Three s Company - The role of triple therapy in chronic obstructive pulmonary

Three s Company - The role of triple therapy in chronic obstructive pulmonary disease (COPD) October 26 th, 2018 Zahava Picado, PharmD PGY1 Pharmacy Resident Central Texas Veterans Healthcare System Zahava.Picado@va.gov 1 P i c a d o

Learning Objectives By the end of this session, the learner should be able to Identify COPD patients who are potential candidates for triple therapy Compare the use of fixed triple therapy with open triple therapy Explain the role of using inhaled corticosteroids (ICS) in a COPD patient Assessment Questions Patient HT is a 69-year-old male who presents to your clinic. His most recent pulmonary tests show an FEV1/FVC: 47%, FEV1: 29% of expected, and 2 exacerbations in previous year, 1 requiring hospitalization. The patient reports that he had to stop for breath several times to enter your office from the parking lot today (mmrc 3). 1. How would you classify this patient s COPD? a. GOLD 1, Group A b. GOLD 2, Group B c. GOLD 3, Group C d. GOLD 4, Group D 2. Which of the following medication regimens would you recommend for HT? a. Albuterol + Tiotropium b. Albuterol + Salmeterol c. Albuterol + Umeclidinium + Vilanterol d. Albuterol + Fluticasone + Salmeterol + Tiotropium Patient OP is a 71-year-old female who presents to your clinic. Her most recent PFTs show an FEV1/FVC: 45%, FEV1: 28% of expected, and 1 exacerbation 8 months ago requiring a hospitalization. The patient is extremely upset that she is not able to run around the backyard and play tag with her grandchildren like she used to (mmrc 2). 3. How would you classify this patient s COPD? a. GOLD 1, Group A b. GOLD 2, Group B c. GOLD 3, Group C d. GOLD 4, Group D 4. Which of the following medication regimens would you recommend for HT? a. Albuterol + Tiotropium b. Albuterol + Salmeterol c. Albuterol + Umeclidinium + Vilanterol d. Albuterol + Fluticasone + Salmeterol + Tiotropium 5. Which of these comorbidities is associated with an increased risk for pneumonia? I. Morbid Obesity II. Current Smoker III. FEV1 30% of predicted A. I only B. I and II C. II and III D. I, II, and III E. None of the above 2 P i c a d o

Background - COPD Epidemiology COPD affects approximately 64 million people worldwide and is the 3rd leading cause of death. Chronic inflammatory disease with persistent airflow limitation Noxious Air/Particle inhalation Classification of COPD Inflammatory cytokine release Mucus hypersecretion Airflow obstruction/air trapping Gas exchange abnormalities Pulmonary hypertension Classification of airflow limitation severity in COPD (based on post-bronchodilator FEV1) in patients with FEV1/FVC < 0.70 GOLD 1 Mild FEV1 > 80% of predicted GOLD 2 Moderate FEV1 50-79% of predicted GOLD 3 Severe FEV1 30-49% of predicted GOLD 4 Very Severe FEV1 < 30% of predicted Exacerbation History > 2 or > 1 leading to hospitalization GROUP C GROUP D 0 or 1 (not leading to hospitalization) GROUP A GROUP B mmrc 0-1 CAT < 10 Pharmacologic Options Beta Agonists o Short acting (SABA) and long acting (LABA) Muscarinic Antagonists o Short acting (SAMA) and long acting (LAMA) Inhaled Corticosteroids Symptom Severity mmrc > 2 CAT > 10 2018 GOLD Guideline Recommendations SABA or SAMA: o Acceptable for occasional dyspnea only (Evidence A) LABA + LAMA: o Increases FEV1 and reduces symptoms compared to monotherapy (Evidence A) o Reduces exacerbations compared to monotherapy or ICS + LABA (Evidence B) ICS + LABA: o Improves lung function and health status, and reduces exacerbations compared to monotherapy (Evidence A) LABA + LAMA + ICS (AKA triple therapy ): o Improves lung function, symptoms and health status (Evidence A) and reduces exacerbations (Evidence B) compared to ICS/LABA and LAMA monotherapy 3 P i c a d o

