung diseases: data from the whole INBUILD trial. Eur Respir J 2021; 59:13993003.04538-2020. [PMID: 34475231 PMCID: PMC8927709 DOI: 10.1183/13993003.04538-2020] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 07/24/2021] [Indexed: 11/23/2022]
Abstract
Background The primary analysis of the INBUILD trial showed that in subjects with progressive fibrosing interstitial lung diseases (ILDs), nintedanib slowed the decline in forced vital capacity (FVC) over 52 weeks. We report the effects of nintedanib on ILD progression over the whole trial. Methods Subjects with fibrosing ILDs other than idiopathic pulmonary fibrosis, who had ILD progression within the 24 months before screening despite management deemed appropriate in clinical practice, were randomised to receive nintedanib or placebo. Subjects continued on blinded randomised treatment until all subjects had completed the trial. Over the whole trial, mean±sd exposure to trial medication was 15.6±7.2 and 16.8±5.8 months in the nintedanib and placebo groups, respectively. Results In the nintedanib (n=332) and placebo (n=331) groups, respectively, the proportions of subjects who had ILD progression (absolute decline in FVC ≥10% predicted) or died were 40.4% and 54.7% in the overall population (hazard ratio (HR) 0.66, 95% CI 0.53–0.83; p=0.0003) and 43.7% and 55.8% among subjects with a usual interstitial pneumonia (UIP)-like fibrotic pattern on high-resolution computed tomography (HRCT) (HR 0.69, 95% CI 0.53–0.91; p=0.009). In the nintedanib and placebo groups, respectively, the proportions who had an acute exacerbation of ILD or died were 13.9% and 19.6% in the overall population (HR 0.67, 95% CI 0.46–0.98; p=0.04) and 15.0% and 22.8% among subjects with a UIP-like fibrotic pattern on HRCT (HR 0.62, 95% CI 0.39–0.97; p=0.03). Conclusion Based on data from the whole INBUILD trial, nintedanib reduced the risk of events indicating ILD progression. In patients with fibrosing ILDs other than IPF who had shown progression of ILD within the prior 2 years, events indicating further progression occurred frequently. Over a 16-month period, nintedanib reduced the risk of such events versus placebo.https://bit.ly/3yiZXnS
Collapse
Affiliation(s)
- Kevin R Flaherty
- Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Athol U Wells
- National Institute for Health Research Respiratory Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Vincent Cottin
- National Reference Center for Rare Pulmonary Diseases, Louis Pradel Hospital, Hospices Civils de Lyon, Claude Bernard University Lyon 1, UMR 754, Lyon, France
| | - Anand Devaraj
- Department of Radiology, Royal Brompton and Harefield NHS Foundation Trust, London, UK.,National Heart and Lung Institute, Imperial College, London, UK
| | - Yoshikazu Inoue
- Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, Sakai City, Osaka, Japan
| | - Luca Richeldi
- Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Simon L F Walsh
- National Heart and Lung Institute, Imperial College, London, UK
| | - Martin Kolb
- McMaster University and St. Joseph's Healthcare, Hamilton, Ontario, Canada
| | | | - Teng Moua
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic Rochester, Rochester, MN, USA
| | - Susanne Stowasser
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | | | | | - Kevin K Brown
- Department of Medicine, National Jewish Health, Denver, CO, USA
| | | |
Collapse
|
13
|
Noth I, Cottin V, Chaudhuri N, Corte TJ, Johannson KA, Wijsenbeek M, Jouneau S, Michael A, Quaresma M, Rohr KB, Russell AM, Stowasser S, Maher TM. Home spirometry in patients with idiopathic pulmonary fibrosis: data from the INMARK trial. Eur Respir J 2021; 58:13993003.01518-2020. [PMID: 33419890 PMCID: PMC8264778 DOI: 10.1183/13993003.01518-2020] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 12/09/2020] [Indexed: 11/24/2022]
Abstract
Background Data from the INMARK trial were used to investigate the feasibility and validity of home spirometry as a measure of lung function decline in patients with idiopathic pulmonary fibrosis (IPF). Methods Subjects with IPF and preserved forced vital capacity (FVC) were randomised to receive nintedanib or placebo for 12 weeks followed by open-label nintedanib for 40 weeks. Clinic spirometry was conducted at baseline and weeks 4, 8, 12, 16, 20, 24, 36 and 52. Subjects were asked to perform home spirometry at least once a week and ideally daily. Correlations between home- and clinic-measured FVC and rates of change in FVC were assessed using Pearson correlation coefficients. Results In total, 346 subjects were treated. Mean adherence to weekly home spirometry decreased over time but remained above 75% in every 4-week period. Over 52 weeks, mean adherence was 86%. Variability in change from baseline in FVC was greater when measured by home rather than clinic spirometry. Strong correlations were observed between home- and clinic-measured FVC at all time-points (r=0.72–0.84), but correlations between home- and clinic-measured rates of change in FVC were weak (r=0.26 for rate of decline in FVC over 52 weeks). Conclusion Home spirometry was a feasible and valid measure of lung function in patients with IPF and preserved FVC, but estimates of the rate of FVC decline obtained using home spirometry were poorly correlated with those based on clinic spirometry. In a 52-week study in 346 subjects with idiopathic pulmonary fibrosis, mean adherence to weekly home spirometry was 86%. Estimates of the rate of decline in forced vital capacity obtained using home and clinic spirometry were poorly correlated.https://bit.ly/2WjIQ4b
Collapse
Affiliation(s)
- Imre Noth
- Division of Pulmonary and Critical Care Medicine, University of Virginia, Charlottesville, VA, USA
| | - Vincent Cottin
- National Reference Centre for Rare Pulmonary Diseases, Louis Pradel Hospital, Hospices Civils de Lyon, Claude Bernard University Lyon 1, Lyon, France
| | - Nazia Chaudhuri
- North West Interstitial Lung Disease Unit, Manchester University NHS Foundation Trust, Manchester, UK
| | - Tamera J Corte
- Royal Prince Alfred Hospital, Camperdown, Australia.,University of Sydney, Sydney, Australia
| | - Kerri A Johannson
- Medicine and Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Marlies Wijsenbeek
- Dept of Respiratory Medicine, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Stephane Jouneau
- Hôpital Pontchaillou - CHU de Rennes, IRSET UMR 1085, Université de Rennes 1, Rennes, France
| | | | - Manuel Quaresma
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Klaus B Rohr
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | | | - Susanne Stowasser
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | | | | |
Collapse
|
14
|
Deterding R, Griese M, Deutsch G, Warburton D, DeBoer EM, Cunningham S, Clement A, Schwerk N, Flaherty KR, Brown KK, Voss F, Schmid U, Schlenker-Herceg R, Verri D, Dumistracel M, Schiwek M, Stowasser S, Tetzlaff K, Clerisme-Beaty E, Young LR. Study design of a randomised, placebo-controlled trial of nintedanib in children and adolescents with fibrosing interstitial lung disease. ERJ Open Res 2021; 7:00805-2020. [PMID: 34164554 PMCID: PMC8215331 DOI: 10.1183/23120541.00805-2020] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 02/01/2021] [Indexed: 12/21/2022] Open
Abstract
Childhood interstitial lung disease (chILD) comprises >200 rare respiratory disorders, with no currently approved therapies and variable prognosis. Nintedanib reduces the rate of forced vital capacity (FVC) decline in adults with progressive fibrosing interstitial lung diseases (ILDs). We present the design of a multicentre, prospective, double-blind, randomised, placebo-controlled clinical trial of nintedanib in patients with fibrosing chILD (1199-0337 or InPedILD; ClinicalTrials.gov: NCT04093024). Male or female children and adolescents aged 6–17 years (≥30; including ≥20 adolescents aged 12–17 years) with clinically significant fibrosing ILD will be randomised 2:1 to receive oral nintedanib or placebo on top of standard of care for 24 weeks (double-blind), followed by variable-duration nintedanib (open-label). Nintedanib dosing will be based on body weight-dependent allometric scaling, with single-step dose reductions permitted to manage adverse events. Eligible patients will have evidence of fibrosis on high-resolution computed tomography (within 12 months of their first screening visit), FVC ≥25% predicted, and clinically significant disease (Fan score of ≥3 or evidence of clinical progression over time). Patients with underlying chronic liver disease, significant pulmonary arterial hypertension, cardiovascular disease, or increased bleeding risk are ineligible. The primary endpoints are pharmacokinetics and the proportion of patients with treatment-emergent adverse events at week 24. Secondary endpoints include change in FVC% predicted from baseline, Pediatric Quality of Life Questionnaire, oxygen saturation, and 6-min walk distance at weeks 24 and 52. Additional efficacy and safety endpoints will be collected to explore long-term effects. We describe the design of #InPedILD, a study of 24 weeks’ nintedanib or placebo on top of standard of care, followed by variable-duration open-label nintedanib in children with interstitial lung disease (ClinicalTrials.gov NCT04093024) #PedILDhttps://bit.ly/3tC1a7P
Collapse
Affiliation(s)
- Robin Deterding
- Section of Pediatric Pulmonary and Sleep Medicine, Dept of Pediatrics, University of Colorado Denver, Denver, CO, USA.,The Children's Hospital Colorado, Aurora, CO, USA.,These authors contributed equally
| | - Matthias Griese
- Hauner Children's Hospital, Ludwig Maximilians University, German Center for Lung Research (DZL), Munich, Germany.,These authors contributed equally
| | - Gail Deutsch
- Dept of Pathology, University of Washington School of Medicine, Seattle, WA, USA.,Seattle Children's Hospital, Seattle, WA, USA
| | - David Warburton
- Children's Hospital Los Angeles, Los Angeles, CA, USA.,Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Emily M DeBoer
- Section of Pediatric Pulmonary and Sleep Medicine, Dept of Pediatrics, University of Colorado Denver, Denver, CO, USA.,The Children's Hospital Colorado, Aurora, CO, USA
| | - Steven Cunningham
- Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
| | - Annick Clement
- Pediatric Pulmonary Dept, Trousseau Hospital, AP-HP Sorbonne University, Paris, France
| | - Nicolaus Schwerk
- Clinic for Pediatric Pulmonology, Allergology and Neonatology, Hannover Medical School, Hannover, Germany
| | - Kevin R Flaherty
- Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Kevin K Brown
- Dept of Medicine, National Jewish Health, Denver, CO, USA
| | - Florian Voss
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim am Rhein, Germany
| | - Ulrike Schmid
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim am Rhein, Germany
| | | | | | | | - Marilisa Schiwek
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim am Rhein, Germany
| | - Susanne Stowasser
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Kay Tetzlaff
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany.,Sports Medicine Dept, University Hospital of Tuebingen, Tuebingen, Germany
| | | | - Lisa R Young
- Division of Pulmonary and Sleep Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,These authors contributed equally
| |
Collapse
|
15
|
Cottin V, Richeldi L, Rosas I, Otaola M, Song JW, Tomassetti S, Wijsenbeek M, Schmitz M, Coeck C, Stowasser S, Schlenker-Herceg R, Kolb M. Nintedanib and immunomodulatory therapies in progressive fibrosing interstitial lung diseases. Respir Res 2021; 22:84. [PMID: 33726766 PMCID: PMC7962343 DOI: 10.1186/s12931-021-01668-1] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 02/18/2021] [Indexed: 01/13/2023] Open
Abstract
Background In the INBUILD trial in patients with chronic fibrosing interstitial lung diseases (ILDs) and a progressive phenotype, nintedanib reduced the rate of ILD progression with adverse events that were manageable for most patients. We investigated the potential impact of immunomodulatory therapies on the efficacy and safety of nintedanib. Methods Subjects with fibrosing ILDs other than idiopathic pulmonary fibrosis, who had shown progression of ILD within the prior 24 months despite management in clinical practice, were randomized to receive nintedanib or placebo. Certain immunomodulatory therapies were restricted for the first 6 months. We analyzed post-hoc the rate of decline in forced vital capacity (FVC) over 52 weeks in subgroups by glucocorticoid use at baseline and in analyses excluding subjects or FVC measurements taken after initiation of restricted immunomodulatory or antifibrotic therapies. Results Of 663 subjects, 361 (54.4%) were taking glucocorticoids at baseline (353 at a dose of ≤ 20 mg/day). In the placebo group, the adjusted rate of decline in FVC (mL/year) over 52 weeks was numerically greater in subjects taking than not taking glucocorticoids at baseline (− 206.4 [SE 20.2] vs − 165.8 [21.9]). The difference between the nintedanib and placebo groups was 133.3 (95% CI 76.6, 190.0) mL/year in subjects taking glucocorticoids at baseline and 76.1 (15.0, 137.2) mL/year in subjects who were not (interaction P = 0.18). The effect of nintedanib on reducing the rate of FVC decline in analyses excluding subjects or measurements taken after initiation of restricted immunomodulatory or antifibrotic therapies was similar to the primary analysis. The adverse event profile of nintedanib was similar between subjects who did and did not use prohibited or restricted therapies at baseline or during treatment with trial drug. Conclusions In patients with progressive fibrosing ILDs, the effect of nintedanib on reducing FVC decline was not influenced by the use of immunomodulatory therapies. Nintedanib can be used in combination with immunomodulatory therapies in patients with progressive fibrosing ILDs. Trial registration ClinicalTrials.gov, NCT02999178. Registered 21 December 2016, https://clinicaltrials.gov/ct2/show/NCT02999178 Supplementary Information The online version contains supplementary material available at 10.1186/s12931-021-01668-1.
Collapse
Affiliation(s)
- Vincent Cottin
- National Reference Center for Rare Pulmonary Diseases, Louis Pradel Hospital, Hospices Civils de Lyon, Claude Bernard University Lyon 1, University of Lyon, INRA, UMR754, Lyon, France.
| | - Luca Richeldi
- Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Ivan Rosas
- Baylor College of Medicine, Houston, TX, USA
| | - Maria Otaola
- Fundación Para El Estudio de Enfermedades Fibrosantes del Pulmón, Buenos Aires, Argentina
| | - Jin Woo Song
- Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Sara Tomassetti
- Department of Experimental and Clinical Medicine, Careggi University Hospital, Florence, Italy
| | - Marlies Wijsenbeek
- Department of Respiratory Medicine, Erasmus MC, University Medical Centre, Rotterdam, The Netherlands
| | | | - Carl Coeck
- SCS Boehringer Ingelheim Comm.V., Brussels, Belgium
| | - Susanne Stowasser
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | | | - Martin Kolb
- McMaster University and St. Joseph's Healthcare, Hamilton, ON, Canada
| | | |
Collapse
|
16
|
Highland KB, Distler O, Kuwana M, Allanore Y, Assassi S, Azuma A, Bourdin A, Denton CP, Distler JHW, Hoffmann-Vold AM, Khanna D, Mayes MD, Raghu G, Vonk MC, Gahlemann M, Clerisme-Beaty E, Girard M, Stowasser S, Zoz D, Maher TM. Efficacy and safety of nintedanib in patients with systemic sclerosis-associated interstitial lung disease treated with mycophenolate: a subgroup analysis of the SENSCIS trial. Lancet Respir Med 2021; 9:96-106. [PMID: 33412120 DOI: 10.1016/s2213-2600(20)30330-1] [Citation(s) in RCA: 98] [Impact Index Per Article: 32.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 06/23/2020] [Accepted: 07/15/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND In the Safety and Efficacy of Nintedanib in Systemic Sclerosis (SENSCIS) trial, nintedanib reduced the rate of decline in forced vital capacity (FVC) in patients with systemic sclerosis-associated interstitial lung disease (SSc-ILD). Patients on stable treatment with mycophenolate for at least 6 months before randomisation could participate. The aim of this subgroup analysis was to examine the efficacy and safety of nintedanib by mycophenolate use at baseline. METHODS The SENSCIS trial was a randomised, double-blind, placebo-controlled trial, in which patients with SSc-ILD were randomly assigned (1:1) to receive 150 mg of oral nintedanib twice daily or placebo for at least 52 weeks. In a prespecified subgroup analysis, we analysed the primary endpoint of rate of decline in FVC over 52 weeks by mycophenolate use at baseline. In a post-hoc analysis, we analysed the proportion of patients with an absolute decrease in FVC of at least 3·3% predicted at week 52 (proposed minimal clinically important difference estimate for worsening of FVC in patients with SSc-ILD) in subgroups by mycophenolate use at baseline. Adverse events were reported in subgroups by mycophenolate use at baseline. Analyses were done in all participants who received at least one dose of study drug. We analysed the annual rate of decline in FVC using a random coefficient regression model (with random slopes and intercepts) including anti-topoisomerase I antibody status, age, height, sex, and baseline FVC as covariates and terms for baseline-by-time, treatment-by-subgroup, and treatment-by-subgroup-by-time interactions. SENSCIS is registered with ClinicalTrials.gov, NCT02597933, and is now complete. FINDINGS Between Nov 30, 2015, and Oct 31, 2017, 819 participants were screened and 576 were enrolled, randomly assigned to, and treated with nintedanib (n=288) or placebo (n=288). 139 (48%) of 288 in the nintedanib group and 140 (49%) of 288 in the placebo group were taking mycophenolate at baseline. In patients taking mycophenolate at baseline, the adjusted mean annual rate of decline in FVC was -40·2 mL per year (SE 19·8) with nintedanib and -66·5 mL per year (19·3) with placebo (difference: 26·3 mL per year [95% CI -27·9 to 80·6]). In patients not taking mycophenolate at baseline, the adjusted mean annual rate of decline in FVC was -63·9 mL per year (SE 19·3) with nintedanib and -119·3 mL per year (19·0) with placebo (difference: 55·4 mL per year [95% CI 2·3 to 108·5]). We found no heterogeneity in the effect of nintedanib versus placebo on the annual rate of decline in FVC between the subgroups by mycophenolate use (p value for interaction=0·45). In a post-hoc analysis, the proportion of patients with an absolute decrease in FVC of at least 3·3% predicted was lower with nintedanib than with placebo in both patients taking mycophenolate (40 [29%] of 138 vs 56 [40%] of 140; odds ratio 0·61 [0·37 to 1·01]) and those not taking mycophenolate (59 [40%] of 149 vs 70 [47%] of 148; 0·73 [0·46 to 1·16]) at baseline. The adverse event profile of nintedanib was similar between the subgroups. Diarrhoea, the most common adverse event, was reported in 106 (76%) of 139 patients in the nintedanib group and 48 (34%) of 140 in the placebo group among those taking mycophenolate at baseline, and in 112 (75%) of 149 in the nintedanib group and 43 (29%) of 148 in the placebo group among those not taking mycophenolate at baseline. Over the entire trial period, 19 patients died (ten in the nintedanib group and nine in the placebo group). One death in the nintedanib group was considered to be related to study drug. INTERPRETATION Nintedanib reduced the progression of interstitial lung disease both in patients with SSc-ILD who were and were not using mycophenolate at baseline, with no heterogeneity in its treatment effect detected between the subgroups. The adverse event profile of nintedanib was similar in the subgroups by mycophenolate use. Our findings suggest that the combination of mycophenolate and nintedanib offers a safe treatment option for patients with SSc-ILD. More data are needed on the benefits of initial combination therapy versus a sequential approach to treatment of SSc-ILD. FUNDING Boehringer Ingelheim.
