Aztreonam for Inhalation Solution vs Tobramycin Inhalation Solution in Patients With Cystic Fibrosis & Pseudomonas Aeruginosa

An Open-Label, Randomized, Phase 3 Trial to Evaluate the Efficacy and Safety of Aztreonam for Inhalation Solution (AZLI) Versus Tobramycin Inhalation Solution (TIS) in an Intermittent Aerosolized Antibiotic Regimen in Subjects With Cystic Fibrosis Followed by an Open-Label, Single Arm Extension (European Union [EU] Only)

The purpose of this study was to assess the comparative safety and effectiveness of aztreonam for inhalation solution versus tobramycin inhalation solution in adult and pediatric patients with cystic fibrosis (CF) and pulmonary Pseudomonas aeruginosa (PA) infection.

Study Overview

• Status: Completed
• Conditions: Cystic Fibrosis
• Intervention / Treatment: Drug: Aztreonam for Inhalation Solution (AZLI); Drug: Tobramycin Inhalation Solution (TIS)

Detailed Description

Number of Subjects Planned: Approximately 240 randomized patients

Target Population: CF patients >= 6 years of age with stable pulmonary disease, who at study entry had a recent positive sputum culture for PA and had been previously treated with aerosolized antibiotics without demonstration of drug intolerance.

The randomized phase of this study, used for hypotheses testing, enrolled participants from both the United States (US) and EU. An open-label, single-arm extension was available for participants in the EU who completed at least one course of AZLI or TIS during the randomized portion of the study. These participants were eligible to receive 3 additional cycles of AZLI in a 28-day, intermittent, repeating treatment regimen. Results of the extension phase will be available the first quarter (Q1) of 2012.

Randomized Phase Study Design (US and EU): This was an open-label, multicenter, randomized, parallel group study. The study design consisted of 2 treatment arms of 28-day, intermittent, repeating treatment regimens: aztreonam for inhalation solution (AZLI) or tobramycin inhalation solution (TIS). The total study period was 26 weeks. The study schedule included 9 visits - Screening, Baseline, Day 14, Day 28, followed by visits every 28 days through the end of the study.

