RESUMO
BACKGROUND: Systemic glucocorticoids are recommended for use in chronic obstructive pulmonary disease (COPD) exacerbations; however, there is increased harm associated with their use. We hypothesised that the use of eosinophil biomarker-directed oral prednisolone therapy at the time of an exacerbation of COPD was effective at reducing prednisolone use without affecting adverse outcomes. METHODS: The studying acute exacerbations and response (STARR2) study was a multicentre, randomised, double-blind, placebo-controlled trial conducted in 14 primary care practices in the UK. We included adults (aged ≥40 years), who were current or former smokers (with at least a 10 pack year smoking history) with a diagnosis of COPD, defined as a post-bronchodilator FEV1/forced vital capacity ratio of less than 0·7 previously recorded by the primary care physician, and a history of at least one exacerbation in the previous 12 months requiring systemic corticosteroids with or without antibiotics. All study staff and participants were masked to study group allocation and to treatment allocation. Participants were randomly assigned (1:1) to blood eosinophil-directed treatment (BET; to receive oral prednisolone 30 mg once daily if eosinophil count was high [≥2%] or placebo if eosinophil count was low [<2%]) or to standard care treatment (ST; to receive prednisolone 30 mg once daily irrespective of the point-of-care eosinophil result). Treatment was prescribed for 14 days and all patients also received antibiotics. The primary outcome was the rate of treatment failure, defined as any need for re-treatment with antibiotics or steroids, hospitalisation for any cause, or death, assessed at 30 days after exacerbation in the modified intention-to-treat population. Participants were eligible for re-randomisation at further exacerbations (with a maximum of four exacerbations per participant). A safety analysis was conducted on all randomly assigned participants. Although designed as a superiority trial, after identification of an error in the randomisation code before data lock the study converted to show non-inferiority. An upper margin of 1·105 for the 95% CI was defined as the non-inferiority margin. This study was registered with EudraCT, 2017-001586-24, and is complete. FINDINGS: Between Nov 6, 2017, and April 30, 2020, 308 participants were recruited from 14 general practices. 144 exacerbations (73 in the BET group and 71 in the ST group) from 93 participants (mean age 70 years [range 46-84] and mean percent predicted FEV1 60·9% [SD 19·4]; 52 [56%] male and 41 [44%] female; ethnicity data was not collected]) were included in the modified intention-to-treat analysis. There were 14 (19%) treatment failures at 30 days post-exacerbation in the BET group and 23 (32%) in the ST group; we found a large non-significant estimated effect between BET and ST (RR 0·60 [95% CI 0·33-1·04]; p=0·070) in reducing treatment failures after a COPD exacerbation. The non-inferiority analysis supported that BET was non-inferior to ST. Frequency of adverse events were similar between the study groups; glycosuria (2/102 [2%] in BET group and 1/101 [1%] in the ST group) and hospital admission for COPD exacerbation (2/102 [2%] in BET group and 1/101 [1%] in the ST group) were the two most common adverse events in both groups. No deaths occurred in the study. INTERPRETATION: Blood eosinophil-directed prednisolone therapy at the time of an acute exacerbation of COPD is non-inferior to standard care and can be used to safely reduce systemic glucocorticoid use in clinical practice. FUNDING: National Institute for Health and Care Research.
Assuntos
Eosinófilos , Doença Pulmonar Obstrutiva Crônica , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Antibacterianos/uso terapêutico , Progressão da Doença , Método Duplo-Cego , Glucocorticoides/uso terapêutico , Prednisolona/uso terapêutico , Atenção Primária à Saúde , Doença Pulmonar Obstrutiva Crônica/complicações , Reino Unido , AdultoRESUMO
Drug resistance is a major obstacle to cancer cure and may influence [18F]-fluorodeoxyglucose (FDG) incorporation. In this study, glucose transport, hexokinase activity and [18F]-FDG incorporation were measured in drug-resistant tumour cells generated by exposing H630 colon and MCF7 breast cancer cells to increasing concentrations of tomudex (raltitrexed) or 5-fluorouracil (5FU). Drug sensitivity was determined using the XTT assay: Tomudex-resistant (H630TDX and MCF7TDX) cells were more than 40,000-fold less sensitive to tomudex than were the parental wild-type, H630WT and MCF7WT cells, respectively. 5FU-resistant (H630R10) cells were 100-fold less sensitive than parental H630WT cells to 5FU. As previously reported for 5FU-resistant MCF7 breast cancer cells, [18F]-FDG incorporation was decreased in H630R10 colon cancer cells compared to the parental line. By contrast, both tomudex-resistant cell lines exhibited increased [18F]-FDG incorporation compared with the parental lines. H630R10 and MCF7TDX cells exhibited higher rates of glucose transport, measured as the initial rate of O-methyl-glucose (OMG) uptake, compared to wild-type cells; however, glucose transport was not significantly different between H630TDX cells and the parental cells. Hexokinase activity was lower in H630R10 and MCF7TDX cells compared with sensitive parental cells but unchanged in H630TDX cells. In conclusion, our results show that [18F]-FDG incorporation is influenced by resistance to antifolate and fluoropyrimidine-based anti-cancer drugs in a drug-dependent manner and the underlying mechanisms appear to be cell- and drug-dependent. Glucose transport may be a useful marker of resistance to 5FU.