Collapse
Affiliation(s)
| | - Oliver Distler
- Department of Rheumatology, University Hospital Zurich, Zurich, Switzerland
| | - Masataka Kuwana
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
| | - Yannick Allanore
- Department of Rheumatology A, Descartes University, APHP, Cochin Hospital, Paris, France
| | - Shervin Assassi
- Division of Rheumatology and Clinical Immunogenetics, University of Texas McGovern Medical School, Houston, TX, USA
| | - Arata Azuma
- Department of Pulmonary Medicine and Oncology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Arnaud Bourdin
- PhyMedExp, University of Montpellier, INSERM U1046, CNRS UMR 9214, Montpellier, France; Department of Respiratory Diseases, University of Montpellier, CHU Montpellier, Montpellier, France
| | - Christopher P Denton
- University College London Division of Medicine, Centre for Rheumatology and Connective Tissue Diseases, London, UK
| | - Jörg H W Distler
- Department of Internal Medicine 3 - Rheumatology and Immunology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU) and University Hospital Erlangen, Erlangen, Germany
| | | | - Dinesh Khanna
- Department of Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Maureen D Mayes
- Division of Rheumatology and Clinical Immunogenetics, University of Texas McGovern Medical School, Houston, TX, USA
| | - Ganesh Raghu
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA, USA
| | - Madelon C Vonk
- Department of Rheumatology, Radboud University Medical Center, Nijmegen, Netherlands
| | | | | | | | | | - Donald Zoz
- Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT, USA
| | - Toby M Maher
- National Heart and Lung Institute, Imperial College London, London, UK; National Institute for Health Research Clinical Research Facility, Royal Brompton Hospital, London, UK; Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
| | | |
Collapse
|
17
|
Patel N, Kaner R, Cerri S, Inoue Y, Mueller H, Rohr K, Stowasser S, Kolb M. EFFECT OF NINTEDANIB IN PATIENTS WITH PROGRESSIVE FIBROSING ILDS AND PRESERVED LUNG FUNCTION AT BASELINE: FURTHER ANALYSES OF THE INBUILD TRIAL. Chest 2020. [DOI: 10.1016/j.chest.2020.08.974] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
|
18
|
Shapera S, Moua T, Nambiar A, Morrison L, Kolb M, Schlenker-Herceg R, Conoscenti C, Goeldner RG, Rohr K, Stowasser S, Brown K. EFFICACY AND SAFETY OF NINTEDANIB IN US/CANADIAN PATIENTS WITH PROGRESSIVE FIBROSING INTERSTITIAL LUNG DISEASES: FURTHER ANALYSES OF THE INBUILD TRIAL. Chest 2020. [DOI: 10.1016/j.chest.2020.09.207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
|
19
|
Matteson E, Kelly C, Distler J, Hoffmann-Vold AM, Seibold J, Mittoo S, Distler O, Dellaripa PF, James A, Schlenker-Herceg R, Stowasser S, Quaresma M, Flaherty KR. OP0115 EFFECT OF NINTEDANIB ON PROGRESSION OF INTERSTITIAL LUNG DISEASE (ILD) IN PATIENTS WITH AUTOIMMUNE DISEASE-RELATED ILDS: FURTHER DATA FROM THE INBUILD TRIAL. Ann Rheum Dis 2020. [DOI: 10.1136/annrheumdis-2020-eular.3211] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Background:In the INBUILD trial in patients with progressive fibrosing ILDs, nintedanib reduced the rate of decline in forced vital capacity (FVC) versus placebo over 52 weeks both in the overall population and in the subgroup with autoimmune disease-related ILDs. Patients continued blinded randomised treatment until the end of the trial.Objectives:Assess the effects of nintedanib on the risks of death, acute exacerbation of ILD or death, and disease progression or death over the whole INBUILD trial in patients with autoimmune disease-related ILDs and a progressive phenotype.Methods:Patients with progressive fibrosing ILDs other than idiopathic pulmonary fibrosis (IPF) were randomised to receive nintedanib 150 mg bid or placebo. Time to i) death, ii) first acute exacerbation of ILD or death, and iii) disease progression (absolute decline in FVC ≥10% predicted) or death, over the whole trial were analysed in patients with autoimmune disease-related ILDs. Incidence rates of adverse events per 100 patient–years were calculated based on events with onset between the first trial drug intake and the last intake plus 28 days. Analyses were descriptive.Results:Of 663 patients, 170 (82 nintedanib, 88 placebo) had autoimmune disease-related ILDs (89 RA-ILD, 39 SSc-ILD, 19 MCTD-ILD, 23 other autoimmune ILDs including Sjogren’s disease-related ILD [n=7], interstitial pneumonia with autoimmune features [n=5] and undifferentiated CTD-ILD [n=3]). Over the whole trial, in the nintedanib and placebo groups, respectively, mean (SD) exposure to drug was 15.4 (7.4) and 16.9 (6.1) months and maximum exposure was 26.0 and 25.2 months; 62 (75.6%) and 68 (77.3%) patients in these groups, respectively, completed the planned observation time. Over the whole trial, in the nintedanib and placebo groups, respectively, 9.8% and 12.5% of patients died, 12.2% and 20.5% of patients had ≥1 acute exacerbation of ILD or died, and 40.2% and 53.4% of patients had disease progression or died (Table). Diarrhoea was the most common adverse event, with incidence rates of 139.2 and 26.3 events per 100 patient–years in the nintedanib and placebo groups, respectively. Adverse events led to treatment discontinuation in 20.7% of patients in the nintedanib group and 13.6% of patients in the placebo group.Conclusion:Data from the INBUILD trial suggest that nintedanib has a clinically meaningful effect on slowing the progression of ILD in patients with progressive fibrosing autoimmune disease-related ILDs, with adverse events that can be tolerated by most patients.Table.Nintedanib (n=82)Placebo (n=88)HR (95% CI)*Death8 (9.8)11 (12.5)0.80 (0.32, 1.98)≥1 acute exacerbation of ILD or death10 (12.2)18 (20.5)0.58 (0.27, 1.27)Disease progression (absolute decline in FVC ≥10% predicted) or death33 (40.2)47 (53.4)0.72 (0.46, 1.13)n (%) with event over the whole trial (mean [SD] exposure: 15.4 [7.4] and 16.9 [6.1] months in nintedanib and placebo groups, respectively). *Based on time to first event.Disclosure of Interests:Eric Matteson Grant/research support from: Pfizer, Consultant of: Boehringer Ingelheim, Gilead, TympoBio, Arena Pharmaceuticals, Speakers bureau: Simply Speaking, Clive Kelly Consultant of: Boehringer Ingelheim, Speakers bureau: Boehringer Ingelheim, Jörg Distler Grant/research support from: Boehringer Ingelheim, Consultant of: Boehringer Ingelheim, Paid instructor for: Boehringer Ingelheim, Speakers bureau: Boehringer Ingelheim, Anna-Maria Hoffmann-Vold Grant/research support from: Boehringer Ingelheim, Consultant of: Boehringer Ingelheim, Actelion, Bayer, GlaxoSmithKline, Speakers bureau: Boehringer Ingelheim, Actelion, Roche, James Seibold Shareholder of: BriaCell, Pacific Therapeutics, Consultant of: Atlantic, Blade Therapeutics, Eicos Sciences, Eiger Biopharmaceuticals, Indalo Therapeutics, Mitsubishi Tanabe Pharma, Bayer, Xenikos, Boehringer Ingelheim, Camurus, Corbus Pharmaceuticals, EMD Serono, Speakers bureau: Boehringer Ingelheim, Shikha Mittoo Grant/research support from: Pfizer, Consultant of: Novartis, Abbvie, Pfizer, Oliver Distler Grant/research support from: Grants/Research support from Actelion, Bayer, Boehringer Ingelheim, Competitive Drug Development International Ltd. and Mitsubishi Tanabe; he also holds the issued Patent on mir-29 for the treatment of systemic sclerosis (US8247389, EP2331143)., Consultant of: Consultancy fees from Actelion, Acceleron Pharma, AnaMar, Bayer, Baecon Discovery, Blade Therapeutics, Boehringer, CSL Behring, Catenion, ChemomAb, Curzion Pharmaceuticals, Ergonex, Galapagos NV, GSK, Glenmark Pharmaceuticals, Inventiva, Italfarmaco, iQvia, medac, Medscape, Mitsubishi Tanabe Pharma, MSD, Roche, Sanofi and UCB, Speakers bureau: Speaker fees from Actelion, Bayer, Boehringer Ingelheim, Medscape, Pfizer and Roche, Paul F. Dellaripa Grant/research support from: Paul Dellaripa has received institutional grants from Genentech, Consultant of: Paul Dellaripa participated in advisory boards for Boehringer Ingelheim, Alexandra James Employee of: Employee of Boehringer Ingelheim, Rozsa Schlenker-Herceg Employee of: Employee of Boehringer Ingelheim, Susanne Stowasser Employee of: Employee of Boehringer Ingelheim, Manuel Quaresma Employee of: Employee of Boehringer Ingelheim, Kevin R. Flaherty Grant/research support from: Kevin Flaherty has received grants from Boehringer Ingelheim, Consultant of: Kevin Flaherty has acted as a consultant for Boehringer Ingelheim, Bellerophon, Blade Therapeutics, Roche/Genentech, and VeracyteHe was a member of the INBUILD trial Steering Committee
Collapse
|
20
|
Riemekasten G, Carreira P, Saketkoo LA, Aringer M, Chung L, Pope J, Miede C, Stowasser S, Gahlemann M, Alves M, Khanna D. THU0363 EFFECTS OF NINTEDANIB IN PATIENTS WITH SYSTEMIC SCLEROSIS-ASSOCIATED ILD (SSC-ILD) AND NORMAL VERSUS ELEVATED C-REACTIVE PROTEIN (CRP) AT BASELINE: ANALYSES FROM THE SENSCIS TRIAL. Ann Rheum Dis 2020. [DOI: 10.1136/annrheumdis-2020-eular.3711] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background:In the SENSCIS trial in patients with SSc-ILD, nintedanib reduced the rate of decline in forced vital capacity (FVC) over 52 weeks. Elevated CRP is a marker of an inflammatory phenotype and has been associated with a greater rate of decline in FVC and higher mortality in patients with SSc.Objectives:To assess the effects of nintedanib in subgroups by CRP at baseline in the SENSCIS trial.Methods:Patients with SSc-ILD with onset of first non-Raynaud symptom <7 years and ≥10% fibrosis of the lungs on HRCT were randomised to receive nintedanib or placebo. We analysed the rate of decline in FVC (mL/year) over 52 weeks, the proportion of patients with an absolute increase in FVC ≥3% predicted (proposed as the minimal clinically important difference for improvement in FVC in patients with SSc-ILD), and absolute change from baseline in mRSS at week 52 in subgroups with normal vs elevated high-sensitivity CRP (≤4.99 vs >4.99 mg/L) at baseline.Results:Of patients with available data, 78/270 (28.9%) and 74/261 (28.4%) in the nintedanib and placebo groups, respectively, had CRP >4.99 mg/L at baseline. Compared with patients with lower CRP, those with CRP >4.99 mg/L included a similar proportion of patients who were ATA-positive (61.8% vs 60.2%, respectively), a greater proportion with diffuse cutaneous SSc (63.2% vs 49.3%) and had a higher mean mRSS (13.7 vs 10.2) and lower mean FVC % predicted (68.6% vs 73.9%). The adjusted annual rate of decline in FVC in the placebo group was numerically greater in patients with CRP >4.99 than ≤4.99 mg/L at baseline (-106.6 [SE 27.6] vs -83.0 [17.1] mL/year). The effect of nintedanib vs placebo on reducing the rate of decline in FVC was numerically more pronounced in patients with CRP >4.99 than ≤4.99 mg/L at baseline but the treatment-by-time-by-subgroup interaction p-value did not indicate heterogeneity in the effect of nintedanib between subgroups (p=0.70) (Figure). In the nintedanib and placebo groups, respectively, the proportions of patients with an absolute increase in FVC ≥3% predicted at week 52 were 20.4% and 15.0% in those with CRP ≤4.99 mg/L and 24.4% and 14.9% in those with CRP >4.99 mg/L at baseline (treatment-by-subgroup interaction p=0.59); adjusted mean changes in mRSS at week 52 were -2.2 (SE 0.3) and -2.1 (0.3) in those with CRP ≤4.99 mg/L (difference -0.1 [95% CI -1.0, 0.8]) and -2.3 (0.5) and -1.0 (0.5) in those with CRP >4.99 mg/L at baseline (difference -1.2 [-2.7, 0.2]; treatment-by-visit-by-subgroup interaction p=0.20).Conclusion:In the SENSCIS trial, the rate of decline in FVC over 52 weeks in the placebo group was numerically greater in patients with elevated CRP at baseline. Nintedanib reduced the rate of decline in FVC both in patients with normal and elevated CRP at baseline, with a numerically greater effect in patients with elevated CRP.Disclosure of Interests:Gabriela Riemekasten Consultant of: Cell Trend GmbH, Janssen, Actelion, Boehringer Ingelheim, Speakers bureau: Actelion, Novartis, Janssen, Roche, GlaxoSmithKline, Boehringer Ingelheim, Pfizer, Patricia Carreira Grant/research support from: Actelion, Roche, MSD, Consultant of: GlaxoSmithKline, VivaCell Biotechnology, Emerald Health Pharmaceuticals, Boehringer Ingelheim, Roche, Speakers bureau: Actelion, GlaxoSmithKline, Roche, Lesley Ann Saketkoo Grant/research support from: Corbus Pharmaceuticals, United Therapeutics, Consultant of: Boehringer Ingelheim, Eicos Sciences, Speakers bureau: Boehringer Ingelheim, Martin Aringer Consultant of: Boehringer Ingelheim, Roche, Speakers bureau: Boehringer Ingelheim, Roche, Lorinda Chung Grant/research support from: United Therapeutics, Boehringer Ingelheim, Consultant of: Bristol-Myers Squibb, Boehringer Ingelheim, Mitsubishi Tanabe, Eicos Sciences, Janet Pope Grant/research support from: AbbVie, Bristol-Myers Squibb, Eli Lilly & Company, Merck, Roche, Seattle Genetics, UCB, Consultant of: AbbVie, Actelion, Amgen, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Eicos Sciences, Eli Lilly & Company, Emerald, Gilead Sciences, Inc., Janssen, Merck, Novartis, Pfizer, Roche, Sandoz, Sanofi, UCB, Speakers bureau: UCB, Corinna Miede Employee of: Employee of Boehringer Ingelheim, Susanne Stowasser Employee of: Employee of Boehringer Ingelheim, Martina Gahlemann Employee of: Employee of Boehringer Ingelheim, Margarida Alves Employee of: Employee of Boehringer Ingelheim, Dinesh Khanna Shareholder of: Eicos Sciences, Inc./Civi Biopharma, Inc., Grant/research support from: Dr Khanna was supported by NIH/NIAMS K24AR063120, Consultant of: Acceleron, Actelion, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Corbus Pharmaceuticals, Horizon Therapeutic, Galapagos, Roche/Genentech, GlaxoSmithKline, Mitsubishi Tanabe, Sanofi-Aventis/Genzyme, UCB
Collapse
|
21
|
Behr J, Kolb M, Song JW, Luppi F, Schinzel B, Stowasser S, Quaresma M, Martinez FJ. Nintedanib and Sildenafil in Patients with Idiopathic Pulmonary Fibrosis and Right Heart Dysfunction. A Prespecified Subgroup Analysis of a Double-Blind Randomized Clinical Trial (INSTAGE). Am J Respir Crit Care Med 2020; 200:1505-1512. [PMID: 31365829 PMCID: PMC6958532 DOI: 10.1164/rccm.201903-0488oc] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Rationale: In the INSTAGE trial in patients with idiopathic pulmonary fibrosis (IPF) and severely impaired gas exchange, nintedanib plus sildenafil was associated with numerical benefits on St. George's Respiratory Questionnaire (SGRQ) total score, brain natriuretic peptide (BNP), and FVC decline versus nintedanib alone. Exploratory analyses of the STEP-IPF (Sildenafil Trial of Exercise Performance in IPF) trial suggested that sildenafil may have a greater effect on SGRQ score in patients with IPF who have right heart dysfunction (RHD).Objectives: Assess whether RHD influenced the effects of nintedanib plus sildenafil versus nintedanib alone in the INSTAGE trial.Methods: Subgroup analyses of patients with (n = 117) versus those without (n = 156) echocardiographic signs of RHD at baseline.Measurements and Main Results: There was no heterogeneity between subgroups by presence of RHD in the effect of nintedanib plus sildenafil versus nintedanib alone on change in SGRQ total score at Week 12 (P = 0.74) or Week 24 (P = 0.90), or change in FVC at Week 12 (P = 0.58) or Week 24 (P = 0.55). In both subgroups, nintedanib plus sildenafil had a numerically greater effect on reducing FVC decline versus nintedanib alone. Between-group differences in change in BNP at Week 24 were -119.9 ng/L (95% confidence interval = -171.3 to -68.5) and -3.6 ng/L (95% confidence interval = -47.2 to 40.0) in patients with and without signs of RHD at baseline, respectively (P < 0.01).Conclusions: In the INSTAGE trial, there were no significant differences in the effects of nintedanib plus sildenafil versus nintedanib alone on changes in SGRQ and FVC between patients with or without echocardiographic signs of RHD at baseline. The benefit of combination therapy on stabilizing BNP was more pronounced in patients with RHD at baseline.Clinical trial registered with www.clinicaltrials.gov (NCT02802345).
