Withdrawal of Inhaled Corticosteroids in Primary Care Patients With COPD

NCT02691988 | Unknown DMC

• 1 other identifier: NL52880.091.15
• Study Type: interventional
• Target: 620
• Locations: 1 country
• Sites: 1

Brief Summary

Rationale: Because long-term use of ICS is associated with an increased likelihood of side-effects such as increased risk of pneumonia and loss of bone density, it is important to limit prescription of ICS to patients who have a clear indication for this treatment. In addition, avoiding unnecessary treatment with ICS could reduce the burden that chronic obstructive pulmonary disease (COPD) puts on healthcare budgets. The recently updated COPD guideline of the Dutch college of General Practitioners (NHG) emphasizes the importance of optimizing medical treatment for COPD patients with only limited room for the use of inhaled corticosteroids. Objective: The objective of the study is to investigate whether discontinuation of inhaled corticosteroids (ICS) for patients without a clear indication for ICS according to current guidelines results in a reduction of ICS use without adverse health effects for the patients involved. Study design: The study is a pragmatic, clustered, parallel group, non-inferiority trial in Dutch general practices with a follow-up of 26 weeks per patient. Study population: 620 COPD patients with confirmed chronic airflow obstruction, aged ≥ 40 yrs who use ICS for at least the prior 6 months without a clear indication. Intervention (if applicable): Guided ICS withdrawal in optimised COPD management. All study participants (of both study arms) will receive recommendations on optimal bronchodilator therapy and a personalized action plan to recognize symptom deterioration in an early stage. Main study parameters/endpoints: Number of exacerbation-free weeks. Secondary study parameters: successful cessation of ICS, time to first exacerbation, number of moderate and severe exacerbations, health-related quality of life, health status, and pneumonias. Moreover, information on the process of care and costs will be collected. Nature and extent of the burden and risks associated with participation, benefit and group relatedness: Many COPD patients use ICS without a clear indication. Long-term use of ICS is associated with an increased likelihood of side-effects such as increased risk of pneumonia and loss of bone density and should be avoided in those who do not benefit from it. However, there is a small subgroup of COPD patients that have reduced numbers of exacerbations because of their ICS use and it is impossible to identify a priori the patients who this applies too. Therefore, it is important that the ICS discontinuation is guided to detect potential deteriorations early on.

Conditions

Pulmonary Disease, Chronic Obstructive

Keywords

Inhaled corticosteroids; General practice; Primary care; Pharmacotherapy

Outcome Measures

Primary Outcomes (1)

• Number of exacerbation-free weeks (EFWs)

  Weeks in which the patient does not experience a worsening of his respiratory condition according to accepted symptom-based definitions of an exacerbation. This outcome is measured on a weekly basis with the Telephonic Exacerbation Assessment System (TEXAS)

  6 months

Secondary Outcomes (7)

• Successful ICS withdrawal

  6 months

• Time to first exacerbation

  Max. 6 months

• Moderate and severe exacerbations

  6 months

• Health status (CCQ)

  6 months

• Health-related quality of life (HRQoL)

  6 months

Study Arms (2)

ICS withdrawal

EXPERIMENTAL

Guided ICS withdrawal combined with optimization of bronchodilator treatment

Other: ICS withdrawal

Usual care

ACTIVE COMPARATOR

Optimization of bronchodilator treatment

Other: Usual care

Interventions

ICS withdrawal OTHER

Bronchodilator therapy is optimized according to the latest COPD guideline of the Dutch College of General Practitioners (NHG) and inhaled corticosteroids are withdrawn.

ICS withdrawal

Usual care OTHER

Bronchodilator therapy is optimized according to the latest COPD guideline of the Dutch College of General Practitioners (NHG)

Usual care

Eligibility Criteria

• Age: 40 Years+
• Sex: all
• Healthy Volunteers: No
• Age Groups: Adult (18-64), Older Adult (65+)

You may qualify if:

• COPD diagnosis in the medical record (ICPC code R95 or R91);
• Most recent spirometry result is less than three years old and shows a ratio of the Forced Expiratory Volume in 1 second (FEV1) to the Forced Vital Capacity (FVC) of less than 0.7, in short: FEV1/FVC ratio \<0.7 (If no recent spirometry results are available, the patient will be scheduled for a diagnostic spirometric test);
• ICS treatment for at least the past 6 months;
• Accessible electronic medical record and prescription data history of at least one year;
• The subject's COPD is primarily managed by the general practioner (GP) (i.e., not by a chest physician); or if a subject's COPD is treated by a chest physician as well, the chest physician agrees with the invitation of the subject.
• Willing to provide written informed consent;
• Mentally competent.

You may not qualify if:

• A spirometry test that has demonstrated airflow reversibility (i.e., post-bd FEV1 improvement of at least 12% and 200 ml compared to baseline and/or post-bd FEV1 improvement of 9% of the baseline FEV1 % predicted value) that preceded the initiation of ICS treatment;
• Diagnosis of asthma in the medical record (ICPC code R96);
• Allergic respiratory disease which has been confirmed by a positive skin prick test or specific immunoglobulin E (IgE) in serum as documented in the medical record, in combination with a documented history respiratory allergic symptoms;
• Two or more exacerbations in the previous 12 months that were treated with oral corticosteroids, antibiotics, or both; and/or required a visit to an emergency care facility or hospital admission;
• Use of oral corticosteroids on a regular basis (i.e., more than six weeks in the previous half year) for any reason;
• Currently participating in another intervention study that interferes with the current study;
• Has one or more serious other diseases that are likely to lead to study drop-out (e.g., diseases with limited life expectancy) or influence the study results; or
• Pregnancy or women who are trying to conceive a child;
• Unable to read or understand the Dutch language.

Sponsors & Collaborators

• Radboud University Medical Center: lead
• Novartis: collaborator
• Boehringer Ingelheim: collaborator

Study Sites (1)

Radboud University Medical Centre, Department of Primary and Community Care

Nijmegen, 6500 HB, Netherlands

RECRUITING

MeSH Terms

Conditions

Pulmonary Disease, Chronic Obstructive

Condition Hierarchy (Ancestors)

Lung Diseases, Obstructive; Lung Diseases; Respiratory Tract Diseases; Chronic Disease; Disease Attributes; Pathologic Processes; Pathological Conditions, Signs and Symptoms

Central Study Contacts

Tjard R Schermer, PhD

CONTACT

0031243614611; Tjard.Schermer@radboudumc.nl

Lisette van den Bemt, PhD

CONTACT

0031243619588; Lisette.vandenbemt@radboudumc.nl

Study Design

• Study Type: interventional
• Phase: not applicable
• Allocation: RANDOMIZED
• Masking: SINGLE
• Who Masked: OUTCOMES ASSESSOR
• Purpose: TREATMENT
• Intervention Model: PARALLEL
• Sponsor Type: OTHER
• Responsible Party: SPONSOR

Study Record Dates

• First Submitted: February 22, 2016
• First Posted: February 25, 2016
• Study Start: December 1, 2015
• Primary Completion: January 1, 2017
• Study Completion: June 1, 2017
• Last Updated: February 25, 2016

Record last verified: 2016-02

Locations

NL (1)