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GB combination delivered via metered-dose inhaler in healthy Chinese subjects
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Pharmacokinetics, pharmacodynamics and safety of a novel extrafine BDP/FF/GB combination delivered via metered-dose inhaler in healthy Chinese subjects Chao Hu , Jia Miao , Shiqing Shu , Ying Wang , Xiaohong Zhu , Zhu Luo PII: DOI: Reference:
S0928-0987(19)30471-3 https://doi.org/10.1016/j.ejps.2019.105198 PHASCI 105198
To appear in:
European Journal of Pharmaceutical Sciences
Received date: Revised date: Accepted date:
15 August 2019 14 December 2019 16 December 2019
Please cite this article as: Chao Hu , Jia Miao , Shiqing Shu , Ying Wang , Xiaohong Zhu , Zhu Luo , Pharmacokinetics, pharmacodynamics and safety of a novel extrafine BDP/FF/GB combination delivered via metered-dose inhaler in healthy Chinese subjects, European Journal of Pharmaceutical Sciences (2019), doi: https://doi.org/10.1016/j.ejps.2019.105198
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Pharmacokinetics, pharmacodynamics and safety of a novel extrafine BDP/FF/GB combination delivered via metered-dose inhaler in healthy Chinese subjects Chao Hu; Jia Miao; Shiqing Shu; Ying Wang; Xiaohong Zhu; Zhu Luo * GCP Center / Institute of Drug Clinical Trials, West China Hospital, Sichuan University, Chengdu 610041, P. R. China; *[correspondence] Zhu Luo，GCP Center / Institute of Drug Clinical Trials, West China Hospital, Sichuan University, Chengdu 610041, P. R. China; Email: [email protected]; Abstract Background: BDP/FF/GB pMDI is a novel triple fixed-dose combination of extra-fine inhalation aerosol beclomethasone dipropionate (BDP)/formoterol fumarate (FF)/glycopyrronium bromide (GB). Limited data on the pharmacokinetic (PK) and pharmacodynamic (PD) properties of BDP/FF/GB fixed-dose combination in healthy subjects was available. Purposes: This study aimed to evaluate the pharmacokinetics, pharmacodynamics and safety of BDP/FF/GB pMDI in healthy Chinese subjects. Methods: This is an open-label, parallel-group, randomized, single and multiple dose study. In the single dose group, subjects received single supra-therapeutic inhaled dose of BDP/FF/GB pMDI (BDP/FF/GB 400/24/50 µg). In the multiple dose group, subjects received therapeutic inhaled dose of BDP/FF/GB pMDI (BDP/FF/GB 200/12/25 µg), twice daily, for 7 consecutive days. Plasma BDP, B17MP, formoterol and GB were determined by a validated ultra performance liquid chromatography method with tandem mass spectrometric detection (UPLC/MS-MS). Heart rate (HR), QTcF, systolic blood pressure (SBP) and diastolic blood pressure (DBP) were evaluated as the surrogate indicators of pharmacodynamic effects. Results: A total of 24 subjects were randomized and 22 (11 in each group) completed the study. The dose adjusted pharmacokinetic profiles of BDP, beclomethasone-17-monopropionate (B17MP, the most active metabolite of BDP),
formoterol and GB were overall similar in therapeutic and supra- therapeutic dose group, showing dose proportional increase of the systemic exposure to BDP, B17MP, formoterol and GB. The pharmacodynamic variables were within the normal range and showed no significant difference between the two groups. All the treatment-emergent adverse events (TEAEs) were mild and no severe TEAE was reported. Conclusions: Dose adjusted PK profiles were similar between therapeutic and supra-therapeutic dose for all compounds, nearly dose proportional systemic exposure to B17MP, formoterol and GB after BDP/FF/GB pMDI administration in healthy Chinese subjects. BDP/FF/GB pMDI was safe and well tolerated in healthy Chinese subjects. The PK profiles were comparable to previously published data from Western European healthy Caucasian subjects. Key words: extrafine BDP/FF/GB combination; pharmacokinetics;pharmacodynamics
1. Introduction Chronic Obstructive Pulmonary Disease (COPD) is currently the fourth cause of morbidity and mortality worldwide [1] and has become a major public-health problem in China [2]. The goals of COPD treatment are to prevent and control symptoms, reduce the frequency and severity of acute COPD exacerbations, and improve exercise tolerance [3]. Inhaled triple therapy, a fixed combination of inhaled corticosteroid (ICS), long-acting beta2 agonists (LABA) andlong-acting muscarinic antagonists (LAMA) is effective for treatment of COPD [4] and it is recommended by the Global Initiative for Obstructive Lung Disease (GOLD) for patients who have further exacerbations [5]. BDP/FF/GB pMDI is a novel triple fixed-dose combination of beclometasone dipropionate (BDP), formoterol fumarate (FF) and glycopyrronium bromide (GB) delivered via pressurised metered-dose inhaler (pMDI) in development for the treatment of COPD [3]. BDP is a synthetic ICS which provides high topical
anti-inflammatory activity together with a low systemic activity. FF is a selective LABA that results in rapid and long-lasting relaxation of bronchial smooth muscle when inhaled. GB is a LAMA and exhibits pharmacological effects through inhibition of M3-receptors on smooth muscle leading to bronchodilation. BDP/FF/GB fixed-dose combination has an extrafine formulation (the diameters are<2 µm for all active ingredients), that enables the particles to penetrate the small peripheral airways, to distribute more uniformly within the airway ,and resulting in higher total lung deposition [6][7][8].Studies have shown that long-term treatment with BDP/FF/GB pMDI is more effective than LAMA monotherapy or dual bronchodilator (LAMA/LABA) or ICS/LABA combination in improving lung function and in reducing exacerbation frequency in COPD patients[9][10][11]. To date, limited data on the pharmacokinetic (PK) and pharmacodynamic (PD) properties of BDP/FF/GB fixed-dosecombination in healthy subjects was available. In our study, we investigated the pharmacokinetics of BDP/FF/GB pMDI single supra-therapeutic (4 inhalations) and multiple therapeutic dose (2 inhalations, twice daily dosing, for 7 consecutive days) in healthy Chinese subjects. As both LAMA and LABA are associated with cardiovascular events
[11][12]
, this study evaluated the
pharmacodynamic effects of BDP/FF/GB pMDI to assess the potential effect on heart and blood vessel. Safety and the tolerability of BDP/FF/GB pMDI in healthy subjects were assessed as well. 2.
Materials and Methods
2.1 Study design This was an open-label, parallel-group, randomized, single and multiple dose study. 24 healthy subjects were planned to be randomised into two groups (Figure 1).Subjects received supra-therapeutic and therapeutic dose of BDP/FF/GB pMDI in the single and multiple dose group, respectively. The study was conducted in compliance with the Declaration of Helsinki and the ICH-GCP guidelines. The study
protocol and informed consent forms were approved by the Independent Ethics Committee of West China Hospital, Sichuan University (Chengdu, China). All subjects provided written informed consent before any study related procedure. This study has been registered registered in the World Health Organization International Clinical Trials Registry Platform (ChiCTR1800019095). 2.2 Study population Healthy male and female Chinese subjects aged 18 to 45 years and with a body mass index between 19.0 and 26.0 kg/m2 were eligible for recruitment. All subjects were to be non- or ex-smokers who had normal blood pressure and electrocardiogram (ECG) results within normal limits at screening and randomization. Normal ECG results were defined as: QRS complex <120 ms, PR <210 ms, 45
Subjects were trained by using placebo inhalers at screening and every day at pre-dose. They also had to be well trained with a flow meter Aerosol Inhalation Monitor (AMITM, placebo chlorofluorocarbons-free inhaler provided by Vitalograph®) during screening and on the first day of administration (Day 1). Subjects were not treated if the training was not completed with success. 2.4 Sampling and medical supervision In the single dose group, 7 mL blood samples were collected at pre-dose, 5, 15, 30 min and 1, 1.5, 2, 3, 4, 6, 8, 12, 24 h post-dose for BDP, B17MP, formoterol and GB determination. For the multiple doses group, blood samples were collected at pre-dose, 5, 15, 30 min and 1, 1.5, 2, 3, 4, 6, 8 and 12 h after the morning dose of study drug administration, on Day 1 and Day 7. All subjects were under continuous medical supervision in the Phase I Unit of West China Hospital, Sichuan University, throughout the study. 12-lead ECG and vital signs were measured due to schedule time. All information, including unexpected symptoms or medical conditions was recorded regardless of the relationship to the study drug. All clinical laboratory tests were performed at the laboratory of West China Hospital, Sichuan University, which was authenticated by College of American Pathologists (CAP). 2.5 Assays of BDP, B17MP, formoterol and GB Plasma samples were separated in a refrigerated centrifuge (+4°C) at 2500g for 15 min and were stored until shipment to the bioanalytical central laboratory. BDP, B17MP, formoterol and GB in human plasma were determined by validated ultra performance liquid chromatography methods with tandem mass spectrometric detection (UPLC/MS-MS). UHPLC was performed with UHPLC 1290 Infinity II system （Agilent，Brussels, Belgium）, mass spectrometric detection for BDP/B17MP, formoterol and GB were performed with API 5500 Q-Trap, API 6500 Q-Trap and API 4000 (all were supplied by AB/MDS Sciex, Nieuwerkerk a/d Ijssel, The Netherlands) , respectively. Column were Kinetex C18 100A, 2.6 µm particle size, 100 x 3.0 mm column (Phenomenex, Utrecht, Belgium), Acquity UPLC HSS C18,
1.8 µm particle size, 50 x 2.1 mm I.D (Waters, Brussels, Belgium) and Acquity UPLC HSS T3, 1.8 µm particle size,50 x 2.1 mm I.D (Waters ,Brussels, Belgium) for BDP/B17MP, formoterol and GB, respectively. Acquisition was performed using the Analyst™ 1.6.2 software of MDS Sciex Analyst® (Ontario, Canada). BDP and B17MP concentration levels were determined in dipotassium ethylene diamine tetraacetic acid (K2EDTA) human plasma after liquid/liquid extraction. Formoterol and GB concentration levels were determined in acidified lithium heparinised human plasma after solid/liquid extraction. Internal standard of BDP, B17MP, formoterol and GB were BDP-d10 (No 2-KMW-3-2), B17MP-d5 (No 2-KMW-3-1), Formoterol-d6 (No 5-CGJ-61-1) and CHF5961 (No K305160), respectively. The CV% of the QCs were 2.93~6.91 %, 2.3~4.84 %, 1.73~6.29 % and 4.89~7.51 % for BDP, B17MP, formoterol and GB, the relative errors were 0.73~7.45 %, -1.8~1.47 %, -4.67~0.13%, -0.43~6.77 %, respectively. Stability of the four compounds was all consistent with method validation requirements. Standard curve linear regression equation were BDP: y=0.00164x+0.00135 (r2=0.9980), B17MP: y=0.00871x+0.00612 (r2=0.9986), formoterol: y=0.0603x+0.00636（r2=0.9980）,GB: y=0.0596x+0.0135 (r2=0.9971). BDP, B17MP, formoterol and GB showed a good linear relationship within the range of 10.0~1000.0, 20.0~2000.0, 1.0~1500 and 1.0~200 pg/mL. Lower limit of quantification of BDP, B17MP, formoterol and GB were 10.0, 20.0, 1.0 and 1.0 pg/mL, respectively. All results of analytical method were in compliance with the requirements. 2.6 Pharmacokinetic parameters and analysis The pharmacokinetic analysis were performed by standard non-compartmental methods using WinNonlin Phoenix (version 6.2 ,Parsight Corporation,PaloAlto, CA, USA). The following parameters were calculated or determined: maximum plasma concentration (Cmax) and time to maximum plasma concentration (Tmax) were determined directly from experimental observations. The terminal half-life (t1/2) was calculated as 0.693/λz (negative slope) from the individual drug concentrations over
the 0-the last measuring point. Area under the concentration–time curve (AUC) were computed using the linear trapezoidal rule, AUC from time zero extrapolated to infinity (AUC0–∞) was calculated as the sum of AUC0-t (AUC from time zero to the last quantifiable concentration) and a residual part extrapolated to infinite time, the residual area from the last concentration data point to infinite time was calculated using the approximation. Descriptive statistics were used to summarize PK parameters. Comparison of PK parameters between dose levels (therapeutic and supra-therapeutic dose) at Day 1 was carried out using analysis of variance (ANOVA). Cmax, AUC0-t, AUC0-12h and AUC0-∞ calculated on Day 1 were normalised for the dose and log-transformed before ANOVA. 2.7 Pharmacodynamic parameters and analysis Heart rate HR, QTcF, systolic blood pressure (SBP) and diastolic blood pressure (DBP) were measured at pre-dose, 15, 30 min, 1, 2, 4, 6, 8, 12 h post-dose, on Day 1 for single dose group and on Day 1 and Day 7 for multiple dose group. The following parameters were summarised: average HR, QTcF, SBP and DBP over 12 h (calculated as AUC0-12h/12h), average maximum HR, QTcF, SBP and DBP over 12 h, the maximum HR, QTcF, SBP and DBP average change from baseline over 12 h. For QTcF, the number and percentage of subjects were evaluated with QTcF >450 ms, >480 ms and >500 ms for males and QTcF >470 ms and >500 ms for females and change from baseline in QTcF >30 ms and >60 ms. The least squares (LS) mean differences in HR, QTcF, SBP and DBP average change from baseline over time between therapeutic dose group and supra-therapeutic dose group were presented with the corresponding 95% confidence intervals (CIs). 3. Results 3.1 Study population A total of 24 healthy subjects were enrolled in the study. One subject was randomized but withdrew the informed consent form, one was withdrawn by the