Collapse
Affiliation(s)
- Jürgen Behr
- Department of Internal Medicine V, University of Munich, LMU, and Asklepios Chest Clinic Gauting, Memeber of the German Center for Lung Research, Germany
| | - Martin Kolb
- McMaster University and St. Joseph's Healthcare, Hamilton, Ontario, Canada
| | - Jin Woo Song
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Fabrizio Luppi
- University of Milan Bicocca, San Gerardo Hospital, Azienda Socio Sanitaria Territoriale Monza, Monza, Italy
| | - Birgit Schinzel
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany; and
| | - Susanne Stowasser
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany; and
| | - Manuel Quaresma
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany; and
| | | |
Collapse
|
22
|
Wells AU, Flaherty KR, Brown KK, Inoue Y, Devaraj A, Richeldi L, Moua T, Crestani B, Wuyts WA, Stowasser S, Quaresma M, Goeldner RG, Schlenker-Herceg R, Kolb M, Aburto M, Acosta O, Andrews C, Antin-Ozerkis D, Arce G, Arias M, Avdeev S, Barczyk A, Bascom R, Bazdyrev E, Beirne P, Belloli E, Bergna M, Bergot E, Bhatt N, Blaas S, Bondue B, Bonella F, Britt E, Buch K, Burk J, Cai H, Cantin A, Castillo Villegas D, Cazaux A, Cerri S, Chaaban S, Chaudhuri N, Cottin V, Crestani B, Criner G, Dahlqvist C, Danoff S, Dematte D'Amico J, Dilling D, Elias P, Ettinger N, Falk J, Fernández Pérez E, Gamez-Dubuis A, Giessel G, Gifford A, Glassberg M, Glazer C, Golden J, Gómez Carrera L, Guiot J, Hallowell R, Hayashi H, Hetzel J, Hirani N, Homik L, Hope-Gill B, Hotchkin D, Ichikado K, Ilkovich M, Inoue Y, Izumi S, Jassem E, Jones L, Jouneau S, Kaner R, Kang J, Kawamura T, Kessler R, Kim Y, Kishi K, Kitamura H, Kolb M, Kondoh Y, Kono C, Koschel D, Kreuter M, Kulkarni T, Kus J, Lebargy F, León Jiménez A, Luo Q, Mageto Y, Maher T, Makino S, Marchand-Adam S, Marquette C, Martinez R, Martínez M, Maturana Rozas R, Miyazaki Y, Moiseev S, Molina-Molina M, Morrison L, Morrow L, Moua T, Nambiar A, Nishioka Y, Nunes H, Okamoto M, Oldham J, Otaola M, Padilla M, Park J, Patel N, Pesci A, Piotrowski W, Pitts L, Poonyagariyagorn H, Prasse A, Quadrelli S, Randerath W, Refini R, Reynaud-Gaubert M, Riviere F, Rodríguez Portal J, Rosas I, Rossman M, Safdar Z, Saito T, Sakamoto N, Salinas Fénero M, Sauleda J, Schmidt S, Scholand M, Schwartz M, Shapera S, Shlobin O, Sigal B, Silva Orellana A, Skowasch D, Song J, Stieglitz S, Stone H, Strek M, Suda T, Sugiura H, Takahashi H, Takaya H, Takeuchi T, Thavarajah K, Tolle L, Tomassetti S, Tomii K, Valenzuela C, Vancheri C, Varone F, Veeraraghavan S, Villar A, Weigt S, Wemeau L, Wuyts W, Xu Z, Yakusevich V, Yamada Y, Yamauchi H, Ziora D. Nintedanib in patients with progressive fibrosing interstitial lung diseases-subgroup analyses by interstitial lung disease diagnosis in the INBUILD trial: a randomised, double-blind, placebo-controlled, parallel-group trial. Lancet Respir Med 2020; 8:453-460. [PMID: 32145830 DOI: 10.1016/s2213-2600(20)30036-9] [Citation(s) in RCA: 263] [Impact Index Per Article: 65.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 01/06/2020] [Accepted: 01/16/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND The INBUILD trial investigated the efficacy and safety of nintedanib versus placebo in patients with progressive fibrosing interstitial lung diseases (ILDs) other than idiopathic pulmonary fibrosis (IPF). We aimed to establish the effects of nintedanib in subgroups based on ILD diagnosis. METHODS The INBUILD trial was a randomised, double-blind, placebo-controlled, parallel group trial done at 153 sites in 15 countries. Participants had an investigator-diagnosed fibrosing ILD other than IPF, with chest imaging features of fibrosis of more than 10% extent on high resolution CT (HRCT), forced vital capacity (FVC) of 45% or more predicted, and diffusing capacity of the lung for carbon monoxide (DLco) of at least 30% and less than 80% predicted. Participants fulfilled protocol-defined criteria for ILD progression in the 24 months before screening, despite management considered appropriate in clinical practice for the individual ILD. Participants were randomly assigned 1:1 by means of a pseudo-random number generator to receive nintedanib 150 mg twice daily or placebo for at least 52 weeks. Participants, investigators, and other personnel involved in the trial and analysis were masked to treatment assignment until after database lock. In this subgroup analysis, we assessed the rate of decline in FVC (mL/year) over 52 weeks in patients who received at least one dose of nintedanib or placebo in five prespecified subgroups based on the ILD diagnoses documented by the investigators: hypersensitivity pneumonitis, autoimmune ILDs, idiopathic non-specific interstitial pneumonia, unclassifiable idiopathic interstitial pneumonia, and other ILDs. The trial has been completed and is registered with ClinicalTrials.gov, number NCT02999178. FINDINGS Participants were recruited between Feb 23, 2017, and April 27, 2018. Of 663 participants who received at least one dose of nintedanib or placebo, 173 (26%) had chronic hypersensitivity pneumonitis, 170 (26%) an autoimmune ILD, 125 (19%) idiopathic non-specific interstitial pneumonia, 114 (17%) unclassifiable idiopathic interstitial pneumonia, and 81 (12%) other ILDs. The effect of nintedanib versus placebo on reducing the rate of FVC decline (mL/year) was consistent across the five subgroups by ILD diagnosis in the overall population (hypersensitivity pneumonitis 73·1 [95% CI -8·6 to 154·8]; autoimmune ILDs 104·0 [21·1 to 186·9]; idiopathic non-specific interstitial pneumonia 141·6 [46·0 to 237·2]; unclassifiable idiopathic interstitial pneumonia 68·3 [-31·4 to 168·1]; and other ILDs 197·1 [77·6 to 316·7]; p=0·41 for treatment by subgroup by time interaction). Adverse events reported in the subgroups were consistent with those reported in the overall population. INTERPRETATION The INBUILD trial was not designed or powered to provide evidence for a benefit of nintedanib in specific diagnostic subgroups. However, its results suggest that nintedanib reduces the rate of ILD progression, as measured by FVC decline, in patients who have a chronic fibrosing ILD and progressive phenotype, irrespective of the underlying ILD diagnosis. FUNDING Boehringer Ingelheim.
Collapse
Affiliation(s)
- Athol U Wells
- National Institute for Health Research Respiratory Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Kevin R Flaherty
- Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Kevin K Brown
- Department of Medicine, National Jewish Health, Denver, CO, USA
| | - Yoshikazu Inoue
- Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, Sakai City, Osaka, Japan
| | - Anand Devaraj
- Department of Radiology, Royal Brompton and Harefield NHS Foundation Trust, London, UK; National Heart and Lung Institute, Imperial College, London, UK
| | - Luca Richeldi
- Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Teng Moua
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic Rochester, Rochester, MN, USA
| | - Bruno Crestani
- Université de Paris, Inserm U1152, APHP, Hôpital Bichat, Centre de reference constitutif pour les maladies pulmonaires rares, Paris, France
| | - Wim A Wuyts
- Unit for Interstitial Lung Diseases, Department of Pulmonary Medicine, University Hospitals Leuven, Leuven, Belgium
| | | | - Manuel Quaresma
- Boehringer Ingelheim International, Ingelheim am Rhein, Germany
| | | | | | - Martin Kolb
- McMaster University and St Joseph's Healthcare, Hamilton, Ontario, Canada
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
23
|
Kreuter M, Wuyts WA, Wijsenbeek M, Bajwah S, Maher TM, Stowasser S, Male N, Stansen W, Schoof N, Orsatti L, Swigris J. Health-related quality of life and symptoms in patients with IPF treated with nintedanib: analyses of patient-reported outcomes from the INPULSIS® trials. Respir Res 2020; 21:36. [PMID: 32000772 PMCID: PMC6990488 DOI: 10.1186/s12931-020-1298-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 01/16/2020] [Indexed: 02/07/2023] Open
Abstract
Background In the Phase III INPULSIS® trials, treatment of patients with idiopathic pulmonary fibrosis (IPF) with nintedanib significantly reduced the annual rate of decline in forced vital capacity (FVC) versus placebo, consistent with slowing disease progression. However, nintedanib was not associated with a benefit in health-related quality of life (HRQoL) assessed using the St George’s respiratory questionnaire (SGRQ). We aimed to further examine the impact of IPF progression on HRQoL and symptoms, and to explore the effect of nintedanib on HRQoL in patients from the INPULSIS® trials stratified by clinical factors associated with disease progression. Methods Patient-reported outcome (PRO) data from the INPULSIS® trials were included in three post hoc analyses. Two analyses used the pooled data set to examine PRO changes from baseline to week 52 according to 1) decline in FVC and 2) occurrence of acute exacerbations. In the third analysis, patients were stratified based on clinical indicators of disease progression (gender, age and physiology [GAP] stage; FVC % predicted; diffusing capacity of the lung for carbon monoxide [DLCO] % predicted; composite physiologic index [CPI]; and SGRQ total score) at baseline; median change from baseline was measured at 52 weeks and treatment groups were compared using the Wilcoxon two-sample test. Results Data from 1061 patients (638 nintedanib, 423 placebo) were analyzed. Greater categorical decline from baseline in FVC % predicted over 52 weeks was associated with significant worsening of HRQoL and symptoms across all PRO measures. Acute exacerbations were associated with deterioration in HRQoL and worsened symptoms. In general, patients with advanced disease at baseline (defined as GAP II/III, FVC ≤ 80%, DLCO ≤ 40%, CPI > 45, or SGRQ > 40) experienced greater deterioration in PROs than patients with less-advanced disease. Among patients with advanced disease, compared with placebo, nintedanib slowed deterioration in several PROs; benefit was most apparent on the SGRQ (total and activity scores). Conclusions In patients with advanced IPF, compared with placebo, nintedanib slowed deterioration in HRQoL and symptoms as assessed by several PROs. HRQoL measures have a higher responsiveness to change in advanced disease and may lack sensitivity to capture change in patients with less-advanced IPF.
Collapse
Affiliation(s)
- Michael Kreuter
- Center for Interstitial and Rare Lung Diseases, Pneumology, Thoraxklinik, Heidelberg University Hospital, Röntgenstraße 1, 69126, Heidelberg, Germany. .,German Center for Lung Research, Gießen, Germany.
| | - Wim A Wuyts
- Unit for Interstitial Lung Diseases, Department of Pulmonary Medicine, University Hospitals Leuven, Leuven, Belgium
| | | | | | - Toby M Maher
- National Heart and Lung Institute, Imperial College, London, UK.,Interstitial Lung Disease Unit, Royal Brompton Hospital, London, UK
| | - Susanne Stowasser
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Natalia Male
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Wibke Stansen
- Boehringer Ingelheim GmbH & Co KG, Ingelheim am Rhein, Germany
| | - Nils Schoof
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Leticia Orsatti
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | | |
Collapse
|
24
|
Tang F, Weber B, Stowasser S, Korell J. Parametric Time-to-Event Model for Acute Exacerbations in Idiopathic Pulmonary Fibrosis. CPT Pharmacometrics Syst Pharmacol 2020; 9:87-95. [PMID: 31919989 PMCID: PMC7020291 DOI: 10.1002/psp4.12485] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 11/11/2019] [Indexed: 12/31/2022]
Abstract
We describe a parametric time‐to‐event model for idiopathic pulmonary fibrosis (IPF) exacerbations and identify predictors of exacerbation risk using data obtained for the tyrosine‐kinase inhibitor nintedanib in two phase III studies (INPULSIS‐1/2). Parametric survival analysis was performed on time to first exacerbation (censoring on day 372), with univariate analysis to select statistically significant covariates (P = 0.05). Multivariate covariate models were developed using stepwise covariate modeling with forward inclusion (P = 0.05) and backward elimination (P = 0.01). Sixty‐three first exacerbation events were reported across 1,061 subjects in the INPULSIS studies. Baseline and decline of forced vital capacity (FVC)/percent‐predicted FVC (%pFVC), supplemental oxygen use, baseline CO diffusing capacity and age were statistically significant in the univariate analysis. The final covariate model included decline in FVC to week 52, baseline %pFVC, supplemental oxygen use, and age. The developed model may be used to identify patients at high risk of IPF exacerbations and accelerate development of novel treatments.
Collapse
Affiliation(s)
- Fei Tang
- Translational Medicine and Clinical Pharmacology, Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, Connecticut, USA.,Department of Pharmaceutical Sciences, College of Pharmacy, University of Kentucky, Lexington, Kentucky, USA
| | - Benjamin Weber
- Translational Medicine and Clinical Pharmacology, Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, Connecticut, USA
| | - Susanne Stowasser
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Julia Korell
- Translational Medicine and Clinical Pharmacology, Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, Connecticut, USA
| |
Collapse
|
25
|
Richeldi L, Kolb M, Jouneau S, Wuyts WA, Schinzel B, Stowasser S, Quaresma M, Raghu G. Efficacy and safety of nintedanib in patients with advanced idiopathic pulmonary fibrosis. BMC Pulm Med 2020; 20:3. [PMID: 31914963 PMCID: PMC6951000 DOI: 10.1186/s12890-019-1030-4] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 12/12/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The two 52-week INPULSIS trials investigated nintedanib versus placebo in patients with IPF, FVC ≥50% predicted and DLco 30-79% predicted. The 24-week INSTAGE trial investigated nintedanib plus sildenafil versus nintedanib alone in patients with IPF and DLco ≤35% predicted. We used data from INPULSIS and INSTAGE to compare the effects of nintedanib in patients with IPF with less versus more severe impairment in gas exchange at baseline. METHODS Analyses were conducted in patients treated with nintedanib alone in the INPULSIS and INSTAGE trials and in patients treated with placebo in the INPULSIS trials. Outcomes included the rate of decline in FVC over 24 weeks, the proportions of patients who had a confirmed or suspected idiopathic acute exacerbation over 24 weeks, deaths over 24 weeks, and adverse events. Analyses were descriptive. RESULTS In total, 638 and 136 patients received nintedanib alone in the INPULSIS and INSTAGE trials, respectively, and 423 patients received placebo in the INPULSIS trials. Rates of FVC decline were - 52.3 and - 66.7 mL/24 weeks in patients treated with nintedanib alone in INPULSIS and INSTAGE, respectively, and - 102.8 mL/24 weeks in patients treated with placebo in INPULSIS. Confirmed or suspected idiopathic acute exacerbations were reported in 0.6 and 3.7% of patients treated with nintedanib alone in INPULSIS and INSTAGE, respectively, and 2.1% of patients treated with placebo in INPULSIS. Deaths occurred in 2.0, 11.0 and 1.9% of patients in these groups, respectively. Diarrhoea adverse events were reported in 52.5 and 48.5% of patients treated with nintedanib alone in INPULSIS and INSTAGE, respectively, and 16.1% of patients treated with placebo in INPULSIS. CONCLUSIONS Based on data from the INSTAGE and INPULSIS trials, nintedanib had a similar effect on FVC decline over 24 weeks, and a similar safety and tolerability profile, in patients with IPF and more versus less severe impairment in gas exchange. These data support the use of nintedanib in patients with IPF who have advanced disease. TRIAL REGISTRATION INPULSIS (NCT01335464 and NCT01335477); INSTAGE (NCT02802345).
Collapse
Affiliation(s)
- Luca Richeldi
- Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy.
| | - Martin Kolb
- McMaster University and St. Joseph's Healthcare, Hamilton, Ontario, Canada
| | - Stéphane Jouneau
- Hôpital Pontchaillou - CHU de Rennes, IRSET UMR 1085, Université de Rennes 1, Rennes, France
| | - Wim A Wuyts
- Unit for Interstitial Lung Diseases, Department of Respiratory Medicine, University Hospitals Leuven, Leuven, Belgium
| | | | | | | | | |
Collapse
|
26
|
Valenzuela C, Torrisi SE, Kahn N, Quaresma M, Stowasser S, Kreuter M. Ongoing challenges in pulmonary fibrosis and insights from the nintedanib clinical programme. Respir Res 2020; 21:7. [PMID: 31906942 PMCID: PMC6945404 DOI: 10.1186/s12931-019-1269-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 12/23/2019] [Indexed: 01/06/2023] Open
Abstract
The approvals of nintedanib and pirfenidone changed the treatment paradigm in idiopathic pulmonary fibrosis (IPF), and increased our understanding of the underlying disease mechanisms. Nonetheless, many challenges and unmet needs remain in the management of patients with IPF and other progressive fibrosing interstitial lung diseases.This review describes how the nintedanib clinical programme has helped to address some of these challenges. Data from this programme have informed changes to the IPF diagnostic guidelines, the timing of treatment initiation, and the assessment of disease progression. The use of nintedanib to treat patients with advanced lung function impairment, concomitant emphysema, patients awaiting lung transplantation and patients with IPF and lung cancer is discussed. The long-term use of nintedanib and an up-to-date summary of nintedanib in clinical practice are discussed. Directions for future research, namely emerging therapeutic options, precision medicine and other progressive fibrosing interstitial lung diseases, are described.Further developments in these areas should continue to improve patient outcomes.
Collapse
Affiliation(s)
- Claudia Valenzuela
- Hospital Universitario de La Princesa, Instituto de Investigación Princesa, Universidad Autónoma de Madrid, Madrid, Spain
| | - Sebastiano Emanuele Torrisi
- University Hospital Policlinico-Vittorio Emanuele, Catania, Italy
- Center for Interstitial and Rare Lung Diseases, Thoraxklinik, University of Heidelberg, Heidelberg, Germany
| | - Nicolas Kahn
- Center for Interstitial and Rare Lung Diseases, Thoraxklinik, University of Heidelberg, Heidelberg, Germany
- Translational Lung Research Center, Member of the German Center for Lung Research, Heidelberg, Germany
| | - Manuel Quaresma
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Susanne Stowasser
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Michael Kreuter
- Center for Interstitial and Rare Lung Diseases, Thoraxklinik, University of Heidelberg, Heidelberg, Germany.