• Study Type: Interventional
• Enrollment (Actual): 274
• Phase: Phase 3

Contacts and Locations

Study Locations

• Austria
  • Innsbruck, Austria, A-6020
  • Salzburg, Austria, A-5020
• Belgium
  • Antwerp, Belgium, 2650
  • Brussels, Belgium, 1090
  • Bruxelles, Belgium, 1070
  • Ghent, Belgium, 9000
  • Leuven, Belgium, 3000
• Denmark
  • Copenhagen, Denmark, DK-2100
• France
  • Amiens, France, 80054
  • Bordeaux, France, 33076
  • Caen, France, 14000
  • Creteil, France, 94000
  • Lille Cedex, France, 59037
  • Lisieux, France, 14100
  • Montpellier, France, 34295
  • Nice cedex 3, France, 06202
  • Paris Cedex, France, 75743
  • Pessac Cedex, France, 33604
  • Rennes, France, 35033
• Germany
  • Berlin, Germany, 13125
  • Berlin, Germany, 123353
  • Bochum, Germany, 44791
  • Essen, Germany, 45122
  • Essen, Germany, 45239
  • Giessen, Germany, 35392
  • Hamburg, Germany, 22763
  • Leipzig, Germany, 04103
  • Magdeburg, Germany, 39120
  • Mainz, Germany, 55101
  • Munchen, Germany, 80336
• Ireland
  • Dublin, Ireland, 4
  • Dublin, Ireland, 9
  • Dublin, Ireland
  • Dublin, Ireland, 24
  • Galway, Ireland
• Italy
  • Ancona, Italy, 60123
  • Catania, Italy, 95123
  • Milano, Italy, 20122
  • Napoli, Italy, 80131
  • Palermo, Italy, 90134
  • Parma, Italy, 43100
  • Rome, Italy, 00161
  • Rome, Italy, 00165
  • Verona, Italy, 37126
• Netherlands
  • Den Haag, Netherlands, 2504 LN
  • Maastricht, Netherlands, 6229
• Portugal
  • Lisboa, Portugal, 1649-035
  • Porto, Portugal, 4200 319
• Spain
  • Madrid, Spain, 28046
  • Madrid, Spain, 28034
  • Madrid, Spain, 28041
  • Madrid, Spain, 28009
  • Malaga, Spain, 29011
• Switzerland
  • Zurich, Switzerland, CH - 8032
  • Zurich, Switzerland, CH - 8091
• United Kingdom
  • Belfast, United Kingdom, BT9 7AB
  • Cambridge, United Kingdom, CB23 3RE
  • Cardiff, United Kingdom, CF64-2XX
  • Leeds, United Kingdom, LS9 7TF
  • Liverpool, United Kingdom, L14 3PE
  • London, United Kingdom, SW3 6NP
  • Southampton, United Kingdom, SO16 6YD
  • West Yorkshire
    • Sheffield, West Yorkshire, United Kingdom, S10 2TH
• United States
  • Alaska
    • Anchorage, Alaska, United States, 99508
  • Arizona
    • Phoenix, Arizona, United States, 85006
    • Tuscon, Arizona, United States, 85724
  • California
    • Orange, California, United States, 92868
  • Colorado
    • Aurora, Colorado, United States, 80045
    • Denver, Colorado, United States, 80206
  • Delaware
    • Wilmington, Delaware, United States, 19803
  • Florida
    • Orlando, Florida, United States, 32801
    • Tampa, Florida, United States, 33606
  • Illinois
    • Chicago, Illinois, United States, 60637
    • Glenview, Illinois, United States, 60025
    • Niles, Illinois, United States, 60714
  • Massachusetts
    • Boston, Massachusetts, United States, 02115
  • Missouri
    • Columbia, Missouri, United States, 65212
  • Nevada
    • Las Vegas, Nevada, United States, 89107
  • New York
    • Albany, New York, United States, 12208
    • New Hyde Park, New York, United States, 11040
  • Ohio
    • Cincinnati, Ohio, United States, 45229
    • Dayton, Ohio, United States, 45404
    • Toledo, Ohio, United States, 43606
  • Oklahoma
    • Oklahoma City, Oklahoma, United States, 73112
  • Pennsylvania
    • Hershey, Pennsylvania, United States, 17033
    • Philadelphia, Pennsylvania, United States, 19104
    • Philadelphia, Pennsylvania, United States, 19102
  • South Carolina
    • Charleston, South Carolina, United States, 29425
  • Texas
    • Houston, Texas, United States, 77030
    • San Antonio, Texas, United States, 78212
  • Utah
    • Salt Lake City, Utah, United States, 84132
  • Virginia
    • Richmond, Virginia, United States, 23298

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 6 years and older (Child, Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• Males or females aged 6 years and older
• Subjects with CF as diagnosed by one of the following: documented sweat chloride >= 60 mEq/L by quantitative pilocarpine iontophoresis test, or documented sweat sodium >= 60 mmol/L, or 2 well characterized genetic mutations in the Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) gene, or abnormal nasal potential difference with accompanying symptoms characteristic of CF
• Documented PA in an expectorated sputum or throat swab culture within 3 months prior to Visit 1 or at Visit 1
• Subjects must be able to provide written informed consent/assent prior to any study related procedures; parent/guardian must be able to give written informed consent as necessary prior to any study related procedure
• Subjects must have received previous treatment with aerosolized antibiotics without demonstration of drug intolerance
• FEV1 <= 75% predicted at Visit 1
• Ability to perform reproducible pulmonary function tests
• Chest radiograph at Visit 1 without significant acute findings (eg, infiltrates [lobar or diffuse interstitial], pleural effusion, pneumothorax); or chest radiograph or magnetic resonance image (MRI) obtained within the 180 days prior to Visit 1 without acute findings and no significant intercurrent illness; chronic, stable findings (eg, chronic scarring or atelectasis) are allowed