investigator due to a difficulty in drawing blood. There were 22 subjects evaluable for PK and PD analysis, and 23 for safety analysis. Demographics of the subjects are shown in Table 1. 3.2 Pharmacokinetic properties Mean plasma concentration vs time profiles of BDP, B17MP, formoterol and GB are presented in Figure 2. The detailed pharmacokinetic parameters by treatment and comparison of the main pharmacokinetic parameters between therapeutic and supra-therapeutic dose are presented in Table 2 to 4. BDP, B17MP, formoterol and GB were rapidly absorbed into plasm and reached peak concentrations after inhalation of BDP/FF/GB pMDI. Repeated administration of BDP/FF/GB pMDI at therapeutic dose for 7 days led to different degree of accumulation, the accumulation ratio of AUC0-12 for formoterol, B17MP and GB were 1.87, 1.46 and 3.61, respectively. Formoterol and BDP dose-normalised Cmax and AUCs were lower in therapeutic dose group than in supra-therapeutic dose group, with point estimate(PE) of geometric mean ratios (GMR) ranging from 72 to 85%; whereas B17MP and GB dose-normalised Cmax and AUCs were similar in the two groups with PE of GMR ranging from 92 to 106%. For BDP, the short half-life compromised the PK evaluation of plasma concentrations as samples can only be measured up to 0.5 h (therapeutic dose group) or 1 h (supra-therapeutic dose group) post-dose, the quantifiable concentrations are most likely not in the terminal elimination phase and therefore the terminal t1/2 and related parameters for BDP were not estimated in this study. 3.3 Pharmacodynamic properties HR, QTcF, SBP and DBP were all within the normal range after inhalation of BDP/FF/GB pMDI at therapeutic or supra-therapeutic dose. The plots of averaged HR, QTcF, SBP and DBP change from baseline were provided in Figure 3. In general, Mean changes in SBP, DBP and QTcF from pre-dose were small (<5 mmHg and <10 ms, respectively). Mean HR was increased and remained above pre-dose values with
the largest change from baseline at 4-hour time point. The average and maximum 12-hour HR and QTcF intervals values were similar during the groups. The maximum HR, QTcF, SBP and DBP change from baseline were 12.8 bpm, 7.6 ms, 4.5 mmHg and 4.6 mmHg, respectively. No QTcF intervals of >450 ms (males) or >470 ms (females) or QTcF interval increases >30 ms were observed. The average HR, QTcF, SBP and DBP change from baseline for BDP/FF/GB pMDI therapeutic dose group vs supra-therapeutic dose were 0.52 bpm, 1.74 ms, 0.89 mmHg and 1.56 mmHg, respectively ( Table 5), all the 95% confidence interval included 0. Overall, 6 subjects (50.0%) reported 8 treatment-emergent adverse event (TEAE) in the therapeutic dose group, 1 TEAE (diarrhea) was considered to be treatment-related and occurred in 1 (4.3%) subject. The most frequently reported TEAE was hyperuricemia (in 2 [8.7%] subjects overall). All reported TEAEs (Table 6) were mildin intensity and no severe TEAEs or TEAEs leading to discontinuation were reported. 4 Discussion BDP/FF/GB pMDI is in development for the treatment of COPD. The pharmacokinetic and pharmacodynamic properties of BDP/FF/GB pMDI were not so clear since few data were published. We investigated the PK and PD properties of single- and multiple-dose of BDP/FF/GB pMDI in healthy Chinese subjects, and assessed safety profile as well. In general, pharmacokinetics profiles of BDP, B17MP, formoterol, and GB in this study accorded with previous study [13]. In view of fact that the inhalation flow and the velocity of aerosol particles released from a device strongly affect the lung deposition pattern
[14]
, to keep under
control and standardize the inhalation flow, we trained the subjects with placebo and an AMITM Vitalograph® which was able to monitor for correct timing of the pMDI actuation and for proper inhalation time and flow(approximately 30 L/min), and breathe holding time. Subjects were not allowed to lie down or sleep until 2 hours post
dose, except when undergoing clinical assessments. They had to remain seated as much as possible and avoid strenuous activities. Special steps to prevent any kind of contamination are essentially important in the PK study of inhaled aerosol formulation. In the present study drug inhalation and blood sample collection were carried out following specific procedures aiming to limit contamination of samples. The results of the UPLC/MS-MS assays indicated that the measures to prevent contamination are successful in the present study. After BDP/FF/GB pMDI administration, maximum plasma concentrations of BDP were achieved at 5 mins in most subjects, this was in accordance with the moderately lipophilic character of BDP, which was soluble in human bronchial secretions and rapidly absorbed across the lung epithelium [15]. 95% of BDP was presystemic metabolismed to B17MP by lung and was prior to its absorption [16]. Systemic exposure of the parent drug is thought to reflect the absorption from the lungs [17][18] . B17MP was also rapidly absorbed as it can be measured and reached the maximum plasma concentration at 5 mins after drug administration. In this study, Cmax of BDP was 2.1-2.7 times higher than that of B17MP while the AUC0-t of B17MP was 9.9-14.7 times higher than that of BDP, this profile is consistent with rapid clearance of the parent drug by conversion to the active metabolite [19]. Small double concentration peaks occurred at 1.5 h post-dose was found in B17MP. The phenomenon might be explained by the intestinal absorption of the swallowed portion of the dose, as a previous study showed that the intestinal absorption contributed to 26% bioavailability of B17MP [16]. Formoterol was quickly absorbed and reached the maximum plasma concentrations at 5 mins, and a second concentration peak occurred 1.5 h after administration. The same phenomenon was also found in previous studies [20][21][22] in healthy individuals and patients, this is due to the gastrointestinal absorption of the swallowed portion of the inhaled dose and enterohepatic recirculation of the formoterol
[19]
. It was reported that the conjugates of formoterol, entering into the
intestinal lumen by bile excretion, are cleaved by the gut flora, and the free drug is reabsorbed by enterocytes and recirculates through the liver
[24][25]
. Animal studies
revealed that biliary excretion of formoterol accounted for about 31–65% of an orally administered dose
[26]
. A study establishing an enterohepatic circulation PK model
found that besides urinary elimination, the biliary excretion, and intestinal absorption, even the fecal elimination might contribute to the total clearance of the formoterol [20]. Glycopyrronium bromide is a new selective inhaled M3 receptor antagonist, is 4-5 fold more selective at M3 receptors than other LAMA
[27]
. Blockadge of M3 can
relax the airway and inhibits airway secretions, thus reversing the bronchoconstriction occurring in COPD. The M3/M2 ratio dissociation half-lives of glycopyrronium has been reported to be 7.3 in in vitro experiments
[28][29]
. Post-synaptic M2 receptors on
airway smooth muscle cells might have a role in modulating airway smooth muscle response as their activation reduces beta2-receptor-induced airway smooth muscle relaxation [30]. GB was approved by the FDA in 2017 as a nebulized monotherapy[31], while it was available as a dry-powder inhaler before. GB concentrations were still quantifiable at the last blood collection point and showed a slow terminal elimination phase, the same situation can be seen in other studies[22][32], those findings were in accordance with the long lasting time of inhaled glycopyrrolate in the body,the reported terminal elimination-phase t½ was 52.5 h following inhalation[33]. Unlike other components of BDP/FF/GB pMDI, GB is poorly absorbed by the gastrointestinal tract[34][35][36], with 80%~93.1% of systematic exposure absorbed through the lung while only 6.9%~18% absorbed through the gastrointestinal tract[37][38]. As for formoterol and GB, 0-12 hours sampling period is probably not enough to estimate half-life with a good reliability for most of the subjects in the therapeutic dose group.Only three t1/2 values can be estimated for GB in the supra-therapeutic dose group. Thus, the t1/2 and related parameters AUC0-∞ of formoterol and GB should be considered with caution or was not reported in the corresponding dose group. This is
one of the limitations of the present study. After single administration of therapeutic and supra-therapeutic BDP/FF/GB pMDI, dose-normalised Cmax and AUCs showed no statistically significant differences in this study. Though formoterol dose-normalised Cmax and AUCs were lower in therapeutic dose group than in supra-therapeutic dose group, dose-normalised AUC0-12 (PE of GMR was 85%) is more suitable for the comparison of system exposure. Dose-normalised Cmax and AUCs for BDP were lower in therapeutic dose group than in supra-therapeutic dose group while for B17MP, dose-normalised Cmax and AUCs were similar in the two groups. B17MP is an active metabolite of BDP, therefore, B17MP is most relevant for the corticosteroid component pharmacokinetics of BDP/FF/GB pMDI. For GB, dose-normalised Cmax and AUCs were similar in the two groups. Overall, the dose adjusted PK profile was similar at therapeutic and supra-therapeutic dose for all compounds, indicating nearly dose proportional exposure to BDP, B17MP, formoterol and GB. After repeated administration of BDP/FF/GB pMDI at therapeutic dose for 7 days, formoterol and B17MP showed limited accumulation of AUC0–12 in plasma (Rac 1.87 and 1.46, respectively). The GB accumulation was more pronounced (Rac 3.61) and was slightly higher than reported in the previous study following repeated inhalation[39][40][41] (Rac2.94 , 2.77 and 3.03, respectively). All the pharmacodynamic variables were within the normal range at DAY7 and were similar to those evaluated at DAY1. The plasm concentration of GB was low 12h post-dose and no TEAE was reported at DAY7. The GB accumulation was not clinically significant. Overall, the observed BDP, B17MP, Formoterol and GB PK profile was consistent with data previously reported for BDP/FF/GB pMDI in healthy Western subjects [13] The systemic effect of the drug was investigated in terms of cardiovascular parameters, focusing mainly on the potential PD effect of formoterol and GB. In the present study no efficacy variables were evaluated since the pulmonary function of
healthy subjects is normal and is not expected to change after inhalation of LABAs and LAMAs. HR, SBP, DBP and QTcF were used as PD variables to assess the potential cardiovascular risk [42][43][44]. In general, all the pharmacodynamic variables were within the normal range after inhalation of the BDP/FF/GB pMDI therapeutic or supra-therapeutic dose. Mean changes in SBP, DBP and QTcF from pre-dose were small (<5 mmHg and <10 ms, respectively), indicating no relevant effect of BDP/FF/GB pMDI on blood pressure and QTcF. No QTcF intervals of >450 ms (males) or >470 ms (females) or QTcF interval increases >30 ms were observed in this study. The mean HR, QTcF, SBP and DBP effect between therapeutic and supra-therapeutic dose within 12 hours was very small (<2), all the 95% confidence intervals included 0, indicating that there was no significant difference between therapeutic and supra-therapeutic dose. It showed that increasing doses of BDP/FF/GB pMDI did not lead to any further incremental effect and the system effect has no proportional relationship with drug dosage. 5 Conclusions The results observed in this clinical study showed that the dose adjusted PK profile was similar at therapeutic and supra-therapeutic dose for all compounds, indicating nearly dose proportional exposure to BDP, B17MP, formoterol and GB after BDP/FF/GB pMDI administration in healthy Chinese subjects. The system effect was small and has no proportional relationship with drug dosage. BDP/FF/GB pMDI therapeutic and supra-therapeutic dose was safe and well tolerated in healthy subjects. Importantly, no TEAEs were reported for the supra-therapeutic dose. The PK and the safety profiles were comparable to previously published data from Western European Caucasian subjects. Conflict of interest The authors have declared that no financial relationships with any organizations that might have an interest in the submitted work; no any other relationships or
activities that could appear to have influenced the submitted work. Acknowledgments This study was sponsored by Chiesi Farmaceutici S.p.A, Parma, Italy. We would like to acknowledge all the study nurses in Phase I Unit of West China Hospital, Sichuan University for blood sampling. We would like to acknowledge the colleagues from Bioanalysis Department of SGS Life Sciences (Wavre, Belgium) for UPLC/MS-MS assays. We would like to acknowledge all the human subjects for their participation in the present study.