- Translational Lung Research Center, Member of the German Center for Lung Research, Heidelberg, Germany.
| |
Collapse
|
27
|
Flaherty KR, Wells AU, Cottin V, Devaraj A, Walsh SLF, Inoue Y, Richeldi L, Kolb M, Tetzlaff K, Stowasser S, Coeck C, Clerisme-Beaty E, Rosenstock B, Quaresma M, Haeufel T, Goeldner RG, Schlenker-Herceg R, Brown KK. Nintedanib in Progressive Fibrosing Interstitial Lung Diseases. N Engl J Med 2019; 381:1718-1727. [PMID: 31566307 DOI: 10.1056/nejmoa1908681] [Citation(s) in RCA: 1087] [Impact Index Per Article: 217.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Preclinical data have suggested that nintedanib, an intracellular inhibitor of tyrosine kinases, inhibits processes involved in the progression of lung fibrosis. Although the efficacy of nintedanib has been shown in idiopathic pulmonary fibrosis, its efficacy across a broad range of fibrosing lung diseases is unknown. METHODS In this double-blind, placebo-controlled, phase 3 trial conducted in 15 countries, we randomly assigned patients with fibrosing lung disease affecting more than 10% of lung volume on high-resolution computed tomography (CT) to receive nintedanib at a dose of 150 mg twice daily or placebo. All the patients met criteria for progression of interstitial lung disease in the past 24 months despite treatment and had a forced vital capacity (FVC) of at least 45% of the predicted value and a diffusing capacity of the lung for carbon monoxide ranging from 30 to less than 80% of the predicted value. Randomization was stratified according to the fibrotic pattern (a pattern of usual interstitial pneumonia [UIP] or other fibrotic patterns) on high-resolution CT. The primary end point was the annual rate of decline in the FVC, as assessed over a 52-week period. The two primary populations for analysis were the overall population and patients with a UIP-like fibrotic pattern. RESULTS A total of 663 patients were treated. In the overall population, the adjusted rate of decline in the FVC was -80.8 ml per year with nintedanib and -187.8 ml per year with placebo, for a between-group difference of 107.0 ml per year (95% confidence interval [CI], 65.4 to 148.5; P<0.001). In patients with a UIP-like fibrotic pattern, the adjusted rate of decline in the FVC was -82.9 ml per year with nintedanib and -211.1 ml per year with placebo, for a difference of 128.2 ml (95% CI, 70.8 to 185.6; P<0.001). Diarrhea was the most common adverse event, as reported in 66.9% and 23.9% of patients treated with nintedanib and placebo, respectively. Abnormalities on liver-function testing were more common in the nintedanib group than in the placebo group. CONCLUSIONS In patients with progressive fibrosing interstitial lung diseases, the annual rate of decline in the FVC was significantly lower among patients who received nintedanib than among those who received placebo. Diarrhea was a common adverse event. (Funded by Boehringer Ingelheim; INBUILD ClinicalTrials.gov number, NCT02999178.).
Collapse
Affiliation(s)
- Kevin R Flaherty
- From the Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor (K.R.F.); the National Institute for Health Research Respiratory Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust (A.U.W.), the National Heart and Lung Institute, Imperial College (A.U.W., A.D., S.L.F.W.), and the Department of Radiology, Royal Brompton and Harefield NHS Foundation Trust (A.D.) - all in London; the National Reference Center for Rare Pulmonary Diseases, Louis Pradel Hospital, Hospices Civils de Lyon, Claude Bernard University Lyon 1, Unité Mixte de Recherche 754, Lyon, France (V.C.); the Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, Sakai City, Japan (Y.I.); Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome (L.R.); McMaster University and St. Joseph's Healthcare, Hamilton, ON, Canada (M.K.); Boehringer Ingelheim International, Ingelheim am Rhein (K.T., S.S., E.C.-B., M.Q., T.H.), the Department of Sports Medicine, University of Tübingen, Tübingen (K.T.), and Boehringer Ingelheim Pharma, Biberach (B.R., R.-G.G.) - all in Germany; Boehringer Ingelheim, Brussels (C.C.); Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT (R.S.-H.); and the Department of Medicine, National Jewish Health, Denver (K.K.B.)
| | - Athol U Wells
- From the Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor (K.R.F.); the National Institute for Health Research Respiratory Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust (A.U.W.), the National Heart and Lung Institute, Imperial College (A.U.W., A.D., S.L.F.W.), and the Department of Radiology, Royal Brompton and Harefield NHS Foundation Trust (A.D.) - all in London; the National Reference Center for Rare Pulmonary Diseases, Louis Pradel Hospital, Hospices Civils de Lyon, Claude Bernard University Lyon 1, Unité Mixte de Recherche 754, Lyon, France (V.C.); the Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, Sakai City, Japan (Y.I.); Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome (L.R.); McMaster University and St. Joseph's Healthcare, Hamilton, ON, Canada (M.K.); Boehringer Ingelheim International, Ingelheim am Rhein (K.T., S.S., E.C.-B., M.Q., T.H.), the Department of Sports Medicine, University of Tübingen, Tübingen (K.T.), and Boehringer Ingelheim Pharma, Biberach (B.R., R.-G.G.) - all in Germany; Boehringer Ingelheim, Brussels (C.C.); Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT (R.S.-H.); and the Department of Medicine, National Jewish Health, Denver (K.K.B.)
| | - Vincent Cottin
- From the Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor (K.R.F.); the National Institute for Health Research Respiratory Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust (A.U.W.), the National Heart and Lung Institute, Imperial College (A.U.W., A.D., S.L.F.W.), and the Department of Radiology, Royal Brompton and Harefield NHS Foundation Trust (A.D.) - all in London; the National Reference Center for Rare Pulmonary Diseases, Louis Pradel Hospital, Hospices Civils de Lyon, Claude Bernard University Lyon 1, Unité Mixte de Recherche 754, Lyon, France (V.C.); the Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, Sakai City, Japan (Y.I.); Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome (L.R.); McMaster University and St. Joseph's Healthcare, Hamilton, ON, Canada (M.K.); Boehringer Ingelheim International, Ingelheim am Rhein (K.T., S.S., E.C.-B., M.Q., T.H.), the Department of Sports Medicine, University of Tübingen, Tübingen (K.T.), and Boehringer Ingelheim Pharma, Biberach (B.R., R.-G.G.) - all in Germany; Boehringer Ingelheim, Brussels (C.C.); Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT (R.S.-H.); and the Department of Medicine, National Jewish Health, Denver (K.K.B.)
| | - Anand Devaraj
- From the Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor (K.R.F.); the National Institute for Health Research Respiratory Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust (A.U.W.), the National Heart and Lung Institute, Imperial College (A.U.W., A.D., S.L.F.W.), and the Department of Radiology, Royal Brompton and Harefield NHS Foundation Trust (A.D.) - all in London; the National Reference Center for Rare Pulmonary Diseases, Louis Pradel Hospital, Hospices Civils de Lyon, Claude Bernard University Lyon 1, Unité Mixte de Recherche 754, Lyon, France (V.C.); the Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, Sakai City, Japan (Y.I.); Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome (L.R.); McMaster University and St. Joseph's Healthcare, Hamilton, ON, Canada (M.K.); Boehringer Ingelheim International, Ingelheim am Rhein (K.T., S.S., E.C.-B., M.Q., T.H.), the Department of Sports Medicine, University of Tübingen, Tübingen (K.T.), and Boehringer Ingelheim Pharma, Biberach (B.R., R.-G.G.) - all in Germany; Boehringer Ingelheim, Brussels (C.C.); Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT (R.S.-H.); and the Department of Medicine, National Jewish Health, Denver (K.K.B.)
| | - Simon L F Walsh
- From the Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor (K.R.F.); the National Institute for Health Research Respiratory Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust (A.U.W.), the National Heart and Lung Institute, Imperial College (A.U.W., A.D., S.L.F.W.), and the Department of Radiology, Royal Brompton and Harefield NHS Foundation Trust (A.D.) - all in London; the National Reference Center for Rare Pulmonary Diseases, Louis Pradel Hospital, Hospices Civils de Lyon, Claude Bernard University Lyon 1, Unité Mixte de Recherche 754, Lyon, France (V.C.); the Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, Sakai City, Japan (Y.I.); Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome (L.R.); McMaster University and St. Joseph's Healthcare, Hamilton, ON, Canada (M.K.); Boehringer Ingelheim International, Ingelheim am Rhein (K.T., S.S., E.C.-B., M.Q., T.H.), the Department of Sports Medicine, University of Tübingen, Tübingen (K.T.), and Boehringer Ingelheim Pharma, Biberach (B.R., R.-G.G.) - all in Germany; Boehringer Ingelheim, Brussels (C.C.); Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT (R.S.-H.); and the Department of Medicine, National Jewish Health, Denver (K.K.B.)
| | - Yoshikazu Inoue
- From the Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor (K.R.F.); the National Institute for Health Research Respiratory Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust (A.U.W.), the National Heart and Lung Institute, Imperial College (A.U.W., A.D., S.L.F.W.), and the Department of Radiology, Royal Brompton and Harefield NHS Foundation Trust (A.D.) - all in London; the National Reference Center for Rare Pulmonary Diseases, Louis Pradel Hospital, Hospices Civils de Lyon, Claude Bernard University Lyon 1, Unité Mixte de Recherche 754, Lyon, France (V.C.); the Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, Sakai City, Japan (Y.I.); Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome (L.R.); McMaster University and St. Joseph's Healthcare, Hamilton, ON, Canada (M.K.); Boehringer Ingelheim International, Ingelheim am Rhein (K.T., S.S., E.C.-B., M.Q., T.H.), the Department of Sports Medicine, University of Tübingen, Tübingen (K.T.), and Boehringer Ingelheim Pharma, Biberach (B.R., R.-G.G.) - all in Germany; Boehringer Ingelheim, Brussels (C.C.); Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT (R.S.-H.); and the Department of Medicine, National Jewish Health, Denver (K.K.B.)
| | - Luca Richeldi
- From the Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor (K.R.F.); the National Institute for Health Research Respiratory Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust (A.U.W.), the National Heart and Lung Institute, Imperial College (A.U.W., A.D., S.L.F.W.), and the Department of Radiology, Royal Brompton and Harefield NHS Foundation Trust (A.D.) - all in London; the National Reference Center for Rare Pulmonary Diseases, Louis Pradel Hospital, Hospices Civils de Lyon, Claude Bernard University Lyon 1, Unité Mixte de Recherche 754, Lyon, France (V.C.); the Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, Sakai City, Japan (Y.I.); Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome (L.R.); McMaster University and St. Joseph's Healthcare, Hamilton, ON, Canada (M.K.); Boehringer Ingelheim International, Ingelheim am Rhein (K.T., S.S., E.C.-B., M.Q., T.H.), the Department of Sports Medicine, University of Tübingen, Tübingen (K.T.), and Boehringer Ingelheim Pharma, Biberach (B.R., R.-G.G.) - all in Germany; Boehringer Ingelheim, Brussels (C.C.); Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT (R.S.-H.); and the Department of Medicine, National Jewish Health, Denver (K.K.B.)
| | - Martin Kolb
- From the Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor (K.R.F.); the National Institute for Health Research Respiratory Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust (A.U.W.), the National Heart and Lung Institute, Imperial College (A.U.W., A.D., S.L.F.W.), and the Department of Radiology, Royal Brompton and Harefield NHS Foundation Trust (A.D.) - all in London; the National Reference Center for Rare Pulmonary Diseases, Louis Pradel Hospital, Hospices Civils de Lyon, Claude Bernard University Lyon 1, Unité Mixte de Recherche 754, Lyon, France (V.C.); the Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, Sakai City, Japan (Y.I.); Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome (L.R.); McMaster University and St. Joseph's Healthcare, Hamilton, ON, Canada (M.K.); Boehringer Ingelheim International, Ingelheim am Rhein (K.T., S.S., E.C.-B., M.Q., T.H.), the Department of Sports Medicine, University of Tübingen, Tübingen (K.T.), and Boehringer Ingelheim Pharma, Biberach (B.R., R.-G.G.) - all in Germany; Boehringer Ingelheim, Brussels (C.C.); Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT (R.S.-H.); and the Department of Medicine, National Jewish Health, Denver (K.K.B.)
| | - Kay Tetzlaff
- From the Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor (K.R.F.); the National Institute for Health Research Respiratory Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust (A.U.W.), the National Heart and Lung Institute, Imperial College (A.U.W., A.D., S.L.F.W.), and the Department of Radiology, Royal Brompton and Harefield NHS Foundation Trust (A.D.) - all in London; the National Reference Center for Rare Pulmonary Diseases, Louis Pradel Hospital, Hospices Civils de Lyon, Claude Bernard University Lyon 1, Unité Mixte de Recherche 754, Lyon, France (V.C.); the Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, Sakai City, Japan (Y.I.); Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome (L.R.); McMaster University and St. Joseph's Healthcare, Hamilton, ON, Canada (M.K.); Boehringer Ingelheim International, Ingelheim am Rhein (K.T., S.S., E.C.-B., M.Q., T.H.), the Department of Sports Medicine, University of Tübingen, Tübingen (K.T.), and Boehringer Ingelheim Pharma, Biberach (B.R., R.-G.G.) - all in Germany; Boehringer Ingelheim, Brussels (C.C.); Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT (R.S.-H.); and the Department of Medicine, National Jewish Health, Denver (K.K.B.)
| | - Susanne Stowasser
- From the Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor (K.R.F.); the National Institute for Health Research Respiratory Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust (A.U.W.), the National Heart and Lung Institute, Imperial College (A.U.W., A.D., S.L.F.W.), and the Department of Radiology, Royal Brompton and Harefield NHS Foundation Trust (A.D.) - all in London; the National Reference Center for Rare Pulmonary Diseases, Louis Pradel Hospital, Hospices Civils de Lyon, Claude Bernard University Lyon 1, Unité Mixte de Recherche 754, Lyon, France (V.C.); the Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, Sakai City, Japan (Y.I.); Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome (L.R.); McMaster University and St. Joseph's Healthcare, Hamilton, ON, Canada (M.K.); Boehringer Ingelheim International, Ingelheim am Rhein (K.T., S.S., E.C.-B., M.Q., T.H.), the Department of Sports Medicine, University of Tübingen, Tübingen (K.T.), and Boehringer Ingelheim Pharma, Biberach (B.R., R.-G.G.) - all in Germany; Boehringer Ingelheim, Brussels (C.C.); Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT (R.S.-H.); and the Department of Medicine, National Jewish Health, Denver (K.K.B.)
| | - Carl Coeck
- From the Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor (K.R.F.); the National Institute for Health Research Respiratory Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust (A.U.W.), the National Heart and Lung Institute, Imperial College (A.U.W., A.D., S.L.F.W.), and the Department of Radiology, Royal Brompton and Harefield NHS Foundation Trust (A.D.) - all in London; the National Reference Center for Rare Pulmonary Diseases, Louis Pradel Hospital, Hospices Civils de Lyon, Claude Bernard University Lyon 1, Unité Mixte de Recherche 754, Lyon, France (V.C.); the Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, Sakai City, Japan (Y.I.); Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome (L.R.); McMaster University and St. Joseph's Healthcare, Hamilton, ON, Canada (M.K.); Boehringer Ingelheim International, Ingelheim am Rhein (K.T., S.S., E.C.-B., M.Q., T.H.), the Department of Sports Medicine, University of Tübingen, Tübingen (K.T.), and Boehringer Ingelheim Pharma, Biberach (B.R., R.-G.G.) - all in Germany; Boehringer Ingelheim, Brussels (C.C.); Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT (R.S.-H.); and the Department of Medicine, National Jewish Health, Denver (K.K.B.)
| | - Emmanuelle Clerisme-Beaty
- From the Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor (K.R.F.); the National Institute for Health Research Respiratory Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust (A.U.W.), the National Heart and Lung Institute, Imperial College (A.U.W., A.D., S.L.F.W.), and the Department of Radiology, Royal Brompton and Harefield NHS Foundation Trust (A.D.) - all in London; the National Reference Center for Rare Pulmonary Diseases, Louis Pradel Hospital, Hospices Civils de Lyon, Claude Bernard University Lyon 1, Unité Mixte de Recherche 754, Lyon, France (V.C.); the Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, Sakai City, Japan (Y.I.); Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome (L.R.); McMaster University and St. Joseph's Healthcare, Hamilton, ON, Canada (M.K.); Boehringer Ingelheim International, Ingelheim am Rhein (K.T., S.S., E.C.-B., M.Q., T.H.), the Department of Sports Medicine, University of Tübingen, Tübingen (K.T.), and Boehringer Ingelheim Pharma, Biberach (B.R., R.-G.G.) - all in Germany; Boehringer Ingelheim, Brussels (C.C.); Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT (R.S.-H.); and the Department of Medicine, National Jewish Health, Denver (K.K.B.)
| | - Bernd Rosenstock
- From the Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor (K.R.F.); the National Institute for Health Research Respiratory Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust (A.U.W.), the National Heart and Lung Institute, Imperial College (A.U.W., A.D., S.L.F.W.), and the Department of Radiology, Royal Brompton and Harefield NHS Foundation Trust (A.D.) - all in London; the National Reference Center for Rare Pulmonary Diseases, Louis Pradel Hospital, Hospices Civils de Lyon, Claude Bernard University Lyon 1, Unité Mixte de Recherche 754, Lyon, France (V.C.); the Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, Sakai City, Japan (Y.I.); Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome (L.R.); McMaster University and St. Joseph's Healthcare, Hamilton, ON, Canada (M.K.); Boehringer Ingelheim International, Ingelheim am Rhein (K.T., S.S., E.C.-B., M.Q., T.H.), the Department of Sports Medicine, University of Tübingen, Tübingen (K.T.), and Boehringer Ingelheim Pharma, Biberach (B.R., R.-G.G.) - all in Germany; Boehringer Ingelheim, Brussels (C.C.); Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT (R.S.-H.); and the Department of Medicine, National Jewish Health, Denver (K.K.B.)
| | - Manuel Quaresma
- From the Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor (K.R.F.); the National Institute for Health Research Respiratory Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust (A.U.W.), the National Heart and Lung Institute, Imperial College (A.U.W., A.D., S.L.F.W.), and the Department of Radiology, Royal Brompton and Harefield NHS Foundation Trust (A.D.) - all in London; the National Reference Center for Rare Pulmonary Diseases, Louis Pradel Hospital, Hospices Civils de Lyon, Claude Bernard University Lyon 1, Unité Mixte de Recherche 754, Lyon, France (V.C.); the Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, Sakai City, Japan (Y.I.); Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome (L.R.); McMaster University and St. Joseph's Healthcare, Hamilton, ON, Canada (M.K.); Boehringer Ingelheim International, Ingelheim am Rhein (K.T., S.S., E.C.-B., M.Q., T.H.), the Department of Sports Medicine, University of Tübingen, Tübingen (K.T.), and Boehringer Ingelheim Pharma, Biberach (B.R., R.-G.G.) - all in Germany; Boehringer Ingelheim, Brussels (C.C.); Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT (R.S.-H.); and the Department of Medicine, National Jewish Health, Denver (K.K.B.)