Exclusion Criteria:

• Current use of oral corticosteroids in doses exceeding the equivalent of 10 mg prednisone a day or 20 mg prednisone every other day
• History of sputum or throat swab culture yielding B. cepacia in the previous 2 years
• Current requirement for daily continuous oxygen supplementation or requirement for more than 2 L/minute at night
• Administration of any investigational drug or device within 28 days of Visit 1 or within 6 half-lives of the investigational drug (whichever is longer)
• Known local or systemic hypersensitivity to monobactam antibiotics
• Known allergies/intolerance to tobramycin
• Inability to tolerate inhalation of a short acting beta agonist
• Changes in or initiation of chronic azithromycin treatment within 28 days prior to Visit 1
• Administration of antipseudomonal antibiotics by inhalation, intravenous or oral routes within the 14 days prior to Randomization/Visit 2
• Changes in antimicrobial, bronchodilator (BD), dornase alfa, or corticosteroid medications within 7 days prior to Visit 1
• Changes in physiotherapy technique or schedule within 7 days prior to Visit 1
• History of lung transplantation
• Abnormal renal or hepatic function or serum chemistry at Visit 1, defined as aspartate aminotransferase (AST), alanine aminotransferase (ALT) > 5 times upper limit of normal range (ULN) or creatinine > 2 times ULN
• Positive pregnancy test at Visit 1; all women of childbearing potential will be tested
• Female of childbearing potential who is lactating or is not (in the opinion of the investigator) practicing an acceptable method of birth control; female subjects who utilize hormonal contraceptives as one of their birth control methods must have used the same method for at least 3 months before study dosing
• Any serious or active medical or psychiatric illness, which in the opinion of the investigator, would interfere with patient treatment, assessment, or compliance with the protocol

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: AZLI 75 mg 3 times a day (TID)	Drug: Aztreonam for Inhalation Solution (AZLI); Aztreonam for inhalation solution (75 mg) was administered 3 times a day (TID) for 28 days for each treatment cycle via the PARI eFlow electronic nebulizer.; Other Names: aztreonam; AZLI; inhaled antibiotic
Active Comparator: TIS 300 mg 2 times a day (BID)	Drug: Tobramycin Inhalation Solution (TIS); Tobramycin inhalation solution (300 mg) was administered 2 times a day (BID) for 28 days for each treatment cycle via the PARI LC Plus nebulizer with compressor or via another nebulizer compatible with country-specified labeling.; Other Names: tobramycin; TNS; inhaled antibiotic

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Relative Change From Baseline in Forced Expiratory Volume in 1 Second (FEV1) Percent Predicted at Day 28	Spirometry was performed according to American Thoracic Society (ATS) guidelines at each visit. FEV1 percent predicted is a normalized value of FEV1 calculated using the Knudson equation and based upon participant age, gender, and height. Treatment effect on the relative change from baseline in FEV1 percent predicted at Day 28 (Visit 4) was tested using an analysis of covariance (ANCOVA) model-based method.	Baseline and end of treatment Course 1 (Day 28)
Mean Actual Change From Baseline in FEV1 Percent Predicted Across 3 Treatment Courses	Spirometry was performed according to ATS guidelines at each visit. FEV1 percent predicted is a normalized value of FEV1 calculated using the Knudson equation and based upon participant age, gender, and height. Treatment effect on the average adjusted means for the actual change in FEV1 percent predicted at Visits 4, 6, and 8 (Weeks 4, 12, and 20) was tested by mixed-effect model repeated measures (MMRM) analysis using the ITT population analysis set.	Baseline, and end of treatment Courses 1 (Week 4), 2 (Week 12), and 3 (Week 20)

