Clinical trial NCT02845752: The Effect of STIOLTO™ RESPIMAT® on Fatigue in Chronic Obstructive Pulmonary Disease
Official title: A Randomized, Crossover, Placebo Controlled, Double-blind Trial of the Effect of STIOLTO™ RESPIMAT® on Central and Peripheral Components of Fatigue During Exercise in Chronic Obstructive Pulmonary Disease
Study type: INTERVENTIONAL
Overall status: COMPLETED
Phase: PHASE4
Conditions: Chronic Obstructive Pulmonary Disease
Lead sponsor: Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center
Sponsor class: OTHER
Collaborators: name: Boehringer Ingelheim
First posted: 2016-07-27
Enrollment: 14
Sex: ALL
Minimum age (years): 45
Maximum age (years): 90
Standard ages: ADULT
OLDER_ADULT
Accepts healthy volunteers: no
Allocation: RANDOMIZED
Intervention model: CROSSOVER
Primary purpose: BASIC_SCIENCE

Brief summary: The purpose of this study is to determine whether exercise can be prolonged in COPD can by the inhaled bronchodilator Stiolto Respimat. The study will identify whether any endurance benefit is due to reduction in fatigue that originates within the skeletal muscles and/or from effects on neural activation of the skeletal muscles.

Detailed description: Patients with chronic obstructive pulmonary disease (COPD) have reduced exercise tolerance. One mechanism for this is thought to be due to dynamic hyperinflation during exercise (an increase in the end-expiratory lung volume) that contributes to the sensation of breathlessness. Whether this also contributes to inhibiting motor recruitment, and reduces the available power output (termed performance fatigue; PF), is not well understood. Preliminary data suggests that many COPD patients, unlike healthy subjects, stop exercise with a 'skeletal muscle power reserve' i.e. the ability to acutely increase muscle power output. This suggests that they are limited in the exercise task by mechanisms other than acute intramuscular limitations to power production (termed muscle fatigue; MF). Exercise tolerance is increased by treatment with the fixed-dose combination bronchodilator, STIOLTO™ RESPIMAT®. We hypothesize that increased exercise tolerance with STIOLTO™ RESPIMAT® (reduced performance fatigue; PF) will be mediated by a combination of: 1) reduced inhibition of muscle activation (termed activation fatigue; AF) allowing patients to drive their leg muscles harder, and thus; 2) increased muscle fatigue (MF).

Eligibility criteria: Inclusion Criteria:

* All patients must have a diagnosis of chronic obstructive pulmonary disease and must meet the following criteria: (a) Patients must be in a stable state of their disease with no exacerbation within the previous 4 weeks; and (b) At visit 1 spirometric must demonstrate a post-bronchodilator FEV1 \<80% of predicted normal and a post-bronchodilator FEV1/FVC \<70%.
* At visit 1, patients will demonstrate appreciable reversibility, defined as a 12% increase in FEV1 in response to albuterol administration.
* Baseline dyspnea index focal score ≤ 9.
* Male or female patients, between 45 and 90 years (inclusive) of age.
* Patients must be current or ex-smokers with a smoking history of more than 10 pack-years
* Patients must be able to perform technically acceptable pulmonary function tests must be able to complete multiple symptom-limited cycle ergometry tests.
* Patients must be able to inhale medication in a competent manner from the inhalers used in the study.

Exclusion Criteria:

* Patients with a significant disease other than COPD; a significant disease is defined as a disease which, in the opinion of the investigator, may (i) put the patient at risk because of participation in the study, (ii) influence the results of the study, or (iii) cause concern regarding the patient's ability to participate in the study.
* Patients with a documented history of asthma. For patients with allergic rhinitis or atopy, medical records will be required to verify that the patient does not have asthma.
* Patients with any of the following conditions:

  1. A history of myocardial infarction within 1 year of screening visit.
  2. Unstable or life-threatening cardiac arrhythmia.
  3. Hospitalized for heart failure within the past year.
  4. Known active tuberculosis.
  5. A malignancy for which patient has undergone resection, radiation therapy or chemotherapy within last two years (patients with treated basal cell carcinoma are allowed).
  6. A history of life-threatening pulmonary obstruction within the past two years.
  7. A history of cystic fibrosis.
  8. Clinically evident bronchiectasis.
  9. A history of significant alcohol or drug abuse within the past two years.
  10. Any contraindications for exercise testing as outlined below (see contraindications to exercise).
  11. Patients who have undergone thoracotomy with pulmonary resection.
* Patients being treated with oral corticosteroid medication at unstable doses (i.e., less than six weeks on a stable dose) or at doses in excess of the equivalent of 10 mg of prednisone per day or 20 mg every other day.
* Patients who regularly use daytime oxygen therapy for more than one hour per day and in the investigator's opinion will be unable to abstain from the use of oxygen therapy during clinic visits.
* Patients who desaturate to SpO2 \<85% on screening incremental exercise testing.
* Patients who have completed a pulmonary rehabilitation program in the six weeks prior to the screening visit or patients who are currently in a pulmonary rehabilitation program.
* Patients who have a limitation of exercise performance as a result of factors other than fatigue or exertional dyspnea, such as arthritis in the leg, angina pectoris or claudication or morbid obesity.
* Patients with a constant power cycle ergometry endurance time less than 4 or greater than 10 minutes after work rate adjustment procedures (described below).
* Patients who have taken an investigational drug within one month or six half-lives (whichever is greater) prior to screening visit (Visit 1).
* Pregnant or nursing women.
* Women of childbearing who have the potential not to be using a highly effective method of birth control. Female patients will be considered to be of childbearing potential unless surgically sterilized by hysterectomy or bilateral tubal ligation, or post-menopausal for at least two years.
* Patients who are currently participating in another interventional study.
* Patients who are unable to comply with pulmonary medication restrictions prior to randomization.

Primary outcomes:
measure: The Magnitude of Change in Isokinetic Power (Performance Fatigue, PF) Associated With Stiolto Respimat Compared With Placebo Respimat at Isotime During Constant Work Rate Exercise (CWR)
timeFrame: Baseline and day 7 of each treatment period
Secondary outcomes:
measure: The Magnitude of Change Electromyographic (EMG) Muscle Activity (Activation Fatigue, AF) Associated With Stiolto Respimat Compared With Placebo Respimat at Isotime During Constant Work Rate Exercise (CWR)
timeFrame: Baseline and day 7 of each treatment period
measure: Exercise Endurance Time During CWR Cycling Exercise
timeFrame: Baseline and day 7 of each treatment period
measure: Change From Period Baseline in the Exercise-isotime Inspiratory Reserve Volume During CWR
timeFrame: Baseline and day 7 of each treatment period
measure: Change From Period Baseline in the Exercise-isotime Inspiratory Capacity During CWR
timeFrame: Baseline and day 7 of each treatment period
measure: Change From Period Baseline in the Forced Expiratory Volume in 1 Second (FEV1)
timeFrame: Baseline and day 7 of each treatment period
measure: Change From Period Baseline in the Exercise-isotime in Pulse Oximeter Oxygen Saturation During CWR
timeFrame: Baseline and day 7 of each treatment period
measure: Change From Period Baseline in the Exercise-isotime Ventilation During CWR
timeFrame: Baseline and day 7 of each treatment period
measure: Change From Period Baseline in the Exercise-isotime Oxygen Uptake (VO2) During CWR
timeFrame: Baseline and day 7 of each treatment period
measure: Change From Period Baseline in the Exercise-isotime Frontal Lobe Oxygen Saturation During CWR
timeFrame: Baseline and day 7 of each treatment period
measure: Change From Period Baseline in the Exercise-isotime Muscle Oxygen Saturation During CWR
timeFrame: Baseline and day 7 of each treatment period
measure: Change From Period Baseline in the Exercise-isotime Borg CR-10 Rating of Perceived Dyspnea During CWR
timeFrame: Baseline and day 7 of each treatment period
measure: Change From Period Baseline in the Exercise-isotime Borg CR-10 Rating of Perceived Leg Fatigue During CWR
timeFrame: Baseline and day 7 of each treatment period
measure: Change From Period Baseline in the Pre/Post Exercise-induced Decline in Peak Isokinetic Power Normalized to the Measured Muscle Activity (Muscle Fatigue, MF) During CWR
timeFrame: Baseline and day 7 of each treatment period
Other outcomes:
Locations:
city: Torrance
country: United States
facility: Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center
state: California
Study officials:
affiliation: LABioMed at Harbor-UCLA Medical Center
name: Richard Casaburi, PhD, MD
role: PRINCIPAL_INVESTIGATOR
affiliation: LABioMed at Harbor-UCLA Medical Center
name: Harry Rossiter, PhD
role: PRINCIPAL_INVESTIGATOR
References:
citation: Cao M, Calmelat RA, Kierstead P, Carraro N, Stringer WW, Porszasz J, Casaburi R, Rossiter HB. A randomized, crossover, placebo controlled, double-blind trial of the effects of tiotropium-olodaterol on neuromuscular performance during exercise in COPD. J Appl Physiol (1985). 2022 May 1;132(5):1145-1153. doi: 10.1152/japplphysiol.00332.2021. Epub 2022 Mar 24.