Actualités dans la prise en charge de l’infection respiratoire par Pseudomonas aeruginosa et les thérapeutiques inhalées

Actualités dans la prise en charge de l’infection respiratoire par Pseudomonas aeruginosa et les thérapeutiques inhalées

5HYXHGHV0DODGLHV5HVSLUDWRLUHV$FWXDOLWpV   ISSN 1877-1203 Revue des Maladies Respiratoires Actualités Organe Officiel de la Soci...

370KB Sizes 1 Downloads 160 Views

5HYXHGHV0DODGLHV5HVSLUDWRLUHV$FWXDOLWpV   ISSN 1877-1203

Revue des

Maladies

Respiratoires Actualités

Organe Officiel de la Société de Pneumologie de Langue Française

'LVSRQLEOH HQ OLJQH VXU

38e Congrès annuel de l’European Cystic Fibrosis Society Bruxelles – 10-13 juin 2015 Coordination : P.-R. Burgel

Cl–

ZZZVFLHQFHGLUHFWFRP

Cl– Cl–

wt-CFTR

Cl–

Cl– Cl–

Cl–

Cl–

I

II

III

IV

V

VI

No protein

No traffic

No Function

Less Function

Less Protein

Less Stable

G542X (a) 394delTT (a) 1717-1G>A (b)

R1066C A561E F508del

G551D S549R G1349D

R117H R334W

A455E 3272-26A>G 3849 + 10 kb C >T

c.120del23 rF508del

85453

Numéro réalisé avec le soutien institutionnel d’Aptalis Pharma SAS

www.splf.org

Décembre Vol. 7 2015



5

$FWXDOLWpVGDQVODSULVHHQFKDUJHGHO·LQIHFWLRQ UHVSLUDWRLUHSDU3VHXGRPRQDVDHUXJLQRVD HWOHVWKpUDSHXWLTXHVLQKDOpHV %&DPDUD &OLQLTXHXQLYHUVLWDLUHGHSQHXPRORJLH3{OH7KRUD[HW9DLVVHDX[&+8*UHQREOH ERXOHYDUGGHODFKDQWRXUQH*UHQREOH&HGH[)UDQFH XQLYHUVLWp-RVHSK)RXULHU*UHQREOH)UDQFH

,QWURGXFWLRQ 3VHXGRPRQDVDHUXJLQRVD 3$ XQEDFLOOHjJUDPQpJDWLI XELTXLWDLUH RSSRUWXQLVWH HVW XQH EDFWpULH GRWpH GH JpQRPHSDUWLFXOLqUHPHQWELHQDGDSWpjFRORQLVHUOHVYRLHV DpULHQQHVGHVSDWLHQWVPXFRYLVFLGRVLTXHV/DSUpYDOHQFH GH O·LQIHFWLRQ FKURQLTXH SDU 3$ FKH] OHV SDWLHQWV VXLYLV SRXU PXFRYLVFLGRVH HQ )UDQFH DWWHLQW   TXDQG RQ FRQVLGqUHO·HQVHPEOHGHVSDWLHQWVHWFKH]OHVSDWLHQWV DGXOWHV >@ &HWWH FRORQLVDWLRQ VH IDLW YLD O·H[SUHVVLRQ GH IDFWHXUV PROpFXODLUHV HQ UpSRQVH DX[ GpIHQVHV GH O·K{WHPDLVDXVVLSDUOHVFDSDFLWpVGH3$jGpYHORSSHUGHV PpFDQLVPHVGHUpVLVWDQFHVDX[DJHQWVDQWLPLFURELHQV>@ /DFRPSRVLWLRQGXPLFURELRWHSXOPRQDLUHHWOHVUpSRQVHV GHO·K{WHVRQWPXWXHOOHPHQWLQÁXHQFpHVPDLVGDQVFHU WDLQHVFRQGLWLRQVO·pPHUJHQFHG·XQSDWKRJqQHSHXWrWUH IDYRULVpH>@$LQVLOHPLFURELRWHUHVSLUDWRLUHGHVSDWLHQWV VXLYLV SRXU PXFRYLVFLGRVH HVW SHX GLYHUVLÀp HW VRXYHQW GRPLQpSDU3$TXLHQHVWOHSDWKRJqQHGRPLQDQW>@/D PRUWDOLWp HVW IRUWHPHQW FRUUpOpH j OD SUpVHQFH GH FH JHUPH GDQV OHV YRLHV UHVSLUDWRLUHV GHV SDWLHQWV >@ /H V\PSRVLXP©)RFXVRQ3VHXGRPRQDVDHUXJLQRVDLQ&\VWLF )LEURVLV 3DVW SUHVHQW DQG IXWXUH ª DQLPp SDU .ULV GH %RHFN /RXYDLQ %HOJLTXH  D FRQVWLWXp XQ SDQRUDPD GHV VWUDWpJLHV GH SULVH HQ FKDUJH GH 3$ SULQFLSDO JHUPH UHVSRQVDEOH G·LQVXIÀVDQFH UHVSLUDWRLUH FKURQLTXH FKH] OHVSDWLHQWVVXLYLVSRXUPXFRYLVFLGRVH

 

