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Kulasekararaj A, Glasmacher A, Liu P, Szer J, Araten D, Rauch G, Gwaltney C, Sierra JR, Lee JW. Composite endpoint to evaluate complement inhibition therapy in patients with paroxysmal nocturnal hemoglobinuria. Eur J Haematol Suppl 2022; 108:391-402. [PMID: 35100459 PMCID: PMC9311164 DOI: 10.1111/ejh.13746] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 01/20/2022] [Accepted: 01/21/2022] [Indexed: 12/16/2022]
Abstract
This study developed and explored a novel composite endpoint to assess the overall impact that treatment can have on patients living with paroxysmal nocturnal hemoglobinuria (PNH). Candidate composite endpoint variables were selected by a group of experts and included: lactate dehydrogenase levels as a measure of intravascular hemolysis; complete terminal complement inhibition; absence of major adverse vascular events, including thrombosis; absence of any adverse events leading to death or discontinuation of study treatment; transfusion avoidance; and improvements in fatigue‐related quality of life as determined by the Functional Assessment of Chronic Illness Therapy (FACIT)‐Fatigue score. From these variables, a novel composite endpoint was constructed and explored using data collected in the ravulizumab PNH Study 301 (NCT02946463). Thresholds were defined and reported for each candidate variable. Five of the six candidate variables were included in the final composite endpoint; the FACIT‐Fatigue score was excluded. Composite endpoint criterion was defined as patients meeting all five selected individual component thresholds. All patients in the ravulizumab arm achieved complete terminal complement inhibition and a reduction in lactate dehydrogenase levels; 51.2% and 41.3% of patients in the ravulizumab arm and eculizumab arm, respectively, achieved all composite endpoint component thresholds (treatment difference: 9.4%; 95% confidence interval: −3.0, 21.5). The composite endpoint provided a single and simultaneous measurement of overall benefit for patients receiving treatment for PNH. Use of the composite endpoint in future PNH research is recommended to determine clinical benefit, and its use in health technology assessments should be evaluated.
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Affiliation(s)
- Austin Kulasekararaj
- King's College Hospital, King's College London, and NIHR/Wellcome Trust King's Clinical Research Facility, London, UK
| | - Axel Glasmacher
- AG Life Science Consulting, Alfter, Germany.,Department of Medicine III, University of Bonn, Bonn, Germany
| | - Peng Liu
- Alexion Pharmaceuticals, Inc., Boston, Massachusetts, USA
| | - Jeff Szer
- Peter MacCallum Cancer Centre and The Royal Melbourne Hospital, Melbourne, Australia
| | - David Araten
- New York University Grossman School of Medicine, New York, New York, USA
| | - Geraldine Rauch
- Institute of Biometry and Clinical Epidemiology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Chad Gwaltney
- Gwaltney Consulting, Westerly, Rhode Island, USA.,Brown University, Providence, Rhode Island, USA
| | | | - Jong Wook Lee
- Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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Martinez FJ, Agusti A, Celli BR, Han MK, Allinson JP, Bhatt SP, Calverley P, Chotirmall SH, Chowdhury B, Darken P, Da Silva CA, Donaldson G, Dorinsky P, Dransfield M, Faner R, Halpin DM, Jones P, Krishnan JA, Locantore N, Martinez FD, Mullerova H, Price D, Rabe KF, Reisner C, Singh D, Vestbo J, Vogelmeier CF, Wise RA, Tal-Singer R, Wedzicha JA. Treatment Trials in Young Patients with Chronic Obstructive Pulmonary Disease and Pre-Chronic Obstructive Pulmonary Disease Patients: Time to Move Forward. Am J Respir Crit Care Med 2022; 205:275-287. [PMID: 34672872 PMCID: PMC8886994 DOI: 10.1164/rccm.202107-1663so] [Citation(s) in RCA: 70] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 10/19/2021] [Indexed: 02/03/2023] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is the end result of a series of dynamic and cumulative gene-environment interactions over a lifetime. The evolving understanding of COPD biology provides novel opportunities for prevention, early diagnosis, and intervention. To advance these concepts, we propose therapeutic trials in two major groups of subjects: "young" individuals with COPD and those with pre-COPD. Given that lungs grow to about 20 years of age and begin to age at approximately 50 years, we consider "young" patients with COPD those patients in the age range of 20-50 years. Pre-COPD relates to individuals of any age who have respiratory symptoms with or without structural and/or functional abnormalities, in the absence of airflow limitation, and who may develop persistent airflow limitation over time. We exclude from the current discussion infants and adolescents because of their unique physiological context and COPD in older adults given their representation in prior randomized controlled trials (RCTs). We highlight the need of RCTs focused on COPD in young patients or pre-COPD to reduce disease progression, providing innovative approaches to identifying and engaging potential study subjects. We detail approaches to RCT design, including potential outcomes such as lung function, patient-reported outcomes, exacerbations, lung imaging, mortality, and composite endpoints. We critically review study design components such as statistical powering and analysis, duration of study treatment, and formats to trial structure, including platform, basket, and umbrella trials. We provide a call to action for treatment RCTs in 1) young adults with COPD and 2) those with pre-COPD at any age.
