"The U.S. Food and Drug Administration today approved Anoro Ellipta (umeclidinium and vilanterol inhalation powder) for the once-daily, long-term maintenance treatment of airflow obstruction in patients with chronic obstructive pulmonary disease ("...
Mechanism of Action
Indacaterol is a long-acting beta2-adrenergic agonist.
When inhaled, indacaterol acts locally in the lung as a bronchodilator. Although beta2-receptors are the predominant adrenergic receptors in bronchial smooth muscle and beta1-receptors are the predominant receptors in the heart, there are also beta2-adrenergic receptors in the human heart comprising 10%-50% of the total adrenergic receptors. The precise function of these receptors is not known, but their presence raises the possibility that even highly selective beta2adrenergic agonists may have cardiac effects.
The pharmacological effects of beta2-adrenoceptor agonist drugs, including indacaterol, are at least in part attributable to stimulation of intracellular adenyl cyclase, the enzyme that catalyzes the conversion of adenosine triphosphate (ATP) to cyclic-3', 5'-adenosine monophosphate (cyclic monophosphate). Increased cyclic AMP levels cause relaxation of bronchial smooth muscle. In vitro studies have shown that indacaterol has more than 24-fold greater agonist activity at beta2-receptors compared to beta1-receptors and 20-fold greater agonist activity compared to beta3-receptors. This selectivity profile is similar to formoterol. The clinical significance of these findings is unknown.
The major adverse effects of inhaled beta2-adrenergic agonists occur as a result of excessive activation of systemic betaadrenergic receptors. The most common adverse effects in adults include skeletal muscle tremor and cramps, insomnia, tachycardia, decreases in serum potassium and increases in plasma glucose.
Changes in serum potassium and plasma glucose were evaluated in COPD patients in double-blind Phase III studies. In pooled data, at the recommended 75 mcg dose, at 1 hour post-dose at week 12, there was no change compared to placebo in serum potassium, and change in mean plasma glucose was 0.07 mmol/L.
The effect of ARCAPTA NEOHALER on the QT interval was evaluated in a double-blind, placebo- and active (moxifloxacin)-controlled study following multiple doses of indacaterol 150 mcg, 300 mcg or 600 mcg once-daily for 2 weeks in 404 healthy volunteers. Fridericia's method for heart rate correction was employed to derive the corrected QT interval (QTcF). Maximum mean prolongation of QTcF intervals were < 5 ms, and the upper limit of the 90% confidence interval was below 10 ms for all time-matched comparisons versus placebo. During these studies, there were no clinically meaningful QT-interval prolongations. There was no evidence of a clinically relevant concentration-delta QTc relationship in the range of doses evaluated.
The effect of 150 mcg and 300 mcg once daily of ARCAPTA NEOHALER on heart rate and rhythm was assessed using continuous 24-hour ECG recording (Holter monitoring) in a subset of 605 patients with COPD from a 26-week, double-blind, placebo-controlled Phase III study. Holter monitoring occurred once at baseline and up to 3 times during the 26week treatment period (at weeks 2, 12 and 26). A comparison of the mean heart rate over 24 hours showed no increase from baseline. The hourly heart rate analysis was similar compared to placebo. The pattern of diurnal variation over 24 hours was maintained and was similar to placebo. No difference from placebo was seen in the rates of atrial fibrillation, time spent in atrial fibrillation and also the maximum ventricular rate of atrial fibrillation. No clear patterns in the rates of single ectopic beats, couplets or runs were seen across visits. Because the summary data on rates of ventricular ectopic beats can be difficult to interpret, specific pro-arrhythmic criteria were analyzed. In this analysis, baseline occurrence of ventricular ectopic beats was compared to change from baseline, setting certain parameters for the change to describe the pro-arrhythmic response. The number of patients with a documented pro-arrhythmic response was very similar compared to placebo. Overall, there was no clinically relevant difference in the development of arrhythmic events in patients receiving indacaterol treatment over those patients who received placebo.