&RUUHVSRQGDQFH $GUHVVHHPDLOEFDPDUD#FKXJUHQREOHIU %&DPDUD 

‹63/)3XEOLpSDU(OVHYLHU0DVVRQ6$67RXVGURLWVUpVHUYpV

0LVHDXSRLQWVXUO·XWLOLVDWLRQ GHVDQWLELRWLTXHVLQKDOpVHQFDV GHPXFRYLVFLGRVHFRORQLVpHSDU3$ 3DWULFN )OXPH &KDUOHVWRQ eWDWV8QLV  D IDLW XQH PLVH DX SRLQW VXU O·KLVWRULTXH GH O·XVDJH GHV DQWLELRWLTXHV LQKDOpV GDQVODSULVHHQFKDUJHGHODPXFRYLVFLGRVHFKH]OHVSDWLHQWV FRORQLVpVSDU3$/·XWLOLVDWLRQGHO·DQWLELRWKpUDSLHLQKDOpH FKH] OHV SDWLHQWV D\DQW XQH FRORQLVDWLRQ FKURQLTXH j 3$ UpSRQGDXGRXEOHREMHFWLIGHSUpVHUYHUODIRQFWLRQUHVSLUD WRLUHHWGHUpGXLUHOHVH[DFHUEDWLRQV$YDQWOHVSRVVL ELOLWpVG·DQWLELRWKpUDSLHVLQKDOpHVDQWL3$pWDLHQWOLPLWpHV jGHX[FODVVHVG·DQWLELRWLTXHVSRO\P\[LQHV FROLVWLQH HW DPLQRVLGHV HQSDUWLFXOLHUODWREUDP\FLQH 3OXVUpFHPPHQW O·D]WUpRQDPO\VLQHLQKDOpHDpWpPLVHjGLVSRVLWLRQSRXUOHV SDWLHQWV PXFRYLVFLGRVLTXHV /·DQWLELRWKpUDSLH LQKDOpH HVW DFWXHOOHPHQWO·XQGHVWUDLWHPHQWVPDMHXUVGHODPXFRYLVFL GRVH­WLWUHG·H[HPSOHHQWUHHWODSUpYDOHQFH GHO·XVDJHGHO·D]WUpRQDPLQKDOpHVWSDVVpHGHj GHVSDWLHQWVHWFHOOHGHODWREUDP\FLQHLQKDOpHHVWSDVVpH GHjFKH]OHVSDWLHQWVPXFRYLVFLGRVLTXHVUHFHYDQW GHVDQWLELRWLTXHVLQKDOpVDX[eWDWV8QLV>@ )LJ &HWWH QRXYHOOH DSSURFKH YRLH LQKDOpH  GH SULVH HQ FKDUJH GHV SDWLHQWVQpFHVVLWHGHVLQQRYDWLRQVFRQVLGpUDEOHVGHODSDUW GHO·LQGXVWULHSRXUUpSRQGUHDX[H[LJHQFHVUpJOHPHQWDLUHV GHV WXWHOOHV HQ WHQDQW FRPSWH GH O·DSSURFKH FOLQLTXH GHV



%&DPDUD

SDWLHQWVGDQVODJHVWLRQDXTXRWLGLHQGHODPDODGLH0DLVOHV SURFKDLQHVpWDSHVFRPPHO·H[SOLTXDLW3DWULFN)OXPHFHVRQW GHVHVVDLVUDQGRPLVpVHWFRQWU{OpVRO·RQPHVXUHO·HIIHWGX WUDLWHPHQWHQSpULRGHDFWLYHVXUODIRQFWLRQUHVSLUDWRLUHHW ODFKDUJHEDFWpULHQQHO·pPHUJHQFHGHUpVLVWDQFHSHQGDQW ODSpULRGHVDQVWUDLWHPHQWPDLVDXVVLRO·RQVWDWXHVXUOD GXUpH GH OD SpULRGH VRXV WUDLWHPHQW (Q HIIHW SRXU GHV UDLVRQVKLVWRULTXHVOLpHVDX[FUDLQWHVLQLWLDOHVGHGpYHORS SHPHQW GH UpVLVWDQFHV GH 3$ DX[ DQWLELRWLTXHV LQKDOpV HW DX[WR[LFLWpVpYHQWXHOOHVOHVDQWLELRWKpUDSLHVLQKDOpHVRQW pWp GpYHORSSpHV VXU OH SULQFLSH GX WUDLWHPHQW VpTXHQWLHO  PRLV VXU  WDEOHDX   ,O DSSDUDvW GH SOXV HQ SOXV FODLU TXH FHWWH VWUDWpJLH HVW SUREOpPDWLTXH FDU HOOH ODLVVH OHV SDWLHQWVVDQVWUDLWHPHQWPRLVVXUDYHFXQHUHPRQWpHGH ODFKDUJHEDFWpULHQQHHWXQHPDMRUDWLRQGHVV\PSW{PHVORUV GHVSpULRGHVVDQVWUDLWHPHQW&HODH[SOLTXHTXHGHQRPEUHX[ FOLQLFLHQVSUpIqUHQWDOWHUQHUGHX[DQWLELRWKpUDSLHVQpEXOLVpHV GHIDoRQjSURSRVHUXQHDQWLELRWKpUDSLHQpEXOLVpHFRQWLQXH /DPHLOOHXUHVWUDWpJLHG·XWLOLVDWLRQGHVDQWLELRWLTXHVLQKDOpV UHVWHQpDQPRLQVjpWDEOLU

