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The effect of exacerbation history on outcomes in the IMPACT trial

David M.G. Halpin, Mark T. Dransfield, MeiLan K. Han, C. Elaine Jones, Sally Kilbride, Peter Lange, David A. Lipson, David A. Lomas, Fernando J. Martinez, Steve Pascoe, Dave Singh, Robert Wise, Gerard J. Criner
European Respiratory Journal 2020 55: 1901921; DOI: 10.1183/13993003.01921-2019
David M.G. Halpin
1University of Exeter Medical School, College of Medicine and Health, University of Exeter, Exeter, UK
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  • For correspondence: d.halpin@nhs.net
Mark T. Dransfield
2Division of Pulmonary, Allergy, and Critical Care Medicine, Lung Health Center, University of Alabama at Birmingham, Birmingham, AL, USA
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MeiLan K. Han
3University of Michigan, Pulmonary & Critical Care, Ann Arbor, MI, USA
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C. Elaine Jones
4GlaxoSmithKline, Research Triangle Park, NC, USA
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Sally Kilbride
5GlaxoSmithKline, Stockley Park, UK
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Peter Lange
6Medical Dept, Herlev and Gentofte Hospital, Herlev, Denmark
7University of Copenhagen, Copenhagen, Denmark
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David A. Lipson
8GlaxoSmithKline, Collegeville, PA, USA
9Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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  • ORCID record for David A. Lipson
David A. Lomas
10UCL Respiratory, University College London, London, UK
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Fernando J. Martinez
11New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY, USA
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Steve Pascoe
8GlaxoSmithKline, Collegeville, PA, USA
12Sanofi, Philadelphia, PA, USA
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Dave Singh
13University of Manchester, NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Hospitals Trust, Manchester, UK
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Robert Wise
14Division of Pulmonary and Critical Care Medicine, Johns Hopkins Medicine, Baltimore, MD, USA
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Gerard J. Criner
15Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
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  • Article
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Figures

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  • FIGURE 1
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    FIGURE 1

    Number of combined moderate or severe COPD exacerbations per patient by prior exacerbation subgroup. The exacerbation history subgroups are defined as single moderate (1 moderate/no severe exacerbation in the prior year), frequent moderate (≥2 moderate/no severe exacerbations in the prior year) and severe (≥1 severe/any moderate exacerbation in the prior year). FF: fluticasone furoate; UMEC: umeclidinium; VI: vilanterol.

  • FIGURE 2
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    FIGURE 2

    Annual rate of on-treatment a) moderate or severe and b) severe exacerbations (post-hoc analysis) according to exacerbation history in the year prior to screening for each treatment comparison. The exacerbation history subgroups are defined as single moderate (1 moderate/no severe exacerbation in the prior year), frequent moderate (≥2 moderate/no severe exacerbations in the prior year) and severe (≥1 severe/any moderate exacerbation in the prior year). Data are presented as model estimated annual rate (95% CI), unless otherwise stated. FF: fluticasone furoate; RR: rate ratio; UMEC: umeclidinium; VI: vilanterol.

  • FIGURE 3
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    FIGURE 3

    Time-to-first combined a) moderate or severe and b) severe COPD exacerbations (post-hoc analysis) by treatment by prior exacerbation subgroup for each treatment comparison. The exacerbation history subgroups are defined as single moderate (1 moderate/no severe exacerbation in the prior year), frequent moderate (≥2 moderate/no severe exacerbations in the prior year) and severe (≥1 severe/any moderate exacerbation in the prior year). Data are presented as patients with events n/N (%), unless otherwise stated. FF: fluticasone furoate; UMEC: umeclidinium; VI: vilanterol.

  • FIGURE 4
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    FIGURE 4

    Annual rate of moderate or severe exacerbations, by baseline blood eosinophil count and individual treatment group by prior exacerbation subgroup: a) single moderate, b) frequent moderate and c) severe. The exacerbation history subgroups are defined as single moderate (1 moderate/no severe exacerbation in the prior year), frequent moderate (≥2 moderate/no severe exacerbations in the prior year) and severe (≥1 severe/any moderate exacerbation in the prior year). FF: fluticasone furoate; UMEC: umeclidinium; VI: vilanterol.

  • FIGURE 5
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    FIGURE 5

    Between-treatment differences of a, c, e) FF/UMEC/VI versus UMEC/VI and b, d, f) FF/VI versus UMEC/VI in rates of moderate or severe exacerbations, by baseline blood eosinophil count and prior exacerbation subgroup: a, b) single moderate, c, d) frequent moderate, e, f) severe. The exacerbation history subgroups are defined as single moderate (1 moderate/no severe exacerbation in the prior year), frequent moderate (≥2 moderate/no severe exacerbations in the prior year) and severe (≥1 severe/any moderate exacerbation in the prior year). FF: fluticasone furoate; UMEC: umeclidinium; VI: vilanterol.

  • FIGURE 6
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    FIGURE 6

    LS mean (95% CI) change in St George's Respiratory Questionnaire (SGRQ) at week 52 by prior exacerbation subgroup. The exacerbation history subgroups are defined as single moderate (1 moderate/no severe exacerbation in the prior year), frequent moderate (≥2 moderate/no severe exacerbations in the prior year) and severe (≥1 severe/any moderate exacerbation in the prior year). Post hoc analysis. Data presented as between-treatment difference (95% CI) in LS mean change from baseline at week 52 in SGRQ total score for FF/UMEC/VI versus UMEC/VI, FF/UMEC/VI versus FF/VI and UMEC/VI versus FF/VI. FF: fluticasone furoate; LS: least squares; UMEC: umeclidinium; VI: vilanterol. *: p<0.05.