Tolerance to the effects of inhaled beta-agonists can occur with regularly-scheduled, chronic use. In two 12-week clinical efficacy trials in 323 and 318 adult patients with COPD, ARCAPTA NEOHALER improvement in lung function (as measured by the forced expiratory volume in one second, FEV1) observed at Week 4 with ARCAPTA NEOHALER was consistently maintained over the 12-week treatment period in both trials.
The median time to reach peak serum concentrations of indacaterol was approximately 15 minutes after single or repeated inhaled doses. Systemic exposure to indacaterol increased with increasing dose (150 mcg to 600 mcg) in a dose proportional manner, and was about dose-proportional in the dose range of 75 mcg to 150 mcg. Absolute bioavailability of indacaterol after an inhaled dose was on average 43-45%. Systemic exposure results from a composite of pulmonary and intestinal absorption.
Indacaterol serum concentrations increased with repeated once-daily administration. Steady-state was achieved within 12 to 15 days. The mean accumulation ratio of indacaterol, i.e. AUC over the 24-hour dosing interval on day 14 or day 15 compared to day 1, was in the range of 2.9 to 3.8 for once-daily inhaled doses between 75 mcg and 600 mcg.
After intravenous infusion the volume of distribution (Vz) of indacaterol was 2,361 L to 2,557 L indicating an extensive distribution. The in vitro human serum and plasma protein binding was 94.1-95.3% and 95.1-96.2%, respectively.
After oral administration of radiolabeled indacaterol in the human ADME (absorption, distribution, metabolism, excretion) study unchanged indacaterol was the main component in serum, accounting for about one third of total drug-related AUC over 24 hours. A hydroxylated derivative was the most prominent metabolite in serum. Phenolic Oglucuronides of indacaterol and hydroxylated indacaterol were further prominent metabolites. A diastereomer of the hydroxylated derivative, a N-glucuronide of indacaterol, and C- and N-dealkylated products were further metabolites identified.
In vitro investigations indicated that UGT1A1 was the only UGT isoform that metabolized indacaterol to the phenolic Oglucuronide. The oxidative metabolites were found in incubations with recombinant CYP1A1, CYP2D6, and CYP3A4. CYP3A4 is concluded to be the predominant isoenzyme responsible for hydroxylation of indacaterol.
In vitro investigations indicated that indacaterol is a low affinity substrate for the efflux pump P-gp.
In vitro investigations indicated that indacaterol has negligible potential to cause metabolic interactions with medications (by inhibition or induction of cytochrome P450 enzymes, or induction of UGT1A1) at the systemic exposure levels achieved in clinical practice. In vitro investigation furthermore indicated that, in vivo, indacaterol is unlikely to significantly inhibit transporter proteins such as P-gp, MRP2, BCRP, the cationic substrate transporters hOCT1 and hOCT2, and the human multidrug and toxin extrusion transporters hMATE1 and hMATE2K, and that indacaterol has negligible potential to induce P-gp or MRP2.
In clinical studies which included urine collection the amount of indacaterol excreted unchanged via urine was generally lower than 2% of the dose. Renal clearance of indacaterol was, on average, between 0.46 and 1.2 L/h. When compared with the serum clearance of indacaterol of 18.8 L/h to 23.3 L/h, it is evident that renal clearance plays a minor role (about 2 to 6% of systemic clearance) in the elimination of systemically available indacaterol.
In a human ADME study where indacaterol was given orally, the fecal route of excretion was dominant over the urinary route. Indacaterol was excreted into human feces primarily as unchanged parent drug (54% of the dose) and, to a lesser extent, hydroxylated indacaterol metabolites (23% of the dose). Mass balance was complete with ≥ 90% of the dose recovered in the excreta.
Indacaterol serum concentrations declined in a multi-phasic manner with an average terminal half-life ranging from 45.5 to 126 hours. The effective half-life, calculated from the accumulation of indacaterol after repeated dosing with once daily doses between 75 mcg and 600 mcg ranged from 40 to 56 hours which is consistent with the observed time-to-steady state of approximately 12-15 days.
