Metabolomic changes related to airway inflammation, asthma pathogenesis and systemic activity following inhaled fluticasone furoate/vilanterol: a randomized controlled trial

Abstract

Background: Fluticasone furoate/vilanterol trifenatate (FF/VI) is an inhaled therapy for the treatment of asthma, with a prolonged duration of anti-inflammatory and bronchodilatory action. This study investigated the global metabolomic and lipidomic profile following treatment with FF/VI or placebo and assessed whether changes correlated with exhaled nitric oxide levels as a measure of airway inflammation.

Methods: This was a single-center, randomized, double-blind, placebo-controlled, two-period, crossover, repeat-dose study. Adults with asthma (forced expiratory volume in 1 s ≥ 60% predicted; fraction of exhaled nitric oxide [FeNO] > 40 parts per billion) received once-daily FF/VI 100 µg/25 µg or placebo for 14 days, followed by a 21-day washout period. Serum samples were taken at pre-dose (T1), and 15 and 21 days (T2 and T3, respectively) post dose in each period. The metabolomic and lipidomic profiles were analyzed by liquid chromatography with tandem mass spectrometry and polar liquid chromatography platforms, and ions were matched to a library of standards for metabolite identification and quantification. FeNO values at each timepoint were evaluated for correlations with the biochemical data.

Results: Of 27 randomized participants (mean age 24.5 years, 63% male), 26 provided serum samples for metabolomic analysis. A total of 1969 metabolites were identified, 1634 of which corresponded to a named structure in a reference library. Treatment-related changes in the metabolome were generally subtle, with a modest increase in metabolite perturbations across timepoints. The percentage of metabolites with significant changes (p < 0.05 for all) (increases↑/decreases↓) versus placebo were: 2.1% (1.1%↑/1.0%↓), 6.7% (0.46%↑/6.2%↓) and 11.8% (0.86%↑/10.9%↓) at T1, T2 and T3, respectively. Treatment with FF/VI reduced FeNO levels by 60%, whereas the systemic intermediates involved in NO biosynthesis remained unaffected. Evidence of systemic anti-inflammatory activity was seen in complex lipid pathways, suggesting reduced phospholipase-A2 activity, but without downstream impact on free fatty acids or inflammatory mediators. Consistent with the pathogenesis of asthma, there was evidence of higher fatty acid β-oxidation and lower glycolysis in the placebo arm; this pattern was reversed in the treatment arm.

Conclusions: Despite the prolonged airway anti-inflammatory action of FF/VI, this was accompanied by only subtle systemic metabolomic and lipidomic changes. Trial registration Prospectively registered on ClinicalTrials.gov registry number NCT02712047.

Keywords: Asthma; Clinical trial; Fluticasone furoate; Inhaled corticosteroid; Long-acting β2-agonist; Metabolomics; Vilanterol.

Conflict of interest statement

GB has no conflicts of interest to declare. JF reports grants from GSK during the conduct of the study; grants, personal fees and non-financial support from AstraZeneca; grants from Genentech; and personal fees and non-financial support from GSK and Boehringer Ingelheim. AB and PDY are employees of, and shareholders in, GSK BK is an employee of Metabolon, Inc, which received funding from GSK to conduct the study.

© 2022. The Author(s).

Figures

Fig. 1

Time-course of anti-inflammatory activity of FF/VI. Figure reproduced with permission from Bardsley et al. Respir Res. 2018;19(1):133. Mean exhaled nitric oxide (ppb), during treatment and after cessation of treatment, plotted over time, for placebo (grey line) and FF/VI (black line). Error bars denote the standard error. FF/VI, fluticasone furoate/vilanterol trifenatate; ppb, parts per billion

Fig. 2

Study design. FF/VI, fluticasone furoate/vilanterol trifenatate; SABA, short-acting β2-agonist; T1, baseline; T2, Day 15; T3, Day 21

Fig. 3

PCA plot for a T1, b T2 and c T3. Three-dimensional PCA plot displaying each individual serum sample from each timepoint (placebo and FF/VI), accounting for all metabolites. Comp., component; FF/VI, fluticasone furoate/vilanterol trifenatate; PCA, principal component analysis; T1, baseline; T2, Day 15; T3, Day 21

Fig. 4

RF importance plot comparing FF/VI with placebo at T3. Metabolites listed at the left of the graph are ordered by importance in their role to separate treatment groups (FF/VI vs placebo). The x-axis shows the “Mean Decrease Accuracy,” which is a measure of the importance of a particular biochemical to the accurate classification of a given sample in the appropriate group. FF/VI, fluticasone furoate/vilanterol trifenatate; RF, random forest; T3, Day 21

Fig. 5

a Heat map and b biochemical pathway for complex lipids. DAG, diacylglycerol; FF/VI, fluticasone furoate/vilanterol trifenatate; LPC, lysophosphatidylcholine; LPE, lysophosphatidylethanolamine; PC, phosphatidylcholine; PE, phosphatidylethanolamine; PLA2, phospholipase A2; TAG, triacylglycerol; T1, baseline; T2, Day 15; T3, Day 21

Fig. 6

a Heat map and b biochemical pathway for fatty acids. Acetyl-CoA, acetyl coenzyme A; FF/VI, fluticasone furoate/vilanterol trifenatate; succinyl-CoA, succinyl coenzyme A; TCA, tricarboxylic acid; T1, baseline; T2, Day 15; T3, Day 21

Fig. 7

a Heat map and b biochemical pathway for antioxidants. Acetyl-CoA, acetyl coenzyme A; acyl-CoA, acyl coenzyme A; BHBA, β-hydroxybutyrate; FF/VI, fluticasone furoate/vilanterol trifenatate; TCA, tricarboxylic acid; T1, baseline; T2, Day 15; T3, Day 21

Fig. 8

Energetics profiles for both (a) patients with asthma (from the literature) and (b) participants treated with active drug versus placebo in this study. Acetyl-CoA, acetyl coenzyme A; TCA, tricarboxylic acid

Fig. 9

a Heat map and b biochemical pathway for mevalonate biosynthesis and the generation of isoprenoids and cholesterol. Acetyl-CoA, acetyl coenzyme A; FF/VI, fluticasone furoate/vilanterol trifenatate; HMG-CoA, 3-hydroxy-3-methyl-glutarate coenzyme A; T1, baseline; T2, Day 15; T3, Day 21