Author contributions Zhu Luo conceived and designed the trial. Zhu Luo, Chao Hu, Jia Miao, Shiqing Shu, Ying Wang and Xiaohong Zhu performed the trial. Zhu Luo analyzed the data. Chao Hu and Zhu Luo wrote the manuscript.
References [1]. World Health Organization. Projections of mortality and causes of death, 2016 and 2030. http://www.who.int/healthinfo/global_burden_disease/projections/en/. Accessed date: 14 July 2019. [2]. Fang L , Gao P , Bao H , et al. Chronic obstructive pulmonary disease in China: a nationwide prevalence study[J]. The Lancet Respiratory Medicine,2018,6:421-30. DOI: 10.1016/S2213-2600(18)30103-6 [3]. Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. http://goldcopd.org/goldreports/. Accessed date: 14 July, 2019. [4]. Montuschi P, Malerba M, Macis G, et al. Triple inhaled therapy for chronic obstructive pulmonary disease[J]. Drug Discovery Today , 2016:Nov;21(11):1820-1847. DOI: 10.1016/j.drudis.2016.07.009 [5]. Tsuda A, Henry F S, Butler J P. Particle transport and deposition: basic physics of particle kinetics[J]. Comprehensive Physiology, 2013, 3(4):1437-1471.DOI:10.1002/cphy.c100085 [6]. Scichilone N, Benfante A, Morandi L, et al. Impact of extrafine formulations of inhaled corticosteroids/long-acting beta-2 agonist combinations on patient-related outcomes in asthma and COPD[J]. Patient Related Outcome Measures, 2014,5:153-162. DOI: 10.2147/PROM.S55276 [7]. Usmani O S. Treating the small airways.[J]. Respiration, 2012, 84(6):441-453. DOI: 10.1159/00034362 [8]. Papi A, Vestbo J, Fabbri L, et al. Extrafine inhaled triple therapy versus dual bronchodilator therapy in chronic obstructive pulmonary disease (TRIBUTE): a double-blind, parallel group, randomised controlled trial[J]. Lancet, 2018, 391(10125):1076-1084. DOI: 10.1016/S0140-6736(18)30206-X [9]. Vestbo J, Papi A, Corradi M , et al. Single inhaler extrafine triple therapy versus long-acting muscarinic antagonist therapy for chronic obstructive pulmonary disease (TRINITY): a
double-blind, parallel group, randomised controlled trial[J]. The Lancet, 2017;389(10082):1919–1929. DOI: 10.1016/S0140-6736(17)30188-5 [10]. Singh D, Papi A, Corradi M, et al. Single inhaler triple therapy versus inhaled corticosteroid plus long-acting β2-agonist therapy for chronic obstructive pulmonary disease (TRILOGY): a double-blind, parallel group, randomised controlled trial.[J]. Lancet, 2016, 388(10048):963-973. DOI: 10.1016/S0140-6736(16)31354-X [11]. Singh S , Loke Y K , Furberg C D . Inhaled Anticholinergics and Risk of Major Adverse Cardiovascular Events in Patients With Chronic Obstructive Pulmonary Disease: A Systematic Review and Meta-analysis[J]. JAMA The Journal of the American Medical Association, 2008, 300(12):1439-1450. DOI: 10.1001/jama.300.12.1439 [12]. Salpeter SR, Ormiston TM, Salpeter EE. Cardiovascular effects of beta-agonists in patients with asthma and COPD: a meta-analysis[J]. Chest. 2004; 125(6): 2309-2321. DOI: 10.1378/chest.125.6.2309 [13]. Mariotti F, Ciurlia G, Spaccapelo L, et al. A Two-Period Open-Label, Single-Dose Crossover Study in Healthy Volunteers to Evaluate the Drug–Drug Interaction Between Cimetidine and Inhaled Extrafine CHF 5993 [J]. European Journal of Drug Metabolism & Pharmacokinetics, 2017, 42(2):269-279.DOI:10.1007/s13318-016-0345-2 [14]. Markus B J, Charlotte K, Ashish S. Inhaled Therapy in Respiratory Disease: The Complex Interplay of Pulmonary Kinetic Processes [J]. Canadian Respiratory Journal, 2018, 2018:1-11. DOI: 10.1155/2018/2732017 [15]. Cote C, Pearle J L, Sharafkhaneh A, et al. Faster onset of action of formoterol versus salmeterol in patients with chronic obstructive pulmonary disease: A multicenter, randomized study.[J]. Pulmonary Pharmacology & Therapeutics, 2009, 22(1):44-49. DOI: 10.1016/j.pupt.2008.11.010 [16]. Daley-Yates P. Beclomethasone dipropionate: absolute bioavailability, pharmacokinetics and metabolism following intravenous, oral, intranasal and inhaled administration in man [J]. Br J Clin Pharmacol, 2001, 51(5):400-409.DOI：10.1046/j.0306-5251.2001.01374.x
[17]. Chrystyn H. Methods to identify drug deposition in the lungs following inhalation[J]. British Journal of Clinical Pharmacology, 2001, 51(4):289–299. DOI:10.1046/j.1365-2125.2001.01304.x [18]. Singh D, Collarini S, Poli G, et al. Effect of AeroChamber PlusTM on the lung and systemic bioavailability of beclometasone dipropionate/formoterol pMDI[J]. British Journal of Clinical Pharmacology, 2011, 72(6):932-939. DOI: 10.1111/j.1365-2125.2011.04024.x [19]. Small C J, Gillespie M. Pharmacokinetics of Beclomethasone Dipropionate Delivered by Breath-Actuated Inhaler and Metered-Dose Inhaler in Healthy Subjects[J]. Journal of Aerosol Medicine and Pulmonary Drug Delivery, 2018 Jun;31(3):182-190. DOI:10.1089/jamp.2017.1397 [20]. Soulele K , Macheras P , Karalis V. On the pharmacokinetics of two inhaled budesonide/formoterol combinations in asthma patients using modeling approaches[J]. Pulmonary Pharmacology & Therapeutics, 2018, 48:168-178. DOI:10.1016/j.pupt.2017.12.002 [21]. Backer D E, Wilfried, DEVOLDER, et al. Lung Deposition of BDP/Formoterol HFA pMDI in Healthy Volunteers, Asthmatic, and COPD Patients[J]. J Aerosol Med Pulm Drug Deliv, 2010, 23(3):137-148. DOI: 10.1089/jamp.2009.0772 [22]. Reisner C, Miller J, Depetrillo P, et al. Pharmacokinetics and safety of a single dose of the novel LAMA/LABA fixed-dose combination of glycopyrronium/formoterol fumarate dihydrate metered dose inhaler, formulated using co-suspension delivery technology, in Japanese healthy subjects[J]. Pulmonary Pharmacology & Therapeutics, 2018, 53:33-38. DOI:10.1016/j.pupt.2018.09.005. [23]. Darken P, Depetrillo P, Reisner C , et al. The pharmacokinetics of three doses of budesonide/glycopyrronium/formoterol fumarate dihydrate metered dose inhaler compared with active controls: A Phase I randomized, single-dose, crossover study in healthy adults[J]. Pulmonary Pharmacology & Therapeutics, 2018,50:11-18. DOI:10.1016/j.pupt.2018.03.001
[24]. Lecaillon J B, Kaiser G, Palmisano M, et al. Pharmacokinetics and tolerability of formoterol in healthy volunteers after a single high dose of Foradil dry powder Inhalation via aerolizerTM[J]. European Journal of Clinical Pharmacology, 1999, 55(2):131-138. DOI: 10.1007/s002280050607 [25]. Rosenborg J, Larsson P, Tegnér K, et al. Mass balance and metabolism of [(3)H]Formoterol in healthy men after combined i.v. and oral administration-mimicking inhalation.[J]. Drug Metabolism & Disposition the Biological Fate of Chemicals, 1999, 27(10):1104–1116. DOI: urn:nbn:se:uu:diva-89461 [26]. Sasaki H, Kamimura H, Shiobara Y, et al. Disposition and metabolism of formoterol fumarate, a new bronchodilator, in rats and dogs[J]. Xenobiotica, 1982, 12(12): 803–812. DOI: 10.3109/00498258209038952 [27]. Montuschi P, Ciabattoni G. Bronchodilating Drugs for Chronic Obstructive Pulmonary Disease: Current Status and Future Trends[J]. Journal of Medicinal Chemistry, 2015, 58(10):4131-4164. DOI: 10.1021/jm5013227 [28]. Gavaldà A, Ramos I,Carcasona C,et al.The in vitro and in vivo profifile of aclidinium bromide in comparison with glycopyrronium bromide[J]. Pulmonary Pharmacology & Therapeutics 2014 Aug;28(2):114-21. DOI: 10.1016/j.pupt.2014.05.005. [29]. Sykes DA,Dowling MR.Leighton-Davies J,et al.The Influence of Receptor Kinetics on the Onset and Duration of Action and the Therapeutic Index of NVA237 and Tiotropium[J]. THE JOURNAL OF PHARMACOLOGY AND EXPERIMENTAL THERAPEUTICS.2012 Nov;343(2):520-8. DOI: 10.1124/jpet.112.194456. [30]. Montuschi P1, Macagno F, Valente S, et al. Inhaled Muscarinic Acetylcholine Receptor Antagonists for Treatment of COPD [J]. Current Medicinal Chemistry, 2013, 20(12):1464-76. DOI: 10.2174/0929867311320120002. [31]. Kerwin E , Donohue J F , Goodin T , et al. Efficacy and safety of glycopyrrolate/eFlow® CS (nebulized glycopyrrolate) in moderate-to-very-severe COPD: Results from the glycopyrrolate for obstructive lung disease via electronic nebulizer (GOLDEN) 3 and 4 randomized controlled trials.[J]. Respiratory Medicine, 2017,132:238-250.
