Morphine for Treatment of Dyspnea in Patients With COPD (MORDYC)

Morphine for Palliative Treatment of Refractory Dyspnea in Patients With Advanced COPD: Benefits and Respiratory Adverse Effects

Dyspnea is the most reported symptom of patients with advanced Chronic Obstructive Pulmonary Disease (COPD) and is undertreated. Morphine is an effective treatment for dyspnea and is recommended in clinical practice guidelines, but questions concerning benefits and concerns about respiratory adverse effects remain. For example, the effect on health-related quality of life and functional capacity is unknown. In one-third of the patients oral sustained release morphine (morphine SR) doesn't relieve dyspnea and it remains unknown whether severity and descriptors of breathlessness may predict a response to morphine. Finally, cost-effectiveness of morphine SR in this patient group is unknown. Therefore, prescription of morphine to patients with COPD is limited.

Objectives of this double blind randomized controlled trial are to study the effect of oral administration of morphine SR on health-related quality of life, respiratory adverse effects, and functional capacity; to explore whether description and severity of breathlessness are related with a clinically relevant response to morphine and to analyse the cost-effectiveness of morphine SR. The study population will consist of 124 clinically stable outpatients with COPD and severe dyspnea despite optimal pharmacological and non-pharmacological treatment.

Study Overview

• Status: Completed
• Conditions: Pulmonary Disease, Chronic Obstructive
• Intervention / Treatment: Drug: sustained release morphine; Drug: placebo

Detailed Description

Participants will be outpatients with a confirmed diagnosis of COPD, who suffer from severe dyspnea despite optimal pharmacological and non-pharmacological treatment. Participants will be recruited at CIRO, a center for pulmonary rehabilitation in the Netherlands after they completed a pulmonary rehabilitation program. After providing informed consent, patients will be randomized. Members of the research team who perform measurements will be blinded for treatment allocation.

Patients in the intervention group will receive regular clinical care and morphine SR 10mg, administered twice daily (20mg/24h), which can be increased after one or two weeks to three times per day 10mg (30mg/24h) in non-responders. Patients will be defined as non-responders if the mean dyspnea numeric rating scale (NRS) score was not reduced by 1 point in comparison with baseline. The control group will receive regular clinical care and placebo medication. Patients will receive morphine or placebo for four weeks. In addition, both groups will receive a prescription for a laxative and metoclopramide at the start of the intervention and will be instructed to adjust the dose as needed.

When the intervention period has ended, participants can choose to continue morphine treatment. They will be followed for twelve weeks to assess their healthcare use, use of morphine and number of adverse effects and exacerbations.

Measurements at baseline will include: demographics, medical history, medication, co-morbidities, exercise capacity, respiratory parameters, generic and disease-specific health-related quality of life (HRQoL), severity of dyspnea, sensory and affective dimensions of dyspnea, impact of dyspnea, cognition, level of daytime sleepiness, and functional capacity. A member of the research team will visit patients after 1 and 2 weeks in their home environment to assess adverse effects, compliance, exacerbations, disease-specific HRQoL, mobility, severity of dyspnea, and some respiratory parameters. A member of the research team will call the patient after 2 days and 3 weeks to assess adverse effects, compliance, exacerbations, and severity of dyspnea. After 4 weeks the following measurements will be performed: respiratory parameters, exercise capacity, general and disease-specific HRQoL, sensory and affective dimensions of dyspnea, impact of dyspnea, functional capacity, and adverse effects. Overnight oximetry will be performed in the home environment at baseline and after four weeks. A diary for costs and healthcare use will be filled in during four weeks.

Measurements during the twelve weeks following the intervention include: retrospective cost questionnaire, generic and disease-specific quality of life severity of dyspnea and adverse effects.