7UDLWHPHQWVDFWXHOVGH3VHXGRPRQDV DHUXJLQRVD /DFRPPXQLFDWLRQGX'U%DUU\3ODQW &RUN,UODQGH DSRUWp VXUOHVWUDLWHPHQWVDFWXHOVGHO·LQIHFWLRQj3$HWOHXUVLQWHUDF WLRQVPpGLFDPHQWHXVHV,ODUDSSHOpODFKDUJHTXHUHSUpVHQWH O·HQVHPEOHGHVWKpUDSHXWLTXHVFKH]OHVSDWLHQWVVXLYLVSRXU PXFRYLVFLGRVHDYHFXQHGXUpHPR\HQQHMRXUQDOLqUHTXLSHXW DWWHLQGUHPLQXWHVFXPXOpHV PLQXWHVSRXUOHVWUDLWH PHQWV RUDX[ MXVTX·j  PLQXWHV SRXU OHV QpEXOLVDWLRQV 

Aminoglycoside (94,7%)

&HWWH ORXUGHXU HVW pYLGHPPHQW XQ IUHLQ SRXU XQH ERQQH REVHUYDQFHDYHFXQLPSDFWVXUODYLHVRFLDOHGHQRVSDWLHQWV 8QHpWXGHVXUO·REVHUYDQFHWKpUDSHXWLTXHPRQWUHTXHF·HVW VHXOHPHQWSDUPLSDWLHQWVVXLYLVSRXUPXFRYLVFLGRVH TXL REVHUYHQW SOXV GH  F\FOHV SDU DQ GH WREUDP\FLQH HQ VROXWLRQSRXUQpEXOLVDWLRQFHTXLHVWDVVRFLpjXQHUpGXFWLRQ GXULVTXHG·KRVSLWDOLVDWLRQHQFRPSDUDLVRQDX[SDWLHQWVD\DQW HIIHFWXpPRLQVGHGHX[F\FOHVGHWREUDP\FLQH RGGVUDWLR DMXVWp ,& >@4XDQGRQFRPSDUH ODWREUDP\FLQHHQSRXGUHYVVROXWLRQ 3RVWHU/DQJPDQ HWDO(&)6 VXUSDWLHQWVD\DQWSDUWLFLSpjFHWWH pWXGHSUpIqUHQWODIRUPHSRXGUHSRXUODFRPPRGLWpVXUOH SODQVRFLDOHWOHJDLQGHWHPSV0DLVVLFHWUDLWHPHQWVHPEOH FRQYHQLU DX[ SDWLHQWV O·HVVDL ($*(5 DYDLW REMHFWLYp SOXV GHWRX[G·LUULWDWLRQHWGHGLVFRQWLQXLWpGDQVO·REVHUYDQFH FKH]OHVSDWLHQWVTXLpWDLHQWVRXVWREUDP\FLQHHQSRXGUHSDU UDSSRUWDXWUDLWHPHQWQpEXOLVp/·LGpDOSRXUUDLWrWUHGDQV OH GpYHORSSHPHQW XQ GLVSRVLWLI GH QpEXOLVDWLRQ SRUWDEOH HIÀFDFHUDSLGHHWVRFLDOHPHQWDFFHSWDEOHFHTXLQ·H[LVWH SDVjO·KHXUHDFWXHOOH(QFHTXLFRQFHUQHOHVLQWHUDFWLRQV PpGLFDPHQWHXVHV%DUU\3ODQWDPRQWUpOHVUpVXOWDWVG·XQH pWXGHUpFHQWHGH1LFNHWDO>@TXLFRQVWLWXHXQHDQDO\VH SRVWKRFG·XQHVVDLFRPSDUDQWO·D]WUpRQDPO\VLQHLQKDOpHWOD WREUDP\FLQHLQKDOpHFKH]VXMHWVPXFRYLVFLGRVLTXHV>@ 4XDWUHJURXSHVRQWpWpFRPSDUpVWREUDP\FLQHQpEXOLVpH Q    WREUDP\FLQH QpEXOLVpH  D]LWKURP\FLQH RUDOH Q    D]WUpRQDP O\VLQH QpEXOLVpH Q    D]WUpRQDP O\VLQHQpEXOLVpHD]LWKURP\FLQHRUDOH Q  /HVDXWHXUV VXJJqUHQWTXHO·D]LWKURP\FLQHRUDOHHQDVVRFLDWLRQDYHFOD WREUDP\FLQHSRXUUDLWUpGXLUHO·HIÀFDFLWpGHFHWWHGHUQLqUH HQWHUPHVGHYDULDWLRQVGH9(06 )LJ 'HVpWXGHVFRPSOp PHQWDLUHVEDVpHVVXUGHVGRQQpHVGHVUHJLVWUHVGHSDWLHQWV

Aminoglycoside (83,9%)

3,9%

Colistimethate (16,4%)

81,0%

11,2%

4,1%

Colistimethate (12,3%) 2,0%

3,5%

3,0%

11,1%

53,8% 0,4% 0,7%

1,8%

22,8%

0,8%

Aztreonam (3,7%)

2009 (N = 12,900)