o o Role against LAMA/LABA still unclear Recommended exclusively for patients with group D COPD who continue to have exacerbations despite dual therapy. Remains inappropriately prescribed to patients despite GOLD recommendations. Overuse of triple therapy results in a waste of limited health resources and increased risk of side effects Group A Short acting bronchodilator (SABA/SAMA) as needed Group B Long-acting bronchodilator (LAMA/LABA) LABA + LAMA Group C LAMA LAMA + LABA LABA + ICS Group D LAMA + LABA LABA + ICS LAMA + LABA + ICS Question 1: Which patients will benefit the most from triple therapy? Trial 1: TRILOGY Treatment Arms Beclomethasone + formoterol + glycopyrrolate (ICS/LABA/LAMA) Beclomethasone + formoterol (ICS/LABA) Primary Outcome Change in pre-dose FEV1 and 2-hour post-dose FEV1 at 26 weeks Select Secondary COPD exacerbation frequency over 52 weeks Outcomes Inclusion Criteria Age 40+ Prebronchodilator FEV1 < 60% predicted 1+ moderate/severe exacerbation within 12 months Current or former smokers (10 pack-year history) CAT > 10 Exclusion Criteria Alpha-1 antitrypsin deficiency Asthma, allergic rhinitis or Non-COPD pulmonary condition COPD exacerbation within last 4 weeks Requiring long term oxygen Already on ICS/LABA/LAMA regimen Baseline Characteristics 1181 patients completed study 602 in ICS/LABA/LAMA 579 in ICS/LABA Average age: 63 years old Average FEV1: ~36% of predicted severe airflow limitation Average CAT score 20.8 47% active smokers 1.2 exacerbations in the previous year COPD medication at study entry ICS/LABA or ICS/LAMA 75% LABA/LAMA 14% LAMA 11% 4 P i c a d o

Results Pre-dose FEV1 at 26 weeks Triple therapy increased FEV1 82 ml; ICS/LABA, increased FEV1 by 1 ml Adjusted mean difference: 81 ml (p<0.001, CI 52-109 ml) Post-dose FEV1 at 26 weeks Triple therapy increased FEV1 261 ml; ICS/LABA, increased FEV1 by 145 ml Adjusted mean difference: 117 ml (p<0.001, CI 86-147 ml) Exacerbation rate over 52 weeks Triple therapy had a 23% lower incidence rate of exacerbations compared to ICS/LABA (RR 0.77, p = 0.005, CI 0.65-0.92) Trial 2: IMPACT Treatment Arms Fluticasone Furoate + Umeclidinium + Vilanterol (ICS/LAMA/LABA) Fluticasone + Vilanterol (ICS/LABA) Umeclidinium + Vilanterol (LAMA/LABA) Primary Outcome Moderate-severe exacerbation rate over 52 weeks Select Secondary Change in FEV1 over 52 weeks Outcomes Change in St Georges Respiratory Questionnaire (SGRQ) over 52 weeks Inclusion Criteria Age 40+ Current or former smokers COPD CAT Score > 10 FEV1 <50% of expected AND 1 mod-severe exacerbation in previous year or FEV1 50-70% of expected AND 2+ moderate exacerbations in previous year Exclusion Criteria Alpha-1 antitrypsin deficiency Severe cardiac dysfunction Allergic rhinitis or non-copd pulmonary condition Requiring long-term oxygen Chronic use of antibiotics or oral steroids Baseline Characteristics Results 10,355 patients in study 4151 in ICS/LABA/LAMA 4134 in ICS/LABA 2070 in LABA/LAMA Average age: 65 years old Average CAT score of 20.1 Average FEV1 ~45% of predicted severe airflow limitation 26%: 1 severe COPD exacerbation in previous year 47%: 2+ moderate COPD exacerbations in previous year 11%: 3+ moderate-severe exacerbations in previous year 4%: 2+ Severe COPD exacerbations in previous year Exacerbation rate over 52 weeks Triple therapy had a 15% lower rate of mod-severe exacerbations compared to ICS/LABA (RR 0.85, P< 0.001, CI 0.80-0.90), and a 25% lower rate of moderate-severe exacerbations compared to LAMA/LABA (RR 0.75, P <0.001, CI 0.70-0.81). Change in FEV1 at 52 weeks Triple therapy increased FEV1 94 ml vs ICS/LABA which decreased FEV1 by 3ml, and LAMA/LABA, which increased FEV1 by 40 ml. Adjusted mean difference: 97 ml (P<0.001, CI 85-109); 54 ml (P<0.001, 39-69) Change in SGRQ Score at 52 weeks Triple therapy decreased SGRQ score by 5.5 points vs ICS/LABA and LAMA/LABA, which decreased SGRQ score by 3.7 points. Adjusted mean difference: 1.8 points ( 2.4 to 1.1) 5 P i c a d o

