A Pragmatic Trial of Corticosteroid Optimisation in Severe Asthma

Not Applicable

Completed

• Conditions: Severe Persistent Asthma
• Interventions: Other: Biomarker based adjustment of corticosteroid dose

• Registration Number: NCT02717689
• Lead Sponsor: Belfast Health and Social Care Trust

Brief Summary

This study explores if a composite biomarker strategy predicts exacerbation risk in patients with asthma on high dose inhaled corticosteroid (+/-long-acting beta agonist) treatment and to evaluate the utility of this composite score to facilitate personalised biomarker specific titration of corticosteroid therapy in this population.

Detailed Description

Asthma affects an estimated 300 million people worldwide with a population prevalence of ca 15% in the UK. The WHO has estimated UK disability adjusted life-years per 100,000 population for asthma to be greater than diabetes and breast cancer. Much of this excessive disability is in the 10-20% of patients with asthma which is difficult to control despite currently available therapies. This high morbidity and disproportionate use of health care resources reflects the considerable unmet need in this patient group, and their significance for health care providers.

Asthma has been traditionally 'stratified' on the basis of response to 'step-wise' incremental treatment with inhaled corticosteroid (ICS) therapy forming the cornerstone of this approach. However, more recently, asthma has been stratified on the basis of inflammatory phenotype to better understand disease heterogeneity with a view to developing biomarkers of therapeutic response and for the better targeting of both new and existing treatments.

Investigators have recently examined the predictive value of a composite biomarker strategy using FeNO, blood eosinophils and serum periostin together to predict exacerbation risk in the placebo arms of clinical trials. Investigators propose to examine if this composite biomarker strategy predicts exacerbation risk in patients with asthma on high dose ICS (+/-long-acting beta agonist) treatment and to evaluate the utility of this composite score to facilitate personalised biomarker specific titration of corticosteroid therapy in this population. This study will examine subjects with FeNO\<45 ppb and the scoring system will potentially allow identification of a 'low-risk' group who can safely reduce corticosteroid dose. This study will address a second important question of estimating the proportion of patients with severe disease who develop typical (T2)-driven eosinophilic inflammation on progressive corticosteroid withdrawal.

Study Timeline

• Study Start: 2016-01-01
• Study First Submitted: 2016-03-16
• Study First Submitted QC: 2016-03-18
• Study First Posted: 2016-03-24
• Primary Completion: 2019-06-19
• Study Completion: 2019-06-19
• Status Verified: 2020-06
• Last Update Submitted: 2020-06-24
• Last Update Posted: 2020-06-25

Recruitment & Eligibility

• Status: COMPLETED
• Sex: All
• Target Recruitment: 300

Inclusion Criteria

1. Age ≥ 18 and ≤ 80 years at screening visit

2. Able and willing to provide written informed consent and to comply with the study protocol

3. Baseline FeNO< 45 ppb at screening

4. Severe asthma confirmed after assessment by an asthma specialist. Diagnosed with asthma at least 12 months prior to screening

5. Current asthma treatment with LABA plus high doses of inhaled corticosteroids (≥1000 µg FP daily or equivalent)

6. Patients on an ICS/LABA single inhaler strategy must be switched to fixed dosing ICS/LABA for 4 weeks prior to screening

7. Documented history of reversibility of ≥12% change in FEV1 within the past 24 months or during screening period, as demonstrated by:

   • Documented airflow obstruction (forced expiratory volume in 1 second/forced vital capacity (FEV1/FVC ) <70%), where FEV1 has varied by ≥12% either spontaneously or in response to oral corticosteroid (OCS) therapy or bronchodilators either between or during clinic visits Or
   • A 20% drop in FEV1 (PC20) to methacholine <8 mg/mL or a 15% fall in FEV1 (PD15) after inhaling a cumulative dose of mannitol of ≤635 mg indicating the presence of airway hyperresponsiveness. If sites customarily use histamine to perform tests of airway responsiveness, this may be used in place of methacholine.

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Exclusion Criteria

1. Acute exacerbation requiring oral corticosteroids in previous 4 weeks before screening.

2. Known severe or clinically significant immunodeficiency, including, but not limited to, human immunodeficiency virus (HIV) infection.

3. Currently receiving or have historically received intravenous immunoglobulin for treatment for immunodeficiency.

4. If recently commenced on a leukotriene receptor antagonist or theophylline, stable on treatment for 4 weeks prior to screening

5. Known current malignancy or current evaluation for a potential malignancy or history of malignancy within 5 years prior to baseline. With the exception of basal-cell and squamous-cell carcinomas of the skin and carcinoma in situ of the cervix uteri that have been excised and cured.