Aztreonam (40,3%)

2012 (N = 13,845)

)LJXUH3UpYDOHQFHDQQXHOOHGHO·XWLOLVDWLRQGHWURLVFODVVHVG·DQWLELRWLTXHVLQKDOpVFKH]OHVSDWLHQWVUHFHYDQWGHVDQWLELRWLTXHVLQKDOpV GXUHJLVWUHDPpULFDLQSRXUODPXFRYLVFLGRVH &\VWLF)LEURVLV)RXQGDWLRQ3DWLHQW5HJLVWU\&))35 3UpYDOHQFHGHO·XVDJHGHVDQWLELRWLTXHV LQKDOpVHQ jJDXFKH HW jGURLWH /HV]RQHVHQHOOLSVHVTXLVHFKHYDXFKHQWLQGLTXHQWOHVSDWLHQWVTXLUHoRLYHQWSOXVG·XQH FODVVHG·DQWLELRWLTXHVLQKDOpVG·DSUqV>@

$FWXDOLWpVGDQVODSULVHHQFKDUJHGHO·LQIHFWLRQUHVSLUDWRLUHSDU3VHXGRPRQDVDHUXJLQRVDHWOHVWKpUDSHXWLTXHVLQKDOpHV



7DEOHDX$QWLELRWLTXHVXWLOLVpVSDUYRLHLQKDOpHFLEODQW3$DGDSWpHGHODFRPPXQLFDWLRQGH3DWULFN)OXPH &KDUOHVWRQeWDWV8QLV V\PSRVLXP©)RFXVRQ3VHXGRPRQDVDHUXJLQRVDLQ&\VWLF)LEURVLVª(&)6 $SSURXYpSDUOD)'$RX(0$

(QFRXUVGHGpYHORSSHPHQW

8VDJHRX$00

$PLQRVLGHV

7REUDP\FLQHVROXWLRQ 7REUDP\FLQHSRXGUH

$PLNDFLQHOLSRVRPDOH

*HQWDP\FLQH $PLNDFLQH

%rWDODFWDPLQHV

$]WUpRQDPO\VLQH

)OXRURTXLQRORQHV 3RO\PL[LQHV

&HIWD]LGLPH /pYRÁR[DFLQHHQDpURVRO &LSURÁR[DFLQHOLSRVRPDOH

&ROLVWLQHVROXWLRQ &ROLVWLQHSRXGUH

)RVIRP\FLQH

)RVIRP\FLQHWREUDP\FLQH

)'$)RRGDQG'UXJ$GPLQLVWUDWLRQ(0$$JHQFHHXURSpHQQHGXPpGLFDPHQW$00$XWRULVDWLRQGHPLVHVXUOHPDUFKp

PXFRYLVFLGRVLTXHVHWRXVXUGHVpWXGHVSURVSHFWLYHVVHURQW QpFHVVDLUHVSRXUDVVHRLUFHVFRQVWDWDWLRQVTXLQ·RQWSDVGH FRQVpTXHQFHFOLQLTXHjO·KHXUHDFWXHOOH

4XHODYHQLUSRXUODSULVHHQFKDUJH GHO·LQIHFWLRQj3VHXGRPRQDVDHUXJLQRVD FKH]XQSDWLHQWDWWHLQW GHPXFRYLVFLGRVH" /D FRPPXQLFDWLRQ GX 'U 0LJXHO &DPDUD 1RWWLQJKDP 5R\DXPH8QL VXUOHIXWXUGHODSULVHHQFKDUJHGHO·LQIHF WLRQ j 3$ FKH] OHV SDWLHQWV PXFRYLVFLGRVLTXHV D SRUWp VXU WURLVD[HVSULQFLSDX[OHVVWUDWpJLHVDQWLTXRUXPVHQVLQJOHV WKpUDSHXWLTXHVEDVpHVVXUOHVEDFWpULRSKDJHVHWODELRORJLH GHV\QWKqVH/HSUHPLHUHVVDLFKH]O·KRPPHVXUO·LQKLELWLRQ GXTXRUXPVHQVLQJpWDLWjEDVHG·KXLOHG·DLOPDFpUpFRQWUH SODFHER KXLOHG·ROLYH DYHFSDWLHQWVGDQVFKDTXHEUDV SHQGDQWVHPDLQHV(QWHUPHVGHUpVXOWDWVLOQ·\DYDLWSDV GHGLIIpUHQFHVLJQLÀFDWLYHHQWHUPHVGHSRLGVGHIRQFWLRQ UHVSLUDWRLUH HW GH V\PSW{PHV UHVSLUDWRLUHV 0DLV OD WROp UDQFH GH O·KXLOH G·DLO pWDLW VDWLVIDLVDQWH FH TXL HVW GRQF HQVRLWHQFRXUDJHDQW/·LQWpUrWG·XQHWKpUDSLHGHFHJHQUH HVW G·pYLWHU O·DFTXLVLWLRQ GH UpVLVWDQFH FRPPH ORUV G·XQH DQWLELRWKpUDSLHFODVVLTXHGHIDYRULVHUO·DFWLRQGHVDQWLELR WLTXHV VXU OH ELRÀOP HW GH SURWpJHU OD ÁRUH FRPPHQVDOH FKH]OHVSDWLHQWVQRWDPPHQWLPPXQRGpSULPpV&RQFHUQDQW OHV EDFWpULRSKDJHV TXL VXVFLWHQW XQ LQWpUrW LPSRUWDQW LO Q·H[LVWHSDVjO·KHXUHDFWXHOOHGHGRQQpHVFKH]OHVSDWLHQWV PXFRYLVFLGRVLTXHV8QHVVDLVXUXQIDLEOHHIIHFWLIGHSDWLHQWV WUDLWpV SRXU GHV EU€OXUHV Q    UpDOLVp HQ %HOJLTXH SDU 5RVH HW DO D SRUWp VXU O·DGPLQLVWUDWLRQ WRSLTXH G·XQ FRFNWDLO GH SKDJH %)& DQWL3$ HW DQWLVWDSK\ORFRTXH GRUpDpWpQRQFRQFOXDQWHQWHUPHVG·HIÀFDFLWpPDLVDYHF XQH ERQQH WROpUDQFH >@ 8Q HVVDL FOLQLTXH HVW HQ FRXUV GHSXLV PDUV  HQ *UDQGH%UHWDJQH $PSOL3KL3DWHQW %LRÀOPEDFWHULRSKDJHWUHDWPHQWIROORZHGE\DQWLELRWLFV  XQ DXWUH HQ GpYHORSSHPHQW SRXU  $PSOL3KDJH IRU3VHXGRPRQDVDHUXJLQRVDLQIHFWLRQLQF\VWLFÀEURVLV ,O SHUVLVWHHQFRUHGHVIUHLQVUpJOHPHQWDLUHVVXUODGpOLYUDQFH GHFHVSKDJHVDX[SDWLHQWVTXLVRQWGHVSDUWLFXOHVYLUDOHV