Tables

  • Figures
  • Supplementary Materials
  • TABLE 1

    Baseline demographics according to exacerbation history in the year prior to screening

    Subgroup
    Single moderateFrequent moderateSevere
    Subjects3056 (30)4628 (45)2671 (26)
    Age years65.2±7.9565.3±8.4665.4±8.29
    Male2069 (68)2922 (63)1879 (70)
    White2408 (79)3604 (78)1971 (74)
    Former smoker1964 (64)3014 (65)1790 (67)
    BMI kg·m−226.10±6.04327.03±5.83326.52±6.532
    Lung function post-bronchodilator
     At screening FEV1 L1.046±0.31931.437±0.50361.247±0.5037
     FEV1 % predicted37.0±8.8551.9±14.7744.4±15.25
     FEV1/FVC ratio0.421±0.10280.510±0.11610.458±0.1201
    Baseline# concomitant COPD medication at screening alone or in combination
     LAMA243 (8)375 (8)213 (8)
     LABA84 (3)166 (4)41 (2)
     LAMA+LABA327 (11)392 (8)215 (8)
     ICS+LABA906 (30)1694 (37)741 (28)
     ICS+LAMA+LABA1258 (41)1651 (36)1274 (48)
    Baseline blood eosinophil counts
     203±186230±256232±242
     Patients with count %
      <100262524
      100–300555352
      >300192323

    Date are presented as n (%) or mean±sd, unless otherwise stated. The exacerbation history subgroups are defined as single moderate (1 moderate/no severe exacerbation in the prior year), frequent moderate (≥2 moderate/no severe exacerbations in the prior year) and severe (≥1 severe/any moderate exacerbation in the prior year). BMI: body mass index; FEV1: forced expiratory volume in 1 s; FVC: forced vital capacity; ICS: inhaled corticosteroid; LABA: long-acting β2-agonist; LAMA: long-acting muscarinic antagonist. #: between day of screening −3 days and date of screening (inclusive).

    • TABLE 2

      Patients with ≥1 moderate, ≥1 severe and ≥1 moderate or severe on-treatment exacerbations during the study period by exacerbation history in the year prior to screening

      Exacerbation history subgroupsOn-treatment COPD exacerbations
      Moderate onlySevere onlyModerate or severe
      FF/UMEC/VI
       Single moderate486 (41)708.1 [750]112 (9)121.8 [129]545 (45)829.9 [879]
       Frequent moderate797 (43)805.4 [1368]117 (6)77.7 [132]859 (46)883.1 [1500]
       Severe436 (40)783.7 [750]218 (20)312.4 [299]555 (51)1096.1 [1049]
      FF/VI
       Single moderate542 (44)857.8 [870]108 (9)135.1 [137]605 (49)992.9 [1007]
       Frequent moderate799 (44)882.2 [1384]120 (7)89.2 [140]847 (46)971.4 [1524]
       Severe454 (42)914.4 [800]233 (22)348.6 [305]587 (55)1263.0 [1105]
      UMEC/VI
       Single moderate252 (41)849.1 [429]55 (9)120.7 [61]281 (46)969.9 [490]
       Frequent moderate430 (46)1002.1 [790]96 (10)145.9 [115]478 (51)1147.9 [905]
       Severe205 (40)958.8 [388]121 (23)410.2 [166]277 (54)1369.0 [554]

      Data are presented as n (%) or rate [number of events]. Rate is reported per 1000 subject-years, calculated as the number of events×1000, divided by the total duration at risk. The exacerbation history subgroups are defined as single moderate (1 moderate/no severe exacerbation in the prior year), frequent moderate (≥2 moderate/no severe exacerbations in the prior year) and severe (≥1 severe/any moderate exacerbation in the prior year). FF: fluticasone furoate; UMEC: umeclidinium; VI: vilanterol.

      Supplementary Materials

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        Supplementary_material ERJ-01921-2019.supplementary_materials

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        Shareable PDF ERJ-01921-2019.Shareable

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      The effect of exacerbation history on outcomes in the IMPACT trial
      David M.G. Halpin, Mark T. Dransfield, MeiLan K. Han, C. Elaine Jones, Sally Kilbride, Peter Lange, David A. Lipson, David A. Lomas, Fernando J. Martinez, Steve Pascoe, Dave Singh, Robert Wise, Gerard J. Criner
      European Respiratory Journal May 2020, 55 (5) 1901921; DOI: 10.1183/13993003.01921-2019

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      The effect of exacerbation history on outcomes in the IMPACT trial
      David M.G. Halpin, Mark T. Dransfield, MeiLan K. Han, C. Elaine Jones, Sally Kilbride, Peter Lange, David A. Lipson, David A. Lomas, Fernando J. Martinez, Steve Pascoe, Dave Singh, Robert Wise, Gerard J. Criner
      European Respiratory Journal May 2020, 55 (5) 1901921; DOI: 10.1183/13993003.01921-2019
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