Statistical analyses Baseline characteristics will be compared between the intervention and control group using descriptive statistics. Chi square tests will be used for categorical variables. Independent sample T-tests and Mann-Whitney U-tests will be used for continuous variables, according to the variable distribution. Change in CAT-score, respiratory parameters and 6MWD between baseline and four weeks will be compared between patients in the intervention and the control group. First, mean change in CAT-score, respiratory parameters and 6MWD will be compared between the two groups using an independent sample T-test or Mann-Whitney U test, according to the variable distribution. Afterwards, multivariate analyses for longitudinal data will be performed. Analyses will be done using an intention-to-treat approach. The relationship between response to opioids and severity of dyspnea and descriptors of breathlessness will be explored using univariate analysis, followed by a binary logistic regression model. A trial-based economic evaluation will be performed, based on empirical data obtained in the RCT. The economic evaluation will be performed from the societal and healthcare perspective, the first including costs inside and outside the health care sector, and will follow published international guidelines. The time horizon of the trial-based economic evaluation will be four weeks. The outcomes of the twelve weeks following the intervention will be used in the model-based economic evaluation. The model will probably take the form of a Markov model; however this will be decided upon during the study.

• Study Type: Interventional
• Enrollment (Actual): 124
• Phase: Phase 4

Contacts and Locations

Study Locations

• Netherlands
  • Horn, Netherlands, 6080 AA
    • Ciro centre of expertise for chronic organ failure

Participation Criteria

Eligibility Criteria

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

Description

Inclusion Criteria:

• Diagnosis of COPD according to the current Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease (GOLD);
• Optimal pharmacological treatment, including including treatment with a combination of a long-acting muscarinic antagonist and an ultra-long-acting β-agonist;
• Grade 3 or 4 dyspnea on the mMRC dyspnea scale;
• Optimal non-pharmacological treatment defined as completed a comprehensive pulmonary rehabilitation program.

Exclusion Criteria:

• History of substance misuse;
• Exacerbation of COPD within two weeks of study enrolment;
• Waiting list for lung transplantation;
• Pregnant or childbearing potential not using contraception;
• Renal failure (creatinine clearance <15mL/min);
• Not being able to read or fill in the questionnaires or diary;
• Allergy for morphine or its excipients;
• Concomitant use of irreversible MAO blockers;
• Use of opioids;
• History of convulsions;
• Head injury;
• Intestinal obstruction;
• Gastroparesis;
• Liver disease.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Double

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Placebo Comparator: control; placebo	Drug: placebo; Patients in the control group will receive placebo, consisting of microcrystalline cellulose (FMC BioPolymer). Hard gelatin capsules of size AA in Swedish orange containing microcrystalline cellulose will be produced.
Active Comparator: intervention; sustained release morphine	Drug: sustained release morphine; Patients will receive morphine SR 10mg two to three times daily or placebo. Hard gelatin capsules of size AA in Swedish orange containing one morphine SR tablet 10 mg per capsule will be produced. Morphine SR has a marketing authorisation for pain and will be used according to current Dutch and international guidelines for treatment of dyspnea.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Disease-specific health-related quality of life (COPD Assessment Test (CAT))	Change in disease-specific health-related quality of life in four weeks measured with CAT	sixteen weeks
Change in partial pressure of CO2 (pCO2)	Change in pCO2 in four weeks	four weeks
Change in partial pressure of O2 (pO2)	Change in pO2 in four weeks	four weeks
Respiratory rate	Change in respiratory rate in four weeks	four weeks
Pulse oximetric saturation (SpO2)	Change in SpO2 in four weeks	four weeks
Transcutaneous carbon dioxide (PtcCO2)	Change in PtcCO2 in four weeks	four weeks
Oxygen saturation during the night	Change in oxygen saturation during the night in four weeks using overnight oximetry	four weeks