A population pharmacokinetic analysis was performed for indacaterol utilizing data from 3 controlled clinical trials that included 1,844 patients with COPD aged 40 to 88 years who received treatment with ARCAPTA NEOHALER.
The population analysis showed that no dose adjustment is warranted based on the effect of age, gender and weight on systemic exposure in COPD patients after inhalation of ARCAPTA NEOHALER. The population pharmacokinetic analysis did not suggest any difference between ethnic subgroups in this population.
Patients with mild and moderate hepatic impairment showed no relevant changes in Cmax or AUC of indacaterol, nor did protein binding differ between mild and moderate hepatically impaired subjects and their healthy controls. Studies in subjects with severe hepatic impairment were not performed.
Due to the very low contribution of the urinary pathway to total body elimination, a study in renally impaired subjects was not performed.
Drug interaction studies were carried out using potent and specific inhibitors of CYP3A4 and P-gp (i.e., ketoconazole, erythromycin, verapamil and ritonavir).
Verapamil: Co-administration of indacaterol 300 mcg (single dose) with verapamil (80 mg t.i.d for 4 days) showed 2-fold increase in indacaterol AUC0-24, and 1.5-fold increase in indacaterol Cmax.
Erythromycin: Co-administration of indacaterol inhalation powder 300 mcg (single dose) with erythromycin (400 mg q.i.d for 7 days) showed a 1.4-fold increase in indacaterol AUC0-24, and 1.2-fold increase in indacaterol Cmax
Ketoconazole: Co-administration of indacaterol inhalation powder 300 mcg (single dose) with ketoconazole (200 mg b.i.d for 7 days) caused a 1.9-fold increase in indacaterol AUC0-24, and 1.3-fold increase in indacaterol Cmax
Ritonavir: Co-administration of indacaterol 300 mcg (single dose) with ritonavir (300 mg b.i.d for 7.5 days) resulted in a 1.7-fold increase in indacaterol AUC0-24 whereas indacaterol Cmax was unaffected. [See DRUG INTERACTIONS].
The pharmacokinetics of indacaterol were prospectively investigated in subjects with the UGT1A1 (TA)7/(TA)7 genotype (low UGT1A1 expression; also referred to as *28) and the (TA)6, (TA)6 genotype. Steady-state AUC and Cmax of indacaterol were 1.2-fold higher in the [(TA)7, (TA)7] genotype, suggesting no relevant effect of UGT1A1 genotype of indacaterol exposure.
The ARCAPTA NEOHALER COPD clinical development program included three dose-ranging trials and six confirmatory trials (Trial 3, a 26-week seamless adaptive design trial that included an initial 2 week dose ranging phase; Trials 4, 5, and 6, 12-week trials; Trial 7, a 26-week trial; and Trial 8, a 52 week trial).
Dose selection for ARCAPTA NEOHALER for COPD was based on three dose-ranging trials (Trial 1, a 2-week dose- ranging trial in an asthma population; Trial 2, a 2-week dose-ranging trial in a COPD population; and Trial 3, a 26-week adaptive seamless design trial that included an initial 2-week dose ranging phase). Although ARCAPTA NEOHALER is not indicated for asthma, dose selection was primarily based upon the results from the dose-ranging trial in asthma patients (Trial 1) as an asthma population is the most responsive to beta-agonist bronchodilation and is most likely to demonstrate a dose response. Dose-ranging in COPD patients (Trials 2 and 3) provided supportive information.
Dose-ranging in asthma
ARCAPTA NEOHALER is not indicated for asthma.
Trial 1 was a 2-week, randomized, double-blinded, placebo-controlled design that enrolled 511 patients with persistent asthma 18 years of age and older. All enrolled patients were required to be taking inhaled corticosteroids, had a forced expiratory volume in one second (FEV1) of ≥ 50% and ≤ 90% predicted, and FEV1 reversibility after albuterol of at least 12% and at least 200 mL. Trial 1 included ARCAPTA NEOHALER doses of 18.75, 37.5, 75, and 150 mcg once daily, a salmeterol active control group, and placebo. The trial showed that the effect on FEV1 in patients treated with ARCAPTA NEOHALER 18.75 and 37.5 mcg doses was lower compared to patients treated with other ARCAPTA NEOHALER doses, particularly after the first dose. The effect did not clearly differ between the 75 and 150 mcg doses.
