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ORIGINAL ARTICLE
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Salmeterol and fluticasone propionate (50/250 mg) administered via combination Diskus inhaler: As effective as when given via separate Diskus inhalers
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Kenneth R Chapman MD1, Nils Ringdal MD2, Vibeke Backer MD3, Mona Palmqvist MD4, Seppo Saarelainen MD5, Mark Briggs BSc6 1Toronto Hospital (Western Division), Toronto, Ontario; 2Molde Hospital, Molde, Norway; 3Department of Internal Medicine, Lung Division, Bispebjerg Hospital, Copenhagen, Denmark; 4Asthma and Allergy Centre, Sahlgrenska University Hospital, Gothenberg, Sweden; 5Tampere University Hospital, Pikonlinna Hospital, Pikonlinna, Finland; 6Respiratory Clinical Research, GlaxoWellcome Research and Development, Greenford, Middlesex, United Kingdom symptoms were measured for the first 12 weeks and safety data were collected throughout the study. RESULTS: Over weeks 1 to 12, adjusted mean improvements in morning PEFR were 43 and 36 L/min for combination and concurrent therapies, respectively. The difference between the two treatment arms was 6 L/min (90% CI –13 to 0 L/min; P=0.114), which was within the predefined criteria for clinical equivalence. Adjusted mean improvements in forced expiratory volume in 1 s from baseline for week 28 were also similar between the two therapies. Thirty-five per cent of patients receiving combination inhaler and 31% of those receiving concurrent therapy had a mean daytime symptom score of zero over weeks 1 to 12 compared with 1% and 2%, respectively, at baseline. There was no difference in the incidence of adverse events between the two treatment arms. Mean serum cortisol levels were similar, and no differences in frequency of abnormal results were noted between the two groups. CONCLUSIONS: This study shows that the combination of salmeterol and fluticasone propionate in a single inhaler is as ef-
KR Chapman, N Ringdal, V Backer, M Palmqvist, S Saarelainen, M Briggs. Salmeterol and fluticasone propionate (50/250 mg) administered via combination Diskus inhaler: As effective as when given via separate Diskus inhalers. Can Respir J 1999;6(1):45-51.
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OBJECTIVE: To compare the efficacy and safety of a new combination Diskus inhaler containing both salmeterol 50 mg and fluticasone propionate 250 mg (Seretide) with the two drugs delivered via separate Diskus inhalers. DESIGN: A multicentre, double-blind, double-dummy study. Three hundred and seventy-one symptomatic asthma patients (age range 13 to 75 years, mean 42 years) receiving inhaled corticosteroids were randomly assigned to two treatement groups: 28 weeks’ treatment with either salmeterol/fluticasone propionate (50/250 mg bid) via a single Diskus inhaler (combination) and placebo bid via another Diskus inhaler, or salmeterol 50 mg bid via one Diskus inhaler and fluticasone propionate 250 mg bid via another (concurrent). Morning peak expiratory flow rate (PEFR) and
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Correspondence: Dr KR Chapman, 4-011 Edith Cavell Wing, Toronto Hospital, Western Division, 399 Bathurst Street, Toronto, Ontario M5T 2S8. Telephone 416-603-5499, fax 416-603-3456, e-mail
[email protected]
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Can Respir J Vol 6 No 1 January/February 1999
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µg deux fois par jour également administré par inhalateur Diskus (concomitamment). Le débit expiratoire de pointe (DEP) du matin et les symptômes ont été évalués pendant les 12 premières semaines et les données concernant l’innocuité ont été recueillies pendant toute la durée de l’étude. RÉSULTATS : De la semaine 1 à la semaine 12, les améliorations moyennes corrigées du DEP du matin étaient respectivement de 43 et 36 L/min pour le traitement combiné et le traitement concomitant. La différence entre les deux branches de traitement était de 6 L/min (IC de 90 %;13 à 0 L/min ; p = 0,114), donc dans les limites des critères prédéfinis pour l’équivalence clinique. Les améliorations moyennes corrigées pour le volume expiratoire maximal/seconde à partir des valeurs de base pour la 28 semaine étaient aussi similaires entre les deux traitements. Trente-cinq pour cent de patients recevant la combinaison des deux médicaments avec un seul inhalateur et 31 % de ceux recevant les deux médicaments concomitamment accusaient un score moyen de symptômes diurnes de zéro de la semaine 1 à la semaine 12 comparativement à 1 % et 2 %, respectivement, aux valeurs de base. On n’a observé aucune différence dans l’incidence des effets indésirables entre les deux branches de traitement. Les taux moyens de cortisol sérique étaient similaires, et aucune différence dans la fréquence de résultats anormaux n’a été notée entre les deux groupes. CONCLUSIONS : La présente étude démontre qu’une combinaison de salmétérol et de propionate de fluticasone administrée par le biais d’un seul inhalateur se révèle aussi efficace à maîtriser l’asthme et est aussi bien tolérée pendant une période de 28 semaines que les deux médicaments administrés séparément.
