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

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.

Anthropometric Factors in the Assessment of Obstructive Sleep Apnea Risk in Patients with Metabolic Syndrome

Metabolic syndrome (MetS) and obstructive sleep apnea (OSA) are related to a higher incidence of cardio-vascular diseases and mortality in patients. The aim of the study was to define the potential use of anthropometric factors for the evaluation of OSA risk in patients with diagnosed MetS. The patient group consisted of 50 obese men with MetS (mean age 49 ± 9 years). The following anthropometric indices were assessed: body mass index (BMI), neck circumference (NC), waist circumference (WC), and waist-to-hip ratio (WHR). In addition, blood glucose and lipid profile were investigated. On the basis of polysomnography, clinical symptoms, and Epworth Sleep Scale, patients were stratified into the OSA group accompanied by MetS (n = 31) and the MetS alone group taken as control (n = 19). OSA was evaluated as severe in 26 out of the 31 patients (>30 apneic episodes per hour). We found a significantly larger NC in the OSA with MetS group then that in the MetS alone group. Further, NC associated with the increase in the apnea/hypopnea index. However, the other anthropometric indices investigated failed to differentiate the two groups. We conclude that increased neck circumference in patients suffering from metabolic syndrome is a risk factor for the development of OSA.

Increased expression of CCL4/MIP-1β in CD8+ cells and CD4+ cells in sarcoidosis

Sarcoidosis is a granulomatous disease with an increased accumulation of T cells in lungs as a result of on-site proliferation and chemotaxis induced by chemokines. It has already been demonstrated that CCL3-5 levels were increased in BAL fluid of sarcoidosis patients. To analyze the expression of CCL3-5 chemokines by T-cell subtypes (CD4+, CD8+, Th1, Th2, Tc1 or Tc2) in the lungs of sarcoidosis patients, fifteen untreated sarcoidosis patients and eighteen control subjects were enrolled in this study. CD4+ and CD8+ cells were isolated from BAL fluid by positive magnetic selection. The expression of CCL3-5 and other cytokines in CD4+ and CD8+ cells were measured by flow cytometry. The percentage of CD4+ or CD8+ cells expressing CCL4 were significantly higher in sarcoidosis patients (22.3% and 58.1%) compared to those seen in healthy subjects (11.1% and 16.5%, P = 0.04 and P = 0.02, respectively). In addition, the expression of CCL3, CCL4 and CCL5 was significantly elevated in CD8+ cells (8.9%, 58.1% and 2.1%) compared to CD4+ cells (2.1%, 22.3% and 0.7%; P = 0.04, P = 0.009 and P = 0.04, respectively), whereas CCL4 was expressed by significantly more Tc1 than Th1 cells in sarcoidosis patients (P = 0.006). Our study shows the possible role of CD8+ cells and CD4+ cells in recruiting T cells to the site of inflammation in sarcoidosis through the release of CCL4, either alone or together with Th1/Tc1-associated cytokines.

COPD pathology in the small airways

In the last quarter of century, the analysis of small airways specimens obtained from chronic obstructive pulmonary disease (COPD) patients compared with those from a control group of age-matched smokers with normal lung function has provided novel insights on the potential role of the different inflammatory and structural cells, pro/anti-inflammatory mediators and intracellular signalling pathways, contributing to a better knowledge of the pathogenesis of stable COPD. This also has provided a scientific rationale for new drugs discovery and targeting to the small airways. This review summarizes and discusses the pathology of small airways of stable COPD patients, of different severity, compared with control smokers with normal lung function.

Interleukin-17 in sputum correlates with airway hyperresponsiveness to methacholine

BACKGROUND

Interleukin-17 (IL-17) is a novel cytokine secreted by activated human memory CD4+ T cells. In vivo IL-17 recruits neutrophils into the airways via the release of CXC chemokines (interleukin-8) from bronchial epithelial cells. Since neutrophils are implicated in pathogenesis of chronic obstructive pulmonary disease (COPD) chronic bronchitis (CB) and asthma, we hypothesized that there would be increased concentration of IL-17 in the airways of these patients. To test this hypothesis, we measured levels of IL-17 in induced sputum of COPD patients, chronic bronchitis and asthmatics and compared them with healthy controls.

METHODS

Levels of IL-17 in induced sputum were measured via ELISA method in 19 COPD, 16 CB, 10 asthma and 11 control subjects. Airway responsiveness to methacholine was performed in people with FEV1 higher than 70% of predicted.