| | - Thomas Haeufel
- From the Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor (K.R.F.); the National Institute for Health Research Respiratory Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust (A.U.W.), the National Heart and Lung Institute, Imperial College (A.U.W., A.D., S.L.F.W.), and the Department of Radiology, Royal Brompton and Harefield NHS Foundation Trust (A.D.) - all in London; the National Reference Center for Rare Pulmonary Diseases, Louis Pradel Hospital, Hospices Civils de Lyon, Claude Bernard University Lyon 1, Unité Mixte de Recherche 754, Lyon, France (V.C.); the Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, Sakai City, Japan (Y.I.); Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome (L.R.); McMaster University and St. Joseph's Healthcare, Hamilton, ON, Canada (M.K.); Boehringer Ingelheim International, Ingelheim am Rhein (K.T., S.S., E.C.-B., M.Q., T.H.), the Department of Sports Medicine, University of Tübingen, Tübingen (K.T.), and Boehringer Ingelheim Pharma, Biberach (B.R., R.-G.G.) - all in Germany; Boehringer Ingelheim, Brussels (C.C.); Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT (R.S.-H.); and the Department of Medicine, National Jewish Health, Denver (K.K.B.)
| | - Rainer-Georg Goeldner
- From the Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor (K.R.F.); the National Institute for Health Research Respiratory Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust (A.U.W.), the National Heart and Lung Institute, Imperial College (A.U.W., A.D., S.L.F.W.), and the Department of Radiology, Royal Brompton and Harefield NHS Foundation Trust (A.D.) - all in London; the National Reference Center for Rare Pulmonary Diseases, Louis Pradel Hospital, Hospices Civils de Lyon, Claude Bernard University Lyon 1, Unité Mixte de Recherche 754, Lyon, France (V.C.); the Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, Sakai City, Japan (Y.I.); Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome (L.R.); McMaster University and St. Joseph's Healthcare, Hamilton, ON, Canada (M.K.); Boehringer Ingelheim International, Ingelheim am Rhein (K.T., S.S., E.C.-B., M.Q., T.H.), the Department of Sports Medicine, University of Tübingen, Tübingen (K.T.), and Boehringer Ingelheim Pharma, Biberach (B.R., R.-G.G.) - all in Germany; Boehringer Ingelheim, Brussels (C.C.); Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT (R.S.-H.); and the Department of Medicine, National Jewish Health, Denver (K.K.B.)
| | - Rozsa Schlenker-Herceg
- From the Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor (K.R.F.); the National Institute for Health Research Respiratory Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust (A.U.W.), the National Heart and Lung Institute, Imperial College (A.U.W., A.D., S.L.F.W.), and the Department of Radiology, Royal Brompton and Harefield NHS Foundation Trust (A.D.) - all in London; the National Reference Center for Rare Pulmonary Diseases, Louis Pradel Hospital, Hospices Civils de Lyon, Claude Bernard University Lyon 1, Unité Mixte de Recherche 754, Lyon, France (V.C.); the Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, Sakai City, Japan (Y.I.); Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome (L.R.); McMaster University and St. Joseph's Healthcare, Hamilton, ON, Canada (M.K.); Boehringer Ingelheim International, Ingelheim am Rhein (K.T., S.S., E.C.-B., M.Q., T.H.), the Department of Sports Medicine, University of Tübingen, Tübingen (K.T.), and Boehringer Ingelheim Pharma, Biberach (B.R., R.-G.G.) - all in Germany; Boehringer Ingelheim, Brussels (C.C.); Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT (R.S.-H.); and the Department of Medicine, National Jewish Health, Denver (K.K.B.)
| | - Kevin K Brown
- From the Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor (K.R.F.); the National Institute for Health Research Respiratory Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust (A.U.W.), the National Heart and Lung Institute, Imperial College (A.U.W., A.D., S.L.F.W.), and the Department of Radiology, Royal Brompton and Harefield NHS Foundation Trust (A.D.) - all in London; the National Reference Center for Rare Pulmonary Diseases, Louis Pradel Hospital, Hospices Civils de Lyon, Claude Bernard University Lyon 1, Unité Mixte de Recherche 754, Lyon, France (V.C.); the Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, Sakai City, Japan (Y.I.); Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome (L.R.); McMaster University and St. Joseph's Healthcare, Hamilton, ON, Canada (M.K.); Boehringer Ingelheim International, Ingelheim am Rhein (K.T., S.S., E.C.-B., M.Q., T.H.), the Department of Sports Medicine, University of Tübingen, Tübingen (K.T.), and Boehringer Ingelheim Pharma, Biberach (B.R., R.-G.G.) - all in Germany; Boehringer Ingelheim, Brussels (C.C.); Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT (R.S.-H.); and the Department of Medicine, National Jewish Health, Denver (K.K.B.)
| |
Collapse
|
28
|
Wollin L, Distler JHW, Redente EF, Riches DWH, Stowasser S, Schlenker-Herceg R, Maher TM, Kolb M. Potential of nintedanib in treatment of progressive fibrosing interstitial lung diseases. Eur Respir J 2019; 54:1900161. [PMID: 31285305 PMCID: PMC6751387 DOI: 10.1183/13993003.00161-2019] [Citation(s) in RCA: 145] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 06/20/2019] [Indexed: 12/19/2022]
Abstract
A proportion of patients with fibrosing interstitial lung diseases (ILDs) develop a progressive phenotype characterised by decline in lung function, worsening quality of life and early mortality. Other than idiopathic pulmonary fibrosis (IPF), there are no approved drugs for fibrosing ILDs and a poor evidence base to support current treatments. Fibrosing ILDs with a progressive phenotype show commonalities in clinical behaviour and in the pathogenic mechanisms that drive disease worsening. Nintedanib is an intracellular inhibitor of tyrosine kinases that has been approved for treatment of IPF and has recently been shown to reduce the rate of lung function decline in patients with ILD associated with systemic sclerosis (SSc-ILD). In vitro data demonstrate that nintedanib inhibits several steps in the initiation and progression of lung fibrosis, including the release of pro-inflammatory and pro-fibrotic mediators, migration and differentiation of fibrocytes and fibroblasts, and deposition of extracellular matrix. Nintedanib also inhibits the proliferation of vascular cells. Studies in animal models with features of fibrosing ILDs such as IPF, SSc-ILD, rheumatoid arthritis-ILD, hypersensitivity pneumonitis and silicosis demonstrate that nintedanib has anti-fibrotic activity irrespective of the trigger for the lung pathology. This suggests that nintedanib inhibits fundamental processes in the pathogenesis of fibrosis. A trial of nintedanib in patients with progressive fibrosing ILDs other than IPF (INBUILD) will report results in 2019.
Collapse
Affiliation(s)
- Lutz Wollin
- Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach, Germany
| | - Jörg H W Distler
- Dept of Internal Medicine 3 - Rheumatology and Immunology, Friedrich-Alexander University Erlangen-Nürnberg (FAU) and University Hospital Erlangen, Erlangen, Germany
| | - Elizabeth F Redente
- Program in Cell Biology, Dept of Pediatrics, National Jewish Health, Denver, CO, USA
| | - David W H Riches
- Program in Cell Biology, Dept of Pediatrics, National Jewish Health, Denver, CO, USA
- University of Colorado School of Medicine, Aurora, CO, USA
| | | | | | - Toby M Maher
- National Heart and Lung Institute, Imperial College London, London, UK
- National Institute for Health Research Clinical Research Facility, Royal Brompton Hospital, London, UK
| | - Martin Kolb
- Dept of Respiratory Medicine, Pathology and Molecular Medicine, McMaster University and St Joseph's Healthcare, Hamilton, ON, Canada
| |
Collapse
|
29
|
Richeldi L, Crestani B, Azuma A, Kolb M, Selman M, Stansen W, Quaresma M, Stowasser S, Cottin V. Outcomes following decline in forced vital capacity in patients with idiopathic pulmonary fibrosis: Results from the INPULSIS and INPULSIS-ON trials of nintedanib. Respir Med 2019; 156:20-25. [DOI: 10.1016/j.rmed.2019.08.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 07/12/2019] [Accepted: 08/05/2019] [Indexed: 10/26/2022]
|
30
|
Song JW, Ogura T, Inoue Y, Xu Z, Quaresma M, Stowasser S, Stansen W, Crestani B. Long-term treatment with nintedanib in Asian patients with idiopathic pulmonary fibrosis: Results from INPULSIS®-ON. Respirology 2019; 25:410-416. [PMID: 31329360 PMCID: PMC7154738 DOI: 10.1111/resp.13647] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 04/10/2019] [Accepted: 06/13/2019] [Indexed: 11/30/2022]
Abstract
Background and objective The efficacy and safety of nintedanib in patients with idiopathic pulmonary fibrosis (IPF) were investigated in the placebo‐controlled INPULSIS® trials. All patients who completed an INPULSIS® trial could receive open‐label nintedanib in the extension trial INPULSIS®‐ON. Methods We assessed the long‐term efficacy and safety of nintedanib in patients of Asian race who were treated in INPULSIS®‐ON. Analyses were descriptive. Results A total of 215 Asian patients were treated in INPULSIS®‐ON, of whom 121 continued nintedanib in INPULSIS®‐ON and 94 initiated nintedanib in INPULSIS®‐ON having received placebo in an INPULSIS® trial. At baseline of INPULSIS®‐ON, the mean (SD) age of Asian patients was 66.3 (7.5) years, 80.5% were males and mean (SD) forced vital capacity (FVC) was 78.9 (19.3) % predicted. Median total exposure to nintedanib in both INPULSIS® and INPULSIS®‐ON was 42.2 months; maximum exposure was 64.1 months. In INPULSIS®, the annual rate (SE) of decline in FVC over 52 weeks in Asian patients was −124 (20) mL/year in the nintedanib group and −218 (24) mL/year in the placebo group. In INPULSIS®‐ON, the annual rate (SE) of decline in FVC over 192 weeks in Asian patients was −127 (11) mL/year. Diarrhoea was reported in Asian patients at event rates of 58.8 and 82.5 events per 100 patient exposure–years in patients who continued and initiated nintedanib in INPULSIS®‐ON, respectively. Conclusion The effect of nintedanib on slowing disease progression in Asian patients with IPF is sustained over the long term. Long‐term treatment with nintedanib has an acceptable safety and tolerability profile. In a subgroup analysis of data from the open‐label extension of the INPULSIS® trials, INPULSIS®‐ON, the effect of nintedanib on slowing disease progression in Asian patients with idiopathic pulmonary fibrosis was sustained over the long term. Long‐term treatment with nintedanib had an acceptable safety and tolerability profile.
Collapse
Affiliation(s)
- Jin Woo Song
- Department of Pulmonary and Critical Care Medicine, ASAN Medical Centre, University of Ulsan College of Medicine, Seoul, South Korea
| | - Takashi Ogura
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Centre, Yokohama, Japan
| | - Yoshikazu Inoue
- Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Centre, Osaka, Japan
| | - Zuojun Xu
- Peking Union Medical College Hospital, Beijing, China
| | - Manuel Quaresma
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Susanne Stowasser
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Wibke Stansen
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim am Rhein, Germany
| | - Bruno Crestani
- Service de Pneumologie A, DHU FIRE, APHP, Hôpital Bichat, Paris, France.,INSERM, Université Paris Diderot, Paris, France
| |
Collapse
|
31
|
Maher TM, Stowasser S, Nishioka Y, White ES, Cottin V, Noth I, Selman M, Rohr KB, Michael A, Ittrich C, Diefenbach C, Jenkins RG. Biomarkers of extracellular matrix turnover in patients with idiopathic pulmonary fibrosis given nintedanib (INMARK study): a randomised, placebo-controlled study. Lancet Respir Med 2019; 7:771-779. [PMID: 31326319 DOI: 10.1016/s2213-2600(19)30255-3] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 05/30/2019] [Accepted: 06/03/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND A hallmark of idiopathic pulmonary fibrosis is the excess accumulation of extracellular matrix in the lungs. Degradation of extracellular matrix generates free-circulating protein fragments called neoepitopes. The aim of the INMARK trial was to investigate changes in neoepitopes as predictors of disease progression in patients with idiopathic pulmonary fibrosis and the effect of nintedanib on these biomarkers. METHODS In this randomised, double-blind, placebo-controlled trial, patients with a diagnosis of idiopathic pulmonary fibrosis within the past 3 years and forced vital capacity (FVC) of 80% predicted or higher were eligible to participate. Patients were recruited from hospitals, private practices, clinical research units, and academic medical centres. Patients were randomly assigned (1:2) with the use of a pseudo-random number generator to receive oral nintedanib 150 mg twice a day or placebo for 12 weeks in a double-blind fashion, followed by open-label nintedanib for 40 weeks. The primary endpoint was the rate of change in C-reactive protein (CRP) degraded by matrix metalloproteinases 1 and 8 (CRPM) from baseline to week 12 in the intention-to-treat population. The trial has been completed and is registered with ClinicalTrials.gov, number NCT02788474, and with the European Clinical Trials Database, number 2015-003148-38. FINDINGS Between June 27, 2016, and May 15, 2017, 347 patients were randomly assigned to the nintedanib group (n=116) or to the placebo group (n=231). One patient from the placebo group was not treated owing to a randomisation error. At baseline, mean FVC was 97·5% (SD 13·5) predicted. In the double-blind period, 116 patients received nintedanib and 230 patients received placebo. The rate of change in CRPM from baseline to week 12 was -2·57 × 10-3 ng/mL/month in the nintedanib group and -1·90 × 10-3 ng/mL/month in the placebo group (between-group difference -0·66 × 10-3 ng/mL/month [95% CI -6·21 × 10-3 to 4·88 × 10-3]; p=0·8146). The adjusted rate of change in FVC over 12 weeks was 5·9 mL in the nintedanib group and -70·2 mL in the placebo group (difference 76·1 mL/12 weeks [31·7 to 120·4]). In patients who received placebo for 12 weeks followed by open-label nintedanib, rising concentrations of CRPM over 12 weeks were associated with disease progression (absolute decline in FVC ≥10% predicted or death) over 52 weeks. In the double-blind period, serious adverse events were reported in eight (7%) patients given nintedanib and 18 (8%) patients given placebo. Grade 3 diarrhoea was reported in two (2%) patients in the nintedanib group and two (1%) patients in the placebo group. No patients had grade 4 diarrhoea. INTERPRETATION In patients with idiopathic pulmonary fibrosis and preserved lung function, treatment with nintedanib versus placebo for 12 weeks did not affect the rate of change in CRPM but was associated with a reduced rate of decline in FVC. These results suggest that change in CRPM is not a marker of response to nintedanib in patients with idiopathic pulmonary fibrosis. FUNDING Boehringer Ingelheim.
Collapse
Affiliation(s)
- Toby M Maher
- National Heart and Lung Institute, Imperial College London, London, UK; National Institute for Health Research Clinical Research Facility, Royal Brompton Hospital, London, UK.
| | - Susanne Stowasser
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Rhein, Germany
| | - Yasuhiko Nishioka
- Graduate School of Biomedical Sciences, Tokushima University, Tokushima, Japan
| | - Eric S White
- University of Michigan, Division of Pulmonary and Critical Care Medicine, Ann Arbor, MI, USA
| | - Vincent Cottin
- National Reference Centre for Rare Pulmonary Diseases, Louis Pradel Hospital, Hospices Civils de Lyon, Claude Bernard University Lyon 1, Lyon, France
| | - Imre Noth
- Division of Pulmonary and Critical Care Medicine, University of Virginia, Charlottesville, VI, USA
| | - Moisés Selman
- Instituto Nacional de Enfermedades Respiratorias Ismael Cosio Villegas, Mexico City, Mexico
| | - Klaus B Rohr
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Rhein, Germany
| | | | - Carina Ittrich
- Boehringer Ingelheim Pharma GmbH & Co KG, Biberach an der Riss, Germany
| | | | - R Gisli Jenkins
- National Institute for Health Research Respiratory Biomedical Research Centre, City Campus, Nottingham University Hospital, Nottingham, UK
| | | |
Collapse
|
32
|
Distler O, Highland KB, Gahlemann M, Azuma A, Fischer A, Mayes MD, Raghu G, Sauter W, Girard M, Alves M, Clerisme-Beaty E, Stowasser S, Tetzlaff K, Kuwana M, Maher TM. Nintedanib for Systemic Sclerosis-Associated Interstitial Lung Disease. N Engl J Med 2019; 380:2518-2528. [PMID: 31112379 DOI: 10.1056/nejmoa1903076] [Citation(s) in RCA: 819] [Impact Index Per Article: 163.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Interstitial lung disease (ILD) is a common manifestation of systemic sclerosis and a leading cause of systemic sclerosis-related death. Nintedanib, a tyrosine kinase inhibitor, has been shown to have antifibrotic and antiinflammatory effects in preclinical models of systemic sclerosis and ILD. METHODS We conducted a randomized, double-blind, placebo-controlled trial to investigate the efficacy and safety of nintedanib in patients with ILD associated with systemic sclerosis. Patients who had systemic sclerosis with an onset of the first non-Raynaud's symptom within the past 7 years and a high-resolution computed tomographic scan that showed fibrosis affecting at least 10% of the lungs were randomly assigned, in a 1:1 ratio, to receive 150 mg of nintedanib, administered orally twice daily, or placebo. The primary end point was the annual rate of decline in forced vital capacity (FVC), assessed over a 52-week period. Key secondary end points were absolute changes from baseline in the modified Rodnan skin score and in the total score on the St. George's Respiratory Questionnaire (SGRQ) at week 52. RESULTS A total of 576 patients received at least one dose of nintedanib or placebo; 51.9% had diffuse cutaneous systemic sclerosis, and 48.4% were receiving mycophenolate at baseline. In the primary end-point analysis, the adjusted annual rate of change in FVC was -52.4 ml per year in the nintedanib group and -93.3 ml per year in the placebo group (difference, 41.0 ml per year; 95% confidence interval [CI], 2.9 to 79.0; P = 0.04). Sensitivity analyses based on multiple imputation for missing data yielded P values for the primary end point ranging from 0.06 to 0.10. The change from baseline in the modified Rodnan skin score and the total score on the SGRQ at week 52 did not differ significantly between the trial groups, with differences of -0.21 (95% CI, -0.94 to 0.53; P = 0.58) and 1.69 (95% CI, -0.73 to 4.12 [not adjusted for multiple comparisons]), respectively. Diarrhea, the most common adverse event, was reported in 75.7% of the patients in the nintedanib group and in 31.6% of those in the placebo group. CONCLUSIONS Among patients with ILD associated with systemic sclerosis, the annual rate of decline in FVC was lower with nintedanib than with placebo; no clinical benefit of nintedanib was observed for other manifestations of systemic sclerosis. The adverse-event profile of nintedanib observed in this trial was similar to that observed in patients with idiopathic pulmonary fibrosis; gastrointestinal adverse events, including diarrhea, were more common with nintedanib than with placebo. (Funded by Boehringer Ingelheim; SENSCIS ClinicalTrials.gov number, NCT02597933.).
