Effect of Theophylline as Adjunct to Inhaled Corticosteroids on Exacerbations in Patients With COPD: A Randomized Clinical Trial.

Devereux, Graham ORCID: https://orcid.org/0000-0002-0024-4887, Cotton, Seonaidh, Fielding, Shona, McMeekin, Nicola, Barnes, Peter J, Briggs, Andrew, Burns, Graham, Chaudhuri, Rekha, Chrystyn, Henry, Davies, Lisa, De Soyza, Anthony, Gompertz, Simon, Haughney, John, Innes, Karen, Kaniewska, Joanna, Lee, Amanda, Morice, Alyn, Norrie, John, Sullivan, Anita, Wilson, Andrew and Price, David (2018) 'Effect of Theophylline as Adjunct to Inhaled Corticosteroids on Exacerbations in Patients With COPD: A Randomized Clinical Trial.'. The Journal of the American Medical Association (JAMA), Vol 320, Issue 15, pp. 1548-1559.

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Abstract

Importance
Chronic obstructive pulmonary disease (COPD) is a major global health issue and theophylline is used extensively. Preclinical investigations have demonstrated that low plasma concentrations (1-5 mg/L) of theophylline enhance antiinflammatory effects of corticosteroids in COPD.

Objective
To investigate the effectiveness of adding low-dose theophylline to inhaled corticosteroids in COPD.

Design, Setting, and Participants
The TWICS (theophylline with inhaled corticosteroids) trial was a pragmatic, double-blind, placebo-controlled, randomized clinical trial that enrolled patients with COPD between February 6, 2014, and August 31, 2016. Final follow-up ended on August 31, 2017. Participants had a ratio of forced expiratory volume in the first second to forced vital capacity (FEV1/FVC) of less than 0.7 with at least 2 exacerbations (treated with antibiotics, oral corticosteroids, or both) in the previous year and were using an inhaled corticosteroid. This study included 1578 participants in 121 UK primary and secondary care sites.

Interventions
Participants were randomized to receive low-dose theophylline (200 mg once or twice per day) to provide plasma concentrations of 1 to 5 mg/L (determined by ideal body weight and smoking status) (n = 791) or placebo (n = 787).

Main Outcomes and Measures
The number of participant-reported moderate or severe exacerbations treated with antibiotics, oral corticosteroids, or both over the 1-year treatment period.

Results
Of the 1567 participants analyzed, mean (SD) age was 68.4 (8.4) years and 54% (843) were men. Data for evaluation of the primary outcome were available for 1536 participants (98%) (772 in the theophylline group; 764 in the placebo group). In total, there were 3430 exacerbations: 1727 in the theophylline group (mean, 2.24 [95% CI, 2.10-2.38] exacerbations per year) vs 1703 in the placebo group (mean, 2.23 [95% CI, 2.09-2.37] exacerbations per year); unadjusted mean difference, 0.01 (95% CI, -0.19 to 0.21) and adjusted incidence rate ratio, 0.99 (95% CI, 0.91-1.08). Serious adverse events in the theophylline and placebo groups included cardiac, 2.4% vs 3.4%; gastrointestinal, 2.7% vs 1.3%; and adverse reactions such as nausea (10.9% vs 7.9%) and headaches (9.0% vs 7.9%).

Conclusions and Relevance
Among adults with COPD at high risk of exacerbation treated with inhaled corticosteroids, the addition of low-dose theophylline, compared with placebo, did not reduce the number COPD exacerbations over a 1-year period. The findings do not support the use of low-dose theophylline as adjunctive therapy to inhaled corticosteroids for the prevention of COPD exacerbations.

Trial Registration
isrctn.org Identifier: ISRCTN27066620.

Item Type:	Article
Subjects:	QS Anatomy > QS 4 General works. Classify here works on regional anatomy QV Pharmacology > Central Nervous System Agents. Local Anesthetics > QV 100 Central nervous system stimulants WF Respiratory System > Lungs > WF 600 Lungs WK Endocrine System > WK 20 Research (General)
Faculty: Department:	Clinical Sciences & International Health > Clinical Sciences Department
Digital Object Identifer (DOI):	https://doi.org/10.1001/jama.2018.14432
Depositing User:	Stacy Murtagh
Date Deposited:	19 Oct 2018 14:34
Last Modified:	30 Aug 2019 13:52
URI:	https://archive.lstmed.ac.uk/id/eprint/9469

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