6. Other clinically significant medical disease or uncontrolled concomitant disease despite treatment that is likely, in the opinion of the investigator, to require a change in therapy or impact the ability to participate in the study

7. History of current alcohol, drug, or chemical abuse or past abuse that would impair or risk the subject's full participation in the study, in the opinion of the investigator

8. Current self-reported history of smoking (including electronic inhaled nicotine products) or former smoker with a smoking history of >15 pack-years

   • A current smoker is defined as someone who has smoked one or more cigarettes per day (or marijuana or pipe or cigar) for ≥ 30 days within the 24 months prior to the screening visit (Day -14) and / or cotinine positive at screening
   • Any individual who smokes (cigarettes, marijuana, pipe, or cigar) occasionally, even if for < 30 days within the 24 months prior to the screening visit (Day -14), must agree to abstain from all smoking from the time of consent through completion of study
   • A former smoker is defined as someone who has smoked one or more cigarettes per day (or marijuana or pipe or cigar) for ≥ 30 days in his or her lifetime (as long as the 30-day total did not include the 24 months prior to the screening visit [Day -14]).
   • A pack-year is defined as the average number of packs per day times the number of years of smoking.

9. Current use of an immunomodulatory/immunosuppressive therapy or past use within 3 months or five drug half-lives (whichever is longer) prior to the screening visit

10. Use of a biologic therapy including Omalizumab at any time during the 6 months prior to the screening visit.

11. Bronchial thermoplasty within prior 6 months of the screening visit

12. Initiation of or change in allergen immunotherapy within 3 months prior to the screening visit.

13. Treatment with an investigational agent within 30 days of the screening visit (or five half lives of the investigational agent, whichever is longer).

14. Female patients who are pregnant or lactating.

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Study & Design

• Study Type: INTERVENTIONAL
• Study Design: PARALLEL

Arm && Interventions

Group	Intervention	Description
Biomarker arm	Biomarker based adjustment of corticosteroid dose	Biomarker based adjustment of corticosteroid dose.

Primary Outcome Measures

Name	Time	Method
Proportion of patients with any reduction in corticosteroid dose	48 weeks	Proportion of patients with any reduction in oral or inhaled corticosteroid dose at any point over the 48 weeks of the study

Secondary Outcome Measures

Name	Time	Method
Time to first severe exacerbation from randomisation	48 weeks
Dose of inhaled steroid at end of study	Week 48
Frequency of hospital admission for asthma	48 weeks
Change in Asthma Control Questionnaire (ACQ-7)	Week 48
Rate of protocol-defined severe exacerbations per patient per year	48 weeks
Cumulative dose of inhaled corticosteroid during study	48 weeks
Proportion of patients on oral corticosteroids at the end of the study	Week 48
Proportion of patients who decline to progress to oral corticosteroids despite composite biomarker score of 2	48 weeks
Change in blood eosinophil count	Week 48
Change in serum periostin levels	Week 48
Change in Asthma Quality of Life Questionnaire (AQLQ)	Week 48
Change in FEV1 (volume)	Week 48
Change in exhaled breath nitric oxide level	Week 48

Trial Locations

Locations (11)

NHS Greater Glasgow and Clyde; 🇬🇧 Glasgow, United Kingdom

University Hospitals of Leicester NHS Trust; 🇬🇧 Leicester, United Kingdom

Heart of England NHS Foundation Trust; 🇬🇧 Birmingham, United Kingdom

Royal Brompton & Harefield NHS Foundation Hospital; 🇬🇧 London, United Kingdom

University College London Hospitals NHS Foundation; 🇬🇧 London, United Kingdom

University Hospitals of South Manchester NHS Trust; 🇬🇧 Manchester, United Kingdom

Newcastle upon Tyne Hospitals NHS Foundation Trust; 🇬🇧 Newcastle upon Tyne, United Kingdom

Nottingham University Hospitals NHS Foundation Trust; 🇬🇧 Nottingham, United Kingdom

Oxford University Hospitals NHS Trust; 🇬🇧 Oxford, United Kingdom

University Hospital of Southampton NHS Foundation Trust; 🇬🇧 Southampton, United Kingdom

Belfast Health and Social Care Trust; 🇬🇧 Belfast, Northern Ireland, United Kingdom