DQWLEDFWpULHQQHVGRQWOHVHIIHWVVHFRQGDLUHVSRWHQWLHOVHWOH SURÀOGHVpFXULWpG·HPSORLUHVWHQWjpWDEOLU8QGHUQLHUDVSHFW GHFHVWKpUDSLHVGXIXWXUDERUGpORUVGHFHV\PSRVLXPHVWOD ELRORJLHGHV\QWKqVH(OOHFRPELQHODELRORJLHHWOHVSULQFLSHV G·LQJpQLHULHGDQVOHEXWGHFRQFHYRLUGHQRXYHDX[V\VWqPHV HWIRQFWLRQVELRORJLTXHV(OOHSHXWDSSRUWHUGHVWKpUDSLHV SOXVHIÀFDFHVDYHFSOXVLHXUVGpÀVjUHQGUHHQFRPSWHGRQWOH ULVTXHGHUpSRQVHVLPPXQHVDX[RUJDQLVPHVJpQpWLTXHPHQW PRGLÀpV HW OD VWUDWpJLH GH OHXU pUDGLFDWLRQ OH FKRL[ GHV K{WHVEDFWpULHQQHVOHV\VWqPHGHGpOLYUDQFHSXLVO·DVSHFW UpJOHPHQWDLUHTXHYRQWQpFHVVLWHUOHXUDGPLQLVWUDWLRQFKH] O·KRPPH0DLVOHYpULWDEOHJUDDOGDQVODOXWWHFRQWUH3$UHVWH ODYDFFLQDWLRQGRQWWRXWHVOHVpWXGHVSXEOLpHVjFHMRXURQW PRQWUpGHVUpVXOWDWVGpFHYDQWV

$XWUHVFRPPXQLFDWLRQV '·DXWUHVFRPPXQLFDWLRQVPDUTXDQWHVSUpVHQWpHVORUVGHFH FRQJUqVDXWRXUGH3$VRQWUDSSRUWpHVFLGHVVRXV

&ROREUHDWKHŠ /·pTXLSHGH0DQFKHVWHUDpYDOXpODWROpUDQFHGH&ROREUHDWKHŠ FROLVWLQHSRXGUHSDUYRLHLQKDOpH)RUHVW/DERUDWRULHV)RUHVW /DERUDWRULHV%DUQVWDSOH*UDQGH%UHWDJQH VXUXQHFRKRUWH GH  SDWLHQWV PXFRYLVFLGRVLTXHV TXL D IDLW O·REMHW G·XQ VXLYLSHQGDQWDQjSDUWLUG·DR€W>@/DWROpUDQFH GXWUDLWHPHQWSDU&ROREUHDWKHŠDpWppYDOXpHDXPRPHQW GHO·LQWURGXFWLRQGXWUDLWHPHQW GRVHGHWHVW SXLVDSUqV PRLVGHWUDLWHPHQW/DVSLURPpWULHOHVFRUHGHV\PSW{PH GHMRXUVVHORQ%HQQHWWHWDOHWODFKDUJHTXHUHSUpVHQWH OHWUDLWHPHQW VFRUHGHj RQWpWpUHFXHLOOLVDXPRPHQW GH O·LQWURGXFWLRQ HW j  PRLV >@ /·kJH PR\HQ pWDLW GH DQVOHYROXPHH[SLUDWRLUHPD[LPDOHQVHFRQGH 9(06  PR\HQpWDLWGHODYDOHXUSUpGLWH/HVIDLWVPDUTXDQWV VRQW OHV VXLYDQWV   SDWLHQWV VXU  VRQW DUULYpV j  DQ GHVXLYL6XUFHVSDWLHQWVRQWSRXUVXLYLOHWUDLWHPHQW DXPRLQVPRLVHWSDWLHQWVSOXVGHDQ&ROREUHDWKHŠ pWDLWFRQVLGpUpFRPPHELHQWROpUpORUVGHODGRVHWHVWHWj PRLVGHWUDLWHPHQWDYHFXQHQHWWHUpGXFWLRQGHODFKDUJH GX WUDLWHPHQW UDSSRUWp SDU OHV SDWLHQWV SDU UDSSRUW DX