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Relative Change From Baseline in FEV1 Percent Predicted at Day 28 in Subjects Who Received Inhaled Tobramycin for >= 84 Days in the 12 Months Prior to Randomization	Spirometry was performed according to ATS guidelines. FEV1 percent predicted is a normalized value of FEV1 calculated using the Knudson equation and based upon participant age, gender, and height. Treatment effect on the relative change from baseline in FEV1 percent predicted at Day 28 (Visit 4) was tested using an ANCOVA model-based method, using the population of participants with prior inhaled tobramycin use of >= 84 days in the previous 12 months.	Baseline and end of treatment Course 1 (Day 28)
Mean Actual Change From Baseline in FEV1 Percent Predicted Across 3 Treatment Courses in Subjects Who Received Inhaled Tobramycin for >= 84 Days in the 12 Months Prior to Randomization	Spirometry was performed according to ATS guidelines at each visit. FEV1 percent predicted is a normalized value of FEV1 calculated using the Knudson equation and based upon participant age, gender, and height. Treatment effect on the average adjusted means for the actual change in FEV1 percent predicted at Visits 4, 6, and 8 (Weeks 4, 12, and 20) was tested by MMRM analysis using the population of participants with prior inhaled tobramycin use of >=84 days in the previous 12 months.	Baseline and end of treatment Courses 1 (Week 4), 2 (Week 12), and 3 (Week 20)
Time to Need for Intravenous (IV) Antipseudomonal Antibiotics for Respiratory Events	IV antipseudomonal antibiotic use for a respiratory event was determined through the adjudication of events by a sponsor-independent, blinded review committee. Use was compiled from data recorded on the concomitant medications electronic case report form (eCRF) and compared to reported adverse events (AEs) to determine use for a respiratory event. The time to IV antipseudomonal antibiotic use was measured in days from baseline (Visit 2) to the date of first IV antipseudomonal antibiotic use or the date of study completion (last visit)/or early withdrawal if censored.	Day 0 to Day 168 (end of study)
Time to First Respiratory Hospitalization	This endpoint was determined through the adjudication of events by a sponsor-independent, blinded review committee. Committee members reviewed all hospitalizations and determined which were related to respiratory events. Details of all hospitalizations, including the dates of admission and discharge, were recorded on the serious adverse event (SAE) eCRF. Time to first respiratory hospitalization was the number of days from baseline (Visit 2) to the date of first respiratory hospitalization or the date of study completion (last visit) /or early withdrawal if censored.	Day 0 to Day 168 (end of study)