DOI: 10.1016/j.rmed.2017.07.011. [32]. Fakih F, Spangenthal S, Sigal B, et al. Randomized study of the effects of Aerochamber Plus ®; Flow-Vu ®; on the efficacy, pharmacokinetics and safety of glycopyrronium/formoterol fumarate dihydrate metered dose inhaler in patients with chronic obstructive pulmonary disease[J]. Respiratory Medicine, 2018, 138:74-80. DOI: 10.1016/j.rmed.2018.03.033. [33]. Bartels C, Looby M, Sechaud R, et al. Determination of the pharmacokinetics of glycopyrronium in the lung using a population pharmacokinetic modelling approach[J]. British Journal of Clinical Pharmacology, 2013, 76(6):868-879. DOI: 10.1111/bcp.12118 [34]. Chiesi Limited, Atimos Modulite 12 Micrograms Inhaler - Summary of ProductCharacteristics, (2015) https://www.medicines.org.uk/emc/medicine/21000, Accessed date: 16 July 2019. [35]. Colonis Pharma Ltd, Glycopyrronium Bromide 1 mg/5 ml Oral Solution – Summaryof Product Characteristics, (2017) https://www.medicines.org.uk/emc/medicine/32263 , Accessed date: 16 July 2019. [36]. Novartis Pharmaceuticals UK Ltd, Foradil® – Summary of Product Characteristics,(2016) https://www.medicines.org.uk/emc/medicine/1286, Accessed date: 16 July 2019 [37]. Fabbri LM, Kerwin EM, Spangenthal S, et al. Dose-response to inhaled glycopyrrolate delivered with a novel Co-Suspension Delivery Technology metered dose inhaler (MDI) in patients with moderate-to-severe COPD[J]. Respir Res. 2016;17(1):109. DOI:10.1016/j.pupt.2018.09.005 [38]. D. Singh, F. Mariotti, S. Collarini, S, et al. Pharmacokinetics, Absolute Bioavailability And Lung Bioavailability Of Extrafine Inhaled Glycopyrronium Bromide Pmdi In Healthy Volunteers. Am J Respir Crit Care Med 191;2015:A5758 [39]. Ren S, Sechaud R, Su Z, et al. Pharmacokinetic sand safety of indacaterol andglycopyrronium (IND/GLY) following repeated once daily inhalation from a fixed-dose combination in healthy Chinese subjects [J]. Clinical Pharmacology and Therapeutics, 2017, 55(2):147-155. DOI:10.5414/CP202558
[40]. Sechaud R, Machineni S, Tillmann H C, et al. Pharmacokinetics of Glycopyrronium Following Repeated Once-Daily Inhalation in Healthy Chinese Subjects[J]. European Journal of Drug Metabolism and Pharmacokinetics, 2015, 41(6):1-9. DOI:10.1007/s13318-015-0300-7 [41]. Chen Q, Hu C, Yu H, et al. Pharmacokinetics and Tolerability of Budesonide/Glycopyrronium/Formoterol Fumarate Dihydrate and Glycopyrronium/Formoterol Fumarate Dihydrate Metered Dose Inhalers in Healthy Chinese Adults: A Randomized, Double-Blind, Parallel-Group Study[J]. Clinical Therapeutics. 2019 May;41(5):897-909.e1. DOI: 10.1016/j.clinthera.2019.03.007. [42]. Guhan A R, Cooper S, Oborne J, et al. Systemic effects of formoterol and salmeterol: a dose-response comparison in healthy subjects[J]. Thorax, 2000, 55(8):650-656. DOI:10.1136/thorax.55.8.650 [43]. Singh D, Ciurlia G, Piccinno A, et al. Acute cardiovascular safety of two formulations of beclometasone dipropionate/formoterol fumarate in COPD patients: A single-dose, randomised, placebo-controlled crossover study[J]. Pulmonary Pharmacology & Therapeutics, 2017, 42:43-51. DOI: 10.1016/j.pupt.2016.12.004 [44]. Anton D, Matthew B, Romain S, et al. Effect of dual bronchodilation with QVA149 on cardiac safety in healthy volunteers[J]. International Journal of Clinical Pharmacology & Therapeutics, 2014, 52(5):369-380. DOI: 10.5414/CP202034
Figure captions Figure 1. The study design Figure 2. Mean plasma concentration vs time profile of BDP (A), B17MP(B), formoterol (C) and GB(D) Figure3. Average HR(A), QTcF(B), SBP (C) and DBP (D)change from baseline over time
Graphical abstract
Table 1 Demographic data for subjects receiving CHF 5993 All values are mean ±standard deviation Single dose
Multiple doses
All Treatments
N=11
N=12
N=23
age, years
24.9 ±2.7
24.8±4.8
24.8±3.8
weight, kg
61.68±12.20
60.15±5.83
60.88±9.23
Height, cm
167.6±9.0
165.3±7.8
166.4±8.3
21.75±2.43
22.07±1.96
21.91±2.15
6/5
6/6
12/11
Parameters
BMI, kg.m
-2
Gender, male/female
Table 2 Summary and Statistical Comparison of BDP and B-17-MP Plasma Pharmacokinetic Parameters after single and multiple dose CHF 5993 in healthy volunteers. All values are mean ±standard deviation, except tmax which is median (range) CHF 5993 pMDI PK Parameter
CHF 5993 pMDI Therapeutic Dose
Supra-Therapeutic
N=11
dose On Day 1
Dose N=10 Cmax (pg/mL) BDP
B17MP
tmax (h)
2162±1241 0.08 (0.08; 0.08)
Therapeutic vs.Supra-Therapeutic
Day 1 737±256
Day 7 n=10
0.08 (0.08;0.08) 107±37
n=10
n=10
Point Estimate and 90% CI
B
A
P-value
935±425
74.38 (50.46, 109.63)
0.2023
0.08 (0.08; 0.13)
－
－
141±54
72.18 (48.32, 107.83)
0.1760 0.6114
AUC0-t (pg.h/mL)
329±195
Cmax (pg/mL)
790±383
347±123
625±263
91.61 (68.37, 122.76)
Cmin (pg/mL)
－
－
41.8 ±8.2
－
tmax (h)
1.00 (0.08; 2.00)
0.50 (0.08;2.00)
0.08 (0.08; 1.50)
－
－
AUC0-t (pg.h/mL)
3257±782
1531±317
2181±340
－
－
－
96.06 (80.23, 115.01)
0.7036
1718±386
n=10
AUC0-∞ (pg.h/mL)
3597±856
AUC0-12h (pg.h/mL)
3257±782
1531±317
2180±340
94.83 (80.19, 112.13)
0.5907
AUC0-24h (pg.h/mL)
3657±873
－
－
－
－
t1/2 (h)
3.51±0.33
3.92±0.77
3.41±0.27
－
－
Cav,ss (pg/mL)
－
－
182 ±28
－
－
Rac
－
－
1.46 ±0.28
－
－
N=number of subjects; n=number of subjects with data; NAP=not applicable A
Dose-normalised PK parameters were log-transformed and submitted to an ANOVA model including group as
fixed effect. B
Point estimate and 90% two-sided confidence intervals (90% CI) of the ratios ( therapeutic dose vs
supra-therapeutic) of adjusted
Table3 Summary and Statistical Comparison of FF Plasma Pharmacokinetic Parameters after single and multiple dose CHF 5993 in healthy volunteers. All values are mean ±standard deviation, except tmax which is median (range)
CHF 5993 pMDI PK Parameter
CHF 5993 pMDI Therapeutic Dose
Supra-Therapeutic Dose
N=11 Day 1
On Day 1 Day 7
N=10
Point Estimate and 90% CI
A
P-value
B
Cmax (pg/mL)
32.4 ±14.7
12.4 ±6.1
25.5 ±10.6
76.06 (54.49, 106.16)
0.1720
Cmin (pg/mL)
－
－
2.7±0.7
－
－
0.08 (0.08; 2.00)
0.08 (0.08; 1.50)
0.08 (0.08; 1.13)
－
－
106.0±19.8
39.4±10.9
72.8±13.8
－
－
－
77.44 (62.17, 96.46)
0.0593
tmax (h) AUC0-t (pg.h/mL) FF
Therapeutic vs. Supra-Therapeutic dose
AUC0-∞ (pg.h/mL)
120.0±22.5
n=9
47.9±15.7
n=8
AUC0-12h (pg.h/mL)
92.9±11.6
40.0±10.3
72.8±13.8
84.55 (73.21, 97.64)
0.0582
AUC0-24h (pg.h/mL)
111.0±15.6
－
－
－
－
－
－
t1/2 (h)
7.0±2.3
n=9
a
4.7±1.6
7.3±2.4
n=10,a
Cav,ss (pg/mL)
－
－
6.1 ±1.2
－
－
Rac
－
－
1.87±0.35
－
－
a: the t1/2 values should be considered with caution because the 0-12 hours sampling period is probably not enough to estimate formoterol half-life with a good reliability for most of the subjects
Table4 Summary and Statistical Comparison of GB Plasma Pharmacokinetic Parameters after single and multiple dose CHF 5993 in healthy volunteers. All values are mean ±standard deviation, except tmax which is median (range)
CHF 5993 pMDI PK Parameter
CHF 5993 pMDI Therapeutic Dose
Supra-Therapeutic
Therapeutic vs. Supra-Therapeutic dose
N=11
Dose
Day 1
On Day 1 Day 7
Point Estimate and
N=10
P-value
B
Cmax (pg/mL)
17.8±8.1
10.3±7.2
34.6±14.9
105.93 (72.41, 154.97)
0.7966
Cmin (pg/mL)
－
－
6.9±3.0
－
－
0.25 (0.08; 3.00)
1.00 (0.08; 3.00)
0.25 (0.08; 0.50)
－
－
105±36.0
36.8±14.6
132±46.7
－
－
－
－
－
tmax (h) AUC0-t (pg.h/mL) GB
90% CI
A
n=3,a
AUC0-∞ (pg.h/mL)
－
AUC0-12h (pg.h/mL)
74.0±19.2
37.4±13.9
132±46.7
97.41 (76.37, 124.24)
0.8541
AUC0-24h (pg.h/mL)
106.0±34.7
－
－
－
－
－
－
d
34.6±18.1
n=6,b
n=5,c
t1/2 (h)
－,
Cav,ss (pg/mL)
－
－
11.0±3.9
－
－
Rac
－
－
3.61 ±0.66
－
－
5.5±2.8
11.5±4.8
a: 5 subiects can not estimated,3 subiects auc0-inf excluded from all statistical analyses as aucextr >20% auc0-inf. b:
the t1/2 could not be estimated because of an adjusted R² value lower than 0.85 in 5 subjects.
c: the t1/2 could not be estimated because of an adjusted R² value lower than 0.85 in 6 subjects. d: the t1/2 could not be estimated because of an adjusted R² value lower than 0.85 in 8 subjects , not enough to estimate the half-life of GB with a good reliability .
