Patent Application
20230033881
The present invention relates to methods of using inhaled nitric oxide gas to treat and/or prevent acute respiratory distress syndrome in children.
Acute respiratory distress syndrome (ARDS), previously known as adult respiratory distress syndrome, is a life-threatening lung condition that prevents enough oxygen from getting to the lungs and into the blood. ARDS may result from an injury to or an infection in the lungs of a patient.
Inhaled nitric oxide (iNO) transiently improves oxygenation in adults with ARDS, but does not significantly decrease mortality. The impact of iNO on outcomes in children with ARDS has not been previously evaluated in a randomized, non-crossover trial.
One or more embodiments are directed to a method for treating a child or adult with ARDS or preventing ARDS in a child at risk of developing ARDS via administration of a low dose of inhaled nitric oxide (iNO). In one or more embodiments, the dose of iNO is less than about 10 ppm, such as in the range from about 0.1 ppm to about 8 ppm or in the range from dose in the range from about 2 ppm to about 6 ppm. In some embodiments, the NO dose is less than about 8 ppm. In one or more embodiments, the NO dose is about 5 ppm.
The iNO may be administered for a relatively short-term treatment, such as for a treatment period of up to 28 days. In exemplary embodiments, the NO is administered for a treatment period in the range from 2 days to 2 months.
In some embodiments, the dose of NO may include an initial dose of about 5 ppm and then initial dose may be incrementally increased to a maximum dose. The maximum dose may be up to 10 ppm, up to 15 ppm, or up to 20 ppm. The dosage increments may be 1 ppm, 2 ppm, 5 ppm, 7 ppm, or 10 ppm. The dosage may be incremented every few minutes, such as every 1 minute, 2 minutes, 5 minutes, 10 minutes, or 15 minutes.
The iNO may be administered during patient inspiration, expiration, or portions thereof. In one or more embodiments, the iNO is administered during only a portion of inspiration, such as only administering iNO during the first half of inspiration.
According to one or more embodiments, the child may be less than 17 years old. Exemplary ages for the child include those in the range from 44 weeks post-conceptional age to 17 years of age.
In one or more embodiments, the child is not subjected to extracorporeal membrane oxygenation during NO administration.
In one or more embodiments, NO increases the number of days that the child is alive and ventilator-free at 28 days after the start of NO administration.
Also provided is a method of increasing extracorporeal membrane oxygenation-free (ECMO-free) survival in children with ARDS or at risk of developing ARDS, the method comprising administering a gas comprising NO to a child in need thereof at a dose of less than 10 ppm NO. In one or more embodiments, the NO dose may be the in range from about 0.1 ppm to about 8 ppm, such as about 5 ppm.
Also provided is a method of increasing the number of ventilator-free days in children with ARDS or at risk of developing ARDS, the method comprising administering a gas comprising nitric oxide (NO) to a child in need thereof at a dose of less than 10 ppm NO. In one or more embodiments, the NO dose may be the in range from about 0.1 ppm to about 8 ppm, such as about 5 ppm.
Also provided is a method of treating ARDS in children by administering a gas comprising nitric oxide (NO) to a child in need thereof at an initial dose of about 5 ppm NO and increasing the initial dose incrementally to a maximum dose of 10 ppm to 20 ppm NO. In some examples, the maximum dose is 20 ppm. Administering the NO may decrease the child's pulmonary arterial pressure (PAP) and improve the child's oxygenation. The method may further include measuring a baseline pulmonary arterial pressure and/or measuring or calculating a baseline oxygenation prior to administering the NO. The decrease and/or improvement in the PAP and/or oxygenation may be in comparison to a baseline measurement or calculation. In some examples, the oxygenation is calculated using an oxygenation index.
In various embodiments, the child is in intensive care and/or is ventilated. The child may not be subjected to extracorporeal membrane oxygenation during NO administration. In some examples, administration of NO increases extracorporeal membrane oxygenation-free (ECMO-free) survival in the child. In other examples, administration of NO increases the number of ventilator-free days in the child after administration of NO has stopped. For example, administration of NO increases the number of days that the child is alive and ventilator-free at 28 days after the start of NO administration.