Results of the ARCAPTA NEOHALER and placebo treatment arms are as follows. After the first dose (Day 1), the peak (4 hour) FEV1 was 2.58L in the placebo group, with a treatment difference of 0.04L (95% CI -0.01, 0.09) in the 18.75 mcg ARCAPTA NEOHALER group, 0.04L (-0.01, 0.09) in the 37.5 mcg group, 0.12L (0.07, 0.17) in the 75 mcg group, and 0.15L (0.10, 0.20) in the 150 mcg group. The Day 2 trough FEV1 was 2.45L in the placebo group, with a treatment difference of 0.02L (95% CI -0.05, 0.08), 0.08L (0.01, 0.15), 0.09L (0.03, 0.16) and 0.16L (0.09, 0.22) in the ARCAPTA NEOHALER groups, respectively. At Day 14, the peak (4 hour) FEV1 was 2.55L in the placebo group, with a treatment difference of 0.12L (95% CI 0.05, 0.20) in the 18.75 mcg ARCAPTA NEOHALER group, 0.14L (0.06, 0.21) in the 37.5 mcg group, 0.23L (0.15, 0.30) in the 75 mcg group, and 0.20L (0.13, 0.27) in the 150 mcg group. The Day 15 FEV1 (primary endpoint) was 2.42L in the placebo group, with a treatment difference of 0.09L (95% CI 0.00, 0.17), 0.11L (0.02, 0.19), 0.17L (0.08, 0.26), and 0.12L (0.04, 0.21) in the ARCAPTA NEOHALER groups, respectively.
Dose-ranging in COPD
Trial 2 was a 2-week, randomized, double-blinded, placebo-controlled design that enrolled 552 patients with a clinical diagnosis of COPD, who were 40 years or older, had a smoking history of at least 10 pack years, had a postbronchodilator FEV1 less than 80% and at least 30% of the predicated normal value and a post-bronchodilator ratio of FEV1 over forced vital capacity (FEV1/FVC) of less than 70%. Trial 2 included ARCAPTA NEOHALER doses of 18.75, 37.5, 75 and 150 mcg once daily, a salmeterol active control group, and placebo. Results of the ARCAPTA NEOHALER and placebo arms are shown in Figure 1. The trial showed that the effect on FEV1 in patients treated with ARCAPTA NEOHALER 18.75 mcg dose was lower compared to patients treated with other ARCAPTA NEOHALER doses. Although a dose-response relationship was observed at Day 1, the effect did not clearly differ among the 37.5, 75 and 150 mcg doses by Day 15.
Figure 1: LS Mean FEV1 time profile curve over 24 hours
after ARCAPTA NEOHALER Day 1 and Week 2 in Trial 2 (COPD dose ranging)
The 2-week dose ranging phase of Trial 3 included ARCAPTA NEOHALER doses of 75, 150, 300, and 600 mcg once daily, placebo, and two active comparators. Although a dose-response relationship was observed at week 2, the effect did not clearly differ among the ARCAPTA NEOHALER doses.
The ARCAPTA NEOHALER COPD development program included six confirmatory trials that were randomized, double-blinded placebo and active-controlled in design (Trial 3, a 26-week seamless adaptive design trial that included an initial 2 week dose-ranging phase; Trials 4, 5, and 6, 12-week trials; Trial 7, a 26-week trial; and Trial 8, a 52 week trial). After the initial 2-week dose-ranging portion of the design, Trial 3 was conducted with ARCAPTA NEOHALER doses of 150 mcg and 300 mcg once daily, placebo, and an active comparator. Trials 4 and 5 were conducted with ARCAPTA NEOHALER dose of 75 mcg once daily, and placebo. Trial 6 was conducted with ARCAPTA NEOHALER dose of 150 mcg once daily and placebo. Trial 7 was conducted with ARCAPTA NEOHALER dose of 150 mcg once daily, an active comparator, and placebo. Trial 8 was conducted with ARCAPTA NEOHALER doses of 300 mcg and 600 mcg once daily, an active comparator, and placebo.