Collapse
Affiliation(s)
- Oliver Distler
- From the Department of Rheumatology, University Hospital Zurich, Zurich (O.D.), and Boehringer Ingelheim (Schweiz), Basel (M. Gahlemann) - both in Switzerland; the Respiratory Institute, Cleveland Clinic, Cleveland (K.B.H.); the Departments of Pulmonary Medicine and Oncology (A.A.) and Allergy and Rheumatology (M.K.), Nippon Medical School Graduate School of Medicine, Tokyo; University of Colorado School of Medicine, Aurora (A.F.); the Division of Rheumatology and Clinical Immunogenetics, University of Texas McGovern Medical School, Houston (M.D.M.); University of Washington, Seattle (G.R.); Boehringer Ingelheim Pharma, Biberach an der Riss (W.S.), Boehringer Ingelheim International, Ingelheim am Rhein (M.A., E.C.-B., S.S., K.T.), and the Department of Sports Medicine, University of Tübingen, Tübingen (K.T.) - all in Germany; Boehringer Ingelheim France, Reims, France (M. Girard); and the National Heart and Lung Institute, Imperial College London, and the National Institute for Health Research Clinical Research Facility, Royal Brompton Hospital, London (T.M.M.)
| | - Kristin B Highland
- From the Department of Rheumatology, University Hospital Zurich, Zurich (O.D.), and Boehringer Ingelheim (Schweiz), Basel (M. Gahlemann) - both in Switzerland; the Respiratory Institute, Cleveland Clinic, Cleveland (K.B.H.); the Departments of Pulmonary Medicine and Oncology (A.A.) and Allergy and Rheumatology (M.K.), Nippon Medical School Graduate School of Medicine, Tokyo; University of Colorado School of Medicine, Aurora (A.F.); the Division of Rheumatology and Clinical Immunogenetics, University of Texas McGovern Medical School, Houston (M.D.M.); University of Washington, Seattle (G.R.); Boehringer Ingelheim Pharma, Biberach an der Riss (W.S.), Boehringer Ingelheim International, Ingelheim am Rhein (M.A., E.C.-B., S.S., K.T.), and the Department of Sports Medicine, University of Tübingen, Tübingen (K.T.) - all in Germany; Boehringer Ingelheim France, Reims, France (M. Girard); and the National Heart and Lung Institute, Imperial College London, and the National Institute for Health Research Clinical Research Facility, Royal Brompton Hospital, London (T.M.M.)
| | - Martina Gahlemann
- From the Department of Rheumatology, University Hospital Zurich, Zurich (O.D.), and Boehringer Ingelheim (Schweiz), Basel (M. Gahlemann) - both in Switzerland; the Respiratory Institute, Cleveland Clinic, Cleveland (K.B.H.); the Departments of Pulmonary Medicine and Oncology (A.A.) and Allergy and Rheumatology (M.K.), Nippon Medical School Graduate School of Medicine, Tokyo; University of Colorado School of Medicine, Aurora (A.F.); the Division of Rheumatology and Clinical Immunogenetics, University of Texas McGovern Medical School, Houston (M.D.M.); University of Washington, Seattle (G.R.); Boehringer Ingelheim Pharma, Biberach an der Riss (W.S.), Boehringer Ingelheim International, Ingelheim am Rhein (M.A., E.C.-B., S.S., K.T.), and the Department of Sports Medicine, University of Tübingen, Tübingen (K.T.) - all in Germany; Boehringer Ingelheim France, Reims, France (M. Girard); and the National Heart and Lung Institute, Imperial College London, and the National Institute for Health Research Clinical Research Facility, Royal Brompton Hospital, London (T.M.M.)
| | - Arata Azuma
- From the Department of Rheumatology, University Hospital Zurich, Zurich (O.D.), and Boehringer Ingelheim (Schweiz), Basel (M. Gahlemann) - both in Switzerland; the Respiratory Institute, Cleveland Clinic, Cleveland (K.B.H.); the Departments of Pulmonary Medicine and Oncology (A.A.) and Allergy and Rheumatology (M.K.), Nippon Medical School Graduate School of Medicine, Tokyo; University of Colorado School of Medicine, Aurora (A.F.); the Division of Rheumatology and Clinical Immunogenetics, University of Texas McGovern Medical School, Houston (M.D.M.); University of Washington, Seattle (G.R.); Boehringer Ingelheim Pharma, Biberach an der Riss (W.S.), Boehringer Ingelheim International, Ingelheim am Rhein (M.A., E.C.-B., S.S., K.T.), and the Department of Sports Medicine, University of Tübingen, Tübingen (K.T.) - all in Germany; Boehringer Ingelheim France, Reims, France (M. Girard); and the National Heart and Lung Institute, Imperial College London, and the National Institute for Health Research Clinical Research Facility, Royal Brompton Hospital, London (T.M.M.)
| | - Aryeh Fischer
- From the Department of Rheumatology, University Hospital Zurich, Zurich (O.D.), and Boehringer Ingelheim (Schweiz), Basel (M. Gahlemann) - both in Switzerland; the Respiratory Institute, Cleveland Clinic, Cleveland (K.B.H.); the Departments of Pulmonary Medicine and Oncology (A.A.) and Allergy and Rheumatology (M.K.), Nippon Medical School Graduate School of Medicine, Tokyo; University of Colorado School of Medicine, Aurora (A.F.); the Division of Rheumatology and Clinical Immunogenetics, University of Texas McGovern Medical School, Houston (M.D.M.); University of Washington, Seattle (G.R.); Boehringer Ingelheim Pharma, Biberach an der Riss (W.S.), Boehringer Ingelheim International, Ingelheim am Rhein (M.A., E.C.-B., S.S., K.T.), and the Department of Sports Medicine, University of Tübingen, Tübingen (K.T.) - all in Germany; Boehringer Ingelheim France, Reims, France (M. Girard); and the National Heart and Lung Institute, Imperial College London, and the National Institute for Health Research Clinical Research Facility, Royal Brompton Hospital, London (T.M.M.)
| | - Maureen D Mayes
- From the Department of Rheumatology, University Hospital Zurich, Zurich (O.D.), and Boehringer Ingelheim (Schweiz), Basel (M. Gahlemann) - both in Switzerland; the Respiratory Institute, Cleveland Clinic, Cleveland (K.B.H.); the Departments of Pulmonary Medicine and Oncology (A.A.) and Allergy and Rheumatology (M.K.), Nippon Medical School Graduate School of Medicine, Tokyo; University of Colorado School of Medicine, Aurora (A.F.); the Division of Rheumatology and Clinical Immunogenetics, University of Texas McGovern Medical School, Houston (M.D.M.); University of Washington, Seattle (G.R.); Boehringer Ingelheim Pharma, Biberach an der Riss (W.S.), Boehringer Ingelheim International, Ingelheim am Rhein (M.A., E.C.-B., S.S., K.T.), and the Department of Sports Medicine, University of Tübingen, Tübingen (K.T.) - all in Germany; Boehringer Ingelheim France, Reims, France (M. Girard); and the National Heart and Lung Institute, Imperial College London, and the National Institute for Health Research Clinical Research Facility, Royal Brompton Hospital, London (T.M.M.)
| | - Ganesh Raghu
- From the Department of Rheumatology, University Hospital Zurich, Zurich (O.D.), and Boehringer Ingelheim (Schweiz), Basel (M. Gahlemann) - both in Switzerland; the Respiratory Institute, Cleveland Clinic, Cleveland (K.B.H.); the Departments of Pulmonary Medicine and Oncology (A.A.) and Allergy and Rheumatology (M.K.), Nippon Medical School Graduate School of Medicine, Tokyo; University of Colorado School of Medicine, Aurora (A.F.); the Division of Rheumatology and Clinical Immunogenetics, University of Texas McGovern Medical School, Houston (M.D.M.); University of Washington, Seattle (G.R.); Boehringer Ingelheim Pharma, Biberach an der Riss (W.S.), Boehringer Ingelheim International, Ingelheim am Rhein (M.A., E.C.-B., S.S., K.T.), and the Department of Sports Medicine, University of Tübingen, Tübingen (K.T.) - all in Germany; Boehringer Ingelheim France, Reims, France (M. Girard); and the National Heart and Lung Institute, Imperial College London, and the National Institute for Health Research Clinical Research Facility, Royal Brompton Hospital, London (T.M.M.)
| | - Wiebke Sauter
- From the Department of Rheumatology, University Hospital Zurich, Zurich (O.D.), and Boehringer Ingelheim (Schweiz), Basel (M. Gahlemann) - both in Switzerland; the Respiratory Institute, Cleveland Clinic, Cleveland (K.B.H.); the Departments of Pulmonary Medicine and Oncology (A.A.) and Allergy and Rheumatology (M.K.), Nippon Medical School Graduate School of Medicine, Tokyo; University of Colorado School of Medicine, Aurora (A.F.); the Division of Rheumatology and Clinical Immunogenetics, University of Texas McGovern Medical School, Houston (M.D.M.); University of Washington, Seattle (G.R.); Boehringer Ingelheim Pharma, Biberach an der Riss (W.S.), Boehringer Ingelheim International, Ingelheim am Rhein (M.A., E.C.-B., S.S., K.T.), and the Department of Sports Medicine, University of Tübingen, Tübingen (K.T.) - all in Germany; Boehringer Ingelheim France, Reims, France (M. Girard); and the National Heart and Lung Institute, Imperial College London, and the National Institute for Health Research Clinical Research Facility, Royal Brompton Hospital, London (T.M.M.)
| | - Mannaig Girard
- From the Department of Rheumatology, University Hospital Zurich, Zurich (O.D.), and Boehringer Ingelheim (Schweiz), Basel (M. Gahlemann) - both in Switzerland; the Respiratory Institute, Cleveland Clinic, Cleveland (K.B.H.); the Departments of Pulmonary Medicine and Oncology (A.A.) and Allergy and Rheumatology (M.K.), Nippon Medical School Graduate School of Medicine, Tokyo; University of Colorado School of Medicine, Aurora (A.F.); the Division of Rheumatology and Clinical Immunogenetics, University of Texas McGovern Medical School, Houston (M.D.M.); University of Washington, Seattle (G.R.); Boehringer Ingelheim Pharma, Biberach an der Riss (W.S.), Boehringer Ingelheim International, Ingelheim am Rhein (M.A., E.C.-B., S.S., K.T.), and the Department of Sports Medicine, University of Tübingen, Tübingen (K.T.) - all in Germany; Boehringer Ingelheim France, Reims, France (M. Girard); and the National Heart and Lung Institute, Imperial College London, and the National Institute for Health Research Clinical Research Facility, Royal Brompton Hospital, London (T.M.M.)
| | - Margarida Alves
- From the Department of Rheumatology, University Hospital Zurich, Zurich (O.D.), and Boehringer Ingelheim (Schweiz), Basel (M. Gahlemann) - both in Switzerland; the Respiratory Institute, Cleveland Clinic, Cleveland (K.B.H.); the Departments of Pulmonary Medicine and Oncology (A.A.) and Allergy and Rheumatology (M.K.), Nippon Medical School Graduate School of Medicine, Tokyo; University of Colorado School of Medicine, Aurora (A.F.); the Division of Rheumatology and Clinical Immunogenetics, University of Texas McGovern Medical School, Houston (M.D.M.); University of Washington, Seattle (G.R.); Boehringer Ingelheim Pharma, Biberach an der Riss (W.S.), Boehringer Ingelheim International, Ingelheim am Rhein (M.A., E.C.-B., S.S., K.T.), and the Department of Sports Medicine, University of Tübingen, Tübingen (K.T.) - all in Germany; Boehringer Ingelheim France, Reims, France (M. Girard); and the National Heart and Lung Institute, Imperial College London, and the National Institute for Health Research Clinical Research Facility, Royal Brompton Hospital, London (T.M.M.)
| | - Emmanuelle Clerisme-Beaty
- From the Department of Rheumatology, University Hospital Zurich, Zurich (O.D.), and Boehringer Ingelheim (Schweiz), Basel (M. Gahlemann) - both in Switzerland; the Respiratory Institute, Cleveland Clinic, Cleveland (K.B.H.); the Departments of Pulmonary Medicine and Oncology (A.A.) and Allergy and Rheumatology (M.K.), Nippon Medical School Graduate School of Medicine, Tokyo; University of Colorado School of Medicine, Aurora (A.F.); the Division of Rheumatology and Clinical Immunogenetics, University of Texas McGovern Medical School, Houston (M.D.M.); University of Washington, Seattle (G.R.); Boehringer Ingelheim Pharma, Biberach an der Riss (W.S.), Boehringer Ingelheim International, Ingelheim am Rhein (M.A., E.C.-B., S.S., K.T.), and the Department of Sports Medicine, University of Tübingen, Tübingen (K.T.) - all in Germany; Boehringer Ingelheim France, Reims, France (M. Girard); and the National Heart and Lung Institute, Imperial College London, and the National Institute for Health Research Clinical Research Facility, Royal Brompton Hospital, London (T.M.M.)
| | - Susanne Stowasser
- From the Department of Rheumatology, University Hospital Zurich, Zurich (O.D.), and Boehringer Ingelheim (Schweiz), Basel (M. Gahlemann) - both in Switzerland; the Respiratory Institute, Cleveland Clinic, Cleveland (K.B.H.); the Departments of Pulmonary Medicine and Oncology (A.A.) and Allergy and Rheumatology (M.K.), Nippon Medical School Graduate School of Medicine, Tokyo; University of Colorado School of Medicine, Aurora (A.F.); the Division of Rheumatology and Clinical Immunogenetics, University of Texas McGovern Medical School, Houston (M.D.M.); University of Washington, Seattle (G.R.); Boehringer Ingelheim Pharma, Biberach an der Riss (W.S.), Boehringer Ingelheim International, Ingelheim am Rhein (M.A., E.C.-B., S.S., K.T.), and the Department of Sports Medicine, University of Tübingen, Tübingen (K.T.) - all in Germany; Boehringer Ingelheim France, Reims, France (M. Girard); and the National Heart and Lung Institute, Imperial College London, and the National Institute for Health Research Clinical Research Facility, Royal Brompton Hospital, London (T.M.M.)
| | - Kay Tetzlaff
- From the Department of Rheumatology, University Hospital Zurich, Zurich (O.D.), and Boehringer Ingelheim (Schweiz), Basel (M. Gahlemann) - both in Switzerland; the Respiratory Institute, Cleveland Clinic, Cleveland (K.B.H.); the Departments of Pulmonary Medicine and Oncology (A.A.) and Allergy and Rheumatology (M.K.), Nippon Medical School Graduate School of Medicine, Tokyo; University of Colorado School of Medicine, Aurora (A.F.); the Division of Rheumatology and Clinical Immunogenetics, University of Texas McGovern Medical School, Houston (M.D.M.); University of Washington, Seattle (G.R.); Boehringer Ingelheim Pharma, Biberach an der Riss (W.S.), Boehringer Ingelheim International, Ingelheim am Rhein (M.A., E.C.-B., S.S., K.T.), and the Department of Sports Medicine, University of Tübingen, Tübingen (K.T.) - all in Germany; Boehringer Ingelheim France, Reims, France (M. Girard); and the National Heart and Lung Institute, Imperial College London, and the National Institute for Health Research Clinical Research Facility, Royal Brompton Hospital, London (T.M.M.)
| | - Masataka Kuwana
- From the Department of Rheumatology, University Hospital Zurich, Zurich (O.D.), and Boehringer Ingelheim (Schweiz), Basel (M. Gahlemann) - both in Switzerland; the Respiratory Institute, Cleveland Clinic, Cleveland (K.B.H.); the Departments of Pulmonary Medicine and Oncology (A.A.) and Allergy and Rheumatology (M.K.), Nippon Medical School Graduate School of Medicine, Tokyo; University of Colorado School of Medicine, Aurora (A.F.); the Division of Rheumatology and Clinical Immunogenetics, University of Texas McGovern Medical School, Houston (M.D.M.); University of Washington, Seattle (G.R.); Boehringer Ingelheim Pharma, Biberach an der Riss (W.S.), Boehringer Ingelheim International, Ingelheim am Rhein (M.A., E.C.-B., S.S., K.T.), and the Department of Sports Medicine, University of Tübingen, Tübingen (K.T.) - all in Germany; Boehringer Ingelheim France, Reims, France (M. Girard); and the National Heart and Lung Institute, Imperial College London, and the National Institute for Health Research Clinical Research Facility, Royal Brompton Hospital, London (T.M.M.)
| | - Toby M Maher
- From the Department of Rheumatology, University Hospital Zurich, Zurich (O.D.), and Boehringer Ingelheim (Schweiz), Basel (M. Gahlemann) - both in Switzerland; the Respiratory Institute, Cleveland Clinic, Cleveland (K.B.H.); the Departments of Pulmonary Medicine and Oncology (A.A.) and Allergy and Rheumatology (M.K.), Nippon Medical School Graduate School of Medicine, Tokyo; University of Colorado School of Medicine, Aurora (A.F.); the Division of Rheumatology and Clinical Immunogenetics, University of Texas McGovern Medical School, Houston (M.D.M.); University of Washington, Seattle (G.R.); Boehringer Ingelheim Pharma, Biberach an der Riss (W.S.), Boehringer Ingelheim International, Ingelheim am Rhein (M.A., E.C.-B., S.S., K.T.), and the Department of Sports Medicine, University of Tübingen, Tübingen (K.T.) - all in Germany; Boehringer Ingelheim France, Reims, France (M. Girard); and the National Heart and Lung Institute, Imperial College London, and the National Institute for Health Research Clinical Research Facility, Royal Brompton Hospital, London (T.M.M.)