Table 5 average SBP,DBP,HR and QTcF from baseline over 12 hours, for Therapeutic Dose group vs Supra-Therapeutic Dose group
Therapeutic Dose vs
least square mean
Supra-Therapeutic Dose
difference
SBP (mmHg)
0.89
-1.22, 2.99
DBP (mmHg)
1.56
-0.33 ,3.45
HR (bpm)
0.52
-3.23 ,4.28
QTcF (ms)
1.74
-1.18 ,4.65
95% confidence interval
Table 6 overall Treatment-Emergent Adverse Events (safety population)
Treatment-Emrgent Adverse Events (TEAEs)
CHF 5993 pMDI
CHF 5993 pMDI
All
Therapeutic Dose
Supra-therapeutic Dose
Treatments
n (%) N=12
E
n (%) N=11
E
n (%) N=23
E
At least one TEAE
6 (50.0)
8
0
-
6 (26.1)
8
Treatment-related AE
1 (8.1)
1
0
-
1 (4.3)
1
1 (8.3)
1
0
-
1 (4.3)
1
Hyperuricemia
2 (16.7)
2
0
-
2 (8.7)
2
Hypercholesterolemia
1 (8.3)
1
0
-
1 (4.3)
1
Blood bilirubin increased
1 (8.3)
1
0
-
1 (4.3)
1
Blood cholesterol increased
1 (8.3)
1
0
-
1 (4.3)
1
White blood cells urine positive
1 (8.3)
1
0
-
1 (4.3)
1
Upper respiratory tract infection
1 (8.3)
1
0
-
1 (4.3)
1
Diarrhoea Other reported TEAEs
N=Number of subjects; n=number of subjects with event; E=number of events
Pharmacokinetics, pharmacodynamics and safety of a novel extrafine BDP/FF/GB combination delivered via metered-dose inhaler in healthy Chinese subjects Chao Hu , Jia Miao , Shiqing Shu , Ying Wang , Xiaohong Zhu , Zhu Luo PII: DOI: Reference:
S0928-0987(19)30471-3 https://doi.org/10.1016/j.ejps.2019.105198 PHASCI 105198
To appear in:
European Journal of Pharmaceutical Sciences
Received date: Revised date: Accepted date:
15 August 2019 14 December 2019 16 December 2019
Please cite this article as: Chao Hu , Jia Miao , Shiqing Shu , Ying Wang , Xiaohong Zhu , Zhu Luo , Pharmacokinetics, pharmacodynamics and safety of a novel extrafine BDP/FF/GB combination delivered via metered-dose inhaler in healthy Chinese subjects, European Journal of Pharmaceutical Sciences (2019), doi: https://doi.org/10.1016/j.ejps.2019.105198
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Pharmacokinetics, pharmacodynamics and safety of a novel extrafine BDP/FF/GB combination delivered via metered-dose inhaler in healthy Chinese subjects Chao Hu; Jia Miao; Shiqing Shu; Ying Wang; Xiaohong Zhu; Zhu Luo * GCP Center / Institute of Drug Clinical Trials, West China Hospital, Sichuan University, Chengdu 610041, P. R. China; *[correspondence] Zhu Luo，GCP Center / Institute of Drug Clinical Trials, West China Hospital, Sichuan University, Chengdu 610041, P. R. China; Email: [email protected]; Abstract Background: BDP/FF/GB pMDI is a novel triple fixed-dose combination of extra-fine inhalation aerosol beclomethasone dipropionate (BDP)/formoterol fumarate (FF)/glycopyrronium bromide (GB). Limited data on the pharmacokinetic (PK) and pharmacodynamic (PD) properties of BDP/FF/GB fixed-dose combination in healthy subjects was available. Purposes: This study aimed to evaluate the pharmacokinetics, pharmacodynamics and safety of BDP/FF/GB pMDI in healthy Chinese subjects. Methods: This is an open-label, parallel-group, randomized, single and multiple dose study. In the single dose group, subjects received single supra-therapeutic inhaled dose of BDP/FF/GB pMDI (BDP/FF/GB 400/24/50 µg). In the multiple dose group, subjects received therapeutic inhaled dose of BDP/FF/GB pMDI (BDP/FF/GB 200/12/25 µg), twice daily, for 7 consecutive days. Plasma BDP, B17MP, formoterol and GB were determined by a validated ultra performance liquid chromatography method with tandem mass spectrometric detection (UPLC/MS-MS). Heart rate (HR), QTcF, systolic blood pressure (SBP) and diastolic blood pressure (DBP) were evaluated as the surrogate indicators of pharmacodynamic effects. Results: A total of 24 subjects were randomized and 22 (11 in each group) completed the study. The dose adjusted pharmacokinetic profiles of BDP, beclomethasone-17-monopropionate (B17MP, the most active metabolite of BDP),
formoterol and GB were overall similar in therapeutic and supra- therapeutic dose group, showing dose proportional increase of the systemic exposure to BDP, B17MP, formoterol and GB. The pharmacodynamic variables were within the normal range and showed no significant difference between the two groups. All the treatment-emergent adverse events (TEAEs) were mild and no severe TEAE was reported. Conclusions: Dose adjusted PK profiles were similar between therapeutic and supra-therapeutic dose for all compounds, nearly dose proportional systemic exposure to B17MP, formoterol and GB after BDP/FF/GB pMDI administration in healthy Chinese subjects. BDP/FF/GB pMDI was safe and well tolerated in healthy Chinese subjects. The PK profiles were comparable to previously published data from Western European healthy Caucasian subjects. Key words: extrafine BDP/FF/GB combination; pharmacokinetics;pharmacodynamics
1. Introduction Chronic Obstructive Pulmonary Disease (COPD) is currently the fourth cause of morbidity and mortality worldwide [1] and has become a major public-health problem in China [2]. The goals of COPD treatment are to prevent and control symptoms, reduce the frequency and severity of acute COPD exacerbations, and improve exercise tolerance [3]. Inhaled triple therapy, a fixed combination of inhaled corticosteroid (ICS), long-acting beta2 agonists (LABA) andlong-acting muscarinic antagonists (LAMA) is effective for treatment of COPD [4] and it is recommended by the Global Initiative for Obstructive Lung Disease (GOLD) for patients who have further exacerbations [5]. BDP/FF/GB pMDI is a novel triple fixed-dose combination of beclometasone dipropionate (BDP), formoterol fumarate (FF) and glycopyrronium bromide (GB) delivered via pressurised metered-dose inhaler (pMDI) in development for the treatment of COPD [3]. BDP is a synthetic ICS which provides high topical
anti-inflammatory activity together with a low systemic activity. FF is a selective LABA that results in rapid and long-lasting relaxation of bronchial smooth muscle when inhaled. GB is a LAMA and exhibits pharmacological effects through inhibition of M3-receptors on smooth muscle leading to bronchodilation. BDP/FF/GB fixed-dose combination has an extrafine formulation (the diameters are<2 µm for all active ingredients), that enables the particles to penetrate the small peripheral airways, to distribute more uniformly within the airway ,and resulting in higher total lung deposition [6][7][8].Studies have shown that long-term treatment with BDP/FF/GB pMDI is more effective than LAMA monotherapy or dual bronchodilator (LAMA/LABA) or ICS/LABA combination in improving lung function and in reducing exacerbation frequency in COPD patients[9][10][11]. To date, limited data on the pharmacokinetic (PK) and pharmacodynamic (PD) properties of BDP/FF/GB fixed-dosecombination in healthy subjects was available. In our study, we investigated the pharmacokinetics of BDP/FF/GB pMDI single supra-therapeutic (4 inhalations) and multiple therapeutic dose (2 inhalations, twice daily dosing, for 7 consecutive days) in healthy Chinese subjects. As both LAMA and LABA are associated with cardiovascular events
[11][12]
, this study evaluated the
pharmacodynamic effects of BDP/FF/GB pMDI to assess the potential effect on heart and blood vessel. Safety and the tolerability of BDP/FF/GB pMDI in healthy subjects were assessed as well. 2.
Materials and Methods
2.1 Study design This was an open-label, parallel-group, randomized, single and multiple dose study. 24 healthy subjects were planned to be randomised into two groups (Figure 1).Subjects received supra-therapeutic and therapeutic dose of BDP/FF/GB pMDI in the single and multiple dose group, respectively. The study was conducted in compliance with the Declaration of Helsinki and the ICH-GCP guidelines. The study
protocol and informed consent forms were approved by the Independent Ethics Committee of West China Hospital, Sichuan University (Chengdu, China). All subjects provided written informed consent before any study related procedure. This study has been registered registered in the World Health Organization International Clinical Trials Registry Platform (ChiCTR1800019095). 2.2 Study population Healthy male and female Chinese subjects aged 18 to 45 years and with a body mass index between 19.0 and 26.0 kg/m2 were eligible for recruitment. All subjects were to be non- or ex-smokers who had normal blood pressure and electrocardiogram (ECG) results within normal limits at screening and randomization. Normal ECG results were defined as: QRS complex <120 ms, PR <210 ms, 45
Subjects were trained by using placebo inhalers at screening and every day at pre-dose. They also had to be well trained with a flow meter Aerosol Inhalation Monitor (AMITM, placebo chlorofluorocarbons-free inhaler provided by Vitalograph®) during screening and on the first day of administration (Day 1). Subjects were not treated if the training was not completed with success. 2.4 Sampling and medical supervision In the single dose group, 7 mL blood samples were collected at pre-dose, 5, 15, 30 min and 1, 1.5, 2, 3, 4, 6, 8, 12, 24 h post-dose for BDP, B17MP, formoterol and GB determination. For the multiple doses group, blood samples were collected at pre-dose, 5, 15, 30 min and 1, 1.5, 2, 3, 4, 6, 8 and 12 h after the morning dose of study drug administration, on Day 1 and Day 7. All subjects were under continuous medical supervision in the Phase I Unit of West China Hospital, Sichuan University, throughout the study. 12-lead ECG and vital signs were measured due to schedule time. All information, including unexpected symptoms or medical conditions was recorded regardless of the relationship to the study drug. All clinical laboratory tests were performed at the laboratory of West China Hospital, Sichuan University, which was authenticated by College of American Pathologists (CAP). 2.5 Assays of BDP, B17MP, formoterol and GB Plasma samples were separated in a refrigerated centrifuge (+4°C) at 2500g for 15 min and were stored until shipment to the bioanalytical central laboratory. BDP, B17MP, formoterol and GB in human plasma were determined by validated ultra performance liquid chromatography methods with tandem mass spectrometric detection (UPLC/MS-MS). UHPLC was performed with UHPLC 1290 Infinity II system （Agilent，Brussels, Belgium）, mass spectrometric detection for BDP/B17MP, formoterol and GB were performed with API 5500 Q-Trap, API 6500 Q-Trap and API 4000 (all were supplied by AB/MDS Sciex, Nieuwerkerk a/d Ijssel, The Netherlands) , respectively. Column were Kinetex C18 100A, 2.6 µm particle size, 100 x 3.0 mm column (Phenomenex, Utrecht, Belgium), Acquity UPLC HSS C18,
1.8 µm particle size, 50 x 2.1 mm I.D (Waters, Brussels, Belgium) and Acquity UPLC HSS T3, 1.8 µm particle size,50 x 2.1 mm I.D (Waters ,Brussels, Belgium) for BDP/B17MP, formoterol and GB, respectively. Acquisition was performed using the Analyst™ 1.6.2 software of MDS Sciex Analyst® (Ontario, Canada). BDP and B17MP concentration levels were determined in dipotassium ethylene diamine tetraacetic acid (K2EDTA) human plasma after liquid/liquid extraction. Formoterol and GB concentration levels were determined in acidified lithium heparinised human plasma after solid/liquid extraction. Internal standard of BDP, B17MP, formoterol and GB were BDP-d10 (No 2-KMW-3-2), B17MP-d5 (No 2-KMW-3-1), Formoterol-d6 (No 5-CGJ-61-1) and CHF5961 (No K305160), respectively. The CV% of the QCs were 2.93~6.91 %, 2.3~4.84 %, 1.73~6.29 % and 4.89~7.51 % for BDP, B17MP, formoterol and GB, the relative errors were 0.73~7.45 %, -1.8~1.47 %, -4.67~0.13%, -0.43~6.77 %, respectively. Stability of the four compounds was all consistent with method validation requirements. Standard curve linear regression equation were BDP: y=0.00164x+0.00135 (r2=0.9980), B17MP: y=0.00871x+0.00612 (r2=0.9986), formoterol: y=0.0603x+0.00636（r2=0.9980）,GB: y=0.0596x+0.0135 (r2=0.9971). BDP, B17MP, formoterol and GB showed a good linear relationship within the range of 10.0~1000.0, 20.0~2000.0, 1.0~1500 and 1.0~200 pg/mL. Lower limit of quantification of BDP, B17MP, formoterol and GB were 10.0, 20.0, 1.0 and 1.0 pg/mL, respectively. All results of analytical method were in compliance with the requirements. 2.6 Pharmacokinetic parameters and analysis The pharmacokinetic analysis were performed by standard non-compartmental methods using WinNonlin Phoenix (version 6.2 ,Parsight Corporation,PaloAlto, CA, USA). The following parameters were calculated or determined: maximum plasma concentration (Cmax) and time to maximum plasma concentration (Tmax) were determined directly from experimental observations. The terminal half-life (t1/2) was calculated as 0.693/λz (negative slope) from the individual drug concentrations over
the 0-the last measuring point. Area under the concentration–time curve (AUC) were computed using the linear trapezoidal rule, AUC from time zero extrapolated to infinity (AUC0–∞) was calculated as the sum of AUC0-t (AUC from time zero to the last quantifiable concentration) and a residual part extrapolated to infinite time, the residual area from the last concentration data point to infinite time was calculated using the approximation. Descriptive statistics were used to summarize PK parameters. Comparison of PK parameters between dose levels (therapeutic and supra-therapeutic dose) at Day 1 was carried out using analysis of variance (ANOVA). Cmax, AUC0-t, AUC0-12h and AUC0-∞ calculated on Day 1 were normalised for the dose and log-transformed before ANOVA. 2.7 Pharmacodynamic parameters and analysis Heart rate HR, QTcF, systolic blood pressure (SBP) and diastolic blood pressure (DBP) were measured at pre-dose, 15, 30 min, 1, 2, 4, 6, 8, 12 h post-dose, on Day 1 for single dose group and on Day 1 and Day 7 for multiple dose group. The following parameters were summarised: average HR, QTcF, SBP and DBP over 12 h (calculated as AUC0-12h/12h), average maximum HR, QTcF, SBP and DBP over 12 h, the maximum HR, QTcF, SBP and DBP average change from baseline over 12 h. For QTcF, the number and percentage of subjects were evaluated with QTcF >450 ms, >480 ms and >500 ms for males and QTcF >470 ms and >500 ms for females and change from baseline in QTcF >30 ms and >60 ms. The least squares (LS) mean differences in HR, QTcF, SBP and DBP average change from baseline over time between therapeutic dose group and supra-therapeutic dose group were presented with the corresponding 95% confidence intervals (CIs). 3. Results 3.1 Study population A total of 24 healthy subjects were enrolled in the study. One subject was randomized but withdrew the informed consent form, one was withdrawn by the