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Affiliation(s)
| | - Alvar Agusti
- Catedra Salut Respiratoria and
- Institut Respiratorio, Hospital Clinic, Barcelona, Spain
- Institut d’investigacions biomediques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Centro de Investigacion Biomedica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Bartolome R. Celli
- Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - MeiLan K. Han
- University of Michigan Health System, Ann Arbor, Michigan
| | - James P. Allinson
- National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Surya P. Bhatt
- Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Peter Calverley
- Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, United Kingdom
| | | | | | | | - Carla A. Da Silva
- Clinical Development, Research and Early Development, Respiratory and Immunology, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Gavin Donaldson
- National Heart and Lung Institute, Imperial College, London, United Kingdom
| | | | - Mark Dransfield
- Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Rosa Faner
- Department of Biomedical Sciences, University of Barcelona, Barcelona, Spain
| | | | - Paul Jones
- St. George’s University of London, London, United Kingdom
| | | | | | | | | | - David Price
- Observational and Pragmatic Research Institute, Singapore
- Centre of Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, United Kingdom
| | - Klaus F. Rabe
- LungenClinic Grosshansdorf, Member of the German Center for Lung Research, Grosshansdorf, Germany
- Department of Medicine, Christian Albrechts University Kiel, Member of the German Center for Lung Research Kiel, Germany
| | | | | | - Jørgen Vestbo
- Manchester University NHS Trust, Manchester, United Kingdom
| | - Claus F. Vogelmeier
- Department of Medicine, Pulmonary and Critical Care Medicine, University of Marburg, Member of the German Center for Lung Research, Marburg, Germany
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Tiotropium/Olodaterol Delays Clinically Important Deterioration Compared with Tiotropium Monotherapy in Patients with Early COPD: a Post Hoc Analysis of the TONADO ® Trials. Adv Ther 2021; 38:579-593. [PMID: 33175291 PMCID: PMC7854451 DOI: 10.1007/s12325-020-01528-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 10/08/2020] [Indexed: 12/19/2022]
Abstract
Introduction Since chronic obstructive pulmonary disease (COPD) is a heterogeneous condition, a composite endpoint of clinically important deterioration (CID) may provide a more holistic assessment of treatment efficacy. We compared long-acting muscarinic antagonist/long-acting β2-agonist combination therapy with tiotropium/olodaterol versus tiotropium alone using a composite endpoint for CID. CID was evaluated overall and in patients with low exacerbation history (at most one moderate exacerbation in the past year [not leading to hospitalisation]), Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2 patients and maintenance-naïve patients with COPD. We assessed whether early treatment optimisation is more effective with tiotropium/olodaterol versus tiotropium in delaying and reducing the risk of CID. Methods Data were analysed from 2055 patients treated with either tiotropium/olodaterol 5/5 μg or tiotropium 5 μg (delivered via Respimat®) in two replicate, 52-week, parallel-group, double-blind studies (TONADO® 1/2). CID was defined as a decline of at least 0.1 L from baseline in trough forced expiratory volume in 1 s, increase from baseline of at least 4 units in St. George’s Respiratory Questionnaire score, or moderate/severe exacerbation. Time to first occurrence of one of these events was recorded as time to first CID. Results Overall, treatment with tiotropium/olodaterol significantly increased the time to, and reduced the risk of, CID versus tiotropium (median time to CID 226 versus 169 days; hazard ratio [HR] 0.76 [95% confidence interval 0.68, 0.85]; P < 0.0001). Significant reductions were also observed in patients with low exacerbation history (241 versus 170; HR 0.73 [0.64, 0.83]; P < 0.0001), GOLD 2 patients (241 versus 169; 0.72 [0.61, 0.84]; P < 0.0001) and maintenance-naïve patients (233 versus 171; 0.75 [0.62, 0.91]; P = 0.0030). Conclusion In patients with COPD, including patients with low exacerbation history, GOLD 2 patients and maintenance-naïve patients, tiotropium/olodaterol reduced the risk of CID versus tiotropium. These results demonstrate the advantages of treatment optimisation with tiotropium/olodaterol over tiotropium monotherapy. Trial Registration ClinicalTrials.gov identifier: TONADO® 1 and 2 (NCT01431274 and NCT01431287, registered 8 September 2011). Graphic Abstract ![]()
Electronic supplementary material The online version of this article (10.1007/s12325-020-01528-2) contains supplementary material, which is available to authorized users. COPD is a complicated disease that deteriorates over time. Worsening of COPD is associated with the lungs working less effectively, a fall in quality of life and a rise in sudden flare-ups of the disease. In this study, we looked at lung function, quality of life and flare-ups together using a measure called “clinically important deterioration” (CID). We looked at 2055 people with COPD to compare the effects of taking two bronchodilators (tiotropium and olodaterol) against taking one bronchodilator (tiotropium alone). Bronchodilators are a type of inhaled medication that relax the muscles in the lungs and widen airways, making it easier to breathe. They have also been shown to reduce sudden flare-ups of COPD. Across a wide range of people with COPD, we found that treatment with tiotropium/olodaterol reduced the risk of a CID compared with tiotropium alone. This includes in those patients at an early stage of disease, who may benefit from finding the best treatment option for them as early as possible.