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
Actual Change From Baseline in CF Questionnaire - Revised (CFQ-R) Respiratory Symptoms Scale (RSS) Score at Day 28	The CFQ-R is a validated patient-reported outcome tool measuring health-related quality of life for children and adults with CF. The CFQ-R contains both general and CF-specific scales. The endpoint was change in respiratory symptoms (e.g., coughing, congestion, wheezing) from baseline, assessed with the CFQ-R RSS (range of scores [units]: 0-100; higher scores indicate fewer symptoms).	Baseline and end of treatment Course 1 (Day 28)
Mean Actual Change From Baseline in CFQ-R RSS Score Across 3 Treatment Courses	The CFQ-R is a validated patient-reported outcome tool measuring health-related quality of life for children and adults with CF. The CFQ-R contains both general and CF-specific scales. The endpoint was the average actual change in respiratory symptoms (e.g., coughing, congestion, wheezing) from baseline, assessed with the CFQ-R RSS (range of scores [units]: 0-100; higher scores indicate fewer symptoms) at the end of each treatment course (Weeks 4, 12, and 20).	Baseline and end of treatment Courses 1 (Week 4), 2 (Week 12), and 3 (Week 20)
Treatment Satisfaction Questionnaire for Medication (TSQM) - Global Satisfaction Results at Week 20	This 14 item questionnaire consists of 3 subscales that gauge participant perceptions of a medication's effectiveness, side effects, and convenience. The measure also contains a global satisfaction scale to evaluate overall participant satisfaction. The global satisfaction score is the endpoint reported here. The range of scores is 0 to 100, with higher scores indicating greater satisfaction.	At Week 20
Total Number of Respiratory Hospitalizations	Respiratory hospitalizations were determined through the adjudication of events by a sponsor-independent, blinded review committee. Committee members reviewed hospitalizations and determined which were related to respiratory events.	Day 0 to Day 168 (end of study)
Number of Respiratory Events Requiring IV and/or Inhaled Antipseudomonal Antibiotics (Other Than Randomized Treatment)	Inhaled and/or IV antipseudomonal antibiotic use for respiratory event was determined through event adjudication by a sponsor-independent, blinded review committee. Use of IV and/or inhaled antipseudomonal antibiotics was compiled from data recorded on the concomitant medications eCRF and compared to reported AEs to determine use for a respiratory event. The time to IV and/or inhaled antipseudomonal antibiotic use was measured in days from baseline (Visit 2) to the date of first antipseudomonal antibiotic use or the date of study completion (last visit)/or early withdrawal if censored.	Day 0 through Day 168 (end of study)
Time to Need for Inhaled and/or IV Antipseudomonal Antibiotics for Respiratory Event (Other Than Randomized Treatment)	Antipseudomonal antibiotic use for respiratory event was determined through event adjudication by a sponsor-independent, blinded review committee. Use of IV and/or inhaled antibiotics for a respiratory event was compiled from data recorded on the concomitant medications eCRF and compared to reported AEs to determine use for a respiratory event. The time to antibiotic use for a respiratory event was measured in days from baseline (Day 0) to the date of first antibiotic use for a respiratory event or the date of study completion (last visit)/or early withdrawal if censored.	Day 0 to Day 168 (end of study)

Collaborators and Investigators

• Sponsor: Gilead Sciences
• Collaborators: Covance; ClinPhone, Inc.; Chiltern International Inc.
• Investigators: Study Director: Mark Bresnik, MD, Gilead Sciences

Publications and helpful links

General Publications

• Assael BM, Pressler T, Bilton D, Fayon M, Fischer R, Chiron R, LaRosa M, Knoop C, McElvaney N, Lewis SA, Bresnik M, Montgomery AB, Oermann CM; AZLI Active Comparator Study Group. Inhaled aztreonam lysine vs. inhaled tobramycin in cystic fibrosis: a comparative efficacy trial. J Cyst Fibros. 2013 Mar;12(2):130-40. doi: 10.1016/j.jcf.2012.07.006. Epub 2012 Sep 15.

Study record dates

Study Major Dates

• Study Start: August 1, 2008
• Primary Completion (Actual): May 1, 2010
• Study Completion (Actual): November 1, 2010

Study Registration Dates

• First Submitted: September 22, 2008
• First Submitted That Met QC Criteria: September 22, 2008
• First Posted (Estimate): September 23, 2008

Study Record Updates

• Last Update Posted (Estimate): July 4, 2011
• Last Update Submitted That Met QC Criteria: June 7, 2011
• Last Verified: June 1, 2011

More Information

Terms related to this study

• Keywords: cystic fibrosis; lung infection; pseudomonas aeruginosa; aztreonam lysine; tobramycin inhalation solution; tobramycin nebuliser solution; CFQ-R; inhaled antibiotic
• Additional Relevant MeSH Terms: Digestive System Diseases; Pathologic Processes; Respiratory Tract Diseases; Respiration Disorders; Lung Diseases; Infant, Newborn, Diseases; Genetic Diseases, Inborn; Pancreatic Diseases; Fibrosis; Respiratory Aspiration; Cystic Fibrosis; Anti-Infective Agents; Antitubercular Agents; Anti-Bacterial Agents; Antibiotics, Antitubercular; Pharmaceutical Solutions; Tobramycin; Aztreonam
• Other Study ID Numbers: GS-US-205-0110