investigator due to a difficulty in drawing blood. There were 22 subjects evaluable for PK and PD analysis, and 23 for safety analysis. Demographics of the subjects are shown in Table 1. 3.2 Pharmacokinetic properties Mean plasma concentration vs time profiles of BDP, B17MP, formoterol and GB are presented in Figure 2. The detailed pharmacokinetic parameters by treatment and comparison of the main pharmacokinetic parameters between therapeutic and supra-therapeutic dose are presented in Table 2 to 4. BDP, B17MP, formoterol and GB were rapidly absorbed into plasm and reached peak concentrations after inhalation of BDP/FF/GB pMDI. Repeated administration of BDP/FF/GB pMDI at therapeutic dose for 7 days led to different degree of accumulation, the accumulation ratio of AUC0-12 for formoterol, B17MP and GB were 1.87, 1.46 and 3.61, respectively. Formoterol and BDP dose-normalised Cmax and AUCs were lower in therapeutic dose group than in supra-therapeutic dose group, with point estimate(PE) of geometric mean ratios (GMR) ranging from 72 to 85%; whereas B17MP and GB dose-normalised Cmax and AUCs were similar in the two groups with PE of GMR ranging from 92 to 106%. For BDP, the short half-life compromised the PK evaluation of plasma concentrations as samples can only be measured up to 0.5 h (therapeutic dose group) or 1 h (supra-therapeutic dose group) post-dose, the quantifiable concentrations are most likely not in the terminal elimination phase and therefore the terminal t1/2 and related parameters for BDP were not estimated in this study. 3.3 Pharmacodynamic properties HR, QTcF, SBP and DBP were all within the normal range after inhalation of BDP/FF/GB pMDI at therapeutic or supra-therapeutic dose. The plots of averaged HR, QTcF, SBP and DBP change from baseline were provided in Figure 3. In general, Mean changes in SBP, DBP and QTcF from pre-dose were small (<5 mmHg and <10 ms, respectively). Mean HR was increased and remained above pre-dose values with
the largest change from baseline at 4-hour time point. The average and maximum 12-hour HR and QTcF intervals values were similar during the groups. The maximum HR, QTcF, SBP and DBP change from baseline were 12.8 bpm, 7.6 ms, 4.5 mmHg and 4.6 mmHg, respectively. No QTcF intervals of >450 ms (males) or >470 ms (females) or QTcF interval increases >30 ms were observed. The average HR, QTcF, SBP and DBP change from baseline for BDP/FF/GB pMDI therapeutic dose group vs supra-therapeutic dose were 0.52 bpm, 1.74 ms, 0.89 mmHg and 1.56 mmHg, respectively ( Table 5), all the 95% confidence interval included 0. Overall, 6 subjects (50.0%) reported 8 treatment-emergent adverse event (TEAE) in the therapeutic dose group, 1 TEAE (diarrhea) was considered to be treatment-related and occurred in 1 (4.3%) subject. The most frequently reported TEAE was hyperuricemia (in 2 [8.7%] subjects overall). All reported TEAEs (Table 6) were mildin intensity and no severe TEAEs or TEAEs leading to discontinuation were reported. 4 Discussion BDP/FF/GB pMDI is in development for the treatment of COPD. The pharmacokinetic and pharmacodynamic properties of BDP/FF/GB pMDI were not so clear since few data were published. We investigated the PK and PD properties of single- and multiple-dose of BDP/FF/GB pMDI in healthy Chinese subjects, and assessed safety profile as well. In general, pharmacokinetics profiles of BDP, B17MP, formoterol, and GB in this study accorded with previous study [13]. In view of fact that the inhalation flow and the velocity of aerosol particles released from a device strongly affect the lung deposition pattern
[14]
, to keep under
control and standardize the inhalation flow, we trained the subjects with placebo and an AMITM Vitalograph® which was able to monitor for correct timing of the pMDI actuation and for proper inhalation time and flow(approximately 30 L/min), and breathe holding time. Subjects were not allowed to lie down or sleep until 2 hours post
dose, except when undergoing clinical assessments. They had to remain seated as much as possible and avoid strenuous activities. Special steps to prevent any kind of contamination are essentially important in the PK study of inhaled aerosol formulation. In the present study drug inhalation and blood sample collection were carried out following specific procedures aiming to limit contamination of samples. The results of the UPLC/MS-MS assays indicated that the measures to prevent contamination are successful in the present study. After BDP/FF/GB pMDI administration, maximum plasma concentrations of BDP were achieved at 5 mins in most subjects, this was in accordance with the moderately lipophilic character of BDP, which was soluble in human bronchial secretions and rapidly absorbed across the lung epithelium [15]. 95% of BDP was presystemic metabolismed to B17MP by lung and was prior to its absorption [16]. Systemic exposure of the parent drug is thought to reflect the absorption from the lungs [17][18] . B17MP was also rapidly absorbed as it can be measured and reached the maximum plasma concentration at 5 mins after drug administration. In this study, Cmax of BDP was 2.1-2.7 times higher than that of B17MP while the AUC0-t of B17MP was 9.9-14.7 times higher than that of BDP, this profile is consistent with rapid clearance of the parent drug by conversion to the active metabolite [19]. Small double concentration peaks occurred at 1.5 h post-dose was found in B17MP. The phenomenon might be explained by the intestinal absorption of the swallowed portion of the dose, as a previous study showed that the intestinal absorption contributed to 26% bioavailability of B17MP [16]. Formoterol was quickly absorbed and reached the maximum plasma concentrations at 5 mins, and a second concentration peak occurred 1.5 h after administration. The same phenomenon was also found in previous studies [20][21][22] in healthy individuals and patients, this is due to the gastrointestinal absorption of the swallowed portion of the inhaled dose and enterohepatic recirculation of the formoterol
[19]
. It was reported that the conjugates of formoterol, entering into the
intestinal lumen by bile excretion, are cleaved by the gut flora, and the free drug is reabsorbed by enterocytes and recirculates through the liver
[24][25]
. Animal studies
revealed that biliary excretion of formoterol accounted for about 31–65% of an orally administered dose
[26]
. A study establishing an enterohepatic circulation PK model
found that besides urinary elimination, the biliary excretion, and intestinal absorption, even the fecal elimination might contribute to the total clearance of the formoterol [20]. Glycopyrronium bromide is a new selective inhaled M3 receptor antagonist, is 4-5 fold more selective at M3 receptors than other LAMA
[27]
. Blockadge of M3 can
relax the airway and inhibits airway secretions, thus reversing the bronchoconstriction occurring in COPD. The M3/M2 ratio dissociation half-lives of glycopyrronium has been reported to be 7.3 in in vitro experiments
[28][29]
. Post-synaptic M2 receptors on
airway smooth muscle cells might have a role in modulating airway smooth muscle response as their activation reduces beta2-receptor-induced airway smooth muscle relaxation [30]. GB was approved by the FDA in 2017 as a nebulized monotherapy[31], while it was available as a dry-powder inhaler before. GB concentrations were still quantifiable at the last blood collection point and showed a slow terminal elimination phase, the same situation can be seen in other studies[22][32], those findings were in accordance with the long lasting time of inhaled glycopyrrolate in the body,the reported terminal elimination-phase t½ was 52.5 h following inhalation[33]. Unlike other components of BDP/FF/GB pMDI, GB is poorly absorbed by the gastrointestinal tract[34][35][36], with 80%~93.1% of systematic exposure absorbed through the lung while only 6.9%~18% absorbed through the gastrointestinal tract[37][38]. As for formoterol and GB, 0-12 hours sampling period is probably not enough to estimate half-life with a good reliability for most of the subjects in the therapeutic dose group.Only three t1/2 values can be estimated for GB in the supra-therapeutic dose group. Thus, the t1/2 and related parameters AUC0-∞ of formoterol and GB should be considered with caution or was not reported in the corresponding dose group. This is
one of the limitations of the present study. After single administration of therapeutic and supra-therapeutic BDP/FF/GB pMDI, dose-normalised Cmax and AUCs showed no statistically significant differences in this study. Though formoterol dose-normalised Cmax and AUCs were lower in therapeutic dose group than in supra-therapeutic dose group, dose-normalised AUC0-12 (PE of GMR was 85%) is more suitable for the comparison of system exposure. Dose-normalised Cmax and AUCs for BDP were lower in therapeutic dose group than in supra-therapeutic dose group while for B17MP, dose-normalised Cmax and AUCs were similar in the two groups. B17MP is an active metabolite of BDP, therefore, B17MP is most relevant for the corticosteroid component pharmacokinetics of BDP/FF/GB pMDI. For GB, dose-normalised Cmax and AUCs were similar in the two groups. Overall, the dose adjusted PK profile was similar at therapeutic and supra-therapeutic dose for all compounds, indicating nearly dose proportional exposure to BDP, B17MP, formoterol and GB. After repeated administration of BDP/FF/GB pMDI at therapeutic dose for 7 days, formoterol and B17MP showed limited accumulation of AUC0–12 in plasma (Rac 1.87 and 1.46, respectively). The GB accumulation was more pronounced (Rac 3.61) and was slightly higher than reported in the previous study following repeated inhalation[39][40][41] (Rac2.94 , 2.77 and 3.03, respectively). All the pharmacodynamic variables were within the normal range at DAY7 and were similar to those evaluated at DAY1. The plasm concentration of GB was low 12h post-dose and no TEAE was reported at DAY7. The GB accumulation was not clinically significant. Overall, the observed BDP, B17MP, Formoterol and GB PK profile was consistent with data previously reported for BDP/FF/GB pMDI in healthy Western subjects [13] The systemic effect of the drug was investigated in terms of cardiovascular parameters, focusing mainly on the potential PD effect of formoterol and GB. In the present study no efficacy variables were evaluated since the pulmonary function of
healthy subjects is normal and is not expected to change after inhalation of LABAs and LAMAs. HR, SBP, DBP and QTcF were used as PD variables to assess the potential cardiovascular risk [42][43][44]. In general, all the pharmacodynamic variables were within the normal range after inhalation of the BDP/FF/GB pMDI therapeutic or supra-therapeutic dose. Mean changes in SBP, DBP and QTcF from pre-dose were small (<5 mmHg and <10 ms, respectively), indicating no relevant effect of BDP/FF/GB pMDI on blood pressure and QTcF. No QTcF intervals of >450 ms (males) or >470 ms (females) or QTcF interval increases >30 ms were observed in this study. The mean HR, QTcF, SBP and DBP effect between therapeutic and supra-therapeutic dose within 12 hours was very small (<2), all the 95% confidence intervals included 0, indicating that there was no significant difference between therapeutic and supra-therapeutic dose. It showed that increasing doses of BDP/FF/GB pMDI did not lead to any further incremental effect and the system effect has no proportional relationship with drug dosage. 5 Conclusions The results observed in this clinical study showed that the dose adjusted PK profile was similar at therapeutic and supra-therapeutic dose for all compounds, indicating nearly dose proportional exposure to BDP, B17MP, formoterol and GB after BDP/FF/GB pMDI administration in healthy Chinese subjects. The system effect was small and has no proportional relationship with drug dosage. BDP/FF/GB pMDI therapeutic and supra-therapeutic dose was safe and well tolerated in healthy subjects. Importantly, no TEAEs were reported for the supra-therapeutic dose. The PK and the safety profiles were comparable to previously published data from Western European Caucasian subjects. Conflict of interest The authors have declared that no financial relationships with any organizations that might have an interest in the submitted work; no any other relationships or
activities that could appear to have influenced the submitted work. Acknowledgments This study was sponsored by Chiesi Farmaceutici S.p.A, Parma, Italy. We would like to acknowledge all the study nurses in Phase I Unit of West China Hospital, Sichuan University for blood sampling. We would like to acknowledge the colleagues from Bioanalysis Department of SGS Life Sciences (Wavre, Belgium) for UPLC/MS-MS assays. We would like to acknowledge all the human subjects for their participation in the present study.