In some aspects, the NO may be administered for a treatment period of at least 2 days, up to 28 days, and/or up to 2 months. The NO may be administered during only a portion of inspiration, for example, NO may not be administered during the second half of inspiration. The child may be less than 17 years old or between the ages of 0-17.
The present disclosure is directed to the unexpected finding that short term treatment of ARDS in children using inhaled nitric oxide (iNO) gas resulted in an increased number of days that a child is ventilator-free at 28 days after the start of iNO therapy. It was also unexpectedly found that the rate of extracorporeal membrane oxygenation oxygenation-free (ECMO-free) survival is significantly higher in children treated with iNO therapy than children administered a placebo. As previous studies investigating the use of iNO for treating ARDS in adults did not meet their primary endpoints of reduced mortality or increase in days alive and off assisted breathing, it was surprising that a clinical study investigating iNO therapy for children with ARDS approached statistical significance for the number of days the patient remains alive and extubated to day 28 after initiating study therapy. It was also unexpectedly found that treatment of patients with iNO gas selectively decreased pulmonary arterial pressure and improved oxygenation in patients with acute respiratory distress syndrome (ARDS) in intensive care.
It was further unexpectedly found that short term administration of nitric oxide to patients undergoing cardiac surgery resulted in treatment of perioperative pulmonary hypertension in these patients. The treatment of the perioperative pulmonary hypertension may result in a decrease in pulmonary artery pressure and/or improved haemodynamics in the patient's pulmonary circulation and oxygenation.
Accordingly, one or more embodiments provide for the treatment and/or prevention of pediatric ARDS and/or decrease pulmonary arterial pressure in patients with perioperative pulmonary hypertension in conjunction with heart surgery using iNO.
As used herein the following terms shall have the definitions set forth below.
As used herein, the term “therapeutic composition” refers to a drug delivered to a patient. The use of the term “therapeutic composition” is in concurrence with the Food and Drug Administration's (FDA) definition of a drug: articles intended for use in the diagnosis, cure, mitigation, treatment, or prevention of disease. Such drugs may include gases comprising nitric oxide, such as nitric oxide in a diluent or carrier gas such as nitrogen or helium. The NO-containing gas may be provided by any known method, such as from a gas cylinder or chemically generating the NO at or near the place of administration. The NO-containing gas may be at a higher concentration in the cylinder or other gas source and be diluted to a delivery concentration prior to use. The drug may be provided by a drug delivery device.
The device designation as defined herein is in concurrence with the Food and Drug Administration's (FDA) definition of a device: A device is defined as an instrument, apparatus, implement, machine, contrivance, implant, in vitro reagent, or other similar or related article, including a component part, or accessory which is:
As described herein, the device may be a nitric oxide delivery device that administers a gas comprising nitric oxide. Exemplary nitric oxide delivery devices include but are not limited to the INOvent®, INOmax® DS, INOmax DSIR®, INOmax DSIR® plus, and other commercially available nitric oxide delivery devices.
As used herein, the term “treating” refers to the treatment of a disease or condition of interest in a patient (e.g., a mammal) having the disease or condition of interest, and includes, for example one or more of the following:
As used herein, the terms “disease” and “condition” may be used interchangeably or may be different in that the particular malady or condition may not have a known causative agent (so that etiology has not yet been worked out) and it is therefore not yet recognized as a disease but only as an undesirable condition or syndrome, wherein a more or less specific set of symptoms have been identified by clinicians.
As used herein, “short term treatment” refers to treatment periods up to about 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 15, 20 or 25 days or one month, two months or three months. The treatments described herein may have a certain minimum and/or maximum treatment periods. Minimum treatment periods may include about 1, 2, 3, 4, 5, 7, 8, 9, 10, 11, 12, 15, 18 or 24 hours or about 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 20, 25, 28 or 30 days. Maximum treatment periods may include about 12, 18 or 24 hours or about 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 20, 25, 28 or 30 days or about 2, 4, 6, 8, 10 or 12 weeks or about 1, 2, 3, 4, 5 or 6 months
As used herein, “chronic treatment” refers to treatment periods of greater than three months.
As used herein, the term “patient” refers to a human to whom treatment is provided according to the methods of the present disclosure. The patient may be a child or an adult. In some examples, the patient may be in intensive care.
As used herein, the term “subject” is used interchangeably with “patient”.
