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Pulmonary Rehab in COPD: Response to Tyvaso

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ClinicalTrials.gov Identifier: NCT02178566
Recruitment Status : Recruiting
First Posted : July 1, 2014
Last Update Posted : August 18, 2017
Sponsor:
Information provided by (Responsible Party):
Inova Health Care Services

Brief Summary:
The investigators' hypothesis is that pretreating patients with COPD with inhaled treprostinil prior to pulmonary rehabilitation sessions will result in improved exercise tolerance during sessions. This in turn will lead to an increased response to pulmonary rehabilitation, resulting in improved exercise tolerance and quality of life.

Condition or disease Intervention/treatment Phase
Chronic Obstructive Pulmonary Disease (COPD) Drug: Inhaled Treprostinil Phase 2

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Detailed Description:

Study Hypothesis:

Our hypothesis is that pre-treating patients with COPD with inhaled treprostinil prior to pulmonary rehabilitation sessions will result in improved exercise tolerance during sessions. This in turn will lead to an increased response to pulmonary rehabilitation, resulting in improved exercise tolerance and quality of life.

Study Background:

Pulmonary rehabilitation (PR) is a widely accepted intervention in patients with advanced COPD. This has consistently been shown to improve patients' quality of life and functional ability. Indeed, enrollment and completion of a course of PR is a prerequisite prior to major interventions such as lung volume reduction surgery or transplantation. A typical course of PR includes 20 sessions of supervised exercise and educational activity over an 8 week period. Sessions are usually held three times per week and last between 2-3 hours each. Most patients with COPD will have a ventilatory limitation to exercise and while many are oxygen dependent, a minority of patients will have a true hypoxic limitation to exercise. Nonetheless, when patients with COPD are ambulated on oxygen they feel better and walk further. Indeed, supplemental oxygen remains one of the few interventions that have been demonstrated to be associated with improved survival in patients with COPD.

There have been a few studies and case reports utilizing inhaled pulmonary vasodilators in patients with COPD, although none to date have used treprostinil. One study of 10 patients with COPD and pulmonary hypertension found improved gas exchange and exercise tolerance following using of inhaled iloprost an alternative inhaled pulmonary vasodilator. No adverse effects were observed. [Dernaika TA, Beavin M, Kinasewitz GT. Iloprost improves gas exchange and exercise tolerance in patients with pulmonary hypertension and chronic obstructive pulmonary disease. Respiration; 2010: 79(5): 377-382.)] A case report of a patient with pulmonary hypertension and COPD found sustained improvements in exercise tolerance with regular use of inhaled iloprost. [Hegewald MJ, Elliott CG. Sustained improvement with iloprost in a COPD patient with severe pulmonary hypertension. Chest 2009; 135(2): 536-537.] While these limited trials support the concept of physiologic improvement with use of inhaled pulmonary vasodilators in COPD, our study differs from these in several important ways. This study is unique in that there has never been a prior similar study of medication pretreatment prior to PR to enhance exercise performance in any patient subgroup. Furthermore, treprostinil has not yet been evaluated for use on an as needed basis.

Indication Studied:

COPD/Pulmonary rehabilitation

Study Objectives:

  • Primary Objective: To determine the effect of inhaled treprostinil, administered prior to pulmonary rehabilitation sessions, on the six minute walk test distance (6MWT) in COPD patients after completing an 8 week course of pulmonary rehabilitation
  • Secondary Objectives: To assess the effect inhaled treprostinil, administered prior to pulmonary rehabilitation in COPD patients, on secondary outcomes including quality of life (as measured by the St. George's respiratory questionnaire, Clinical COPD Questionaire), BODE index, lowest nadir of oxygen saturation on 6 minute walk test, number of exacerbations, ER visits, hospitalizations, and change in measures of strength training.

