“A 4-Year Trial of Tiotropium in Chronic Obstructive Pulmonary Disease”
by the Understanding Potential Impacts on Function with Tiotropium (UPLIFT) investigators
N Engl J Med. 2008 October 9; 359(15):1543-1554 [free full text]
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The 2008 UPLIFT trial was a four-year, randomized, double-blind, prospective study investigating whether or not tiotropium could reduce the rate of decline of FEV1 (a common metric for COPD progression). A previous retrospective study had shown a reduced rate of FEV1 decline at one year with daily tiotropium. However, this finding had not been shown in any prospective study. As of 2008, smoking cessation was the only intervention demonstrated prospectively to decrease the rate of decline in FEV1.
Population: Patients were selected from 490 investigational centers in 37 countries
Inclusion: COPD, age ≥ 40, ≥ 10 pack-year smoking history, post-bronchodilator FEV1 ≤70% of predicted value, and FEV1/FVC ≤70%
Exclusion: history of asthma, COPD exacerbation or respiratory infection within the past 4 weeks, history of pulmonary resection, or use of supplemental O2 for more than 12 hours per day
Intervention: daily tiotropium 18mcg + usual respiratory medications
Control: daily placebo + usual respiratory medications
(Of note, in both arms, the usual respiratory medications could not include an anticholinergic.)
Outcomes:
Co-primary:
- Rate of decline in mean FEV1 before bronchodilation
- Rate of decline in mean FEV1 after bronchodilation
Secondary:
- Rate of decline in FVC
- Quality of life as measured by St. George’s Respiratory Questionnaire (SGRQ, ranges 0-100 with lower scores indicating improved quality)
- Rate of COPD exacerbations
- All-cause mortality
Results:
2987 patients were assigned to receive tiotropium, and 3006 were assigned to receive placebo. Baseline characteristics were similar between the two groups. 44.6% of placebo and 36.2% of tiotropium patients did not complete at least 45 months of treatment.
The primary outcomes of decline in mean FEV1 either before or after bronchodilation were not significantly different between the two groups. Before bronchodilation, the difference in mean decline was 0 ml/year (p=0.95). After bronchodilation, the mean decline with tiotropium was 2 ml/year less than with placebo (p=0.21)
Regarding secondary outcomes:
There was no significant difference in rate of decline of FVC. The SGRQ was significantly lower (better) at all time points in the tiotropium group and, on average, was 2.7 points lower than in the placebo group (95% CI 2.0-3.3, p<0.001). The number of COPD exacerbations per year in the tiotropium group was 0.73 vs. 0.85 in the placebo group (RR 0.86, 95% CI 0.81-0.91; p<0.001), and the median time to first exacerbation was longer in the tiotropium group (16.7 months vs. 12.5 months, 95% CI 11.5-13.8,). All-cause mortality was not significantly different among the two groups (14.9% vs. 16.5%, HR 0.89; 95% CI 0.79-1.02; p=0.09). Respiratory failure developed in 88 patients in the tiotropium group vs. 120 in the placebo group (RR 0.67, 95% CI 0.51 to 0.89).
Discussion:
The UPLIFT study demonstrated no significant change in rate of decline in FEV1 with tiotropium therapy compared to placebo. However, tiotropium therapy improved quality of life and reduced the frequency of COPD exacerbations and respiratory failure. Overall, this study is an excellent example how a well-designed prospective study can overturn the results of prior retrospective analyses.
The authors offered three potential reasons for the lack of difference in rate of FEV1 decline among the groups. First, tiotropium may not actually alter the decline of lung function in COPD. Second, since both groups were permitted any respiratory medications other than another anticholinergic, there may have been a “ceiling effect” reached by the alternative medications, and thus no additional benefit offered by tiotropium therapy. Third, the authors noted the placebo group dropouts tended to be have more severe COPD, and so the remaining “healthy survivor” patients may have biased the group differences toward a null result.
Limitations of this study include a high dropout rate in both groups as well as a large male predominance (~75%) that limits generalizability. Finally, the limited clinical benefits of daily tiotropium use are not likely to be cost-effective. In 2010, researchers applied the treatment effects demonstrated in UPLIFT to an observational dataset of 56,321 tiotropium users in Belgium and estimated an average cost of 1.2 million euros per quality-adjusted life year (QALY) gained.
Further Reading/References:
1. Wiki Journal Club
2. 2 Minute Medicine
3. Neyt et al., “Tiotropium’s cost-effectiveness for the treatment of COPD: a cost-utility analysis under real-world conditions” (2010)
Summary by Gordon Pelegrin, MD