Roflumilast in Non-CF Bronchiectasis Study (2019)
Keywords
Abstract
Description
In a 4-week crossover study in 38 patients with COPD, roflumilast 500μg daily significantly reduced sputum absolute neutrophil count, IL-8 and neutrophil elastase compared with placebo treatment. Interestingly, the mechanism of anti-neutrophilic inflammation with roflumilast treatment in patients with COPD was recently found to be mediated through decreasing prolyl endopeptidase activity and acetyl-proline-glycine-proline (AcPGP), thus providing a clear biological plausibility for clinical activity of roflumilast. The clinical benefits of roflumilast treatment in COPD were subsequently demonstrated in 2 identical RCTs involving 3,096 patients with COPD having severe airflow limitation and history of exacerbations. Treatment with roflumilast 500μg daily resulted in better prebronchodilator FEV1 (by 48 ml in 52 weeks) and lower rate of exacerbations (reduction by 17%) compared with placebo treatment. The benefit of roflumilast on lung function has also been confirmed in another 2 identical RCTs among those patients with moderate to severe COPD already treated with long-acting bronchodilators (salmeterol or tiotropium). The mean pre-bronchodilator FEV1 was significantly improved with roflumilast compared to placebo treatment for 24 weeks by 49ml and 80ml respectively in patients with COPD already treated with salmeterol and tiotropium respectively. More recently, among patients with more severe COPD requiring combination ICS/long-acting β2 agonist, roflumilast treatment for 52 weeks significantly reduced the rate of moderate-to-severe exacerbations by 13.2% compared to placebo group. The safety and adverse effects of roflumilast have been well-tolerated, resulting in worldwide (including Hong Kong) approval for clinical use in COPD. The common adverse effects of roflumilast treatment include weight reduction (>10% loss in 7% subjects), decreased appetite (2%), insomnia (2%), headache (4%), diarrhea (10%) and nausea (5%).
Our group has previously embarked on various clinical studies in non-CF bronchiectasis: a 4-week treatment of inhaled fluticasone (ICS) compared with placebo (1), a subsequent 52-week randomized controlled trial of inhaled fluticasone in 86 patients (4), and a separate study on sputum elastase in 30 patients (2). These support the feasibility of conducting similar clinical trials, like the current proposal, on non-CF bronchiectasis in our unit. To prepare for the current study proposal, we have conducted a pilot and feasibility study of 4-week treatment of roflumilast in stable-state non-CF bronchiectasis with the exact inclusion/exclusion criteria as the current proposal (HKU/HA HKW IRB approval no. UW 17-444) since March 2018. Up to January 2019, we have successfully recruited 15 eligible study subjects. The initial study protocol mandated the starting dose of roflumilast at 500 microgram daily. The first two study subjects experienced intolerable gastrointestinal side effects within 1-2 weeks of treatment, leading to premature treatment cessation. An amended study protocol (HKU/HA HKW IRB approval dated 24 July 2018) was approved that allowed a lower initiating dose of 250 microgram daily, which is in line with the current recommended prescription in COPD patients. Nine out of the subsequent 13 subjects (including the most recent 8 subjects consecutively) were able to complete roflumilast 250 microgram daily treatment for a total of 4 weeks, with less than grade 1 toxicities. The characteristics of the nine per-protocol study subjects include: M:F=4:5, age of 69.9 ± 9.1 years (mean ± SD) and baseline 24-h sputum volume of 30.00 ± 26.93 ml (for all 15 subjects: 27.47 ± 22.59 ml). The preliminary results showed insignificant change in sputum volume and a trend of reduced sputum IL-1β (pre- vs post-treatment: 10.84 vs 2.63 ng/ml, p=0.102). This indicates a possible anti-inflammatory effect of roflumilast in non-CF bronchiectasis with just 4 weeks of treatment, though this pilot was meant for feasibility study and not powered to detect significant change. The true benefit will likely require a longer duration of treatment (thus proposing 12 weeks in this study) with sufficient sample size.