Trial 3: SUNSET Treatment Arms 3-week run-in period of Tiotropium + Salmeterol + Fluticasone, then: Tiotropium + Salmeterol + Fluticasone (LAMA/LABA/ICS) Indacaterol + glycopyrrolate (LABA/LAMA) Primary Outcome Change in FEV1 after 26 weeks of treatment Select Secondary Exacerbation rate over 26 weeks Outcomes Inclusion Criteria Age 40+ FEV1 40-80% predicted No more than 1 moderate/severe exacerbation within 12 months Current or former smokers (10 pack-year history) Receiving ICS/LABA/LAMA for 6+ months Exclusion Criteria Alpha-1 antitrypsin deficiency Asthma, allergic rhinitis or Non-COPD pulmonary condition Requiring long term oxygen Blood eosinophil count > 600 cells/µl Baseline 1053 patients in study Characteristics 527 in ICS/LABA 526 in ICS/LABA/LAMA Average age: 65 years old Average FEV1 ~56.6% of predicted moderate airflow limitation 34.1% had one exacerbation in previous year Results Difference in FEV1 (Non-inferiority margin: -50 ml) ICS withdrawal led to a decrease in FEV1 of -26 ml (95% CI -53 to 1) compared to patients who remained on triple therapy. De-escalation with dual therapy is not non-inferior to triple therapy. Exacerbation rate over 26 weeks Withdrawal of ICS led to 8% higher rate of moderate-severe exacerbations compared to patients left on triple therapy (RR 1.08, P = 0.58, CI 0.83-1.40) Triple Therapy Class D COPD only Severe airflow restriction High eosinophil counts (300-600 cells/µl) Dual Therapy Inappropriately escalated Stable on triple therapy for > 6 months. 6 P i c a d o

Question 2: Is fixed triple therapy better than open triple therapy? Trial 4: TRINITY Treatment Arms Beclomethasone + formoterol + glycopyrrolate (FIXED) Tiotropium alone Beclomethasone + formoterol + tiotropium (OPEN) Primary Outcome COPD moderate-severe exacerbation rate Select Secondary Change in pre-dose FEV1 at week 52 Outcomes Inclusion Criteria Age 40-80 Post-bronchodilator FEV1 <50% predicted CAT > 10 Current or former smokers (10 pack-year history) 1+ moderate/severe exacerbation within 12 months Exclusion Criteria Alpha-1 antitrypsin deficiency Already receiving triple therapy Asthma, allergic rhinitis or Non-COPD pulmonary condition COPD exacerbation within last 4 weeks Requiring long term oxygen Baseline Characteristics Results 2691 patients 1078 in fixed triple 1075 in tiotropium 538 in open triple Average age: 63 years old Average FEV1 ~ 36.6% of predicted Severe airflow limitation Average CAT score 21 48% active smokers COPD medication at study entry ICS/LABA or ICS/LAMA 75% LABA/LAMA 12% LAMA 13% Exacerbation Rate at 52 weeks 20% lower exacerbation rate with fixed triple therapy compared to tiotropium alone (RR 0.80, P = 0.0025, CI 0.69-0.92) 21% lower exacerbation rate with open triple therapy compared to tiotropium alone (RR = 0.79, P = 0.0095, CI 0.66-0.94) 1% higher exacerbation rate with fixed triple therapy compared to open triple therapy (RR = 1.01, P = 0.89, CI 0.85-1.21) Change in FEV1 at 52 weeks Fixed triple therapy increased FEV1 by 85 ml (65-100 ml) Tiotropium therapy increased FEV1 by 21 ml (3-39 ml) Open Triple therapy increased FEV1 by 85 ml (61-110 ml) Study Conclusion: When compared to multiple inhalers, fixed triple therapy does not appear to have an impact on FEV1 or exacerbation rate. 7 P i c a d o