| |
Collapse
|
33
|
Ryerson CJ, Kolb M, Richeldi L, Lee J, Wachtlin D, Stowasser S, Poletti V. Effects of nintedanib in patients with idiopathic pulmonary fibrosis by GAP stage. ERJ Open Res 2019; 5:00127-2018. [PMID: 31044139 PMCID: PMC6487272 DOI: 10.1183/23120541.00127-2018] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Accepted: 02/08/2019] [Indexed: 11/26/2022] Open
Abstract
We conducted a post hoc analysis to assess the potential impact of GAP (gender, age, physiology) stage on the treatment effect of nintedanib in patients with idiopathic pulmonary fibrosis. Outcomes were compared in patients at GAP stage I versus II/III at baseline in the INPULSIS® trials. At baseline, 500 patients were at GAP stage I (nintedanib 304, placebo 196), 489 were at GAP stage II (nintedanib 296, placebo 193) and 71 were at GAP stage III (nintedanib 38, placebo 33). In nintedanib-treated patients, the annual rate of decline in forced vital capacity (FVC) was similar in patients at GAP stage I and GAP stage II/III at baseline (−110.1 and −116.6 mL·year−1, respectively), and in both subgroups was lower than in placebo-treated patients (−218.5 and −227.6 mL·year−1, respectively) (treatment-by-time-by-subgroup interaction p=0.92). In the nintedanib group, the number of deaths was 43.8% of those predicted based on GAP stage (35 versus 79.9). In the placebo group, the number of deaths was 59.8% of those predicted based on GAP stage (33 versus 55.2). In conclusion, data from the INPULSIS® trials suggest that nintedanib has a similar beneficial effect on the rate of FVC decline in patients at GAP stage I versus II/III at baseline. Nintedanib provides a similar benefit versus placebo on the rate of decline in forced vital capacity in patients with idiopathic pulmonary fibrosis irrespective of GAP stage at baselinehttp://ow.ly/HfJ730nNkRT
Collapse
Affiliation(s)
- Christopher J Ryerson
- Dept of Medicine and Centre for Heart Lung Innovation, University of British Columbia, Vancouver, BC, Canada
| | - Martin Kolb
- Dept of Medicine, McMaster University, Hamilton, ON, Canada
| | - Luca Richeldi
- Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Joyce Lee
- Dept of Medicine, University of Colorado Denver, Aurora, CO, USA
| | - Daniel Wachtlin
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Susanne Stowasser
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | | |
Collapse
|
34
|
Cottin V, Azuma A, Raghu G, Stansen W, Stowasser S, Schlenker-Herceg R, Kolb M. Therapeutic effects of nintedanib are not influenced by emphysema in the INPULSIS trials. Eur Respir J 2019; 53:13993003.01655-2018. [PMID: 30655282 DOI: 10.1183/13993003.01655-2018] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 01/03/2019] [Indexed: 11/05/2022]
Affiliation(s)
- Vincent Cottin
- National Reference Center for Rare Pulmonary Diseases, Louis Pradel Hospital, Hospices Civils de Lyon, Claude Bernard University Lyon 1, Lyon, France
| | | | | | - Wibke Stansen
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim am Rhein, Germany
| | - Susanne Stowasser
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | | | | |
Collapse
|
35
|
Lancaster L, Crestani B, Hernandez P, Inoue Y, Wachtlin D, Loaiza L, Quaresma M, Stowasser S, Richeldi L. Safety and survival data in patients with idiopathic pulmonary fibrosis treated with nintedanib: pooled data from six clinical trials. BMJ Open Respir Res 2019; 6:e000397. [PMID: 31179001 PMCID: PMC6530503 DOI: 10.1136/bmjresp-2018-000397] [Citation(s) in RCA: 97] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 02/26/2019] [Indexed: 11/17/2022] Open
Abstract
Introduction Nintedanib slows disease progression in patients with idiopathic pulmonary fibrosis (IPF) by reducing the rate of decline in forced vital capacity, with an adverse event profile that is manageable for most patients. We used data from six clinical trials to characterise the safety and tolerability profile of nintedanib and to investigate its effects on survival. Methods Data from patients treated with ≥1 dose of nintedanib 150 mg two times per day or placebo in the 52-week TOMORROW trial and/or its open-label extension; the two 52-week INPULSIS trials and/or their open-label extension, INPULSIS-ON; and a Phase IIIb trial with a placebo-controlled period of ≥6 months followed by open-label nintedanib were pooled. All adverse events, irrespective of causality, were included in descriptive analyses. Parametric survival distributions were fit to pooled Kaplan-Meier survival data from the trials and extrapolated to estimate long-term survival. Results There were 1126 patients in the pooled nintedanib group and 565 patients in the pooled placebo group. The mean duration of nintedanib treatment was 28 months. No new safety signals were observed. Incidence rates of bleeding, liver enzyme elevations and cardiovascular events were consistent with those observed in the INPULSIS trials. Diarrhoea was reported at a lower event rate in the pooled nintedanib group than in nintedanib-treated patients in the INPULSIS trials (76.5 vs 112.6 events per 100 patient exposure-years) and infrequently led to permanent treatment discontinuation (3.6 events per 100 patient exposure-years). Based on the Weibull distribution, mean (95% CI) survival was estimated as 11.6 (9.6, 14.1) years in nintedanib-treated patients and 3.7 (2.5, 5.4) years in placebo-treated patients. Conclusions Based on pooled data from six clinical trials, the adverse event profile of nintedanib was manageable for most patients. Exploratory analyses based on extrapolation of survival data suggest that nintedanib extends life expectancy in patients with IPF.
Collapse
Affiliation(s)
- Lisa Lancaster
- Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Bruno Crestani
- APHP, Service de Pneumologie, Hôpital Bichat, Paris, France; Université Paris Diderot, Paris, France
| | - Paul Hernandez
- QEII Health Sciences Centre, Halifax, Nova Scotia, Canada
| | - Yoshikazu Inoue
- Diffuse Lung Diseases and Respiratory Failure, National Hospital Organization Kinki-Chuo Chest Medical Center, Osaka, Japan
| | - Daniel Wachtlin
- Boehringer Ingelheim Pharma GmbH & Co KG, Ingelheim am Rhein, Germany
| | - Lazaro Loaiza
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Manuel Quaresma
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Susanne Stowasser
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Luca Richeldi
- Fondazione Policlinico A Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| |
Collapse
|
36
|
Cottin V, Wollin L, Fischer A, Quaresma M, Stowasser S, Harari S. Fibrosing interstitial lung diseases: knowns and unknowns. Eur Respir Rev 2019; 28:28/151/180100. [PMID: 30814139 DOI: 10.1183/16000617.0100-2018] [Citation(s) in RCA: 157] [Impact Index Per Article: 31.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 01/07/2019] [Indexed: 01/19/2023] Open
Abstract
Patients with certain types of fibrosing interstitial lung disease (ILD) are at risk of developing a progressive phenotype characterised by self-sustaining fibrosis, decline in lung function, worsening quality of life, and early mortality. It has been proposed that such progressive fibrosing ILDs, which show commonalities in clinical behaviour and in the pathogenetic mechanisms that drive progressive fibrosis, may be "lumped" together for the purposes of clinical research and, potentially, for treatment. At present, no drugs are approved for the treatment of ILDs other than nintedanib and pirfenidone for the treatment of idiopathic pulmonary fibrosis. For other progressive fibrosing ILDs, the mainstay of drug therapy is immunosuppression. However, it is postulated that, once the response to lung injury in fibrosing ILDs has reached the stage at which fibrosis has become progressive and self-sustaining, targeted antifibrotic therapy would be required to slow disease progression. Nintedanib, an intracellular inhibitor of tyrosine kinases, has shown antifibrotic, anti-inflammatory and vascular remodelling effects in several non-clinical models of fibrosis, irrespective of the trigger for the injury. Ongoing clinical trials will provide insight into the role of antifibrotic treatment with nintedanib or pirfenidone in the management of fibrosing ILDs with a progressive phenotype.
Collapse
Affiliation(s)
- Vincent Cottin
- National Reference Centre for Rare Pulmonary Diseases, Louis Pradel Hospital, Hospices Civils de Lyon, Claude Bernard University Lyon 1, Lyon, France
| | - Lutz Wollin
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Aryeh Fischer
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Denver, CO, USA
| | - Manuel Quaresma
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Susanne Stowasser
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Sergio Harari
- Division of Pulmonary and Critical Care Medicine, San Giuseppe Hospital MultiMedica IRCCS, Milan, Italy
| |
Collapse
|
37
|
Richeldi L, Fletcher S, Adamali H, Chaudhuri N, Wiebe S, Wind S, Hohl K, Baker A, Schlenker-Herceg R, Stowasser S, Maher TM. No relevant pharmacokinetic drug-drug interaction between nintedanib and pirfenidone. Eur Respir J 2019; 53:13993003.01060-2018. [PMID: 30442716 DOI: 10.1183/13993003.01060-2018] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 10/28/2018] [Indexed: 01/08/2023]
Abstract
Nintedanib and pirfenidone are approved treatments for idiopathic pulmonary fibrosis (IPF). This open-label, two-group trial investigated the pharmacokinetic drug-drug interaction between these two drugs in patients with IPF.Subjects not treated with antifibrotics at screening (group 1, n=20) received a single nintedanib dose (150 mg) followed by pirfenidone (titrated to 801 mg thrice daily) for 3 weeks, with a further single nintedanib dose (150 mg) on the last day (day 23). Subjects treated with pirfenidone at screening (group 2, n=17) continued to receive pirfenidone alone (801 mg thrice daily) for 7 days, then co-administered with nintedanib (150 mg twice daily) for a further 7 days, before single doses of both treatments on day 16.In group 1, adjusted geometric mean (gMean) ratios (with/without pirfenidone) were 88.6% and 80.6% for nintedanib area under the plasma concentration-time curve (AUC) and maximum plasma concentration (Cmax), respectively. In group 2, gMean ratios (with/without nintedanib) were 97.2% and 99.5% for pirfenidone AUC and Cmax, respectively. For all parameters, the 90% confidence intervals included 100%, suggesting similar exposure for administration alone and when co-administered. Both treatments were well tolerated.These data indicate there is no relevant pharmacokinetic drug-drug interaction between nintedanib and pirfenidone when co-administered in IPF patients.
Collapse
Affiliation(s)
- Luca Richeldi
- Università Cattolica del Sacro Cuore, Fondazione Policlinico A. Gemelli, Rome, Italy.,Dept of Respiratory Medicine, University Hospital Southampton and Southampton NIHR Respiratory Biomedical Research Unit, University Hospital Southampton, Southampton, UK
| | - Sophie Fletcher
- Dept of Respiratory Medicine, University Hospital Southampton and Southampton NIHR Respiratory Biomedical Research Unit, University Hospital Southampton, Southampton, UK.,Translational Research Collaboration - Inflammatory Respiratory Disease Centre, Manchester, UK
| | - Huzaifa Adamali
- Bristol Interstitial Lung Disease Service, North Bristol NHS Trust, Southmead Hospital, Bristol, UK
| | - Nazia Chaudhuri
- Translational Research Collaboration - Inflammatory Respiratory Disease Centre, Manchester, UK.,North West Lung Centre, Manchester University NHS Foundation Trust, Manchester, UK
| | | | - Sven Wind
- Boehringer Ingelheim Pharma, Biberach, Germany
| | | | | | | | | | - Toby M Maher
- Translational Research Collaboration - Inflammatory Respiratory Disease Centre, Manchester, UK.,National Institute for Health Research Respiratory Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust, and Fibrosis Research group, National Heart and Lung Institute, Imperial College, London, UK
| |
Collapse
|
38
|
Israel-Biet D, Maher T, Stowasser S, Nishioka Y, White E, Cottin V, Noth I, Selman M, Wachtlin D, Diefenbach C, Jenkins R. Étude de l’effet du nintédanib sur les variations des biomarqueurs du renouvellement de la MEC chez les patients présentant une FPI et un déclin limité de la CVF : plan de l’étude INMARK. Rev Mal Respir 2019. [DOI: 10.1016/j.rmr.2018.10.290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
|
39
|
Valeyre D, Lancaster L, Hernandez P, Inoue Y, Wachtlin D, Loaiza L, Conoscenti S, Quaresma M, Stowasser S, Richeldi L. Sécurité d’emploi et tolérance du nintédanib chez les patients atteints de fibrose pulmonaire idiopathique (FPI) : données groupées de six essais cliniques. Rev Mal Respir 2019. [DOI: 10.1016/j.rmr.2018.10.293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
|
40
|
Bourdin A, Tang W, Menjoge S, Stowasser S, Korell J. Prédiction de la mortalité chez les patients atteints de fibrose pulmonaire idiopathique (FPI) traités par le nintédanib. Rev Mal Respir 2019. [DOI: 10.1016/j.rmr.2018.10.287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
|
41
|
Jouneau S, Kolb M, Wells A, Behr J, Richeldi L, Schnaidt S, Quaresma M, Stowasser S, Raghu G, Martinez J. INSTAGE : essai randomisé du nintédanib plus sildénafil versus nintédanib seul chez des patients présentant une fibrose pulmonaire idiopathique (FPI) et une altération avancée de la fonction pulmonaire. Rev Mal Respir 2019. [DOI: 10.1016/j.rmr.2018.10.291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
42
|
Crestani B, Ryerson J, Wijsenbeek M, Bonella F, Spagnolo P, Stansen W, Stowasser S, Richeldi L. Mortalité prédite versus observée dans les essais cliniques du nintédanib dans la fibrose pulmonaire idiopathique (FPI). Rev Mal Respir 2019. [DOI: 10.1016/j.rmr.2018.10.289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
|
43
|
Brown KK, Flaherty KR, Cottin V, Raghu G, Inoue Y, Azuma A, Huggins JT, Richeldi L, Stowasser S, Stansen W, Schlenker-Herceg R, Maher TM, Wells AU. Lung function outcomes in the INPULSIS ® trials of nintedanib in idiopathic pulmonary fibrosis. Respir Med 2018; 146:42-48. [PMID: 30665517 DOI: 10.1016/j.rmed.2018.11.012] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 11/16/2018] [Accepted: 11/18/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND In the INPULSIS® trials, nintedanib reduced the annual rate of decline in forced vital capacity (FVC) versus placebo, consistent with slowing of disease progression. We characterised the effects of nintedanib on physiologic outcomes using pooled data from the INPULSIS® trials. METHODS Post-hoc analyses included changes in FVC over time, cumulative distribution of patients by change in FVC % predicted, and annual rate of decline in FVC in subgroups by diffusing capacity of the lung for carbon monoxide (DLco) and composite physiologic index (CPI) at baseline. Changes from baseline in DLco and oxygen saturation by pulse oximetry (SpO2) were pre-specified. RESULTS Nintedanib significantly reduced FVC decline versus placebo from week 12. A higher proportion of patients treated with nintedanib than placebo had an improvement or no decline in FVC % predicted, whereas a smaller proportion had absolute declines in FVC ≥5% or ≥10% predicted from baseline to week 52. The effect of nintedanib on FVC decline was similar in patients with baseline DLco >40% versus ≤40% predicted or CPI ≤45 versus >45. There were no significant differences between nintedanib and placebo in change from baseline in DLco % predicted, CPI, or SpO2 at week 52. However, change (deterioration) in CPI was significantly lower with nintedanib versus placebo in patients with CPI > 45 at baseline (1.0 versus 2.9) and CPI >55 at baseline (-1.2 versus 3.3). CONCLUSIONS A range of physiologic outcome measures in the INPULSIS® trials support the effect of nintedanib on reducing disease progression in patients with IPF.
Collapse
Affiliation(s)
| | | | - Vincent Cottin
- Louis Pradel Hospital, Hospices Civils de Lyon, Claude Bernard University Lyon 1, Lyon, France
| | - Ganesh Raghu
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Yoshikazu Inoue
- Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, Osaka, Japan
| | - Arata Azuma
- Department of Pulmonary Medicine and Oncology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - John T Huggins
- Medical University of South Carolina, Charleston, SC, USA
| | - Luca Richeldi
- Fondazione Policlinico A. Gemelli, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Susanne Stowasser
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Wibke Stansen
- Boehringer Ingelheim GmbH & Co. KG, Ingelheim am Rhein, Germany
| | | | - Toby M Maher
- National Institute for Health Research Biomedical Research Unit Royal Brompton Hospital, London, UK and Fibrosis Research Group, National Heart and Lung Institute, Imperial College London, UK
| | - Athol U Wells
- National Institute for Health Research Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust, and National Heart and Lung Institute, Imperial College London, UK.
| |
Collapse
|
44
|
Kolb M, Raghu G, Wells AU, Behr J, Richeldi L, Schinzel B, Quaresma M, Stowasser S, Martinez FJ. Nintedanib plus Sildenafil in Patients with Idiopathic Pulmonary Fibrosis. N Engl J Med 2018; 379:1722-1731. [PMID: 30220235 DOI: 10.1056/nejmoa1811737] [Citation(s) in RCA: 172] [Impact Index Per Article: 28.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Nintedanib is an approved treatment for idiopathic pulmonary fibrosis (IPF). A subgroup analysis of a previously published trial suggested that sildenafil may provide benefits regarding oxygenation, gas exchange as measured by the diffusion capacity of the lungs for carbon monoxide (DlCO), symptoms, and quality of life in patients with IPF and severely decreased DlCO. That idea was tested in this trial. METHODS We randomly assigned, in a 1:1 ratio, patients with IPF and a DlCO of 35% or less of the predicted value to receive nintedanib at a dose of 150 mg twice daily plus sildenafil at a dose of 20 mg three times daily (nintedanib-plus-sildenafil group) or nintedanib at a dose of 150 mg twice daily plus placebo three times daily (nintedanib group) for 24 weeks. The primary end point was the change from baseline in the total score on the St. George's Respiratory Questionnaire (SGRQ) at week 12 (the total score ranges from 0 to 100, with higher scores indicating worse health-related quality of life). Secondary end points included measures of dyspnea and safety. RESULTS A total of 274 patients underwent randomization. There was no significant difference in the adjusted mean change from baseline in the SGRQ total score at week 12 between the nintedanib-plus-sildenafil group and the nintedanib group (-1.28 points and -0.77 points, respectively; P=0.72). A benefit from sildenafil treatment was not observed with regard to dyspnea as measured with the use of the University of California, San Diego, Shortness of Breath Questionnaire. No new safety signals were observed, as compared with previous trials. CONCLUSIONS In patients with IPF and a DlCO of 35% or less of the predicted value, nintedanib plus sildenafil did not provide a significant benefit as compared with nintedanib alone. No new safety signals were identified with either treatment regimen in this population of patients. (Funded by Boehringer Ingelheim; INSTAGE ClinicalTrials.gov number, NCT02802345 .).