ficacious in achieving asthma control and as well tolerated over a 28-week period as the two drugs administered individually. Key Words: Asthma, Combination therapy, Fluticasone propionate, Salmeterol
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Nouvel inhalateur Diskus combinant salmétérol et propionate de fluticasone (50/250 µg) : aussi efficace que deux inhalateurs Diskus utilisés séparément pour administrer chacun des médicaments
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OBJECTIF : Comparer l’efficacité et l’innocuité du nouvel inhalateur Diskus combinant 50 µg de salmétérol et 250 µg de propionate de fluticasone (Seretide) aux deux inhalateurs Diskus utilisés séparément pour administrer chacun des médicaments. MODÈLE : Étude multicentrique, à double insu, à double placebo. Trois cent soixante et un patients asthmatiques et symptomatiques (âgés de 13 à 75 ans, moyenne de 42 ans) recevant des corticostéroïdes en inhalation ont été répartis au hasard dans deux groupes de traitement : un traitement de 28 semaines avec soit du propionate de fluticasone et du salmétérol (50/250 µg deux fois par jour) combiné dans un seul inhalateur Diskus et un placebo deux fois par jour administré au moyen d’un autre inhalateur Diskus, ou du salmétérol seul à raison de 50 µg deux fois par jour administré à l’aide d’un inhalateur Diskus et du propionate de fluticasone seul à raison de 250
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without potential problems. Most obvious, compliance is thought to suffer as the complexity of the regimen increases (20,21). The availability of a long-acting beta2-agonist and an effective inhaled corticosteroid in a single combination inhaler would diminish the risk of suboptimal compliance and, in particular, would ensure that patients using such beta2-agonists would always use the anti-inflammatory corticosteroid concurrently. The primary objective of this study was to determine whether salmeterol and fluticasone propionate dry powder in combination (Seretide, Glaxo Wellcome, UK) via one Diskus (Glaxo Wellcome Inc) inhaler (known as the Accuhaler inhaler in some countries) show clinical equivalence compared with the two active components at equivalent dosage delivered by separate Diskus inhalers. The secondary objective of this study was to demonstrate the safety of salmeterol and fluticasone propionate in combination over a 28-week treatment period.
sthma is a chronic disease of the lungs characterized by airway inflammation, bronchoconstriction and increased airway responsiveness to challenge (such as allergen or spasmogen). Inhaled corticosteroids improve lung function and symptom control, decrease bronchial hyperresponsiveness and reduce the frequency of exacerbations in patients with asthma (1-5). However, the dose-response curve to inhaled corticosteroids is not linear. In patients whose asthma is incompletely controlled with a moderate daily dose of inhaled corticosteroid, greater symptom control is achieved by the addition of a long-acting beta2-agonist than by doubling the dose of inhaled corticosteroid. Two studies have demonstrated that the addition of salmeterol, a longacting beta2-agonist, to existing inhaled beclomethasone dipropionate (BDP) therapy provides more effective control of symptoms than doubling the dose of BDP (6,7). Similar findings have been reported for the combination of salmeterol and fluticasone propionate (8,9), and for the combination of formoterol and budesonide (10). Combining long-acting inhaled agents such as salmeterol (11,12) with potent, topically active, inhaled corticosteroids such as fluticasone propionate (13) has been recognized as a potentially useful management strategy in asthma of moderate or greater severity (14-16). Employing this combination strategy not only improves the control of symptoms better than inhaled corticosteroids alone but also allows for the use of lower doses of inhaled corticosteroid, presumably lowering any risk of systemic side effects from the inhaled corticosteroid (17-19). Although some have speculated that the long term use of long-acting beta2-agonists might be associated with increased exacerbations, the opposite appears to be true. Nonetheless, combination maintenance therapy is not
PATIENTS AND METHODS This multicentre, randomized, double-blind, doubledummy, parallel group study was performed in 43 centres in five countries. The study conformed to Good Clinical Practice Guidelines and to the Declaration of Helsinki 1964, as modified by the 41st World Medical Assembly, Hong Kong, 1989; local ethics committee approval was obtained at all participating sites. All patients provided written informed consent; in the case of minors, this consent was given by their parents or guardians. During the initial two-week run-in period, patients continued to take inhaled BDP or budesonide 800 to 1200 mg/day, or fluticasone propionate 400 to 600 mg/day, and any bron-
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TABLE 1 Day and night-time scores definitions used in the study of salmeterol plus fluticasone propionate in one inhaler Score
TABLE 2 Patient demographics and characteristics at baseline
Definition
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Treatment group Salmeterol Salmeterol/ (50 mg bid) plus fluticasone fluticasone propionate propionate (combination; (concurrent; 50/250 mg bid) 250 mg bid)
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No symptoms during the day
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Symptoms for one short period during the day
Characteristics
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Symptoms for two or more short periods during the day
Number of patients 180 191 Sex, n (%) Female 88 (49) 109 (57) Male 92 (51) 82 (43) Mean age, years (range) 42.8 (13-73) 41.4 (15-75) Smoking history, n (%) Current 27 (15) 25 (13) Ex-smoker 53 (29) 69 (36) Never 100 (56) 97 (51) Mean baseline PEFR, L/min (% predicted), n (%) Morning 398 (84) 391 (85) Evening 415 (88) 415 (89) 2.51 (75) 2.55 (77) Mean baseline FEV1 (L) (% predicted) Patients using concurrent asthma medication, n (%) Methylxanthines 7 (4) 6 (3) Ipratropium bromide 2 (1) 1 (