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Rabe KF, Halpin DMG, Han MK, Miravitlles M, Singh D, Grönke L, Voß F, Martinez FJ. Composite endpoints in COPD: clinically important deterioration in the UPLIFT trial. Respir Res 2020; 21:177. [PMID: 32646424 PMCID: PMC7350568 DOI: 10.1186/s12931-020-01431-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 06/21/2020] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Assessments of lung function, exacerbations and health status are common measures of chronic obstructive pulmonary disease (COPD) progression and treatment response in clinical trials. We hypothesised that a composite endpoint could more holistically assess clinically important deterioration (CID) in a COPD clinical trial setting. METHODS A composite endpoint was tested in a post hoc analysis of 5652 patients with Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2-4 COPD from the 4-year UPLIFT study. Patients received tiotropium 18 μg or placebo. RESULTS The composite endpoint included time to first confirmed decrease in trough forced expiratory volume in 1 s (FEV1) ≥100 mL, confirmed increase in St. George's Respiratory Questionnaire (SGRQ) total score ≥ 4 units, or moderate/severe exacerbation. Most patients (> 80%) experienced CID, with similar incidence among GOLD subgroups. Most confirmed trough FEV1 (74.6-81.6%) and SGRQ (72.3-78.1%) deteriorations were sustained across the study and in all GOLD subgroups. Patients with CID more frequently experienced subsequent exacerbation (hazard ratio [HR] 1.79; 95% confidence interval [CI] 1.67, 1.92) or death (HR 1.21; 95% CI 1.06, 1.39) by Month 6. CID was responsive to bronchodilator treatment. CONCLUSIONS Composite endpoints provide additional information on COPD progression and treatment effects in clinical trials. TRIAL REGISTRATION ClinicalTrials.gov NCT00144339 .
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Affiliation(s)
- Klaus F Rabe
- Member of the German Center for Lung Research (DZL), LungClinic Grosshansdorf, Wöhrendamm 80, 22927, Grosshansdorf, Germany.
- Member of the German Center for Lung Research (DZL), Christian Albrechts University Kiel, Kiel, Germany.
| | - David M G Halpin
- University of Exeter Medical School, College of Medicine and Health, University of Exeter, Exeter, UK
| | - MeiLan K Han
- Division of Pulmonary and Critical Care, University of Michigan Health System, Ann Arbor, MI, USA
| | - Marc Miravitlles
- Pneumology Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Ciber de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| | - Dave Singh
- Medicines Evaluation Unit (MEU), University of Manchester, Manchester University NHS Foundation Trust, Manchester, UK
| | - Lars Grönke
- Clinical Development, CSL Behring GmbH, Marburg, Germany
| | - Florian Voß
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim am Rhein, Germany
| | - Fernando J Martinez
- Department of Internal Medicine, Weill Cornell School of Medicine, New York, NY, USA
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Cardoso J, Coelho R, Rocha C, Coelho C, Semedo L, Bugalho Almeida A. Prediction of severe exacerbations and mortality in COPD: the role of exacerbation history and inspiratory capacity/total lung capacity ratio. Int J Chron Obstruct Pulmon Dis 2018; 13:1105-1113. [PMID: 29670346 PMCID: PMC5896658 DOI: 10.2147/copd.s155848] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Severe exacerbations and mortality are major outcomes in COPD, and risk factors for these events are actively searched for. Several predictors of mortality have been identified in COPD. The inspiratory capacity/total lung capacity (IC/TLC) ratio has been shown to be a strong predictor of all cause and respiratory mortality in patients with COPD. The major objectives of this study were to analyze which clinical parameters, including lung volumes, were the best predictors of the 5-year cumulative risk of hospital admissions or death and the 5-year risk of exacerbations, in stable COPD patients. METHODS This study retrospectively reviewed data from 98 stable COPD patients, consecutively recruited in 2012. Forced expiratory volume in 1 s (FEV1), modified Medical Research Council dyspnea scale, exacerbation history (ExH), Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2011 groups, and lung volumes were reviewed. Five years later, this population was evaluated for cumulative exacerbations, hospital admissions, and mortality. All the population, and GOLD group D separately, were analyzed. RESULTS The cumulative 5-year combined risk of hospital admission or death was significantly predicted by the ExH and the IC/TLC ratio. Analyzing separately group D, FEV1 was the only predictor of this outcome. The frequency of exacerbations in the previous year was the best predictor of future cumulative 5-year risk of subsequent exacerbations, both for the total population and the GOLD D group. CONCLUSION ExH and IC/TLC ratio were the best predictors of the most severe outcomes in COPD (admissions or mortality), independently of COPD severity. FEV1 was the only predictor of the cumulative 5-year combined risk of hospital admission or death in the GOLD D group. ExH was the best predictor of 5-year cumulative future risk of exacerbations. Besides FEV1 and ExH, the IC/TLC ratio can be a useful predictor of severe outcomes in COPD.
