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Schultz A, McLeod C, Berry S, Marsh J, McKenzie A, Messer M, Wood J, Saville B, Jaffe A, Ranganathan S, Stick S, Wark P, Webb S, Snelling T. BEAT CF pulmonary exacerbations core protocol for evaluating the management of pulmonary exacerbations in people with cystic fibrosis. Trials 2023; 24:211. [PMID: 36949472 PMCID: PMC10031862 DOI: 10.1186/s13063-023-07076-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 01/05/2023] [Indexed: 03/24/2023] Open
Abstract
BACKGROUND Cystic fibrosis (CF) is a rare, inherited, life-limiting condition predominantly affecting the lungs, for which there is no cure. The disease is characterized by recurrent pulmonary exacerbations (PEx), which are thought to drive progressive lung damage. Management of these episodes is complex and generally involves multiple interventions targeting different aspects of disease. The emergence of innovative trials and use of Bayesian statistical methods has created renewed opportunities for studying heterogeneous populations in rare diseases. Here, we present the protocol for the BEAT CF PEx cohort, a prospective, multi-site, perpetual, platform enrolling adults and children with CF. The BEAT CF PEx cohort will be used to evaluate the comparative effectiveness of interventions for the treatment of PEx requiring intensive therapy (PERITs), with a primary focus on short-term improvements in lung function. This will be achieved through the conduct of cohort-nested studies, including adaptive clinical trials, within the BEAT CF PEx cohort. This protocol will outline key features of the BEAT CF PEx cohort, including the design, implementation, data collection and management, governance and analysis, and dissemination of results. METHODS This platform will be conducted across multiple sites, commencing with CF treatment centers in Australia. People of all ages with a clinical diagnosis of CF will be eligible to participate, except those who have previously received a lung transplant. Data including demographic and clinical information, treatment details, and outcomes (including safety, microbiology, and patient-reported outcome measures including quality of life scores) will be systematically collected and securely stored via a digital centralized trial management system (CTMS). The primary endpoint is the absolute change in the percentage predicted forced expiratory volume in 1 s (ppFEV1) from the commencement of intensive therapy to 7 to 10 days afterwards. DISCUSSION The BEAT CF PEx cohort will report clinical, treatment, and outcome data for PEx among people with CF and is intended to serve as a core (master) protocol for future nested, interventional trials evaluating treatment(s) for these episodes. The protocols for nested sub-studies are beyond the scope of this document and will be reported separately. TRIAL REGISTRATION ANZCTR BEAT CF Platform - ACTRN12621000638831. Registration date: Sept. 26, 2022.
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Affiliation(s)
- Andre Schultz
- Wal-yan Respiratory Research Centre, Telethon Kids Institute, University of Western Australia, Nedlands, Australia
- Department of Respiratory and Sleep Medicine, Perth Children's Hospital, Nedlands, Australia
| | - Charlie McLeod
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, Nedlands, Australia.
- Department of Infectious Diseases, Perth Children's Hospital, Nedlands, Australia.
| | | | - Julie Marsh
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, Nedlands, Australia
| | - Anne McKenzie
- School of Population and Global Health, University of Western Australia, Nedlands, Australia
| | - Mitch Messer
- Telethon Kids CONNECT, Telethon Kids Institute, Nedlands, Australia
| | - Jamie Wood
- Department of Rehabilitation and Human Performance, Abilities Research Centre, Icahn School of Medicine, Mount Sinai, New York, USA
| | | | - Adam Jaffe
- Discipline of Paediatrics and Child Health, Faculty of Medicine and Health, University of New South Wales, Kensington, Australia
- Sydney Children's Hospital, Randwick, Australia
| | - Sarath Ranganathan
- Department of Paediatrics, University of Melbourne, Parkville, Australia
- Department of Respiratory and Sleep Medicine, Royal Children's Hospital, Parkville, Australia
- Respiratory Diseases Research Group, Infection and Immunity, Murdoch Children's Research Institute, Parkville, Australia
| | - Steve Stick
- Wal-yan Respiratory Research Centre, Telethon Kids Institute, University of Western Australia, Nedlands, Australia
- Department of Respiratory and Sleep Medicine, Perth Children's Hospital, Nedlands, Australia
- School of Population and Global Health, University of Western Australia, Nedlands, Australia
| | - Peter Wark
- Immune Health Program, Hunter Medical Research Institute, University of Newcastle, Callaghan, Australia
- Sleep Medicine Division, John Hunter Hospital, New Lambton Heights, Australia
| | - Steve Webb
- Australian and New Zealand Intensive Care Research Centre, Monash University, Clayton, Australia
- St John of God Hospital, Subiaco, Australia
| | - Tom Snelling
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