%&DPDUD

Relative Δ P <0.01

Change FEV1 % Pred

a Absolute Δ P <0.01

15 10 5 0 -5

RA

ZM

TB

A ABR

RA

ZM

TB

T

A ABR

T

Group Change FEV1 % Pred

b

15

Relative Δ

10 Absolute Δ 5

$NLWDŠ-HW

0 TR

AZ

ZM

A

R-

T AZ

TR

AZ

ZM

A

R-

T AZ

Relative Change FEV1 %

Group

c

WUDLWHPHQW DQWpULHXU TXL FRPSRUWDLW VRXYHQW GHV DQWLELR WKpUDSLHVQpEXOLVpHV6XUOHSODQGHODIRQFWLRQUHVSLUDWRLUH 9(06 HWGXVFRUHGHV\PSW{PHVGHMRXUVLOQ·\DYDLWSDV GHGLIIpUHQFHVLJQLÀFDWLYH$XERXWGHDQGHWUDLWHPHQW GHVSDWLHQWVDYDLHQWDUUrWpOHWUDLWHPHQWGXIDLWG·XQH WRX[G·XQHGRXOHXUWKRUDFLTXHG·XQHVHQVDWLRQG·RSSUHVVLRQ WKRUDFLTXHRXG·XQHLUULWDWLRQSKDU\QJpH/DPrPHpTXLSHD pYDOXpO·LQWURGXFWLRQGXWUDLWHPHQWSDUWREUDP\FLQHSRXGUH LQKDOpH FKH]  SDWLHQWV DGXOWHV PXFRYLVFLGRVLTXHV >@ /·kJHPR\HQpWDLWGHDQVOH9(06PR\HQpWDLWGH OD YDOHXU SUpGLWH 6RL[DQWHKXLW SDWLHQWV RQW HIIHFWXp DX PRLQV  PRLV GH WUDLWHPHQW HW VHXOHPHQW  SDWLHQWV RQW SRXUVXLYLOHWUDLWHPHQWSOXVGHPRLV/jHQFRUHODFKDUJH WKpUDSHXWLTXHpWDLWGLPLQXpHSRXUOHVSDWLHQWVGpEXWDQWXQ WUDLWHPHQWLQKDOpHQSRXGUH2QHVWIUDSSpGDQVFHVGHX[ pWXGHVSDUXQWDX[G·DEDQGRQGXWUDLWHPHQWpOHYpjDQ FH TXL FRQÀUPH OD QpFHVVLWp G·LGHQWLÀHU SUpFLVpPHQW OHV IDFWHXUVDVVRFLpVjXQDUUrWGXWUDLWHPHQWGHIDoRQjSRX YRLUSURSRVHUXQHSULVHHQFKDUJHDGDSWpHSHUPHWWDQWXQH SRXUVXLWHGXWUDLWHPHQWHWXQH REVHUYDQFH WKpUDSHXWLTXH RSWLPDOHGHO·DQWLELRWKpUDSLHLQKDOpH

P <0.05

15 10 5 0 -5 TR

RA

M

AZ

AZ

TR

ZM

TB

AZ

A ABR

T

Group )LJXUH$9DULDWLRQDEVROXHHWUHODWLYHGHODYDOHXUSUpGLWHGX 9(06DXFRXUVGXSUHPLHUF\FOHGHO·DQWLELRWKpUDSLHLQKDOpH -j - FKH]OHVSDWLHQWVVRXVWREUDP\FLQHHQVROXWLRQSRXULQKDODWLRQ 7%5$ DYHFRXVDQVDGMRQFWLRQGHO·D]LWKURP\FLQH $=0  %*URXSHVUHFHYDQWO·D]WUpRQDP $=75 O\VLQHHQLQKDODWLRQVHXOH RXHQDVVRFLDWLRQDYHF$=0SDVGHYDULDWLRQVLJQLÀFDWLYHGX9(06 GDQV OHV  JURXSHV HQ YDOHXU DEVROXH RX HQ SRXUFHQWDJH GH OD YDOHXUSUpGLWH & 9DULDWLRQ UHODWLYH GX 9(06 VXU WURLV F\FOHV G·DQWLELRWKpUDSLH LQKDOpH -- SRXUOHVJURXSHVFRPSDUpV 7%5$7%5$$=0 $=75$=75$=0 *URXSH7%5$$=0VLJQLÀFDWLYHPHQWGLIIpUHQW GXJURXSH7%5$ S  '·DSUqV>@