Author contributions Zhu Luo conceived and designed the trial. Zhu Luo, Chao Hu, Jia Miao, Shiqing Shu, Ying Wang and Xiaohong Zhu performed the trial. Zhu Luo analyzed the data. Chao Hu and Zhu Luo wrote the manuscript.
References [1]. World Health Organization. Projections of mortality and causes of death, 2016 and 2030. http://www.who.int/healthinfo/global_burden_disease/projections/en/. Accessed date: 14 July 2019. [2]. Fang L , Gao P , Bao H , et al. Chronic obstructive pulmonary disease in China: a nationwide prevalence study[J]. The Lancet Respiratory Medicine,2018,6:421-30. DOI: 10.1016/S2213-2600(18)30103-6 [3]. Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. http://goldcopd.org/goldreports/. Accessed date: 14 July, 2019. [4]. Montuschi P, Malerba M, Macis G, et al. Triple inhaled therapy for chronic obstructive pulmonary disease[J]. Drug Discovery Today , 2016:Nov;21(11):1820-1847. DOI: 10.1016/j.drudis.2016.07.009 [5]. Tsuda A, Henry F S, Butler J P. Particle transport and deposition: basic physics of particle kinetics[J]. Comprehensive Physiology, 2013, 3(4):1437-1471.DOI:10.1002/cphy.c100085 [6]. Scichilone N, Benfante A, Morandi L, et al. Impact of extrafine formulations of inhaled corticosteroids/long-acting beta-2 agonist combinations on patient-related outcomes in asthma and COPD[J]. Patient Related Outcome Measures, 2014,5:153-162. DOI: 10.2147/PROM.S55276 [7]. Usmani O S. Treating the small airways.[J]. Respiration, 2012, 84(6):441-453. DOI: 10.1159/00034362 [8]. Papi A, Vestbo J, Fabbri L, et al. Extrafine inhaled triple therapy versus dual bronchodilator therapy in chronic obstructive pulmonary disease (TRIBUTE): a double-blind, parallel group, randomised controlled trial[J]. Lancet, 2018, 391(10125):1076-1084. DOI: 10.1016/S0140-6736(18)30206-X [9]. Vestbo J, Papi A, Corradi M , et al. Single inhaler extrafine triple therapy versus long-acting muscarinic antagonist therapy for chronic obstructive pulmonary disease (TRINITY): a
double-blind, parallel group, randomised controlled trial[J]. The Lancet, 2017;389(10082):1919–1929. DOI: 10.1016/S0140-6736(17)30188-5 [10]. Singh D, Papi A, Corradi M, et al. Single inhaler triple therapy versus inhaled corticosteroid plus long-acting β2-agonist therapy for chronic obstructive pulmonary disease (TRILOGY): a double-blind, parallel group, randomised controlled trial.[J]. Lancet, 2016, 388(10048):963-973. DOI: 10.1016/S0140-6736(16)31354-X [11]. Singh S , Loke Y K , Furberg C D . Inhaled Anticholinergics and Risk of Major Adverse Cardiovascular Events in Patients With Chronic Obstructive Pulmonary Disease: A Systematic Review and Meta-analysis[J]. JAMA The Journal of the American Medical Association, 2008, 300(12):1439-1450. DOI: 10.1001/jama.300.12.1439 [12]. Salpeter SR, Ormiston TM, Salpeter EE. Cardiovascular effects of beta-agonists in patients with asthma and COPD: a meta-analysis[J]. Chest. 2004; 125(6): 2309-2321. DOI: 10.1378/chest.125.6.2309 [13]. Mariotti F, Ciurlia G, Spaccapelo L, et al. A Two-Period Open-Label, Single-Dose Crossover Study in Healthy Volunteers to Evaluate the Drug–Drug Interaction Between Cimetidine and Inhaled Extrafine CHF 5993 [J]. European Journal of Drug Metabolism & Pharmacokinetics, 2017, 42(2):269-279.DOI:10.1007/s13318-016-0345-2 [14]. Markus B J, Charlotte K, Ashish S. Inhaled Therapy in Respiratory Disease: The Complex Interplay of Pulmonary Kinetic Processes [J]. Canadian Respiratory Journal, 2018, 2018:1-11. DOI: 10.1155/2018/2732017 [15]. Cote C, Pearle J L, Sharafkhaneh A, et al. Faster onset of action of formoterol versus salmeterol in patients with chronic obstructive pulmonary disease: A multicenter, randomized study.[J]. Pulmonary Pharmacology & Therapeutics, 2009, 22(1):44-49. DOI: 10.1016/j.pupt.2008.11.010 [16]. Daley-Yates P. Beclomethasone dipropionate: absolute bioavailability, pharmacokinetics and metabolism following intravenous, oral, intranasal and inhaled administration in man [J]. Br J Clin Pharmacol, 2001, 51(5):400-409.DOI：10.1046/j.0306-5251.2001.01374.x
[17]. Chrystyn H. Methods to identify drug deposition in the lungs following inhalation[J]. British Journal of Clinical Pharmacology, 2001, 51(4):289–299. DOI:10.1046/j.1365-2125.2001.01304.x [18]. Singh D, Collarini S, Poli G, et al. Effect of AeroChamber PlusTM on the lung and systemic bioavailability of beclometasone dipropionate/formoterol pMDI[J]. British Journal of Clinical Pharmacology, 2011, 72(6):932-939. DOI: 10.1111/j.1365-2125.2011.04024.x [19]. Small C J, Gillespie M. Pharmacokinetics of Beclomethasone Dipropionate Delivered by Breath-Actuated Inhaler and Metered-Dose Inhaler in Healthy Subjects[J]. Journal of Aerosol Medicine and Pulmonary Drug Delivery, 2018 Jun;31(3):182-190. DOI:10.1089/jamp.2017.1397 [20]. Soulele K , Macheras P , Karalis V. On the pharmacokinetics of two inhaled budesonide/formoterol combinations in asthma patients using modeling approaches[J]. Pulmonary Pharmacology & Therapeutics, 2018, 48:168-178. DOI:10.1016/j.pupt.2017.12.002 [21]. Backer D E, Wilfried, DEVOLDER, et al. Lung Deposition of BDP/Formoterol HFA pMDI in Healthy Volunteers, Asthmatic, and COPD Patients[J]. J Aerosol Med Pulm Drug Deliv, 2010, 23(3):137-148. DOI: 10.1089/jamp.2009.0772 [22]. Reisner C, Miller J, Depetrillo P, et al. Pharmacokinetics and safety of a single dose of the novel LAMA/LABA fixed-dose combination of glycopyrronium/formoterol fumarate dihydrate metered dose inhaler, formulated using co-suspension delivery technology, in Japanese healthy subjects[J]. Pulmonary Pharmacology & Therapeutics, 2018, 53:33-38. DOI:10.1016/j.pupt.2018.09.005. [23]. Darken P, Depetrillo P, Reisner C , et al. The pharmacokinetics of three doses of budesonide/glycopyrronium/formoterol fumarate dihydrate metered dose inhaler compared with active controls: A Phase I randomized, single-dose, crossover study in healthy adults[J]. Pulmonary Pharmacology & Therapeutics, 2018,50:11-18. DOI:10.1016/j.pupt.2018.03.001
[24]. Lecaillon J B, Kaiser G, Palmisano M, et al. Pharmacokinetics and tolerability of formoterol in healthy volunteers after a single high dose of Foradil dry powder Inhalation via aerolizerTM[J]. European Journal of Clinical Pharmacology, 1999, 55(2):131-138. DOI: 10.1007/s002280050607 [25]. Rosenborg J, Larsson P, Tegnér K, et al. Mass balance and metabolism of [(3)H]Formoterol in healthy men after combined i.v. and oral administration-mimicking inhalation.[J]. Drug Metabolism & Disposition the Biological Fate of Chemicals, 1999, 27(10):1104–1116. DOI: urn:nbn:se:uu:diva-89461 [26]. Sasaki H, Kamimura H, Shiobara Y, et al. Disposition and metabolism of formoterol fumarate, a new bronchodilator, in rats and dogs[J]. Xenobiotica, 1982, 12(12): 803–812. DOI: 10.3109/00498258209038952 [27]. Montuschi P, Ciabattoni G. Bronchodilating Drugs for Chronic Obstructive Pulmonary Disease: Current Status and Future Trends[J]. Journal of Medicinal Chemistry, 2015, 58(10):4131-4164. DOI: 10.1021/jm5013227 [28]. Gavaldà A, Ramos I,Carcasona C,et al.The in vitro and in vivo profifile of aclidinium bromide in comparison with glycopyrronium bromide[J]. Pulmonary Pharmacology & Therapeutics 2014 Aug;28(2):114-21. DOI: 10.1016/j.pupt.2014.05.005. [29]. Sykes DA,Dowling MR.Leighton-Davies J,et al.The Influence of Receptor Kinetics on the Onset and Duration of Action and the Therapeutic Index of NVA237 and Tiotropium[J]. THE JOURNAL OF PHARMACOLOGY AND EXPERIMENTAL THERAPEUTICS.2012 Nov;343(2):520-8. DOI: 10.1124/jpet.112.194456. [30]. Montuschi P1, Macagno F, Valente S, et al. Inhaled Muscarinic Acetylcholine Receptor Antagonists for Treatment of COPD [J]. Current Medicinal Chemistry, 2013, 20(12):1464-76. DOI: 10.2174/0929867311320120002. [31]. Kerwin E , Donohue J F , Goodin T , et al. Efficacy and safety of glycopyrrolate/eFlow® CS (nebulized glycopyrrolate) in moderate-to-very-severe COPD: Results from the glycopyrrolate for obstructive lung disease via electronic nebulizer (GOLDEN) 3 and 4 randomized controlled trials.[J]. Respiratory Medicine, 2017,132:238-250.