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McLeod C, Smyth AR, Messer M, Schultz A, Wood J, Norman R, Blyth CC, Webb S, Elliott Z, Van Devanter D, Stephenson AL, Tong A, Snelling TL. Protocol for establishing a core outcome set for evaluation in studies of pulmonary exacerbations in people with cystic fibrosis. BMJ Open 2022; 12:e056528. [PMID: 36153014 PMCID: PMC9511571 DOI: 10.1136/bmjopen-2021-056528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Pulmonary exacerbations are associated with increased morbidity and mortality in people with cystic fibrosis (CF). There is no consensus about which outcomes should be evaluated in studies of pulmonary exacerbations or how these outcomes should be measured. Outcomes of importance to people with lived experience of the disease are frequently omitted or inconsistently reported in studies, which limits the value of such studies for informing practice and policy. To better standardise outcome reporting and measurement, we aim to develop a core outcome set for studies of pulmonary exacerbations in people with CF (COS-PEX) and consensus recommendations for measurement of core outcomes. METHODS AND ANALYSIS Preliminary work for development of COS-PEX has been reported, including (1) systematic reviews of outcomes and methods for measurement reported in existing studies of pulmonary exacerbations; (2) workshops with people affected by CF within Australia; and (3) a Bayesian knowledge expert elicitation workshop with health professionals to ascertain outcomes of importance. Here we describe a protocol for the additional stages required for COS-PEX development and consensus methods for measurement of core outcomes. These include (1) an international two-round online Delphi survey and (2) consensus workshops to review and endorse the proposed COS-PEX and to agree with methods for measurement. ETHICS AND DISSEMINATION National mutual ethics scheme approval has been provided by the Child and Adolescent Health Service Human Research Ethics Committee (RGS 4926). Results will be disseminated via consumer and research networks and peer-reviewed publications. This study is registered with the Core Outcome Measures in Effectiveness Trials database.
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Affiliation(s)
- Charlie McLeod
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, Perth, Western Australia, Australia
- Infectious Diseases Department, Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - Alan Robert Smyth
- Division of Child Health, Obstetrics and Gynaecology, University of Nottingham, Nottingham, UK
| | - Mitch Messer
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, Perth, Western Australia, Australia
| | - Andre Schultz
- Wal-Yan Respiratory Research Centre, Telethon Kids Institute, The University of Western Australia, Perth, Western Australia, Australia
- Department of Respiratory and Sleep Medicine, Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - Jamie Wood
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Richard Norman
- School of Public Health, Curtin University, Perth, Western Australia, Australia
| | - Christopher C Blyth
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, Perth, Western Australia, Australia
- Infectious Diseases Department, Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - Steve Webb
- Intensive Care Unit, St John of God Health Care, West Perth, Western Australia, Australia
- School of Population Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Zoe Elliott
- Consumer representative, University of Nottingham, Nottingham, UK
| | | | - Anne L Stephenson
- Department of Respirology, St Michael's Hospital, Toronto, Ontario, Canada
| | - Allison Tong
- Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Thomas L Snelling
- School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
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Treatment of Pulmonary Disease of Cystic Fibrosis: A Comprehensive Review. Antibiotics (Basel) 2021; 10:antibiotics10050486. [PMID: 33922413 PMCID: PMC8144952 DOI: 10.3390/antibiotics10050486] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 04/13/2021] [Accepted: 04/17/2021] [Indexed: 01/08/2023] Open
Abstract
Cystic fibrosis (CF) is a genetic disease that causes absence or dysfunction of a protein named transmembrane conductance regulatory protein (CFTR) that works as an anion channel. As a result, the secretions of the organs where CFTR is expressed are very viscous, so their functionality is altered. The main cause of morbidity is due to the involvement of the respiratory system as a result of recurrent respiratory infections by different pathogens. In recent decades, survival has been increasing, rising by around age 50. This is due to the monitoring of patients in multidisciplinary units, early diagnosis with neonatal screening, and advances in treatments. In this chapter, we will approach the different therapies used in CF for the treatment of symptoms, obstruction, inflammation, and infection. Moreover, we will discuss specific and personalized treatments to correct the defective gene and repair the altered protein CFTR. The obstacle for personalized CF treatment is to predict the drug response of patients due to genetic complexity and heterogeneity of uncommon mutations.
