Effect of Sublingual Fentanyl on Breathlessness in COPD : A Randomized Cross-over Trial
试验速览
- 阶段
- 2 期
- 状态
- 终止
- 入组人数
- 40
- 试验地点
- 1
- 主要终点
- Breathlessness
研究概览
简要总结
There is actually no physiologic or clinical data in the literature to clearly define the potential benefits and side effects of sublingual fentanyl in patients with COPD. Therefore, the purpose of this study is to test the hypothesis that sublingual fentanyl will improve exercise capacity and dyspnea control in severe COPD patients experiencing persistent breathlessness despite optimal management.
详细描述
The purpose of this study is to test the hypothesis that sublingual fentanyl will improve exercise capacity and dyspnea control in severe COPD patients experiencing persistent breathlessness despite optimal management.
To demonstrate the effectiveness of sublingual fentanyl, the investigators suggest a dose of 12,5 mcg. The investigators base this decision on several considerations :
- Local practice and experience : the safety of a dose of 12,5 mcg of sublingual fentanyl has been show in the investigators local experience (see section 1.3 Clinical experience with fentanyl).
- Although there is not enough information to determine the exact equivalence between sublingual fentanyl and oral morphine, the conversion between intravenous fentanyl and oral morphine can be done. Based on the monograph of fentanyl citrate, 10 mcg of intravenous fentanyl citrate are equivalent to 10 mg of intravenous morphine, which are equivalent to 20 to 30 mg of oral morphine. Subsequently, 12,5 mcg of sublingual fentanyl may be equivalent to a oral morphine dose between 2,5 and 3,75 milligrams. This represent a smaller dose than the dose of 0,1 mg/kg oral morphine that was demonstrated to be safe in a recent study done by a group at McGill in a severe COPD population (Abdallah et al. Eur Respir J 2017; 50: 1701235).
- The study will only include patients who are already on morphine, because they represent the target population and have less risk of adverse events than an opioid-naive population.
- To ensure safety, participants will be actively monitored during the study. A doctor will be present at administration of the drug and the antidote, naloxone, will be readily available if needed. Participants will be monitored on-site for 30 minutes after completion of CPET and discharge only if no evidence of side effects. Participants will be informed to not drive for 24 hours following each period of treatment. A phone call follow-up will be done 24-48 hours after treatment visits.
General Objective:
The general objective is to demonstrate the role of sublingual fentanyl liquid to improve exertional shortness of breath in patients with severe to very severe COPD.
研究设计
- 研究类型
- Interventional
- 分配方式
- Randomized
- 干预模型
- Crossover
- 主要目的
- Treatment
- 盲法
- Quadruple (Participant, Care Provider, Investigator, Outcomes Assessor)
盲法说明
All research staff, treating clinicians, analysts and patients will remain blinded to the treatment allocation.
Unbinding will only occur in emergency situations following consultation with the principal investigator and at the conclusion of collecting the last data point for the last participant in the entire study.
入排标准
- 年龄范围
- 40 Years 至 —（Adult, Older Adult）
- 性别
- All
- 接受健康志愿者
- 否
入选标准
- •Male or female aged ≥ 40 years
- •Cigarette smoking history ≥10 pack years
- •Clinical diagnosis of severe to very severe COPD, i.e. post-β2-agonist FEV1 <50% and FEV1/FVC <0.70
- •Chronic activity-related dyspnea, define as any one or combination of a modified MRC of 3-4 or a BDI focal score ≤ 8
- •Uncontrolled daily activity-related dyspnea despite optimal medical treatment, including oral morphine treatment at a dose of a least 4 mg per day
- •No change in medication dosage or frequency of administration in the previous 2 weeks
- •No exacerbations or hospitalizations in the preceding 4 weeks
排除标准
- •CO2 retention, defined as a resting arterial/capillary PCO2 of >50 mmHg
- •Self-reported history of addiction/substance abuse
- •Acute alcoholism
- •Presence of important contraindications to cardiopulmonary exercise testing (CPET)
- •History of hypersensitivity to fentanyl or any component of the formulation
- •Actual use of methadone
- •Concurrent use or use within 14 days of a monoamine oxidase (MAO) inhibitor
- •Severe CNS depression
- •Convulsive disorders
- •Known or suspected mechanical GI obstruction (e.g., bowel obstruction or strictures) or any diseases/conditions that affect bowel transit (e.g., ileus of any type)
- •Increased cerebrospinal or intracranial pressure and head injury
- •Active mouth mucositis
- •Dementia diagnosis or significant neurocognitive problems
- •History of severe chronic kidney disease (stage 4-5)
- •Women of child bearing potential (defined as not having gone at least 12 months without a menstrual period) will be required to take a routine (urine) pregnancy test to rule out the possibility of pregnancy
- •Breast-Feeding women
- •Acute or unstable, clinically significant abnormal findings in physical exam, vital signs or ECG (as per Investigators opinion)
- •Patients receiving long-term treatment with Oxygen >4.0 liters/minute (L/min). They must be ambulatory and be able to attend clinic visits. While breathing supplemental oxygen, they must demonstrate an oxyhemoglobin saturation ≥ 89%.
- •Malignancy, current or within the past 2 years. that the patient is not stable
- •Scheduled major surgical procedure during the course of the study
研究组 & 干预措施
Fentanyl s/l
Sublingual fentanyl will consist in liquid fentanyl at a concentration of 25 mcg/mL, with preparation by the pharmacist of pre-dosed syringes of 12,5 mcg (0,5 mL).
干预措施: Fentanyl citrate solution sublingual (Drug)
Fentanyl s/l
Sublingual fentanyl will consist in liquid fentanyl at a concentration of 25 mcg/mL, with preparation by the pharmacist of pre-dosed syringes of 12,5 mcg (0,5 mL).
干预措施: Placebo oral liquid (Drug)
Placebo
Placebo will consist in simple syrup (simple syrup B.P. - NPN: 00050121) administered sublingually with syringe.
干预措施: Fentanyl citrate solution sublingual (Drug)
Placebo
Placebo will consist in simple syrup (simple syrup B.P. - NPN: 00050121) administered sublingually with syringe.
干预措施: Placebo oral liquid (Drug)
结局指标
主要结局
Breathlessness
时间窗: Up to 10 days after visit 1
Post-dose difference in exertional breathlessness at isotime (isotime definition : highest equivalent 2 min interval of exercise completed by a given participant).
Exercise capacity
时间窗: Up to 10 days after visit 1
Post-dose difference in exercise endurance time (EET)
次要结局
- Participant blinded preference(Up to 10 days after visit 1)
- Difference in the locus of symptoms limiting exercise during a cardio-pulmonary exercise test response when comparing responders to non-responders.(Up to 10 days after visit 1)
- Change in multidimensional evaluation of dyspnea(Up to 10 days after visit 1)
- Number and description of adverse effects(Up to 48 hours after treatment administration)
- Locus of Symptoms(Up to 10 days after visit 1)
- Qualitative descriptors of breathlessness at end exercise(Up to 10 days after visit 1)
研究者
Jean Bourbeau
Professor
McGill University Health Centre/Research Institute of the McGill University Health Centre