RESULTS

There were no significant differences in IL-17 levels between control group and the other groups. However, levels of IL-17 in sputum of COPD patients were significantly lower than in asthma (P=0.004) and in CB (P=0.01) groups. Medians and (ranges) were as follows: asthma--37.6 pg/ml (18.8-55.7 pg/ml), CB 293 pg/ml (18.8-49.7 pg/ml) and COPD 24.6 pg/ml (0-34.1 pg/ml). Comparison of healthy control subjects (PC20 > 8 mg/ml) to a group with bronchial hyperreactivity, which consisted of asthmatics and CB patients, whose PC20 was less than 8 mg/ml, revealed that levels of IL-17 were significantly increased in the second group (P=0.02). Also, levels of IL-17 were significantly increased (P=0.02) in the asthmatic patients with bronchial hyperreactivity compared to healthy subjects. Moreover levels of IL-17 in sputum of all studied subjects correlated negatively with PC20 (r=-0.51, P=0.002).

CONCLUSIONS

According to our results IL-17 is probably not involved in pathogenesis of stable COPD, but it may play a role in people with airway hyperresponsiveness.

[Risk factors of venous thromboembolism]

Authors discussed the known risk factors of venous thromboembolism (VTE), which is complex disease with two manifestations: deep venous thrombosis (DVT) and pulmonary embolism (PE). Acquired risk factors of VTE are following: age over 40 years, bed rest, surgery, trauma, cancer, myocardial infarction, ischemic stroke, use of oral contraceptives, hormone-replacement therapy, pregnancy and puerperium, previous VTE, long lasting travel and presence of antiphospholipid antibodies. Group of genetic defects predisposing to thromboembolic events are called thrombophilia. The best known causes of thrombophilia are: resistance to activated protein C (factor V Leiden), the prothrombin 20210A, protein C deficiency, protein S deficiency, antithrombin deficiency, hyperhomocysteinemia and abnormality in the fibrinolytic system. Genetic predisposition to thrombosis may be detected in up to one-third of patients with VTER and more than 50% of patients with familial thrombosis. Detection of factor V Leiden is important for patients: with recurrent incidences of VTE, with other known causes of thrombophilia and in members of families with frequent occurrence of VTE. It is important also to detect deficiency of: protein C, protein S and especially of antithrombin in patient with previous VTE, because such patients have 8 to 10 fold increase risk of next incident of VTE. Chronic prevention of thrombosis should be used in all these cases.

[Levels of CC-chemokine (MCP-1 alpha, MIP-1 beta) in induced sputum of patients with chronic obstructive pulmonary disease and patients with chronic bronchitis]

BACKGROUND

MCP-1, MIP-1 alpha and MIP-1 beta are CC-chemokines, which act as chemoattractants for inflammatory cells like macrophages, lymphocytes and eosinophils. These cells are known to be important for development of chronic obstructive pulmonary disease (COPD) and chronic bronchitis (CB).

METHODS

Sputum was obtained from 14 patients with COPD, 12 patients with CB and 14 healthy persons by means of the sputum induction method. The MCP-1, MIP-1 alpha and MIP-1 beta levels were measured in induced sputum via ELISA method.

RESULTS

MIP-1 alpha levels in sputum were significantly higher in CB patients compared to healthy persons (p = 0.01). Median and (range) were following: CB patients--22.7 pg/ml (9.2-95.9 pg/ml), control subjects--17.5 pg/ml (0-27.1 pg/ml). The MIP-1 beta levels in sputum were significantly higher in COPD patients compared to healthy persons (p = = 0.003). Median and (range) were following: COPD patients--173.2 pg/ml (30.6-1880 pg/ml), control subjects--19.0 pg/ml (0-570.5 pg/ml). No significant differences were detected among studied groups for MCP-1 levels in induced sputum. There was positive correlation in CB group between levels of MIP-1 beta and number of eosinophils in gram of sputum (r = 0.81 and p = 0.001).

CONCLUSIONS

MIP-1 alpha maybe important for development of chronic bronchitis and MIP-1 beta for development of chronic obstructive pulmonary disease. MIP-1 beta is probably a chemoattractant for eosinophils in patients with chronic bronchitis.

Sperm capacitation and primary sex ratio

The observations of many years enabled determination of maternal factors which influence the sex of progeny. Factors on side of the father have long been neglected, even though the sex of progeny depends on the sex chromosome in fertilizing spermatozoon. The data obtained by penetration method 'hamster oocyte - human sperm' show differences in the proportion of sperm cells, depending on the method of capacitation used. On this basis the hypothesis has been formulated that the factor which precludes the proportion of sex at fertilization may be different time of capacitation of sperm cells. The cause of the phenomenon remains unclear.