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Pulmonary Exacerbations in Adults With Cystic Fibrosis: A Grown-up Issue in a Changing Cystic Fibrosis Landscape. Chest 2021; 159:93-102. [PMID: 32966813 PMCID: PMC7502225 DOI: 10.1016/j.chest.2020.09.084] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 09/11/2020] [Accepted: 09/14/2020] [Indexed: 11/24/2022] Open
Abstract
Pulmonary exacerbations (PExs) are significant life events in people with cystic fibrosis (CF), associated with declining lung function, reduced quality of life, hospitalizations, and decreased survival. The adult CF population is increasing worldwide, with many patients surviving prolonged periods with severe multimorbid disease. In many countries, the number of adults with CF exceeds the number of children, and PExs are particularly burdensome for adults as they tend to require longer courses and more IV treatment than children. The approach to managing PExs is multifactorial and needs to evolve to reflect this changing adult population. This review discusses PEx definitions, precipitants, treatments, and the wider implications to health-care resources. It reviews current management strategies, their relevance in particular to adults with CF, and highlights some of the gaps in our knowledge. A number of studies are underway to try to answer some of the unmet needs, such as the optimal length of treatment and the use of nonantimicrobial agents alongside antibiotics. An overview of these issues is provided, concluding that with the changing landscape of adult CF care, the definitions and management of PExs may need to evolve to enable continued improvements in outcomes across the age spectrum of CF.
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Bhatt J, Jahnke N, Smyth AR. Once-daily versus multiple-daily dosing with intravenous aminoglycosides for cystic fibrosis. Cochrane Database Syst Rev 2019; 9:CD002009. [PMID: 31483853 PMCID: PMC6726357 DOI: 10.1002/14651858.cd002009.pub7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND People with cystic fibrosis, who are chronically colonised with the organism Pseudomonas aeruginosa, often require multiple courses of intravenous aminoglycoside antibiotics for the management of pulmonary exacerbations. The properties of aminoglycosides suggest that they could be given in higher doses less often. This is an update of a previously published review. OBJECTIVES To assess the effectiveness and safety of once-daily versus multiple-daily dosing of intravenous aminoglycoside antibiotics for the management of pulmonary exacerbations in cystic fibrosis. SEARCH METHODS We searched the Cystic Fibrosis Specialist Register held at the Cochrane Cystic Fibrosis and Genetic Disorders Group's editorial base, comprising references identified from comprehensive electronic database searches, handsearching relevant journals and handsearching abstract books of conference proceedings.Date of the most recent search: 31 January 2019.We also searched online trial registries. Date of latest search: 25 February 2019. SELECTION CRITERIA All randomised controlled trials, whether published or unpublished, in which once-daily dosing of aminoglycosides has been compared with multiple-daily dosing in terms of efficacy or toxicity or both, in people with cystic fibrosis. DATA COLLECTION AND ANALYSIS The two authors independently selected the studies to be included in the review and assessed the risk of bias of each study; authors also assessed the quality of the evidence using the GRADE criteria. Data were independently extracted by each author. Authors of the included studies were contacted for further information. As yet unpublished data were obtained for one of the included studies. MAIN RESULTS We identified 15 studies for possible inclusion in the review. Five studies reporting results from a total of 354 participants (aged 5 to 50 years) were included in this review. All studies compared once-daily dosing with thrice-daily dosing. One cross-over trial had 26 participants who received the first-arm treatment but only 15 received the second arm. One study had a low risk of bias for all criteria assessed; the remaining included studies had a high risk of bias from blinding, but for other criteria were judged to have either an unclear or a low risk of bias.There was little or no difference between treatment groups in: forced expiratory volume in one second, mean difference (MD) 0.33 (95% confidence interval (CI) -2.81 to 3.48, moderate-quality evidence); forced vital capacity, MD 0.29 (95% CI -6.58 to 7.16, low-quality evidence); % weight for height, MD -0.82 (95% CI -3.77 to 2.13, low-quality evidence); body mass index, MD 0.00 (95% CI -0.42 to 0.42, low-quality evidence); or in the incidence of ototoxicity, relative risk 0.56 (95% CI 0.04 to 7.96, moderate-quality evidence). Once-daily treatment in children probably improved the percentage change in creatinine, MD -8.20 (95% CI -15.32 to -1.08, moderate-quality evidence), but showed no difference in adults, MD 3.25 (95% CI -1.82 to 8.33, moderate-quality evidence). The included trials did not report antibiotic resistance patterns or quality of life. AUTHORS' CONCLUSIONS Once- and three-times daily aminoglycoside antibiotics appear to be equally effective in the treatment of pulmonary exacerbations of cystic fibrosis. There is evidence of less nephrotoxicity in children.