Question 3: Which patients are at an increased risk for pneumonia with inhaled steroids? Role of ICS in COPD Historically, providers hypothesized that patients with COPD and inflammation would respond to inhaled steroids similar to patients with asthma. Data supporting the use of ICS is limited. There is evidence that ICS use leads to adverse reactions, such as candidiasis, bruising, and pneumonia. Trial 5: TORCH Treatment Arms Fluticasone Propionate (ICS) Salmeterol (LABA) Fluticasone + Salmeterol (ICS/LABA) Placebo Primary Outcome All-cause mortality at 3 years COPD-related mortality at 3 years Select Secondary Rate of exacerbations Outcomes Change in FEV1 Inclusion Criteria Age 40-80 Prebronchodilator FEV1 <60% predicted Poor reversibility of airflow obstruction Current or former smokers (10 pack-year history) Exclusion Criteria Alpha-1 antitrypsin deficiency Asthma or Non-COPD pulmonary condition COPD exacerbation within last 4 weeks Baseline Characteristics Results 6112 patients included 1500 in each treatment arm Average age: 65 years old Average FEV1 ~ 44% of predicted severe airflow limitation Average pre-study exacerbation history: 1 ± 1.4 exacerbations/year requiring antibiotics/oral steroids 43% active smokers, 48 pack-year history All-cause mortality at 3 years ICS/LABA did not significantly reduce risk of death compared to placebo (HR 0.825, CI 0.68-1.00, P=0.052) or salmeterol alone (HR 0.932, CI 0.765-1.134, P=0.48) ICS/LABA was associated with a 23% reduction in risk of death compared to fluticasone alone (HR 0.774, CI 0.641-0.934, P=0.007) COPD-related mortality at 3 years ICS/LABA was associated with a 22% reduction in risk of COPD-related death compared to placebo (HR 0.78, CI 0.57-1.06, P=0.011) ICS/LABA did not significantly reduce risk of COPD-related death compared to salmeterol (HR 0.77, CI 0.56-1.04, P=0.09) ICS/LABA was associated with a 33% reduction in risk of COPD-related death compared to fluticasone (HR 0.67, CI 0.50-0.90, P=0.008) Pneumonia ICS/LABA had 7.3% more pneumonia events compared to placebo (19.6% vs. 12.3%, P<0.001) Fluticasone alone had 6% more pneumonia events compared to placebo (18.3% vs. 12.3% P<0.001) Salmeterol alone had 1% more pneumonia events compared to placebo (13.3% vs 12.3% P<0.001) 8 P i c a d o