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Affiliation(s)
- João Cardoso
- Department of Respiratory Medicine, Hospital de Santa Marta, Centro Hospitalar Lisboa Central, Lisboa, Portugal
- Nova Medical School/ Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Portugal
| | - Ricardo Coelho
- Department of Respiratory Medicine, Hospital de Santa Marta, Centro Hospitalar Lisboa Central, Lisboa, Portugal
| | - Carla Rocha
- Department of Respiratory Medicine, Hospital de Santa Marta, Centro Hospitalar Lisboa Central, Lisboa, Portugal
| | | | - Luísa Semedo
- Department of Respiratory Medicine, Hospital de Santa Marta, Centro Hospitalar Lisboa Central, Lisboa, Portugal
- Nova Medical School/ Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Portugal
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Anzueto AR, Vogelmeier CF, Kostikas K, Mezzi K, Fucile S, Bader G, Shen S, Banerji D, Fogel R. The effect of indacaterol/glycopyrronium versus tiotropium or salmeterol/fluticasone on the prevention of clinically important deterioration in COPD. Int J Chron Obstruct Pulmon Dis 2017; 12:1325-1337. [PMID: 28496316 PMCID: PMC5422319 DOI: 10.2147/copd.s133307] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Endpoints that evaluate deterioration rather than improvement of disease may have clinical utility in COPD. In this analysis, we compared the effects of different maintenance treatments on the prevention of clinically important deterioration (CID) in moderate-to-severe COPD patients. METHODS Data were analyzed from three 26-week studies comparing indacaterol/glycopyrronium (IND/GLY) with tiotropium (TIO) or salmeterol/fluticasone (SFC). Two definitions of CID were used; each was a composite of three outcome measures typically associated with COPD. Definition 1 (D1) comprised a ≥100 mL decrease in forced expiratory volume in 1 second (FEV1), a ≥4-unit increase in St George's Respiratory Questionnaire, and a moderate-to-severe COPD exacerbation. In Definition 2 (D2), a ≥1-unit decrease in transition dyspnea index replaced FEV1. RESULTS Using D1, IND/GLY significantly reduced the risk of first or sustained CID versus either TIO (hazard ratio 0.72 [0.61, 0.86], P=0.0003 and 0.73 [0.61, 0.89], P=0.001) or SFC (0.67 [0.57, 0.80] and 0.63 [0.52, 0.77], both P<0.0001). With D2, IND/GLY significantly reduced the risk of first, but not sustained, CID versus TIO (0.80 [0.64 to 0.99], P=0.0359 and 0.85 [0.66, 1.10], P=0.2208) and both first and sustained CID versus SFC (0.73 [0.61, 0.88], P=0.001 and 0.72 [0.58, 0.90], P=0.0036). CONCLUSION These data confirm the utility of the CID endpoint as a means of monitoring COPD worsening in patients with moderate-to-severe COPD. Using the CID measure, we demonstrated that dual bronchodilation with IND/GLY significantly reduced the risk of CID versus either long-acting muscarinic antagonist or long-acting β2-agonist/inhaled corticosteroid treatment, providing further evidence for the benefit of dual bronchodilation in this patient population.
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Affiliation(s)
- Antonio R Anzueto
- University of Texas Health Science Center
- South Texas Veterans Healthcare System, University of Texas, San Antonio, TX, United States
| | - Claus F Vogelmeier
- Department of Medicine, Pulmonary and Critical Care Medicine, University Medical Center Giessen and Marburg, Philipps-Universität Marburg, Marburg, Germany
| | | | | | - Sebastian Fucile
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, United States
| | | | - Steven Shen
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, United States
| | - Donald Banerji
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, United States
| | - Robert Fogel
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, United States
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