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Affiliation(s)
- Jayesh Bhatt
- Nottingham University HospitalsPaediatric Respiratory MedicineQMC CampusDerby RoadNottinghamUKNG7 2UH
| | - Nikki Jahnke
- University of LiverpoolDepartment of Women's and Children's HealthAlder Hey Children's NHS Foundation TrustEaton RoadLiverpoolUKL12 2AP
| | - Alan R Smyth
- School of Medicine, University of NottinghamDivision of Child Health, Obstetrics & Gynaecology (COG)Queens Medical CentreDerby RoadNottinghamUKNG7 2UH
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McLeod C, Norman R, Schultz A, Mascaro S, Webb S, Snelling T. Discrete choice experiment to evaluate preferences of patients with cystic fibrosis among alternative treatment-related health outcomes: a protocol. BMJ Open 2019; 9:e030348. [PMID: 31427340 PMCID: PMC6701658 DOI: 10.1136/bmjopen-2019-030348] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Clinical decision-making is a complex process. Patient preference information regarding desirable health states should inform treatment and is critical to agreeing on goals of therapy. Cystic fibrosis (CF) is a common, inheritable multisystem disorder for which the major manifestation is progressive, chronic lung disease. Intermittent pulmonary exacerbations are a hallmark of disease and these drive lung damage that results in premature death. We suspect that clinicians make assumptions, most likely implicit assumptions, about outcomes that are desired by patients who are treated for pulmonary exacerbations. The aim of this study is to identify and quantify the preferences of patients with cystic fibrosis regarding treatment outcomes. METHODS AND ANALYSIS We will develop a discrete choice experiment (DCE) in collaboration with people with CF and their carers, and evaluate how patients make trade-offs between different aspects of health-related status when considering treatment options. ETHICS AND DISSEMINATION Ethics approval for all aspects of this study was granted by the Western Australia Child and Adolescent Health Service Human Research Ethics Committee [RGS903]. Weighted preference information from the DCE will be used to develop a multiattribute utility instrument as a measure of treatment success in the upcoming Bayesian Evidence-Adaptive Trial to optimise management of CF. Dissemination of results will also occur through peer-reviewed publications and presentations to relevant stakeholders and research networks.
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Affiliation(s)
- Charlie McLeod
- Infectious Diseases, Perth Children's Hospital, Nedlands, Western Australia, Australia
- School of Medicine, University of Western Australia, Nedlands, Western Australia, Australia
| | - Richard Norman
- School of Public Health, Curtin University, Bentley, Western Australia, Australia
| | - Andre Schultz
- Respiratory Medicine, Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - Steven Mascaro
- Clayton School of IT, Monash University, Clayton, Victoria, Australia
| | - Steve Webb
- Intensive care, St John of God Hospital, Subiaco, Western Australia, Australia
- School of Population Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Tom Snelling
- Infectious Diseases, Perth Children's Hospital, Nedlands, Western Australia, Australia
- Wesfarmers Centre of Vaccines & Infectious Diseases, Telethon Kids Institute, West Perth, Western Australia, Australia
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Schultz A, Marsh JA, Saville BR, Norman R, Middleton PG, Greville HW, Bellgard MI, Berry SM, Snelling T. Trial Refresh: A Case for an Adaptive Platform Trial for Pulmonary Exacerbations of Cystic Fibrosis. Front Pharmacol 2019; 10:301. [PMID: 30983998 PMCID: PMC6447696 DOI: 10.3389/fphar.2019.00301] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 03/11/2019] [Indexed: 12/21/2022] Open
Abstract
Cystic fibrosis is a genetic disease typically characterized by progressive lung damage and premature mortality. Pulmonary exacerbations, or flare-ups of the lung disease, often require hospitalization for intensive treatment. Approximately 25% of patients with cystic fibrosis do not recover their baseline lung function after pulmonary exacerbations. There is a relative paucity of evidence to inform treatment strategies for exacerbations. Compounding this lack of evidence, there are a large number of treatment options already as well as becoming available. This results in significant variability between medication regimens prescribed by different physicians, treatment centers and regions with potentially adverse impact to patients. The conventional strategy is to undertake essential randomized clinical trials to inform treatment decisions and improve outcomes for patients with exacerbations. However, over the past several decades, clinical trials have generally failed to provide information critical to improved treatment and management of exacerbations. Bayesian adaptive platform trials hold the promise of addressing clinical uncertainties and informing treatment. Using modeling and response adaptive randomization, they allow for the evaluation of multiple treatments across different management domains, and progressive improvement in patient outcomes throughout the course of the trial. Bayesian adaptive platform trials require substantial amounts of preparation. Basic preparation includes extensive stakeholder involvement including elicitation of consumer preferences and clinician understanding of the research topic, defining the research questions, determining the best outcome measures, delineating study sub-groups, in depth statistical modeling, designing end-to-end digital solutions seamlessly supporting clinicians, researchers and patients, constructing randomisation algorithms and importantly, defining pre-determined intra-study end-points. This review will discuss the motivation and necessary steps required to embark on a Bayesian adaptive platform trial to optimize medication regimens for the treatment of pulmonary exacerbations of cystic fibrosis.