As used herein, the term “child” refers to a human that is under 18 years of age. In one or more embodiments, the child to be treated may be between the ages of 44 weeks post-conceptional age to 17 years of age. “Post-conceptional age” refers to the age of an infant relative to the date of conception plus the chronological age. In various embodiments, the lower age range for the child may be 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49 or 50 weeks post-conceptional age or 1, 2, 3, 4, 5, 6, 7 or 8 weeks chronological age or 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 15, 18, 21 or 24 months chronological age. The term “chronological age” refers to the age relative to the date of birth. In various embodiments, the upper age range for the child may be 18, 17, 16, 15, 14, 13, 12, 11, 10, 9, 8, 7, 6, 5, 4, 3, 2 or 1 years of age.
As used herein, the term “adult” refers to a human that is 18 years of age or older. In one or more embodiments, the adult to be treated may be over 17 years of age.
As used herein, the term “administering” refers to any mode of transferring, delivering, introducing or transporting the therapeutic composition, device or other agent to a subject. Administration of the therapeutic composition, device or other agent may be conducted concurrently or sequentially in time. Additionally, administration of the therapeutic composition, device and other agent(s) may be via the same or different route(s).
As used herein, the term “effective amount” refers to that amount of which, when administered to a patient (e.g., a mammal) for a period of time is sufficient to cause an intended effect or physiological outcome. The amount of therapeutic composition which constitutes an “effective amount” will vary depending on the condition and its severity, the manner of administration, and the patient (e.g., the age of the mammal to be treated), but can be determined routinely by one of ordinary skill in the art having regard to his own knowledge and to this disclosure.
For example, in one embodiment, the term “effective amount” refers to the amount that can achieve a measurable result. In one embodiment, an “effective amount” is, for example, an amount that when administered to a human subject in need of medical treatment in a controlled Phase 2 or Phase 3 clinical trial produces a statistically significant benefit on a predefined clinical endpoint.
As used herein, the term “indications” includes, but is not limited to, pulmonary disease, acute lung injury (ALI), acute respiratory distress syndrome (ARDS) and acute hypoxemic respiratory failure (AHRF). ARDS is related to the medical condition AHRF, and ARDS often has a perfusion-related component such as pulmonary hypertension (PH). ARDS is more severe than AHRF and therefore more difficult to achieve patient results.
AHRF is defined as (1) acute onset weeks) of respiratory problems; (2) PaO2≤50 mmHg or PaO2/FiO2 (P/F ratio) ≥300 mmHg for ≤12 hours; (3) requiring endotracheal intubation and mechanical ventilation (FiO2>0.3 and positive end-expiratory pressure (PEEP)>2 cm H2O to maintain PaO2>60 mmHg or SpO2>90%); and (4) P/F ratio remained ≥300 mmHg after 12 hours of ventilation, i.e. the worst values recorded during 12-24 hours after initiation of respiratory support.
ARDS and ALI may be determined by any acceptable criteria by one of ordinary skill in the art. On such set of criteria include (1) acute bilateral infiltrates on chest radiographic appearance, (2) the ratio of the partial pressure of oxygen in arterial blood to the fraction of inspired oxygen (PaO2/FiO2 or PF ratio) of less than 200 for ARDS and less than 300 for acute lung injury (ALI), and (3) noncardiogenic pulmonary edema based on an assessment of the left atrial filling pressure by means of a wedged pulmonary artery catheterization or clinical assessment. ARDS is defined by the American-European Consensus Conference as acute hypoxemia (PaO2/FiO2 ratio less than 200 mmHg) with bilateral infiltrates seen on chest xray and no evidence of left atrial hypertension. Typically in children, chest radiographs or echocardiograms are substituted for pulmonary artery catheterization to assess left atrial filling pressures, especially given the relatively low incidence of cardiogenic pulmonary edema in children. The accepted medical criteria used to determine any of the diseases or disorders described herein may adjust due to developments in the medical community or advances in technology
The methods and compositions provided herein may be used to treat or prevent a variety of diseases and disorders, including any disease or disorder that has been treated using any of a gaseous form of nitric oxide, a liquid nitric oxide composition or any medically applicable useful form of nitric oxide, including any described in U.S. Pat. No. 6,103,275.