DOI: 10.1016/j.rmed.2017.07.011. [32]. Fakih F, Spangenthal S, Sigal B, et al. Randomized study of the effects of Aerochamber Plus ®; Flow-Vu ®; on the efficacy, pharmacokinetics and safety of glycopyrronium/formoterol fumarate dihydrate metered dose inhaler in patients with chronic obstructive pulmonary disease[J]. Respiratory Medicine, 2018, 138:74-80. DOI: 10.1016/j.rmed.2018.03.033. [33]. Bartels C, Looby M, Sechaud R, et al. Determination of the pharmacokinetics of glycopyrronium in the lung using a population pharmacokinetic modelling approach[J]. British Journal of Clinical Pharmacology, 2013, 76(6):868-879. DOI: 10.1111/bcp.12118 [34]. Chiesi Limited, Atimos Modulite 12 Micrograms Inhaler - Summary of ProductCharacteristics, (2015) https://www.medicines.org.uk/emc/medicine/21000, Accessed date: 16 July 2019. [35]. Colonis Pharma Ltd, Glycopyrronium Bromide 1 mg/5 ml Oral Solution – Summaryof Product Characteristics, (2017) https://www.medicines.org.uk/emc/medicine/32263 , Accessed date: 16 July 2019. [36]. Novartis Pharmaceuticals UK Ltd, Foradil® – Summary of Product Characteristics,(2016) https://www.medicines.org.uk/emc/medicine/1286, Accessed date: 16 July 2019 [37]. Fabbri LM, Kerwin EM, Spangenthal S, et al. Dose-response to inhaled glycopyrrolate delivered with a novel Co-Suspension Delivery Technology metered dose inhaler (MDI) in patients with moderate-to-severe COPD[J]. Respir Res. 2016;17(1):109. DOI:10.1016/j.pupt.2018.09.005 [38]. D. Singh, F. Mariotti, S. Collarini, S, et al. Pharmacokinetics, Absolute Bioavailability And Lung Bioavailability Of Extrafine Inhaled Glycopyrronium Bromide Pmdi In Healthy Volunteers. Am J Respir Crit Care Med 191;2015:A5758 [39]. Ren S, Sechaud R, Su Z, et al. Pharmacokinetic sand safety of indacaterol andglycopyrronium (IND/GLY) following repeated once daily inhalation from a fixed-dose combination in healthy Chinese subjects [J]. Clinical Pharmacology and Therapeutics, 2017, 55(2):147-155. DOI:10.5414/CP202558
[40]. Sechaud R, Machineni S, Tillmann H C, et al. Pharmacokinetics of Glycopyrronium Following Repeated Once-Daily Inhalation in Healthy Chinese Subjects[J]. European Journal of Drug Metabolism and Pharmacokinetics, 2015, 41(6):1-9. DOI:10.1007/s13318-015-0300-7 [41]. Chen Q, Hu C, Yu H, et al. Pharmacokinetics and Tolerability of Budesonide/Glycopyrronium/Formoterol Fumarate Dihydrate and Glycopyrronium/Formoterol Fumarate Dihydrate Metered Dose Inhalers in Healthy Chinese Adults: A Randomized, Double-Blind, Parallel-Group Study[J]. Clinical Therapeutics. 2019 May;41(5):897-909.e1. DOI: 10.1016/j.clinthera.2019.03.007. [42]. Guhan A R, Cooper S, Oborne J, et al. Systemic effects of formoterol and salmeterol: a dose-response comparison in healthy subjects[J]. Thorax, 2000, 55(8):650-656. DOI:10.1136/thorax.55.8.650 [43]. Singh D, Ciurlia G, Piccinno A, et al. Acute cardiovascular safety of two formulations of beclometasone dipropionate/formoterol fumarate in COPD patients: A single-dose, randomised, placebo-controlled crossover study[J]. Pulmonary Pharmacology & Therapeutics, 2017, 42:43-51. DOI: 10.1016/j.pupt.2016.12.004 [44]. Anton D, Matthew B, Romain S, et al. Effect of dual bronchodilation with QVA149 on cardiac safety in healthy volunteers[J]. International Journal of Clinical Pharmacology & Therapeutics, 2014, 52(5):369-380. DOI: 10.5414/CP202034
Figure captions Figure 1. The study design Figure 2. Mean plasma concentration vs time profile of BDP (A), B17MP(B), formoterol (C) and GB(D) Figure3. Average HR(A), QTcF(B), SBP (C) and DBP (D)change from baseline over time
Graphical abstract
Table 1 Demographic data for subjects receiving CHF 5993 All values are mean ±standard deviation Single dose
Multiple doses
All Treatments
N=11
N=12
N=23
age, years
24.9 ±2.7
24.8±4.8
24.8±3.8
weight, kg
61.68±12.20
60.15±5.83
60.88±9.23
Height, cm
167.6±9.0
165.3±7.8
166.4±8.3
21.75±2.43
22.07±1.96
21.91±2.15
6/5
6/6
12/11
Parameters
BMI, kg.m
-2
Gender, male/female
Table 2 Summary and Statistical Comparison of BDP and B-17-MP Plasma Pharmacokinetic Parameters after single and multiple dose CHF 5993 in healthy volunteers. All values are mean ±standard deviation, except tmax which is median (range) CHF 5993 pMDI PK Parameter
CHF 5993 pMDI Therapeutic Dose
Supra-Therapeutic
N=11
dose On Day 1
Dose N=10 Cmax (pg/mL) BDP
B17MP
tmax (h)
2162±1241 0.08 (0.08; 0.08)
Therapeutic vs.Supra-Therapeutic
Day 1 737±256
Day 7 n=10
0.08 (0.08;0.08) 107±37
n=10
n=10
Point Estimate and 90% CI
B
A
P-value
935±425
74.38 (50.46, 109.63)
0.2023
0.08 (0.08; 0.13)
－
－
141±54
72.18 (48.32, 107.83)
0.1760 0.6114
AUC0-t (pg.h/mL)
329±195
Cmax (pg/mL)
790±383
347±123
625±263
91.61 (68.37, 122.76)
Cmin (pg/mL)
－
－
41.8 ±8.2
－
tmax (h)
1.00 (0.08; 2.00)
0.50 (0.08;2.00)
0.08 (0.08; 1.50)
－
－
AUC0-t (pg.h/mL)
3257±782
1531±317
2181±340
－
－
－
96.06 (80.23, 115.01)
0.7036
1718±386
n=10
AUC0-∞ (pg.h/mL)
3597±856
AUC0-12h (pg.h/mL)
3257±782
1531±317
2180±340
94.83 (80.19, 112.13)
0.5907
AUC0-24h (pg.h/mL)
3657±873
－
－
－
－
t1/2 (h)
3.51±0.33
3.92±0.77
3.41±0.27
－
－
Cav,ss (pg/mL)
－
－
182 ±28
－
－
Rac
－
－
1.46 ±0.28
－
－
N=number of subjects; n=number of subjects with data; NAP=not applicable A
Dose-normalised PK parameters were log-transformed and submitted to an ANOVA model including group as
fixed effect. B
Point estimate and 90% two-sided confidence intervals (90% CI) of the ratios ( therapeutic dose vs
supra-therapeutic) of adjusted
Table3 Summary and Statistical Comparison of FF Plasma Pharmacokinetic Parameters after single and multiple dose CHF 5993 in healthy volunteers. All values are mean ±standard deviation, except tmax which is median (range)
CHF 5993 pMDI PK Parameter
CHF 5993 pMDI Therapeutic Dose
Supra-Therapeutic Dose
N=11 Day 1
On Day 1 Day 7
N=10
Point Estimate and 90% CI
A
P-value
B
Cmax (pg/mL)
32.4 ±14.7
12.4 ±6.1
25.5 ±10.6
76.06 (54.49, 106.16)
0.1720
Cmin (pg/mL)
－
－
2.7±0.7
－
－
0.08 (0.08; 2.00)
0.08 (0.08; 1.50)
0.08 (0.08; 1.13)
－
－
106.0±19.8
39.4±10.9
72.8±13.8
－
－
－
77.44 (62.17, 96.46)
0.0593
tmax (h) AUC0-t (pg.h/mL) FF
Therapeutic vs. Supra-Therapeutic dose
AUC0-∞ (pg.h/mL)
120.0±22.5
n=9
47.9±15.7
n=8
AUC0-12h (pg.h/mL)
92.9±11.6
40.0±10.3
72.8±13.8
84.55 (73.21, 97.64)
0.0582
AUC0-24h (pg.h/mL)
111.0±15.6
－
－
－
－
－
－
t1/2 (h)
7.0±2.3
n=9
a
4.7±1.6
7.3±2.4
n=10,a
Cav,ss (pg/mL)
－
－
6.1 ±1.2
－
－
Rac
－
－
1.87±0.35
－
－
a: the t1/2 values should be considered with caution because the 0-12 hours sampling period is probably not enough to estimate formoterol half-life with a good reliability for most of the subjects
Table4 Summary and Statistical Comparison of GB Plasma Pharmacokinetic Parameters after single and multiple dose CHF 5993 in healthy volunteers. All values are mean ±standard deviation, except tmax which is median (range)
CHF 5993 pMDI PK Parameter
CHF 5993 pMDI Therapeutic Dose
Supra-Therapeutic
Therapeutic vs. Supra-Therapeutic dose
N=11
Dose
Day 1
On Day 1 Day 7
Point Estimate and
N=10
P-value
B
Cmax (pg/mL)
17.8±8.1
10.3±7.2
34.6±14.9
105.93 (72.41, 154.97)
0.7966
Cmin (pg/mL)
－
－
6.9±3.0
－
－
0.25 (0.08; 3.00)
1.00 (0.08; 3.00)
0.25 (0.08; 0.50)
－
－
105±36.0
36.8±14.6
132±46.7
－
－
－
－
－
tmax (h) AUC0-t (pg.h/mL) GB
90% CI
A
n=3,a
AUC0-∞ (pg.h/mL)
－
AUC0-12h (pg.h/mL)
74.0±19.2
37.4±13.9
132±46.7
97.41 (76.37, 124.24)
0.8541
AUC0-24h (pg.h/mL)
106.0±34.7
－
－
－
－
－
－
d
34.6±18.1
n=6,b
n=5,c
t1/2 (h)
－,
Cav,ss (pg/mL)
－
－
11.0±3.9
－
－
Rac
－
－
3.61 ±0.66
－
－
5.5±2.8
11.5±4.8
a: 5 subiects can not estimated,3 subiects auc0-inf excluded from all statistical analyses as aucextr >20% auc0-inf. b:
the t1/2 could not be estimated because of an adjusted R² value lower than 0.85 in 5 subjects.
c: the t1/2 could not be estimated because of an adjusted R² value lower than 0.85 in 6 subjects. d: the t1/2 could not be estimated because of an adjusted R² value lower than 0.85 in 8 subjects , not enough to estimate the half-life of GB with a good reliability .
Table 5 average SBP,DBP,HR and QTcF from baseline over 12 hours, for Therapeutic Dose group vs Supra-Therapeutic Dose group
Therapeutic Dose vs
least square mean
Supra-Therapeutic Dose
difference
SBP (mmHg)
0.89
-1.22, 2.99
DBP (mmHg)
1.56
-0.33 ,3.45
HR (bpm)
0.52
-3.23 ,4.28
QTcF (ms)
1.74
-1.18 ,4.65
95% confidence interval
Table 6 overall Treatment-Emergent Adverse Events (safety population)
Treatment-Emrgent Adverse Events (TEAEs)
CHF 5993 pMDI
CHF 5993 pMDI
All
Therapeutic Dose
Supra-therapeutic Dose
Treatments
n (%) N=12
E
n (%) N=11
E
n (%) N=23
E
At least one TEAE
6 (50.0)
8
0
-
6 (26.1)
8
Treatment-related AE
1 (8.1)
1
0
-
1 (4.3)
1
1 (8.3)
1
0
-
1 (4.3)
1
Hyperuricemia
2 (16.7)
2
0
-
2 (8.7)
2
Hypercholesterolemia
1 (8.3)
1
0
-
1 (4.3)
1
Blood bilirubin increased
1 (8.3)
1
0
-
1 (4.3)
1
Blood cholesterol increased
1 (8.3)
1
0
-
1 (4.3)
1
White blood cells urine positive
1 (8.3)
1
0
-
1 (4.3)
1
Upper respiratory tract infection
1 (8.3)
1
0
-
1 (4.3)
1
Diarrhoea Other reported TEAEs
N=Number of subjects; n=number of subjects with event; E=number of events