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Affiliation(s)
- Andre Schultz
- Faculty of Health and Medical Sciences, The University of Western Australia, Crawley, WA, Australia.,Department of Respiratory Medicine, Perth Children's Hospital, Nedlands, WA, Australia.,Wesfarmers Centre of Vaccines & Infectious Diseases, Telethon Kids Institute, The University of Western Australia, Nedlands, WA, Australia
| | - Julie A Marsh
- Wesfarmers Centre of Vaccines & Infectious Diseases, Telethon Kids Institute, The University of Western Australia, Nedlands, WA, Australia.,School of Population and Global Health, The University of Western Australia, Nedlands, WA, Australia
| | - Benjamin R Saville
- Berry Consultants, Austin, TX, United States.,Department of Biostatistics, Vanderbilt University, Nashville, TN, United States
| | - Richard Norman
- School of Public Health, Curtin University, Bentley, WA, Australia
| | - Peter G Middleton
- Ludwig Engel Centre for Respiratory Research, Westmead Institute for Medical Research, Sydney, NSW, Australia
| | - Hugh W Greville
- Department of Thoracic Medicine, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Matthew I Bellgard
- eResearch Office, Queensland University of Technology, Brisbane, QLD, Australia
| | | | - Tom Snelling
- Wesfarmers Centre of Vaccines & Infectious Diseases, Telethon Kids Institute, The University of Western Australia, Nedlands, WA, Australia.,School of Public Health, Curtin University, Bentley, WA, Australia.,Department of Infectious Diseases, Perth Children's Hospital, Nedlands, WA, Australia.,Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia
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Innovating cystic fibrosis clinical trial designs in an era of successful standard of care therapies. Curr Opin Pulm Med 2018; 23:530-535. [PMID: 28708817 DOI: 10.1097/mcp.0000000000000418] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
PURPOSE OF REVIEW Evolving cystic fibrosis 'standards of care' have influenced recent cystic fibrosis clinical trial designs for new therapies; care additions/improvements will require innovative trial designs to maximize feasibility and efficacy detection. RECENT FINDINGS Three cystic fibrosis therapeutic areas (pulmonary exacerbations, Pseudomonas aeruginosa airway infections, and reduced cystic fibrosis transmembrane conductance regulator [CFTR] protein function) differ with respect to the duration for which recognized 'standards of care' have been available. However, developers of new therapies in all the three areas are affected by similar challenges: standards of care have become so strongly entrenched that traditional placebo-controlled studies in cystic fibrosis populations likely to benefit from newer therapies have become less and less feasible. Today, patients/clinicians are more likely to entertain participation in active-comparator trial designs, that have substantial challenges of their own. Foremost among these are the selection of 'valid' active comparator(s), estimation of a comparator's current clinical efficacy (required for testing noninferiority hypotheses), and effective blinding of commercially available comparators. SUMMARY Recent and future cystic fibrosis clinical trial designs will have to creatively address this collateral result of successful past development of effective cystic fibrosis therapies: patients and clinicians are much less likely to accept simple, placebo-controlled studies to evaluate future therapies.
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Heltshe SL, West NE, VanDevanter DR, Sanders DB, Beckett VV, Flume PA, Goss CH. Study design considerations for the Standardized Treatment of Pulmonary Exacerbations 2 (STOP2): A trial to compare intravenous antibiotic treatment durations in CF. Contemp Clin Trials 2017; 64:35-40. [PMID: 29170074 DOI: 10.1016/j.cct.2017.11.012] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Revised: 11/14/2017] [Accepted: 11/18/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND Pulmonary exacerbations (PEx) in cystic fibrosis (CF) are common and contribute to morbidity and mortality. Duration of IV antibiotic therapy to treat PEx varies widely in the US, and there are few data to guide treatment decisions. METHODS We combined a survey of CF stakeholders with retrospective analyses of a recent observational study of CF PEx to design a multicenter, randomized, prospective study comparing the efficacy and safety of different durations of IV antibiotics for PEx to meet the needs of people with CF and their caregivers. RESULTS IV antibiotic duration was cited as the most important PEx research question by responding CF physicians and top concern among surveyed CF patients/caregivers. During PEx, forced expiratory volume in 1s (FEV1% predicted) and symptom responses at 7-10days of IV antibiotics identified two distinct groups: early robust responders (ERR) who subsequently experienced greater FEV1 improvements compared to non-ERR (NERR). In addition to greater FEV1 and symptom responses, only 14% of ERR patients were treated with IV antibiotics for >15days, compared with 45% of NERR patients. CONCLUSIONS A divergent trial design that evaluates subjects' interim improvement in FEV1 and symptoms to tailor randomization to IV treatment duration (10 vs. 14days for ERR, 14 vs. 21days for NERR) may alleviate physician and patient concerns about excess or inadequate treatment. Such a study has the potential to provide evidence necessary to standardize IV antibiotic duration in CF PEx care -a first step to conducting PEx research of other treatment features.