Trial 6: SUMMIT Treatment Arms Fluticasone Furoate Vilanterol Fluticasone + vilanterol Placebo Primary Outcome Time to death from any cause Select Secondary Cardiovascular death, MI, stroke, UA, and TIA. Outcomes Inclusion Criteria Age 40-80 FEV1 50 and 70% predicted 2 on the mmrc dyspnea scale History of cardiovascular disease or increased cardiovascular risk Current or former smokers (10 pack-year history) Exclusion Criteria Alpha-1 antitrypsin deficiency Asthma or Non-COPD pulmonary condition COPD exacerbation within last 4 weeks Requiring long term oxygen Baseline Characteristics Results 16,568 patients included 4100 in each treatment arm Average age: 65 years old Average FEV1 ~ 59% of predicted Moderate airflow limitation Exacerbation History 61% patients had 0 exacerbations 25% of patients had 1 exacerbation 15% of patients had 2+ exacerbations 47% active smokers, 41 pack-year history Time to death from any cause ICS/LABA did not significantly reduce risk of death compared to placebo (HR 0 88, CI 0 74-1 04, p=0 137) Fluticasone did not significantly reduce risk of death compared to placebo (HR 0 91, CI 0 77-1 08, p=0 284) Vilanterol did not significantly reduce risk of death compared to placebo (HR 0 96, CI 0 81-1 14, p=0 655) Pneumonia ICS/LABA had 0.5% more pneumonia events compared to placebo (5.7% vs 5.2%, P<0.001) Fluticasone did not have significantly higher pneumonia events compared to placebo (5.5% vs 5.2%, P = 0.716) Vilanterol had 1.3% less pneumonia events compared to placebo (3.9% vs 5.2%, P<0.001) Study Conclusions: Patients at higher risk of pneumonia are: Current smokers Age 55+ BMI < 25 Poor mmrc grade and/or severe airflow limitation (FEV1< 50%) History of exacerbations and/or pneumonia 9 P i c a d o

Presenter s Conclusions Triple therapy o Recommended exclusively for patients with group D COPD who continue to have exacerbations despite dual therapy. Additional patients with high eosinophil counts may benefit from triple therapy. o Consider de-escalating patients from triple therapy who are stable on their triple therapy for at least 6 months Open vs fixed triple therapy o When compared to multiple inhalers, fixed triple therapy does not appear to have an impact on FEV1 or exacerbation rate. Role of ICS and pneumonia o o Future Studies Use of ICS should be weighed strongly in patients who: are current smokers, age 55+, BMI < 25, are extremely symptomatic with significant airflow limitation, and who have a history of exacerbations and/or pneumonia ICS should never be used as monotherapy 1. INTREPID - Investigation of TRELEGY Effectiveness: Usual Practice Design (December 2019) a. Randomized, open-label, effectiveness, phase 4 study b. Fluticasone Furoate/Umeclidinium/Vilanterol single inhaler vs. multiple-inhaler triple therapy 2. TRIVOLVE - Fixed Dose Triple Therapy in Severe COPD in a Real-World Setting (August 2019) a. Prospective, non-interventional study b. Beclomethasone/Formoterol/Glycopyrrolate vs. multiple inhaler triple therapy 3. AIRWISE - Assessment in a Real-World Setting of the Effect of Inhaled Steroid-based Triple Therapy Versus the Combination of Tiotropium and Olodaterol on Reducing COPD Exacerbations (June 2020) a. Randomized, open-label effectiveness phase 4 study b. Tiotropium/Olodaterol vs multiple inhaler triple therapy 10 P i c a d o