8QHFRPPXQLFDWLRQGHO·pTXLSHGH%UX[HOOHVDSRUWpVXUOH GLVSRVLWLI G·LQKDODWLRQ$NLWDŠ -HW $FWLYDHUR *HPXHQGHQ :RKUD$OOHPDJQH >@/DWHFKQRORJLH$NLWDŠ-HWSHUPHWGH FRQWU{OHUOHÁX[LQVSLUDWRLUHDLQVLTXHOHYROXPHG·LQKDODWLRQHQ V·DGDSWDQWjO·pWDWGXSDWLHQW8QHVVDLRXYHUWPXOWLFHQWULTXH DpWpUpDOLVpSRXUpYDOXHUOHVUpVXOWDWVFOLQLTXHVDSUqVPRLV G·XWLOLVDWLRQGXGLVSRVLWLI$NLWDŠ-HW/HVpOpPHQWVG·pYDOXDWLRQ pWDLHQWOHSRLGVO·LQGLFHGHPDVVHFRUSRUHOOH ,0& ODIRQFWLRQ UHVSLUDWRLUHHWOHVpFKHOOHVGHTXDOLWpVGHYLH &)45 FKH] GHVSDWLHQWVVWDEOHVjO·pWDWEDVDOjPRLVHWPRLVDSUqV O·DUUrW$XWRWDOSDWLHQWVG·kJHPR\HQGHDQVRQWIDLW O·REMHWGHO·pYDOXDWLRQ(QFHTXLFRQFHUQHOHVSDUDPqWUHV FOLQLTXHVHWIRQFWLRQQHOV>SRLGV S  ,0& S  9(06 S  HWFDSDFLWpYLWDOHIRUFpH>&9)@ S  @LOQ·\ DYDLWSDVGHGLIIpUHQFHHQWUHDYDQWHWDSUqVXVDJHGHO·$NLWDŠ -HW/DPHVXUHGHO·LQGLFHGHFODLUDQFHSXOPRQDLUHHVWUHVWpH LQFKDQJpHGDQVXQVRXVJURXSHGHSDWLHQWV/HVFRUHGH TXDOLWpGHYLH &)45 DXSUqVGHSDWLHQWVQHPRQWUDLWSDV GHGLIIpUHQFH/HVSDWLHQWVpWDLHQWJOREDOHPHQWVDWLVIDLWVGX GLVSRVLWLI/DSHUVRQQDOLVDWLRQGHVSDUDPqWUHVGXQpEXOLVHXU QRWDPPHQWOHWHPSVG·LQVSLUDWLRQGpOLYUpSUpVHQWHXQLQWpUrW PDQLIHVWHGHFHGLVSRVLWLI

0DQQLWROLQKDOp 8QHFRPPXQLFDWLRQVXUO·H[SpULHQFHGH/RQGUHVFRQFHUQH O·XVDJHGXPDQQLWROLQKDOp 6KDZ:6(&)& /H PDQQLWROHVWXQÁXLGLÀDQWEURQFKLTXHLQGLTXpGDQVODSULVH HQ FKDUJH GH OD PXFRYLVFLGRVH HQ WUDLWHPHQW G·DSSRLQW PDLV TXL Q·HVWSDV FRPPHUFLDOLVp HQ)UDQFH /D SRVRORJLH HVWGHPJGHX[IRLVSDUMRXUHWFRQVLVWHHQJpOXOHV j LQKDOHU GHX[ IRLV SDU MRXU j O·DLGH G·XQ GLVSRVLWLI G·LQ KDODWLRQ /·LQLWLDWLRQ GX WUDLWHPHQW VH IDLW HQ PLOLHX KRVSLWDOLHUDYHFXQHVXUYHLOODQFHGX9(06GHODVDWXUDWLRQ

$FWXDOLWpVGDQVODSULVHHQFKDUJHGHO·LQIHFWLRQUHVSLUDWRLUHSDU3VHXGRPRQDVDHUXJLQRVDHWOHVWKpUDSHXWLTXHVLQKDOpHV

HW G·DXWUHV V\PSW{PHV UHVSLUDWRLUHV WHOV TXH OD VXUYHQXH GHEURQFKRVSDVPH8QHHQTXrWHSURVSHFWLYHjWUDYHUVGHV TXHVWLRQQDLUHVpYDOXHO·HIÀFDFLWpFOLQLTXHDpWpDXSUqVGHV SDWLHQWVDSUqVODSKDVHG·LQLWLDWLRQSXLVjVHPDLQHVDSUqV 9LQJWWURLVSDWLHQWVRQWpWpFROOLJpVGRQW GHIHPPHV Q  D\DQWÀQLO·pWXGH/·kJHPpGLDQpWDLWGHDQVHW 9(06PpGLDQGH/VRLWGHODYDOHXUSUpGLWH/HV VFRUHVG·pYDOXDWLRQGHjRQWpWpUpDOLVpVjO·LQLWLDWLRQGX WUDLWHPHQWSXLVjVHPDLQHV,O\DYDLWXQHDPpOLRUDWLRQ VLJQLÀFDWLYH GHV VpDQFHV GH GUDLQDJH EURQFKLTXH DYHF XQ VFRUHTXLYDULHGHj S  ,OQ·\DYDLWSDVGH FKDQJHPHQWGDQVODGXUpHGHVVpDQFHVGHNLQpVLWKpUDSLHDYHF XQHPpGLDQHGHPLQXWHVHWLOQ·\DYDLWSDVG·KpPRSW\VLH UDSSRUWpH4XLQ]HSDWLHQWV  RQWGpFODUpDYRLUWHUPLQp WRXWHVOHVFDSVXOHVjFKDTXHGRVHVDQVYDULDWLRQGX9(06 &HWWHSHWLWHpWXGHVXUXQWUqVIDLEOHHIIHFWLIPRQWUHTXHOH PDQQLWROLQKDOpDpWpHIÀFDFHORUVGHVVpDQFHVGHGUDLQDJH EURQFKLTXHDYHFJOREDOHPHQWXQHERQQHWROpUDQFH