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Affiliation(s)
- Sonya L Heltshe
- CFF Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, WA 98121, USA; Department of Pediatrics, University of Washington School of Medicine, Seattle, WA 98195, USA.
| | - Natalie E West
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | | | - D B Sanders
- Department of Pediatrics, Riley Hospital for Children, School of Medicine, Indiana University, Indiana, IN 46202, USA
| | - Valeria V Beckett
- CFF Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, WA 98121, USA
| | - Patrick A Flume
- Departments of Medicine and Pediatrics, Medical University of South Carolina, Charleston, SC 29425, USA
| | - Christopher H Goss
- CFF Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, WA 98121, USA; Department of Pediatrics, University of Washington School of Medicine, Seattle, WA 98195, USA; Division of Pulmonary Medicine, Department of Medicine, University of Washington School of Medicine, Seattle, WA 98121, USA
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Athanazio RA, Silva Filho LVRFD, Vergara AA, Ribeiro AF, Riedi CA, Procianoy EDFA, Adde FV, Reis FJC, Ribeiro JD, Torres LA, Fuccio MBD, Epifanio M, Firmida MDC, Damaceno N, Ludwig-Neto N, Maróstica PJC, Rached SZ, Melo SFDO. Brazilian guidelines for the diagnosis and treatment of cystic fibrosis. ACTA ACUST UNITED AC 2017; 43:219-245. [PMID: 28746534 PMCID: PMC5687954 DOI: 10.1590/s1806-37562017000000065] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2017] [Accepted: 05/22/2017] [Indexed: 12/15/2022]
Abstract
Cystic fibrosis (CF) is an autosomal recessive genetic disorder characterized by dysfunction of the CFTR gene. It is a multisystem disease that most often affects White individuals. In recent decades, various advances in the diagnosis and treatment of CF have drastically changed the scenario, resulting in a significant increase in survival and quality of life. In Brazil, the current neonatal screening program for CF has broad coverage, and most of the Brazilian states have referral centers for the follow-up of individuals with the disease. Previously, CF was limited to the pediatric age group. However, an increase in the number of adult CF patients has been observed, because of the greater number of individuals being diagnosed with atypical forms (with milder phenotypic expression) and because of the increase in life expectancy provided by the new treatments. However, there is still great heterogeneity among the different regions of Brazil in terms of the access of CF patients to diagnostic and therapeutic methods. The objective of these guidelines was to aggregate the main scientific evidence to guide the management of these patients. A group of 18 CF specialists devised 82 relevant clinical questions, divided into five categories: characteristics of a referral center; diagnosis; treatment of respiratory disease; gastrointestinal and nutritional treatment; and other aspects. Various professionals working in the area of CF in Brazil were invited to answer the questions devised by the coordinators. We used the PubMed database to search the available literature based on keywords, in order to find the best answers to these questions.
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Affiliation(s)
- Rodrigo Abensur Athanazio
- . Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | | | - Alberto Andrade Vergara
- . Hospital Infantil João Paulo II, Rede Fundação Hospitalar do Estado de Minas Gerais - FHEMIG - Belo Horizonte (MG) Brasil
| | | | | | | | - Fabíola Villac Adde
- . Instituto da Criança, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | - Francisco José Caldeira Reis
- . Hospital Infantil João Paulo II, Rede Fundação Hospitalar do Estado de Minas Gerais - FHEMIG - Belo Horizonte (MG) Brasil
| | - José Dirceu Ribeiro
- . Hospital de Clínicas, Universidade Estadual de Campinas, Campinas (SP) Brasil
| | - Lídia Alice Torres
- . Hospital das Clínicas, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto (SP) Brasil
| | - Marcelo Bicalho de Fuccio
- . Hospital Júlia Kubitschek, Fundação Hospitalar do Estado de Minas Gerais - FHEMIG - Belo Horizonte (MG) Brasil
| | - Matias Epifanio
- . Hospital São Lucas, Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre (RS) Brasil
| | | | - Neiva Damaceno
- . Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo (SP) Brasil
| | - Norberto Ludwig-Neto
- . Hospital Infantil Joana de Gusmão, Florianópolis (SC) Brasil.,. Serviço de Fibrose Cística e Triagem Neonatal para Fibrose Cística, Secretaria Estadual de Saúde de Santa Catarina, Florianópolis (SC) Brasil
| | - Paulo José Cauduro Maróstica
- . Hospital de Clínicas de Porto Alegre, Porto Alegre (RS) Brasil.,. Universidade Federal do Rio Grande do Sul Porto Alegre (RS) Brasil
| | - Samia Zahi Rached
- . Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
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12
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Hoo ZH, Wildman MJ, Curley R, Walters SJ, Campbell MJ. Rescue therapy within the UK Cystic Fibrosis Registry: An exploration of predictors of intravenous antibiotic use amongst adults with CF. Respirology 2017; 23:190-197. [PMID: 28905459 PMCID: PMC5813205 DOI: 10.1111/resp.13174] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Revised: 06/06/2017] [Accepted: 07/17/2017] [Indexed: 01/09/2023]
Abstract