As Trials 3, 6, 7, and 8 were conducted with doses of ARCAPTA NEOHALER higher than 75 mcg, the results of Trials 4 and 5, which included ARCAPTA NEOHALER 75 mcg are the focus of this section.
These six trials enrolled 5474 patients with a clinical diagnosis of COPD, who were 40 years or older, had a smoking history of at least 10 pack years, had a post-bronchodilator FEV1 less than 80% and at least 30% of the predicted normal value and a post-bronchodilator ratio of FEV1 over FVC of less than 70%.
Assessment of efficacy in these six COPD trials was based on FEV1. The primary efficacy endpoint was 24-hour post-dose trough FEV1 (defined as the average of two FEV1 measurements taken after 23 hours 10 minutes and 23 hours and 45 minutes after the previous dose) after 12 weeks of treatment in all 6 trials. Other efficacy variables included other FEV1 and FVC time points, rescue medication use, symptoms, and health-related quality of life measured using the St. George's Respiratory Questionnaire (SGRQ).
In all six confirmatory COPD trials, all doses of ARCAPTA NEOHALER tested (75 mcg, 150 mcg, 300 mcg, and 600 mcg) showed significantly greater 24-hour post-dose trough FEV1 compared to placebo at 12 weeks. Results of Trials 4 and 5, which compared ARCAPTA NEOHALER at the dose of 75 mcg once daily to placebo are shown in Table 2.
Table 2: LS Mean for trough FEV1 at 12 weeks
|Treatment||Trough FEV1 at Week 12 (liters)||Treatment Difference LS Mean (95% CI)|
|Trial 4 (N=323)|
|Indacaterol 75 mcg||1.38||0.12 (0.08, 0.15)|
|Trial 5 (N=318)|
|Indacaterol 75 mcg||1.49||0.14 (0.10, 0.18)|
In addition, serial FEV1 measurements in patients treated with ARCAPTA NEOHALER demonstrated a bronchodilatory treatment effect after the first dose compared to placebo at 5 minutes post dose of 0.09 L (Trial 4) and 0.10 L (Trial 5). The mean peak improvement relative to baseline within the first 4 hours after the first dose (Day 1) was 0.19 L (Trial 4) and 0.22 L (Trial 5) and was 0.24 L (Trial 4) and 0.27 L (Trial 5) after 12 weeks. Improvement in lung function observed at week 4 was consistently maintained over the 12-week treatment period in both trials. In Trial 5, 24-hour spirometry was assessed in a subset of 239 patients. See Figure 2.
Figure 2 : LS Mean FEV1 time profile curve over 24 hours
at Week 12 in Trial 5
In both COPD clinical trials including the 75 mcg dose (Trials 4 and 5), patients treated with ARCAPTA NEOHALER used less daily rescue albuterol during the trial compared to patients treated with placebo.
Health-related quality of life was measured using the St. George's Respiratory Questionnaire (SGRQ) in all six confirmatory COPD clinical trials. SGRQ is a disease-specific patient reported instrument which measures symptoms, activities, and its impact on daily life. At week 12, pooled data from these trials demonstrated an improvement over placebo in SGRQ total score of -3.8 with a 95% CI of (-5.3, -2.3) for the ARCAPTA NEOHALER 75 mcg dose, -4.6 with a 95% CI of (-5.5, -3.6) for 150 mcg, and -3.8 with a 95% CI of (-4.9, -2.8) for 300 mcg. The confidence intervals for this change are widely overlapping with no dose ordering. Results from individual studies were variable, but are generally consistent with the pooled data results.
Last reviewed on RxList: 10/15/2012
This monograph has been modified to include the generic and brand name in many instances.
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