/LHQVG·LQWpUrWV /·DXWHXUGpFODUHQHSDVDYRLUGHOLHQG·LQWpUrWVHQUDSSRUW DYHFOHWKqPHGHFHWDUWLFOH

5pIpUHQFHV >@ 5HJLVWUH)UDQoDLVGHOD0XFRYLVFLGRVHDQQpH >@ )RONHVVRQ$-HOVEDN/@ 0DUVODQG%-*ROOZLW]HU(6+RVWPLFURRUJDQLVPLQWHUDFWLRQV LQOXQJGLVHDVHV1DW5HY,PPXQRO



>@ 5RJHUV*%YDQGHU*DVW&-6HULVLHU'-3UHGRPLQDQWSDWKRJHQ FRPSHWLWLRQDQGFRUHPLFURELRWDGLYHUJHQFHLQFKURQLFDLUZD\ LQIHFWLRQ,60(- >@ &RXUWQH\-0%UDGOH\-0FFDXJKDQ-2·&RQQRU706KRUWW& %UHGLQ&3HWDO3UHGLFWRUVRIPRUWDOLW\LQDGXOWVZLWKF\VWLF ÀEURVLV3HGLDWU3XOPRQRO >@ 'DVHQEURRN (& .RQVWDQ 0: 9DQ'HYDQWHU '5$VVRFLDWLRQ EHWZHHQWKHLQWURGXFWLRQRIDQHZF\VWLFÀEURVLVLQKDOHGDQWL ELRWLFFODVVDQGFKDQJHLQSUHYDOHQFHRISDWLHQWVUHFHLYLQJPXO WLSOHLQKDOHGDQWLELRWLFFODVVHV-&\VW)LEURV >@ %ULHVDFKHU%$4XLWWQHU$/6DLPDQ/6DFFR3)RXD\]L+4XLW WHOO/0$GKHUHQFHZLWKWREUDP\FLQLQKDOHGVROXWLRQDQGKHDOWK FDUHXWLOL]DWLRQ%0&3XOP0HG >@ 1LFN -$ 0RVNRZLW] 60 &KPLHO -) )RUVVpQ $9 .LP 6+ 6DDYHGUD07HWDO$]LWKURP\FLQPD\DQWDJRQL]HLQKDOHGWREUD P\FLQZKHQWDUJHWLQJ3VHXGRPRQDVDHUXJLQRVDLQF\VWLFÀEUR VLV$QQ$P7KRUDF6RF >@ $VVDHO%03UHVVOHU7%LOWRQ')D\RQ0)LVFKHU5&KLURQ5HWDO ,QKDOHGD]WUpRQDPO\VLQHYVLQKDOHGWREUDP\FLQLQF\VWLFÀEUR VLVDFRPSDUDWLYHHIÀFDF\WULDO-&\VW)LEURV >@ 5RVH79HUEHNHQ*9RV''0HUDELVKYLOL09DQHHFKRXWWH0 /DYLJQH5 HWDO([SHULPHQWDOSKDJHWKHUDS\RIEXUQZRXQG LQIHFWLRQGLIÀFXOWÀUVWVWHSV,QW-%XUQV7UDXPD >@ /DQJPDQ+%%UHQQDQ$/%ULJKW7KRPDV5--RQHV$05LOH\ ':-RKQVRQ6&´5HDOZRUOGµH[SHULHQFHRILQWURGXFWLRQRI &ROREUHDWKHŒ &ROR LQDGXOWVZLWKF\VWLFÀEURVLV-&\V)LEUR VLV6 :6  >@ %HQQHWW$93DWULFN'//\PS-)(GZDUGV7&*RVV&+&RP SDULVRQRIGD\DQGUHSHDWHGKRXUUHFDOORIV\PSWRPVRI F\VWLFÀEURVLV-&\VW)LEURV >@ /DQJPDQ +% %UHQQDQ $/ %ULJKW7KRPDV 5- -RQHV $0 5LOH\':-RKQVRQ6&´5HDOZRUOGµLQWURGXFWLRQRIWREUDP\ FLQLQKDODWLRQSRZGHU7,3ŒLQDGXOWVZLWKF\VWLFÀEURVLV-&\V )LEURVLV6   >@ (\QV + :LOOHNHQV - 2SGHNDPS & 9DQ +RYH 2 *DVSDU 9 *DODVVR & HW DO 8VH RI WKH$.,7$ -(7 IRU LQKDODWLRQ WUHDW PHQWLQF\VWLFÀEURVLV² 3DUW,,3DWLHQWV·VDWLVIDFWLRQ-&\V )LEURVLV6 :6