Unrefined Salmon Oil as Dietary Supplement in Patient With Chronic Obstructive Pulmonary Disease

Research has over decades showed that marine food carries nutritional characteristics that promote human health. As seen in epidemiological studies and based on in vitro and in vivo studies, it is hypothesized that unrefined salmon oil as dietary supplement have anti-inflammatory effect. However, there is sufficient preliminary data to indicate bioactive compounds effect for clinical use, and further clinical trials investigating effect are needed. This trial will investigate the potential anti-inflammatory effect and reduction in the risk of cardio artery disease in patients diagnosed with chronic obstructive disease, COPD.

This study is a double-blind, placebo-controlled, randomized trial, investigating unrefined salmon oil, CARDIO®, additional to standard care for patients suffering from COPD. The investigational product is an unrefined salmon oil based soft-gel formulation containing 21 different fatty acids (more than 99.1%), lipopeptides (less than 0.9%), antioxidants and other micro metabolites. Research has shown that marine foods carry nutritional characteristics that promote human health, particularly the high intake of long-chain n-3 polyunsaturated fatty acid (n-3 PUFA), eicosapentaeonic acid (EPA), and docosahexaenoic acid (DHA). Cell culture and mouse studies have shown that n-3 PUFAs, such as EPA and DHA, reduce lung leucocyte infiltration and decrease inflammatory cytokines.

Accumulating evidence points to elevated circulating levels of oxidative low-density lipoprotein (ox-LDL) as a key factor that couples COPD with coronary artery disease (CAD). When normal lipoprotein (LDL) becomes oxidized, the structural alteration confers highly pro-inflammatory properties, inducing inflammation and oxidative stress processes central to both COPD and CAD. Ox-LDL is a potent activator of eosinophils, after which the eosinophils appear to mediate chronic inflammation. Based on the literature and studies on the investigational product, the investigators will investigate if CARDIO® can influence eosinophilic inflammation and ox-LDL. This could have positive consequences for improving COPD control and reducing the risk of exacerbations and cardiovascular events. The generalized anti-inflammatory effects and inflammation-resolution promoting effects of unrefined salmon oil might reduce systemic inflammation and benefit COPD patients with co-existing CAD. In this study, the investigators intend to recruit patients with raised oxidative stress represented by patients with serum ox-LDL level at the 25th percentile and above. Therefore, the investigators intend to recruit 20 participants (part 1) with the same inclusion criteria as in part 2, but only measure/analysis serum ox-LDL. The ox-LDL levels derived from part 1 of the study will provide a cut-off level of ox-LDL for patient inclusion into the study part 2. Patient with an ox-LDL value above the 25th percentile will be asked to participate in part 2 of the study. The investigators believe that this will provide the most accurate inclusion of patients to part 2 of the study - the intervention study.

However, clinical trials in humans diagnosed with COPD, have shown varied results investigating n-3 PUFA supplementation. The objective of this study is to evaluate specifically the impact of CARDIO® compared to placebo, on ox-LDL, forced expiratory airflow, blood eosinophils and markers of inflammation in COPD.

Data will be collected by pulmonary function tests (spirometry), blood sample, nutritional log, quality of life questionnaires (CAT), and blood and stool collected for research biobanking. Study intervention period will be 20 weeks, plus 4 weeks post-intervention follow-up, foremost of safety reasons.

As this study is explorative in nature, a sample size which balance the need of statistical power and resource constraints is chosen. The available resources, predetermine those 100 participants, 50 in each arm, can be recruited. Expecting a drop-out rate of about 20% in total (10 subjects per group), and assuming a standard deviation of Ox-LDL of 6 ng/mL the given sample size enables us to detect a mean difference in ox-LDL levels of 3.85 ng/mL. This corresponds to an effect size of 0.64 and shows that the study is reasonably powered. These calculations are done under the standard assumption of power equal to 80% and a significance level of 5%.

Eligibility Criteria:
Inclusion Criteria:

* Diagnosed and under treatment for COPD with regular maintenance therapy.
* Postbronchodilator FEV1-FVC ratio less than 0.70 the last 3 months.
* FEV1\<90%.
* Current smoker or ex-smoker at least 10 pack-years.
* COPD Assessment Test score level (CAT) ≥10.
* Patients with overlapping COPD and asthma disease may be included.
* Speaks fluent Norwegian.
* Signed informed consent and expected cooperation of the patients for the treatment and follow up must be obtained and documented according to ICH GCP, and national/local regulation.

Exclusion Criteria:

* Evidence and/or diagnose of clinically significant uncontrolled non-pulmonary disease.

  * Myocardial infarction or stroke within the last 12 months, angina pectoralis diagnosed \< 3 months or unstable angina
  * Stage 4 of Congestive Heart Failure according to The New York Heart Association (NYHA) (severe heart failure with poor outcome and decreased survival rate).
  * Cancer diagnosed within the last 12 months (except basal cell carcinoma of the skin), and/or ongoing active cancer therapy.
  * Severe liver disease
  * Severe autoimmune diseases requiring immunosuppressant treatment.
* Pulmonary fibrosis, interstitial lung disease, pulmonary hypertension, sarcoidosis, or significant bronchiectasis.
* Treatment with oral steroid \< 1 month prior to baseline visit.
* Oral/intravenous antibiotics \< 1 month prior to baseline visit.
* Immunosuppressant therapy such as Cyclosporine and Azathioprine.
* Consumption regularly of fish/krill oil (liquid, capsule, powder) as an oral supplement \< 1 month prior baseline visit.
* Known fish or shellfish allergy.
* Participant in any other clinical study.
* Inflammatory bowel disease (Crohn's disease, UC, microscopic colitis), celiac disease, malabsorption, lactose intolerance.
* Severe cognitive impairment where the participants are not able to comply to protocol.
* Any reason why, in the opinion of the investigator, the patient cannot participate, or is not in the patient's best interest.