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
distance walked in 6 Minute Walking Test (6-MWT)	Change in exercise capacity in four weeks measured with 6-MWT	four weeks
Care dependency (Care Dependency Scale (CDS)	Change in care dependency in four weeks measured with CDS	four weeks
Mobility (Timed 'Up & Go' (TUG) test)	Change in mobility in four weeks measured with TUG test.	four weeks
Sensory and affective dimensions of dyspnea (Multidimensional Dyspnea Profile (MDP)	Sensory and affective dimensions of dyspnea in four weeks measured with MDP	four weeks
Impact of dyspnea (Pulmonary Functional Status and Dyspnea Questionnaire, PFSDQ-M)	Change in impact of dyspnea in four weeks measured with PFSDQ-M	four weeks
Severity of dyspnea (Numeric Rating Scale (NRS)	Change in severity of dyspnea in four weeks measured with NRS	sixteen weeks
Daytime sleepiness (Epworth Sleep Questionnaire)	Change in level of daytime sleepiness in four weeks measured with Epworth Sleep Questionnaire	four weeks
Cognition (Montreal Cognitive Assessment, (MoCA)	Change in cognition in four weeks measured with MoCA	four weeks
Number of patients with adverse effects	Adverse effects, including nausea, vomiting, constipation, drowsiness	sixteen weeks
Intake of medication	Number of missed medication intakes in four weeks	four weeks
Number of exacerbations	Number of exacerbations in four weeks	sixteen weeks
Cost of healthcare use in euro's	Cost of healthcare use in euro's based on the number of hospitalizations, number and type of contact with physician, use of (professional) homecare, use of medication and absence of (voluntary) work due to illness	sixteen weeks

Collaborators and Investigators

• Sponsor: Maastricht University Medical Center
• Collaborators: ZonMw: The Netherlands Organisation for Health Research and Development
• Investigators: Principal Investigator: Daisy JA Janssen, MD, PhD, Maastricht UMC; Principal Investigator: E. FM Wouters, MD, PhD, Maastricht UMC

Publications and helpful links

General Publications

• Verberkt CA, van den Beuken-van Everdingen MHJ, Dirksen CD, Schols JMGA, Wouters EFM, Janssen DJA. Cost-effectiveness of sustained-release morphine for refractory breathlessness in COPD: A randomized clinical trial. Respir Med. 2021 Apr;179:106330. doi: 10.1016/j.rmed.2021.106330. Epub 2021 Feb 10.
• Verberkt CA, van den Beuken-van Everdingen MHJ, Schols JMGA, Hameleers N, Wouters EFM, Janssen DJA. Effect of Sustained-Release Morphine for Refractory Breathlessness in Chronic Obstructive Pulmonary Disease on Health Status: A Randomized Clinical Trial. JAMA Intern Med. 2020 Oct 1;180(10):1306-1314. doi: 10.1001/jamainternmed.2020.3134.

Study record dates

Study Major Dates

• Study Start (Actual): November 16, 2016
• Primary Completion (Actual): March 6, 2019
• Study Completion (Actual): July 1, 2019

Study Registration Dates

• First Submitted: April 2, 2015
• First Submitted That Met QC Criteria: April 28, 2015
• First Posted (Estimate): April 29, 2015

Study Record Updates

• Last Update Posted (Actual): September 4, 2019
• Last Update Submitted That Met QC Criteria: September 2, 2019
• Last Verified: March 1, 2019

More Information

Terms related to this study

• Keywords: Opioid; Morphine; Chronic Obstructive Pulmonary Disease; Dyspnea; Breathlessness; Symptom Management
• Additional Relevant MeSH Terms: Respiratory Tract Diseases; Respiration Disorders; Signs and Symptoms, Respiratory; Lung Diseases, Obstructive; Lung Diseases; Pulmonary Disease, Chronic Obstructive; Dyspnea; Physiological Effects of Drugs; Central Nervous System Depressants; Peripheral Nervous System Agents; Analgesics; Sensory System Agents; Analgesics, Opioid; Narcotics; Morphine
• Other Study ID Numbers: 152002; 80-83600-98-3006 (Other Grant/Funding Number: ZonMw)