References 1. Global Initiative for Chonic Obstructive Lung Disease. The Global Strategy for the Diagnosis, Management and Prevention of COPD. 2018 [accessed 2018 August]. Available from: http://goldcopd.org 2. Hatipoglu U, Aboussquan L. Chronic obstructive pulmonary disease: An update for the primary physician. Clev Clin J Med 2014;81(6):373 383. 3. Singh, D., Papi, A., et al. (2016). Single inhaler triple therapy versus inhaled corticosteroid plus long-acting β2- agonist therapy for chronic obstructive pulmonary disease (TRILOGY): A double-blind, parallel group, randomised controlled trial. The Lancet, 388(10048), 963-973. doi:10.1016/s0140-6736(16)31354-x 4. Chapman, K. R., Hurst, J. R., Frent, S., et al. (2018). Long-Term Triple Therapy De-escalation to Indacaterol/Glycopyrronium in Patients with Chronic Obstructive Pulmonary Disease (SUNSET): A Randomized, Double-Blind, Triple-Dummy Clinical Trial. American Journal of Respiratory and Critical Care Medicine, 198(3), 329-339. doi:10.1164/rccm.201803-0405oc 5. Vestbo, J., Papi, A., Corradi, M., et al. (2017). Single inhaler extra fine triple therapy versus long-acting muscarinic antagonist therapy for chronic obstructive pulmonary disease (TRINITY): A double-blind, parallel group, randomized controlled trial. The Lancet, 389(10082), 1919-1929. doi:10.1016/s0140-6736(17)30188-5 6. Calverley PM, Anderson JA, Celli B, et al. Salmteterol and fluticasone propionate and survival in chronic obstructive pulmonary disease. N Engl J Med 2007; 356(8): 775-89. 7. Vestbo J, Anderson JA, Brook RD et al. Fluticasone furoate and vilanterol and survival in chronic obstructive pulmonary disease with heightened cardiovascular risk (SUMMIT): a double-blind randomized controlled trial. Lance 2016; 387(10030): 1817-26 8. https://clinicaltrials.gov/ct2/show/nct03467425?term=intrepid&cond=copd&rank=1 9. https://clinicaltrials.gov/ct2/show/nct03627858?term=trivolve&rank=1 10. https://clinicaltrials.gov/ct2/show/nct03265145?term=airwise&rank=1 11 P i c a d o

Supplementary Material COPD Chronic Obstructive Pulmonary Disease LABA Long Acting Beta Agonist LAMA Long Acting Muscarinic Antagonist ICS Inhaled Corticosteroid GOLD Global Initiative for Obstructive Lung Disease Table 1: Terms and Abbreviations SGRQ St Georges Respiratory Questionnaire mmrc Modified Medical Research Council Dyspnea Scale CAT COPD Assessment Test FEV1 - Volume of air expired in the 1 st second during maximal respiratory effort FVC - total volume of air expired after full inspiration Table 2: Modified Medical Research Council (mmrc) Questionnaire for categorizing COPD severity Severity Score Level of breathlessness None 0 Only breathless with strenuous exercise Mild 1 Shortness of breath hurrying or walking up a slight hill Moderate 2 Walks slower than age group or must stop for breath when walking on level ground at own pace Severe 3 Stops for breath after walking 100 meters or a few minutes on level ground Very Severe 4 Breathless when dressing/too breathless to leave the house Adapted from: Global Initiative for Chronic Obstructive Lung Disease. 2018 Table 3: Common inhaler formulations/combinations ICS/LABA LABA/LAMA ICS Budesonide/Formoterol (Symbicort) Fluticasone/Salmeterol (Advair) Fluticasone/Vilanterol (Breo) Mometasone/Formoterol (Dulera) Olodaterol/Tiotropium (Stiolto) Umeclidinium/Vilanterol (Anoro) Indacterol/Glycopyrrolate (Utibron) Formoterol/Glycopyrrolate (Bevespi) Fluticasone (Flovent) Flunisolide (Aerospan) Mometasone (Asmanex) QVAR (Beclomethasone) Budesonide (Pulmicort) LABA LAMA SABA Olodaterol (Striverdi) Indacterol (Arcapta) Salmeterol (Serevent) Formoterol (Foradil, Perforomist) Tiotropium (Spiriva) Glycopyrrolate (Seebri) Aclidinium (Tudorza) Umeclidinium (Incruse) ICS/LAMA/LABA Fluticasone/Umeclidinium/Vilanterol (Trelegy) Albuterol (Proair, Ventolin, Proventil) Levalbuterol (Xopenex) 12 P i c a d o

Figure 1. COPD Assessment Test 13 P i c a d o