Collapse
Affiliation(s)
- Martin Kolb
- From McMaster University and St. Joseph's Healthcare, Hamilton, ON, Canada (M.K.); the University of Washington, Seattle (G.R.); the National Institute for Health Research Respiratory Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust, and the National Heart and Lung Institute, Imperial College, London (A.U.W.); Medizinische Klinik und Poliklinik V, University of Munich and Asklepios Klinik München-Gauting, German Center for Lung Research, Munich (J.B.), and Boehringer Ingelheim International, Ingelheim (B.S., M.Q., S.S.) - both in Germany; Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome (L.R.); and Weill Cornell Medicine, New York (F.J.M.)
| | - Ganesh Raghu
- From McMaster University and St. Joseph's Healthcare, Hamilton, ON, Canada (M.K.); the University of Washington, Seattle (G.R.); the National Institute for Health Research Respiratory Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust, and the National Heart and Lung Institute, Imperial College, London (A.U.W.); Medizinische Klinik und Poliklinik V, University of Munich and Asklepios Klinik München-Gauting, German Center for Lung Research, Munich (J.B.), and Boehringer Ingelheim International, Ingelheim (B.S., M.Q., S.S.) - both in Germany; Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome (L.R.); and Weill Cornell Medicine, New York (F.J.M.)
| | - Athol U Wells
- From McMaster University and St. Joseph's Healthcare, Hamilton, ON, Canada (M.K.); the University of Washington, Seattle (G.R.); the National Institute for Health Research Respiratory Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust, and the National Heart and Lung Institute, Imperial College, London (A.U.W.); Medizinische Klinik und Poliklinik V, University of Munich and Asklepios Klinik München-Gauting, German Center for Lung Research, Munich (J.B.), and Boehringer Ingelheim International, Ingelheim (B.S., M.Q., S.S.) - both in Germany; Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome (L.R.); and Weill Cornell Medicine, New York (F.J.M.)
| | - Jürgen Behr
- From McMaster University and St. Joseph's Healthcare, Hamilton, ON, Canada (M.K.); the University of Washington, Seattle (G.R.); the National Institute for Health Research Respiratory Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust, and the National Heart and Lung Institute, Imperial College, London (A.U.W.); Medizinische Klinik und Poliklinik V, University of Munich and Asklepios Klinik München-Gauting, German Center for Lung Research, Munich (J.B.), and Boehringer Ingelheim International, Ingelheim (B.S., M.Q., S.S.) - both in Germany; Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome (L.R.); and Weill Cornell Medicine, New York (F.J.M.)
| | - Luca Richeldi
- From McMaster University and St. Joseph's Healthcare, Hamilton, ON, Canada (M.K.); the University of Washington, Seattle (G.R.); the National Institute for Health Research Respiratory Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust, and the National Heart and Lung Institute, Imperial College, London (A.U.W.); Medizinische Klinik und Poliklinik V, University of Munich and Asklepios Klinik München-Gauting, German Center for Lung Research, Munich (J.B.), and Boehringer Ingelheim International, Ingelheim (B.S., M.Q., S.S.) - both in Germany; Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome (L.R.); and Weill Cornell Medicine, New York (F.J.M.)
| | - Birgit Schinzel
- From McMaster University and St. Joseph's Healthcare, Hamilton, ON, Canada (M.K.); the University of Washington, Seattle (G.R.); the National Institute for Health Research Respiratory Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust, and the National Heart and Lung Institute, Imperial College, London (A.U.W.); Medizinische Klinik und Poliklinik V, University of Munich and Asklepios Klinik München-Gauting, German Center for Lung Research, Munich (J.B.), and Boehringer Ingelheim International, Ingelheim (B.S., M.Q., S.S.) - both in Germany; Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome (L.R.); and Weill Cornell Medicine, New York (F.J.M.)
| | - Manuel Quaresma
- From McMaster University and St. Joseph's Healthcare, Hamilton, ON, Canada (M.K.); the University of Washington, Seattle (G.R.); the National Institute for Health Research Respiratory Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust, and the National Heart and Lung Institute, Imperial College, London (A.U.W.); Medizinische Klinik und Poliklinik V, University of Munich and Asklepios Klinik München-Gauting, German Center for Lung Research, Munich (J.B.), and Boehringer Ingelheim International, Ingelheim (B.S., M.Q., S.S.) - both in Germany; Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome (L.R.); and Weill Cornell Medicine, New York (F.J.M.)
| | - Susanne Stowasser
- From McMaster University and St. Joseph's Healthcare, Hamilton, ON, Canada (M.K.); the University of Washington, Seattle (G.R.); the National Institute for Health Research Respiratory Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust, and the National Heart and Lung Institute, Imperial College, London (A.U.W.); Medizinische Klinik und Poliklinik V, University of Munich and Asklepios Klinik München-Gauting, German Center for Lung Research, Munich (J.B.), and Boehringer Ingelheim International, Ingelheim (B.S., M.Q., S.S.) - both in Germany; Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome (L.R.); and Weill Cornell Medicine, New York (F.J.M.)
| | - Fernando J Martinez
- From McMaster University and St. Joseph's Healthcare, Hamilton, ON, Canada (M.K.); the University of Washington, Seattle (G.R.); the National Institute for Health Research Respiratory Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust, and the National Heart and Lung Institute, Imperial College, London (A.U.W.); Medizinische Klinik und Poliklinik V, University of Munich and Asklepios Klinik München-Gauting, German Center for Lung Research, Munich (J.B.), and Boehringer Ingelheim International, Ingelheim (B.S., M.Q., S.S.) - both in Germany; Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome (L.R.); and Weill Cornell Medicine, New York (F.J.M.)
| |
Collapse
|
45
|
Vancheri C, Kreuter M, Richeldi L, Quaresma M, Stowasser S, Wuyts WA. Reply to Rajchgot et al.: Combination Nintedanib and Pirfenidone for Treatment of Idiopathic Pulmonary Fibrosis. Am J Respir Crit Care Med 2018; 198:1105-1106. [DOI: 10.1164/rccm.201806-1116le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
| | | | | | - Manuel Quaresma
- Boehringer Ingelheim International GmbHIngelheim am Rhein, Germanyand
| | - Susanne Stowasser
- Boehringer Ingelheim International GmbHIngelheim am Rhein, Germanyand
| | | |
Collapse
|
46
|
Crestani B, Huggins JT, Kaye M, Costabel U, Glaspole I, Ogura T, Song JW, Stansen W, Quaresma M, Stowasser S, Kreuter M. Long-term safety and tolerability of nintedanib in patients with idiopathic pulmonary fibrosis: results from the open-label extension study, INPULSIS-ON. Lancet Respir Med 2018; 7:60-68. [PMID: 30224318 DOI: 10.1016/s2213-2600(18)30339-4] [Citation(s) in RCA: 137] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 08/02/2018] [Accepted: 08/03/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND The efficacy and safety of nintedanib, an intracellular tyrosine kinase inhibitor, in patients with idiopathic pulmonary fibrosis were assessed in two phase 3, placebo-controlled INPULSIS trials. Patients who completed the 52-week treatment period in an INPULSIS trial could receive open-label nintedanib in the extension trial, INPULSIS-ON. We aimed to assess the long-term efficacy and safety of nintedanib in INPULSIS-ON. METHODS Patients who completed the 52-week treatment period of INPULSIS, and the follow-up visit 4 weeks later, were eligible for INPULSIS-ON. The off-treatment period between INPULSIS and INPULSIS-ON could be 4-12 weeks. Patients receiving nintedanib 150 mg twice daily or placebo at the end of an INPULSIS trial received nintedanib 150 mg twice daily in INPULSIS-ON. Patients receiving nintedanib 100 mg twice daily or placebo at the end of an INPULSIS trial could receive nintedanib 100 mg twice daily or 150 mg twice daily in INPULSIS-ON. Spirometric tests were done at baseline, at weeks 2, 4, 6, 12, 24, 36, 48, and then every 16 weeks. The primary outcome of INPULSIS-ON was to characterise the long-term safety and tolerability of nintedanib in patients with idiopathic pulmonary fibrosis, and this was analysed in patients who received at least one dose of nintedanib in INPULSIS-ON. This study is registered with ClinicalTrials.gov, number NCT01619085, and with EudraCT, number 2011-002766-21. FINDINGS The first patient was enrolled into INPULSIS-ON in July 2, 2012. Of 807 patients who completed the INPULSIS trials, 734 (91%) were treated in INPULSIS-ON. 430 (59%) patients had received nintedanib in INPULSIS and continued nintedanib in INPULSIS-ON, and 304 (41%) had received placebo in INPULSIS and initiated nintedanib in INPULSIS-ON. Median exposure time for patients treated with nintedanib in both the INPULSIS and INPULSIS-ON trials was 44·7 months (range 11·9-68·3). The safety profile of nintedanib in INPULSIS-ON was consistent with that observed in INPULSIS. Diarrhoea was the most frequent adverse event in INPULSIS-ON (60·1 events per 100 patient exposure-years in patients who continued nintedanib, 71·2 events per 100 patient exposure-years in patients who initiated nintedanib). 20 (5%) of 430 patients who continued nintedanib and 31 (10%) of 304 patients who initiated nintedanib permanently discontinued nintedanib because of diarrhoea. The adverse event that most frequently led to permanent discontinuation of nintedanib was progression of idiopathic pulmonary fibrosis (51 [12%] patients continuing nintedanib and 43 [14%] patients initiating nintedanib). The event rate of bleeding was 8·4 events per 100 patient exposure-years in patients who continued nintedanib and 6·7 events per 100 patient exposure-years in patients who initiated nintedanib. The event rate of major adverse cardiovascular events was 3·6 events per 100 patient exposure-years in patients who continued nintedanib and 2·4 events per 100 patient exposure-years in patients who initiated nintedanib. The event rate of myocardial infarction using the broad scope (ie, all possible cases) was 1·3 events per 100 patient exposure-years in patients who continued nintedanib and 0·7 events per 100 patient exposure-years in patients who initiated nintedanib. INTERPRETATION These findings suggest that nintedanib has a manageable safety and tolerability profile over long-term use, with no new safety signals. Patients with idiopathic pulmonary fibrosis could use nintedanib over the long-term to slow disease progression. FUNDING Boehringer Ingelheim.
Collapse
Affiliation(s)
- Bruno Crestani
- Assistance Publique-Hôpitaux de Paris, Service de Pneumologie A, Hôpital Bichat, DHU FIRE, Paris, France; INSERM, Unité 1152, Paris, France; Université Paris Diderot, Paris, France.
| | - John T Huggins
- Medical University of South Carolina, Charleston, SC, USA
| | | | - Ulrich Costabel
- Ruhrlandklinik, University Hospital, University of Duisburg-Essen, Essen, Germany
| | - Ian Glaspole
- Department of Allergy, Immunology and Respiratory Medicine, Alfred Health, and Department of Medicine, Monash University, Melbourne, VIC, Australia
| | - Takashi Ogura
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Kanagawa, Japan
| | - Jin Woo Song
- Department of Pulmonary and Critical Care Medicine, ASAN Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Wibke Stansen
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Manuel Quaresma
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Susanne Stowasser
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Michael Kreuter
- Center for Interstitial and Rare Lung Diseases, Pneumology, Thoraxklinik, University of Heidelberg, Heidelberg, Germany; German Center for Lung Research, Germany
| |
Collapse
|
47
|
Costabel U, Behr J, Crestani B, Stansen W, Schlenker-Herceg R, Stowasser S, Raghu G. Anti-acid therapy in idiopathic pulmonary fibrosis: insights from the INPULSIS® trials. Respir Res 2018; 19:167. [PMID: 30176872 PMCID: PMC6122773 DOI: 10.1186/s12931-018-0866-0] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 08/20/2018] [Indexed: 01/20/2023] Open
Abstract
Background The benefits and risks of anti-acid medication in patients with idiopathic pulmonary fibrosis (IPF) remain a topic of debate. We investigated whether use of anti-acid medication at baseline was associated with differences in the natural course of disease or influenced the treatment effect of nintedanib in patients with IPF. Methods Post-hoc analyses of outcomes in patients receiving versus not receiving anti-acid medication (proton pump or histamine-2 receptor inhibitor) at baseline using pooled data from the two Phase III randomized placebo-controlled INPULSIS® trials of nintedanib in patients with IPF. Results At baseline, 406 patients were receiving anti-acid medication (244 nintedanib; 162 placebo) and 655 were not (394 nintedanib; 261 placebo). In an analysis of the natural course of IPF by anti-acid medication use at baseline, the adjusted annual rate of decline in FVC was − 252.9 mL/year in placebo-treated patients who were receiving anti-acid medication at baseline and − 205.4 mL/year in placebo-treated patients who were not (difference of − 47.5 mL/year [95% CI: –105.1, 10.1]; p = 0.1057). In an analysis of the potential influence of anti-acid medication use on the treatment effect of nintedanib, the adjusted annual rates of decline in FVC were − 124.4 mL/year in the nintedanib group and − 252.9 mL/year in the placebo group (difference of 128.6 mL/year [95% CI: 74.9, 182.2]) in patients who were receiving anti-acid medication at baseline and − 107.0 mL/year in the nintedanib group and − 205.3 mL/year in the placebo group (difference of 98.3 mL/year [95% CI: 54.1, 142.5]) in patients who were not (treatment-by-time-by-subgroup interaction p = 0.3869). The proportions of patients who had ≥1 investigator-reported acute exacerbation were 11.7% and 5.0% in placebo-treated patients, and 4.9% and 4.8% of nintedanib-treated patients, among patients who were and were not receiving anti-acid medication at baseline, respectively. Conclusions In post-hoc analyses of data from the INPULSIS® trials, anti-acid medication use at baseline was not associated with a more favorable course of disease, and did not impact the treatment effect of nintedanib, in patients with IPF. Trial registration ClinicalTrials.gov identifiers: NCT01335464 and NCT01335477. Electronic supplementary material The online version of this article (10.1186/s12931-018-0866-0) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Ulrich Costabel
- Ruhrlandklinik, University Hospital, University of Duisburg-Essen, Essen, Germany
| | - Jürgen Behr
- Medizinische Klinik und Poliklinik V, University of Munich (LMU) and Asklepios Klinik München-Gauting, Member of the German Center for Lung Research, Munich, Germany
| | - Bruno Crestani
- APHP, Hôpital Bichat, Service de Pneumologie A, DHU FIRE; INSERM, Unité 1152; Université Paris Diderot, Paris, France
| | - Wibke Stansen
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | | | - Susanne Stowasser
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | | |
Collapse
|
48
|
Maher TM, Stowasser S, Nishioka Y, White ES, Cottin V, Noth I, Selman M, Blahova Z, Wachtlin D, Diefenbach C, Jenkins RG. Investigating the effects of nintedanib on biomarkers of extracellular matrix turnover in patients with IPF: design of the randomised placebo-controlled INMARK®trial. BMJ Open Respir Res 2018; 5:e000325. [PMID: 30167310 PMCID: PMC6109823 DOI: 10.1136/bmjresp-2018-000325] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 07/25/2018] [Accepted: 07/26/2018] [Indexed: 01/06/2023] Open
Abstract
Introduction A feature of the pathogenesis of idiopathic pulmonary fibrosis (IPF) is the excess accumulation of extracellular matrix (ECM) in the lungs. Cleavage of the ECM by metalloproteinases (MMPs) generates free-circulating protein fragments known as neoepitopes. The PROFILE study suggested that changes in ECM turnover proteins may be of value as markers of disease progression in patients with IPF. Nintedanib is an approved treatment for IPF that slows disease progression by reducing decline in forced vital capacity (FVC). Methods and analysis The INMARK® trial is evaluating the effect of nintedanib on the rates of change of biomarkers of ECM turnover in patients with IPF, the value of changes in these biomarkers as predictors of disease progression and whether nintedanib affects the associations between changes in these biomarkers and disease progression. Following a screening period, 347 patients with IPF and FVC ≥80% predicted were randomised 1:2 to receive nintedanib 150 mg two times a day or placebo for 12 weeks, followed by an open-label period in which all patients will receive nintedanib for 40 weeks. The primary endpoint is the rate of change in C reactive protein degraded by MMP-1/8 from baseline to week 12. Ethics and dissemination This trial is being conducted in compliance with the protocol, the ethical principles detailed in the Declaration of Helsinki and in accordance with the International Conference on Harmonisation Harmonised Tripartite Guideline for Good Clinical Practice. The results of the trial will be presented at national and international meetings and published in peer-reviewed journals. Trial registration number NCT02788474.
Collapse
Affiliation(s)
- Toby M Maher
- National Institute for Health Research Respiratory Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust, London, UK.,National Heart and Lung Institute, Imperial College, London, UK.,Fibrosis Research Group, National Heart and Lung Institute, Imperial College, London, UK
| | - Susanne Stowasser
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Yasuhiko Nishioka
- Graduate School of Biomedical Sciences, Tokushima University, Tokushima, Japan
| | - Eric S White
- Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Vincent Cottin
- National Reference Center, Louis Pradel Hospital, Claude Bernard University Lyon 1, UMR754, Lyon, France
| | - Imre Noth
- Division of Pulmonary and Critical Care Medicine, University of Virginia, Charlottesville, Virginia, USA
| | - Moisés Selman
- Instituto Nacional de Enfermedades Respiratorias "Ismael Cosio Villegas", Mexico City, Mexico
| | | | - Daniel Wachtlin
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim am Rhein, Germany
| | - Claudia Diefenbach
- Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach an der Riss, Germany
| | | |
Collapse
|
49
|
Stowasser S, Quaresma M, Rieck M. Comment on: ‘Pirfenidone Tablets in Idiopathic Pulmonary Fibrosis: A Profile of Their Use’. Drugs Ther Perspect 2018. [DOI: 10.1007/s40267-018-0489-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
50
|
Kreuter M, Wuyts WA, Grutters JC, Richeldi L, Ryerson CJ, Valeyre D, Wiebe S, Stansen W, Quaresma M, Stowasser S, Vancheri C. Pharmacokinetics (PK) of nintedanib with add-on pirfenidone in patients with idiopathic pulmonary fibrosis (IPF): results from INJOURNEY. Pneumologie 2018. [DOI: 10.1055/s-0037-1619239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- M Kreuter
- Center for Interstitial and Rare Lung Diseases, Pneumology, Thoraxklinik, University of Heidelberg; Member of the German Center for Lung Research
| | - WA Wuyts
- Department of Respiratory Medicine, University Hospitals Leuven
| | - JC Grutters
- Ild Center of Excellence, Department of Pulmonology, St. Antonius Hospital, and Division of Heart & Lungs, University Medical Center Utrecht
| | - L Richeldi
- Catholic University of the Sacred Heart, Rome
| | - CJ Ryerson
- University of British Columbia, Vancouver
| | - D Valeyre
- Assistance Publique-Hôpitaux de Paris; Avicenne Hospital University, Bobigny
| | - S Wiebe
- Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach
| | - W Stansen
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim am Rhein
| | - M Quaresma
- Center for Interstitial and Rare Lung Diseases, Pneumology, Thoraxklinik, University of Heidelberg; Member of the German Center for Lung Research; Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim am Rhein
| | - S Stowasser
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim am Rhein
| | - C Vancheri
- Department of Clinical and Experimental Medicine, University of Catania
| |
Collapse
|