This study aims to investigate the effect of 12-week treatment with roflumilast on neutrophilic airway inflammation in stable-state non-CF bronchiectasis. The primary outcome measure is 24-h sputum volume. The extent of airway inflammation in non-CF bronchiectasis is indicated by sputum leukocyte density, pro-inflammatory cytokines (IL-1β, IL-8, TNF-alpha, LTB4 and IL-17) and neutrophil elastase. Health-related quality of life (HRQoL) is a key secondary outcome. We hypothesize that 12-week treatment of roflumilast in stable-state non-CF bronchiectasis can result in: (1) reduction in 24-h sputum volume (primary hypothesis); (2) reduction in sputum leukocyte density; (3) reduction in sputum pro-inflammatory cytokines (IL-1β, IL-8, TNF-alpha, and IL-17) and LTB4; (4) reduction in sputum neutrophil elastase; (5) no change in sputum bacterial colonization and load; (6) improvement in HRQoL.
Dates
| Last Verified: | 02/29/2020 |
| First Submitted: | 03/23/2020 |
| Estimated Enrollment Submitted: | 03/23/2020 |
| First Posted: | 03/25/2020 |
| Last Update Submitted: | 03/23/2020 |
| Last Update Posted: | 03/25/2020 |
| Actual Study Start Date: | 04/29/2020 |
| Estimated Primary Completion Date: | 02/27/2022 |
| Estimated Study Completion Date: | 06/29/2022 |
Condition or disease
Intervention/treatment
Drug: Oral roflumilast
Phase
Arm Groups
| Arm | Intervention/treatment |
|---|---|
| Experimental: Oral roflumilast Oral roflumilast 250 microgram daily will be started at the baseline visit for 4 weeks. For those who can tolerate the initial 4-week treatment, roflumilast will be increased to 500 microgram daily, allowing subsequent dose reduction back to 250 microgram daily in case of CTCAE grade 3 or 4 toxicities. | Drug: Oral roflumilast Roflumilast, a phosphodiesterase 4 (PDE4) inhibitor is approved worldwide (including Hong Kong) for treatment of severe chronic obstructive pulmonary disease (COPD) with frequent exacerbations. Roflumilast has been shown to have anti-inflammatory effect in patients with COPD, with significant reduction of sputum absolute neutrophil count, IL-8 and neutrophil elastase compared with placebo treatment. Roflumilast can also improve the lung function parameters in patients with COPD and reduce the rate of moderate-to-severe exacerbations. |
Eligibility Criteria
| Ages Eligible for Study | 18 Years To 18 Years |
| Sexes Eligible for Study | All |
| Accepts Healthy Volunteers | Yes |
| Criteria | Inclusion Criteria: 1. Aged 18 years or above, male or female. 2. Never-smokers or those who have smoked less than 100 cigarettes in their lifetime. 3. Confirmed diagnosis of non-CF bronchiectasis based on high-resolution computed tomography (HRCT) scan. 4. Significant sputum production (≥ 10 ml per day). 5. In stable-state bronchiectasis with no change in regular medications (e.g. inhaled steroid, macrolide) or exacerbations in the past 3 months. 6. Written informed consent obtained. Exclusion Criteria: 1. Eversmokers (≥ 100 cigarettes in their lifetime). 2. Known chronic obstructive pulmonary disease or asthma. 3. Moderate to severe liver impairment (Child-Pugh B or C). 4. Known psychiatric illness with increased suicidal risks. 5. Body-mass index below 18 kg/m2. 6. Concomitant use of strong cytochrome P450 inducers (e.g. rifampicin, phenobarbital, carbamazepine, phenytoin). 7. Patients who are hypersensitive to roflumilast or its constituents. 8. Pregnant or lactating women. |
Outcome
Primary Outcome Measures
1. 24-hour sputum volume [Reduction in 24-h sputum volume in 12 weeks]
Secondary Outcome Measures
1. Sputum leukocyte density [Reduction in sputum leukocyte density in 12 weeks]
2. Sputum pro-inflammatory cytokines (IL-1β, IL-8, TNF-alpha, and IL-17) and LTB4 [Reduction in sputum pro-inflammatory cytokines in 12 weeks]
3. Sputum neutrophil elastase [Reduction in sputum neutrophil elastase in 12 weeks]
4. Sputum bacterial colonization and load [No change in sputum bacterial colonization and load in 12 weeks]
5. Health-related quality of life (HRQoL) [Improvement in HRQoL in 12 weeks]