Background and objective Intravenous (i.v.) antibiotics are needed for rescue when preventative therapy fails to achieve stability among adults with cystic fibrosis (CF). Understanding the distribution of i.v. days can provide insight into the care that adults with CF need. We aim to determine the baseline characteristics that are associated with higher i.v. use, in particular to test the hypothesis that prior‐year i.v. use is associated with future‐year i.v. use. Methods This is a cross‐sectional analysis of the 2013–2014 UK CF registry data. Stepwise logistic regression was performed using current‐year i.v. days as the dependent variable, and demographic variables including prior‐year i.v. days as the covariates. Based on these results, study sample was divided into clinically meaningful subgroups using analysis similar to tree‐based method. Results Data were available for 4269 adults in 2013 and 4644 adults in 2014. Prior‐year i.v. use was the strongest predictor for current‐year i.v. use followed by forced expiratory volume in 1 s (FEV1). Adults with high prior‐year i.v. use (>14 days) continued to require high levels of i.v., regardless of FEV1. Those with high prior‐year i.v. use and FEV1 ≥70% had higher current‐year i.v. days compared to adults with low prior‐year i.v. use and FEV1 <40% (28 days, interquartile range (IQR): 11–41 days vs 14 days, IQR: 0–28 days; Mann–Whitney P‐value <0.001 in 2013). Conclusion CF people with prior high levels of rescue often continue to need high levels of rescue even if they have good FEV1. The reasons for this require further investigations. Intravenous (i.v.) antibiotic is an important treatment option in cystic fibrosis and is also a marker of pulmonary exacerbations. Our study showed that previous‐year i.v. use is a strong predictor of current‐year i.v. use. This finding could help clinicians to identify people most at risk of future exacerbation.
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Affiliation(s)
- Zhe Hui Hoo
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK.,Sheffield Adult CF Centre, Northern General Hospital, Sheffield, UK
| | - Martin J Wildman
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK.,Sheffield Adult CF Centre, Northern General Hospital, Sheffield, UK
| | - Rachael Curley
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK.,Sheffield Adult CF Centre, Northern General Hospital, Sheffield, UK
| | - Stephen J Walters
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Michael J Campbell
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
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Smyth AR, Bhatt J, Nevitt SJ. Once-daily versus multiple-daily dosing with intravenous aminoglycosides for cystic fibrosis. Cochrane Database Syst Rev 2017; 3:CD002009. [PMID: 28349527 PMCID: PMC6464251 DOI: 10.1002/14651858.cd002009.pub6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND People with cystic fibrosis, who are chronically colonised with the organism Pseudomonas aeruginosa, often require multiple courses of intravenous aminoglycoside antibiotics for the management of pulmonary exacerbations. The properties of aminoglycosides suggest that they could be given in higher doses less often. This is an update of a previously published review. OBJECTIVES To assess the effectiveness and safety of once-daily versus multiple-daily dosing of intravenous aminoglycoside antibiotics for the management of pulmonary exacerbations in cystic fibrosis. SEARCH METHODS We searched the Cystic Fibrosis Specialist Register held at the Cochrane Cystic Fibrosis and Genetic Disorders Group's editorial base, comprising references identified from comprehensive electronic database searches, handsearching relevant journals and handsearching abstract books of conference proceedings.Date of the most recent search: 24 June 2016. SELECTION CRITERIA All randomised controlled trials, whether published or unpublished, in which once-daily dosing of aminoglycosides has been compared with multiple-daily dosing in terms of efficacy or toxicity or both, in people with cystic fibrosis. DATA COLLECTION AND ANALYSIS The two authors independently selected the studies to be included in the review and assessed the risk of bias of each study; authors also assessed the quality of the evidence using the GRADE criteria. Data were independently extracted by each author. Authors of the included studies were contacted for further information. As yet unpublished data were obtained for one of the included studies. MAIN RESULTS Fifteen studies were identified for possible inclusion in the review. Four studies reporting results from a total of 328 participants (aged 5 to 50 years) were included in this review. All studies compared once-daily dosing with thrice-daily dosing. One study had a low risk of bias for all criteria assessed; the remaining three included studies had a high risk of bias from blinding, but for other criteria were judged to have either an unclear or a low risk of bias.There was no significant difference between treatment groups in: forced expiratory volume in one second, mean difference 0.33 (95% confidence interval -2.81 to 3.48, moderate quality evidence); forced vital capacity, mean difference 0.29 (95% confidence interval -6.58 to 7.16, low quality evidence); % weight for height, mean difference -0.82 (95% confidence interval -3.77 to 2.13, low quality evidence); body mass index, mean difference 0.00 (95% confidence interval -0.42 to 0.42, low quality evidence); or in the incidence of ototoxicity, relative risk 0.56 (95% confidence interval 0.04 to 7.96, moderate quality evidence). The percentage change in creatinine significantly favoured once-daily treatment in children, mean difference -8.20 (95% confidence interval -15.32 to -1.08, moderate quality evidence), but showed no difference in adults, mean difference 3.25 (95% confidence interval -1.82 to 8.33, moderate quality evidence). The included trials did not report antibiotic resistance patterns or quality of life. AUTHORS' CONCLUSIONS Once- and three-times daily aminoglycoside antibiotics appear to be equally effective in the treatment of pulmonary exacerbations of cystic fibrosis. There is evidence of less nephrotoxicity in children.