[Rational empiric antibiotic therapy of nosocomial pneumonia]

Antibiotic therapy is the method of choice for treatment of nosocomial pneumonia. It can be divided into empiric and specific therapy. First of them is based on predicting potential pathogens which may cause pneumonia. Important factors modifying the choice of initial empiric therapy are following: clinical history (e.g. time in hospital, type of hospital department, prior usage of antimicrobial agents), severity of pneumonia, presence of other risk factors and information given by direct microscopic examination of pulmonary secretions. Based on them it is frequently possible to select group of possible pathogens and then choose effective antibiotics with broad coverage. After a few days when specific etiology is found and antibiogram is performed antibiotic with narrow coverage should replace previous one. Specific therapy possesses several advantages when comparing with empiric therapy. It is more effective and cheaper. But necessity to wait a few days for the result of culture and its relatively low reliability are clear disadvantages.

[Practical management of nosocomial pneumonia]

Among all nosocomial infections, pneumonia is the second most common (after urinary tract infections) but has the highest mortality rate. Proper antibiotic treatment based on adequate diagnostic methods appears to decrease morbidity and mortality. Practical management of nosocomial pneumonia was shown on graphic diagrams.

[Survey of diagnostic methods used in the management of pneumonia]

Routine examinations done in patients with pneumonia are following: chest radiograph, Gram stain and culture of sputum. For patients who require hospitalization two sets of blood culture should also be performed. Gram stain and culture of pleural fluid are advised in patients with pleural effusion. Serological testing is important in the diagnosis of atypical pneumonia, but they usually provide retrospective information useful mainly in epidemiological studies. Less frequently used methods are following: bacterial antigen-detection and molecular biology techniques, which may be applied to sputum samples and other biological specimens (pleural fluid, blood, urine etc.). Invasive diagnostic techniques (bronchoalveolar lavage (BAL), protected specimen brush (PSB) or transtracheal aspiration (TTA)) are performed mainly in patients with nosocomial pneumonia especially in critically ill ones. For intubated and mechanically ventilated patients those methods are used to confirm the diagnosis of pneumonia, but for other nosocomial patients the aim is to find causative organism. In spite of higher efficiency of invasive techniques (comparing to non-invasive), one should remember that they may cause dangerous complications and thus before applying them it is necessary to consider if potential benefits overweight risk.

[A proposal for management of severe acute bronchial asthma]

The term acute severe asthma has recently replaced status asthmaticus to describe severe asthma attack. Perhaps, this change was associated with better asthma treatment, which prevents currently patients from occurrence of such a severe exacerbation of this disease, to call it status asthmaticus. "Global Initiative for Asthma Global strategy for asthma management and prevention" contains rational guidance on management of this disease, but provide little information about status asthmaticus. This fact was the main reason to prepare present proposal, which was based on suggestion of Global Initiative for Asthma, other current scientific papers and our own experience. We hope that this proposal will begin further discussion, which will bring us closer to more rational solution of this problem.

[Aberration of somatic karyotype in normozoospermic males from infertile couples]

During the complex investigation of couple infertility, a group of 40 normozoospermic males having low density of semen was selected. Cytogenetic analysis revealed 2 cases of somatic karyotype aberrations: 47,XYY and 46,XY,t(14;19), and 2 cases of chromosomal polymorphisms: 46,XYq+ i 46,XY,14p+. In the article the mechanism of fertility disturbances evoked by these findings is discussed in aspects of the function of spermatozoa and its genetic material content.

[Sperm penetration assay in normozoospermia]

The ability of human spermatozoa to fertilization was assessed using hamster oocyte penetration test. The sperm examined after preservation in liquid nitrogen was obtained from 18 males with normozoospermia, 12 infertile and 6 fertile. There was very significant difference between these two groups. Hamster oocyte penetration test could be useful in male infertility diagnostics, especially when routine sperm analysis is normal.

[A method for visualization of chromosomes from human sperm and its application]

A cytogenetic technique for analysis of human sperm chromosomes is described in this article. It is based on penetration of hamster oocytes after enzymatic treatment and inhibition of cell division during pronuclei stage. Two different methods of capacitation of sperm, that is necessary for them to penetrate the eggs have been considered. Attention is paid to manipulations and technical difficulties on consecutive steps of realisation of this method. This method is applied mainly in analysis of chromosome segregation in males, that are carriers of chromosome aberrations. The possibility of using this method in other clinical cases and basic research has been presented.

[A method for demonstrating chromosomes from human sperm and its application]

A cytogenetic technique for analysis of human sperm chromosomes is described in this article. It is based on penetration of hamster oocytes after enzymatic treatment and inhibition of cell division during pronuclei stage. Two different methods of capacitation of sperm, that is necessary for them to penetrate the eggs have been considered. Attention is paid to manipulations and technical difficulties on consecutive steps of realization of this method. This method is applied mainly in analysis of chromosome segregation in males, that are carriers of chromosome aberrations. The possibility of using this method in other clinical cases and basic research has been presented.