PPSV23 Pneumococcal Vaccine in Chronic Obstructive Pulmonary Disease (COPD)

Phase 4 Study of PPSV23 Pneumococcal Vaccine in COPD Patients Using High Daily Dose of Inhaled Corticosteroid

Streptococcus pneumoniae is the most common causes of community-acquired pneumonia and exacerbations in chronic obstructive pulmonary disease (COPD) patients, which are associated with morbidity, mortality, and higher health-care cost. In addition, recently high daily dose of inhaled corticosteroid (ICS) therapy became more evident to be beneficial in moderate-to-severe COPD patients, but excess risk of pneumonia shown in database analysis was worried about by primary physicians. The use of pneumococcal polysaccharide vaccination (PPSV23) has protective efficacy to eliminate infection of Streptococcus pneumoniae from previous studies. If the use of PPSV23 can reduce the incidence of pneumonia or exacerbations in COPD patients using high daily dose of ICS, the benefit of ICS can be preserved and risk of pneumonia can be reduced. However, there is only limited data supporting this hypothesis. In this study, the investigators will conduct a double-blinded, randomized controlled trial to evaluate the clinical efficacy of PPSV23 in severe COPD patients using high daily dose of ICS.

Study Overview

• Status: Completed
• Conditions: Chronic Obstructive Pulmonary Disease
• Intervention / Treatment: Biological: PPSV23 pneumococcal vaccine (Pneumovax®); Drug: Normal Saline

Detailed Description

Exacerbations are a common feature in moderate-to-severe chronic obstructive pulmonary disease (COPD). Morbidity, mortality and health-care costs of these patients largely result from exacerbations. The most common causes of an exacerbation are infection of tracheobronchial tree. Among them, Streptococcus pneumoniae is the most frequently isolated organism, accounting for 5-25% patients of COPD, while it is also the most commonly identified cause in community-acquired pneumonia (CAP), accounting for 16.5-38.9% of CAP patients.

In recent years, widespread emergence of antimicrobial resistance in Streptococcus pneumoniae has became a major global concern, especially in Taiwan, one of the highest levels of antibiotic-resistant pneumococci in the world. Therefore, primary prevention by vaccination is encouraged for those high-risk patients with COPD. The currently available adult pneumococcal vaccine consists of the capsular polysaccharide of 23 different serotypes of Streptococcus pneumoniae (PPSV23). The antibodies produced in response to this polysaccharide can provide protection by inducing host immune cells to kill or to opsonize bacteria for phagocytosis.

Until now, few studies have been designed to specifically examine vaccine efficacy in COPD patients. Among 3 available randomized controlled trials, only one study involving 596 patients found, from post-hoc analyses, some protective efficacy for pneumonia in patients of < 65 years of age and of an FEV1 < 40% predicted. Based on above evidence (only limited body of data), the Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2006 Guideline has recommended the PPSV23 inoculation as evidence B.

By the way, in comparison to placebo and the single components, a superior control by means of the inhaled corticosteroids (ICS)/long-acting beta2-agonist (LABA) fixed combination therapy has been demonstrated for significant clinical improvement in moderate-to-severe COPD patients, except mortality, by meta-analysis and large prospective studies (TORCH [Towards a Revolution in COPD Health] trial and INSPIRE [Investigating New Standards for Prophylaxis in Reduction of Exacerbations] trial). However, those database indicated that high daily dose of ICS (fluticasone propionate at a dose of 500-1000mcg daily) was associated with an excess risk of pneumonia, which doubles the pneumonia incidence in patients not receiving ICS. The immunogenicity of PPSV23 in COPD patients using systemic steroid was demonstrated but the clinical efficacy of vaccination has not been investigated.

From above-mentioned background, if the use of PPSV23 can reduce the incidence of pneumonia or exacerbations in COPD patients using high daily dose of ICS, the benefit of ICS can be preserved and risk of pneumonia can be reduced. For primary physicians, this hypothesis, if true, is very beneficial. So, in this study, the investigators want to conduct a double-blinded, randomized controlled trial to evaluate the clinical efficacy of PPSV23 in COPD patients using high daily dose of ICS.

• Study Type: Interventional
• Enrollment (Actual): 38
• Phase: Phase 4

Contacts and Locations

Study Locations

• Taiwan
  • Taipei County
    • Pan-Chiao, Taipei County, Taiwan, 220
      • Far Eastern Memorial Hospital

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years to 65 years (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

1. no previously vaccination with PPSV23,
2. a clinical diagnosis of severe COPD which is defined according to the GOLD 2006 guideline (11): FEV1/FVC < 70%, FEV1 reversibility test < 200 ml, and FEV1 < 50% of predicted,
3. current or past exposure of smoking,
4. no exacerbation in the month prior to enrollment,
5. age < 65 years,
6. using high daily dose of ICS (budesonide > 800-1600 mcg/day or fluticasone > 500-1000 mcg/day),
7. providing written informed consent.

Exclusion Criteria:

1. Patients are excluded from the study if they are pregnant, or have immunosuppressed status (known current neoplasm, renal insufficiency in dialysis, human immunodeficiency virus (HIV) infection, severe hepatic impairment, hypogammaglobulinemia, anatomical or functional asplenia).
2. Asthma, cystic fibrosis, bronchiectasis, and severe sequelae of pulmonary tuberculosis are also excluded by pulmonary function study and chest imaging before patient's enrollment.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Prevention
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Quadruple

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Vaccine; Enrolled COPD patients receiving PPSV23 pneumococcal vaccine	Biological: PPSV23 pneumococcal vaccine (Pneumovax®); The adult anti-pneumococcal vaccine was a 23-polyvalent pneumococcal vaccine (Pneumovax®, Aventis Pastuer MSD), 0.5 ml of which was given subcutaneously. Duration of the efficacy is about 4-5 years.; Other Names: Pneumovax®, Aventis Pastuer MSD
Placebo Comparator: Normal saline; Enrolled COPD patient receiving placebo normal saline	Drug: Normal Saline; normal saline, 0.5ml given subcutaneously

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Time Frame
the incidence of pneumonia and exacerbations	1 year

Secondary Outcome Measures

Outcome Measure	Time Frame
all cause mortality	1 year
time to the first episode of pneumonia or exacerbation	1 year
change in lung function (post-bronchodilator FEV1, FVC)	1 year

Collaborators and Investigators

• Sponsor: Far Eastern Memorial Hospital
• Investigators: Principal Investigator: Ming-Tzer Lin, MD, Far Eastern Memorial Hospital

Study record dates

Study Major Dates

• Study Start: February 1, 2009
• Primary Completion (Actual): June 1, 2011
• Study Completion (Actual): June 1, 2011

Study Registration Dates

• First Submitted: February 16, 2009
• First Submitted That Met QC Criteria: June 24, 2011
• First Posted (Estimate): June 27, 2011

Study Record Updates

• Last Update Posted (Estimate): June 27, 2011
• Last Update Submitted That Met QC Criteria: June 24, 2011
• Last Verified: June 1, 2011

More Information

Terms related to this study

• Keywords: Chronic obstructive pulmonary disease; Acute exacerbation; Pneumococcal vaccine; Inhaled corticosteroid; High-dose daily inhaled corticosteroid usage; Efficacy of the PPSV23 pneumococcal vaccine
• Additional Relevant MeSH Terms: Respiratory Tract Diseases; Lung Diseases; Lung Diseases, Obstructive; Pulmonary Disease, Chronic Obstructive; Physiological Effects of Drugs; Immunologic Factors; Heptavalent Pneumococcal Conjugate Vaccine
• Other Study ID Numbers: FEMH-97-C-037