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Affiliation(s)
- Alan R Smyth
- School of Medicine, University of NottinghamDivision of Child Health, Obstetrics & Gynaecology (COG)Queens Medical CentreDerby RoadNottinghamUKNG7 2UH
| | - Jayesh Bhatt
- Nottingham University HospitalsPaediatric Respiratory MedicineQMC CampusDerby RoadNottinghamUKNG7 2UH
| | - Sarah J Nevitt
- University of LiverpoolDepartment of BiostatisticsBlock F, Waterhouse Building1‐5 Brownlow HillLiverpoolUKL69 3GL
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Abstract
This article describes the nature and significance of pulmonary exacerbations in cystic fibrosis (CF). The effectiveness and safety of current exacerbation treatment are explored. The article concludes with a summary of clinical trials (completed and ongoing) which aim to improve the efficacy and safety of exacerbation treatment.
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Affiliation(s)
- Alan Smyth
- School of Medicine, University of Nottingham.
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Affiliation(s)
- Sonya L. Heltshe
- Department of Pediatrics, University of Washington School of
Medicine, Seattle, WA
- Cystic Fibrosis Foundation Therapeutics Development Network
Coordinating Center, Seattle Children’s Research Institute, Seattle,
WA
| | - Christopher H. Goss
- Division of Pulmonary and Critical Care Medicine, Department of
Medicine, University of Washington School of Medicine Seattle, WA
- Department of Pediatrics, University of Washington School of
Medicine, Seattle, WA
- Cystic Fibrosis Foundation Therapeutics Development Network
Coordinating Center, Seattle Children’s Research Institute, Seattle,
WA
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Hurley MN, Prayle AP, Flume P. Intravenous antibiotics for pulmonary exacerbations in people with cystic fibrosis. Paediatr Respir Rev 2015; 16:246-8. [PMID: 26298057 DOI: 10.1016/j.prrv.2015.07.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Accepted: 07/09/2015] [Indexed: 11/18/2022]
Affiliation(s)
- Matthew N Hurley
- Department of Child Health, School of Clinical Sciences, University of Nottingham, Nottingham, UK; Paediatric Respiratory Medicine, Nottingham University Hospitals NHS Trust, Nottingham, UK.
| | - Andrew P Prayle
- Department of Child Health, School of Clinical Sciences, University of Nottingham, Nottingham, UK
| | - Patrick Flume
- Department of Medicine, Division of Pulmonary and Critical Care, Medical University of South Carolina, Charleston, South Carolina, USA
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Hurley M, Smyth A. Fluoroquinolones in the treatment of bronchopulmonary disease in cystic fibrosis. Ther Adv Respir Dis 2012; 6:363-73. [PMID: 22968160 PMCID: PMC3509170 DOI: 10.1177/1753465812459899] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Fluoroquinolones are commonly used to treat lung infections in patients with cystic fibrosis. These patients are susceptible to lung infection with common bacteria such as Staphylococcus aureus and Haemophilus influenzae, but are also prone to infection by opportunistic bacteria, including Pseudomonas aeruginosa. The good oral bioavailability and broad antimicrobial spectrum of activity, including antipseudomonal properties, make this class of antimicrobial attractive. We review the evidence assessing the use of fluoroquinolones in the context of preventing and eradicating early lung infection and in managing chronic lung infection and pulmonary exacerbations. The safety of fluoroquinolones and the use of newer agents in the class are also discussed.
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Affiliation(s)
- Matthew Hurley
- Division of Child Health, University of Nottingham, Queens Medical Centre, Nottingham, UK.
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