Trial Design:

An adaptive, prospective, randomized, double-blind, placebo-controlled study of 34 patients with advanced COPD who have been referred for pulmonary rehabilitation. All patients will be screened at baseline with an arterial blood gas. A test dose of inhaled nitric oxide (NO) will be administered to all subjects for 2-5 minutes. An ABG will then be repeated. Patients who have a worsened A-a gradient will be screened out. Patients will be randomized to receive one dose of inhaled treprostinil or placebo prior to each of their exercise sessions. All patients will be pretreated with albuterol prior to the dose of inhaled treprostinil (or placebo).

Patient Population:

We plan to screen 50 patients with a goal of enrolling 34 patients. Patients referred for pulmonary rehabilitation at Inova Fairfax Hospital with moderate to severe COPD as a primary diagnosis will be screened for inclusion in the trial. Inclusion and exclusion criteria are listed below.


Study Type : Interventional  (Clinical Trial)
Estimated Enrollment : 34 participants
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Triple (Participant, Care Provider, Investigator)
Primary Purpose: Treatment
Official Title: Pulmonary Rehabilitation in COPD: Response to Inhaled Treprostinil (Tyvaso)
Actual Study Start Date : August 2015
Estimated Primary Completion Date : July 2020
Estimated Study Completion Date : October 2020

Resource links provided by the National Library of Medicine

MedlinePlus related topics: Rehabilitation

Arm Intervention/treatment
Placebo Comparator: Inhaled Treprostinil Placebo
A dose of placebo resembling inhaled treprostinil will be administered to all study participants in the placebo comparator arm prior to each of their Pulmonary Rehab sessions. A dose of inhaled albuterol will be administered prior to each inhaled agent. Vitals signs will be taken prior to administering the dose and no medication will be given if the systolic blood pressure in < 85 mm Hg. Three puffs of inhaled trepostinil dose will be administered each time to all patients .
Drug: Inhaled Treprostinil
A dose of inhaled treprostinil or placebo will be administered to all study participants prior to each of their Pulmonary Rehab sessions. Three puffs of inhaled treprostinil dose will be administered each time to all patients .
Other Name: Tyvaso

Active Comparator: Inhaled Treprostinil
A dose of inhaled treprostinil will be administered to all study participants prior to each of their Pulmonary Rehab sessions. A dose of inhaled albuterol will be administered prior to each inhaled agent. Vitals signs will be taken prior to administering the dose and no medication will be given if the systolic blood pressure in < 85 mm Hg. Three puffs of inhaled treprostinil dose will be administered each time to all patients .
Drug: Inhaled Treprostinil
A dose of inhaled treprostinil or placebo will be administered to all study participants prior to each of their Pulmonary Rehab sessions. Three puffs of inhaled treprostinil dose will be administered each time to all patients .
Other Name: Tyvaso




Primary Outcome Measures :
  1. distance walked on 6MWT [ Time Frame: 9 weeks ]
    To determine the effect of inhaled treprostinil, administered prior to pulmonary rehabilitation sessions, on the six minute walk test distance (6MWT) in COPD patients after completing an 8 week course of pulmonary rehabilitation


Secondary Outcome Measures :
  1. Quality of Life [ Time Frame: 9 weeks ]
    To assess the effect inhaled treprostinil, administered prior to pulmonary rehabilitation in COPD patients, on secondary outcomes including quality of life (as measured by the St. George's respiratory questionnaire, Clinical COPD Questionaire), BODE index, lowest nadir of oxygen saturation on 6 minute walk test, number of exacerbations, ER visits, hospitalizations, and change in measures of strength training.



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Ages Eligible for Study:   40 Years and older   (Adult, Older Adult)
Sexes Eligible for Study:   All
Accepts Healthy Volunteers:   No
Criteria

Inclusion Criteria:

  1. Willing to sign informed consent prior to initiation of any study mandated procedure
  2. Male or female ≥ 40 years of age
  3. Women of childbearing potential must use a reliable method of contraception from screening until 1 month after end of study medication
  4. Clinical diagnosis of moderate to severe COPD, with an obstructive pattern on pulmonary function tests showing both:

    • FEV1/FVC < 0.7 and
    • FEV1 ≤ 60% of predicted value, on standard COPD therapy
  5. Current or past smokers of ≥ 10 pack years
  6. If taking oral (< 20 mg/day of prednisone equivalent) or inhaled corticosteroids, inhaled beta-agonists (short and long acting), or inhaled muscarinic antagonists (short and long acting), or statins the dose must be stable for at least 30 days prior to initial PR visit.
  7. Ability to adequately participate in exercise testing/pulmonary rehabilitation program with supplemental oxygen use over the period of the study (in the best opinion of the investigator)

Exclusion Criteria:

  1. Patients fulfilling one or more of the following criteria of documented COPD exacerbation within 1 months prior to screening:

    • Use of antibiotics for COPD exacerbation
    • Initiation or dose increase of steroids (inhaled, oral or intravenous) for COPD exacerbation
    • Hospitalization for COPD exacerbation
  2. BMI > 40 kg/m2
  3. Unstable coronary artery disease, unstable angina, or myocardial infarction within 3 months prior to screening
  4. History of pulmonary edema, or uncontrolled heart failure
  5. Uncontrolled systemic hypertension with a blood pressure >180/105 mmHg at rest
  6. Systemic hypotension with systolic blood pressure < 85 mmHg
  7. Uncontrolled arrhythmias
  8. History of syncope
  9. Planned surgical intervention during the study period
  10. Any known factor or disease that might interfere with treatment compliance, study conduct or interpretation of the results including musculo-skeletal limitations, peripheral arterial disease, drug or alcohol dependence or psychiatric disease
  11. Severe hepatic impairment (Child-Pugh Class C)
  12. Chronic renal insufficiency, as defined by serum creatinine of > 2.5 mg/dL or estimated creatinine clearance < 30 mL/min or the requirement for dialysis
  13. Pregnant or nursing
  14. Currently (within 30 days prior to enrollment) taking specific pulmonary arterial hypertension therapy (e.g., bosentan, ambrisentan, tadalafil, sildenafil, epoprostenol, treprostinil, iloprost, beraprost), sildenafil and tadalafil for erectile dysfunction is permitted
  15. Initiation of a pulmonary rehabilitation program within 3 months prior to screening or initiation or changes during the study
  16. Participation in any other clinical trial, except observational, or receipt of an investigational medicinal product within 30 days prior to RHC visit
  17. Known concomitant life-threatening disease with a life expectancy < 6 months
  18. Known hypersensitivity to treprostinil or any of the excipients of the drug formulations.
  19. Known hypersensitivity to inhaled nitric oxide

Information from the National Library of Medicine

To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor.

Please refer to this study by its ClinicalTrials.gov identifier (NCT number): NCT02178566


Contacts
Contact: Christopher King, MD 703-776-3582 christopher.king@inova.org
Contact: Edwinia Battle, RN, BSN 703-776-3067 edwinia.battle@inova.org

Locations
United States, Virginia
Inova Fairfax Medical Campus Recruiting
Falls Church, Virginia, United States, 22042
Contact: Christopher King, Md    703-776-3582      
Principal Investigator: Christopher King, Md         
Principal Investigator: Steven Nathan, Md         
Sponsors and Collaborators
Inova Health Care Services
Investigators
Principal Investigator: Steven Nathan, MD Inova Fairfax Medical Campus
Principal Investigator: Christopher King, MD Inova Fairfax Medical Campus

Publications:
Responsible Party: Inova Health Care Services
ClinicalTrials.gov Identifier: NCT02178566     History of Changes
Other Study ID Numbers: Inova-TY-PR-001
First Posted: July 1, 2014    Key Record Dates
Last Update Posted: August 18, 2017
Last Verified: August 2017

Keywords provided by Inova Health Care Services:
COPD
Trepostinil
Pulmonary Rehabilitation

Additional relevant MeSH terms:
Lung Diseases
Lung Diseases, Obstructive
Pulmonary Disease, Chronic Obstructive
Respiratory Tract Diseases
Treprostinil
Antihypertensive Agents