As used herein, the term “tissue” refers to any mammalian body tissue, desirably a human body tissue, including damaged tissue. A body tissue may be, but is not limited to, muscle tissue, particularly cardiac tissue and, more particularly, myocardial tissue, such as left ventricular wall myocardial tissue.
As used herein, the term “damaged tissue” refers to any damaged mammalian body tissue, including, for example, damaged pulmonary tissue, and particularly, damaged lung tissue.
Methods of Treating ARDS Acute respiratory distress syndrome is a broad categorization of patients who fail to oxygenate because of acute respiratory failure. This results from the central pathophysiology of ARDS, which is an inflammatory reaction in the lungs that leads to neutrophil extravasation into the pulmonary interstitial tissue and release of tissue destructive proteases. Capillary damage leads to alveolar edema causing progressive worsening of lung compliance and volumes.
The clinical presentation of ARDS can be linked to over 60 possible etiologies, which can be broadly divided into pulmonary (e.g., pneumonia) or extra-pulmonary (e.g., sepsis, trauma or pancreatitis). The most common risk factors for ARDS in adults are sepsis, pneumonia, and shock. In contrast to adult ARDS, in pediatric ARDS (PARDS) there is a much higher rate of a pulmonary-specific etiology, with respiratory tract infection accounting for a majority of cases, followed by sepsis. Mortality rates may vary based on the etiology of the ARDS. For example, pneumonia may be associated with a lower risk of mortality compared to an estimated overall rate of mortality.
Methods for safe and effective administration of NO by inhalation are well known in the art. See, e.g., Zapol, U.S. Pat. No. 5,570,683; Zapol et al., U.S. Pat. No. 5,904,938; Bathe et al., U.S. Pat. No. 5,558,083; Frostell et al., 1991, Circulation 83:2038-2047. NO for inhalation is available commercially (INOmax®, Mallinckrodt Pharmaceuticals, Hampton, N.J.). Each of these references is incorporated by reference in its entirety. In the present disclosure, NO inhalation preferably is in accordance with established medical practice.
iNO is commercially available as INOmax® for the treatment of hypoxic respiratory failure in term and near-term neonates. See, e.g., INOmax®, package insert (www.inomax.com), which is incorporated by reference in its entirety.
Inhaled nitric oxide may be formulated for use by dilution in nitrogen and/or other inert gases and may be administered in admixture with oxygen, air, and/or any other appropriate gas or combination of multiple gases at a desired ratio. In an embodiment, iNO may be delivered to the patient via mechanical ventilation after dilution with an oxygen/air mixture using a nitric oxide gas delivery system. In some examples, a controlled flow of 800 ppm iNO may be delivered to the ventilator circuit via an injector tube where it is diluted by the ventilator gas flow to the concentration set by the operator. This concentration may not exceed 20 ppm. The delivery system may provide a constant inhaled nitric oxide concentration irrespective of the ventilator.
In some aspects, iNO may be administered while monitoring for PaO2, methemoglobin, and NO2. Neonates are known to have diminished methemoglobin reductase activity compared to adults. Methemoglobin level may be measured within one hour after initiation of NO therapy, using an analyser which can reliably distinguish between fetal hemoglobin and methemoglobin. If the methemoglobin level is >2.5%, the NO dose may be decreased and an administration of reducing agents may be considered. Although it is unusual for methemoglobin level to increase significantly if the first level is low, the methemoglobin measurement may be repeated every one to two days.
Immediately prior to each patient initiation, the NO delivery system may be purged of NO2. The NO2 concentration may be maintained as low as possible and always <0.5 ppm. If the NO2 is >0.5 ppm, the NO delivery system may be assessed for malfunction, the NO2 analyser may be recalibrated, and the NO and/or FiO2 may be reduced if possible. If there is an unexpected change in NO concentration, the delivery system may be assessed for malfunction and the analyser may be recalibrated.
The delivery system may provide a constant iNO concentration irrespective of the ventilator. For example, with a continuous flow neonatal ventilator, this may be achieved by infusing a low flow of iNO into the inspiratory limb of the ventilator circuit. Intermittent flow neonatal ventilation may be associated with spikes in nitric oxide concentration. The nitric oxide delivery system for intermittent flow ventilation may be adequate to avoid spikes in nitric oxide concentration.
The inspired NO concentration may be measured continuously in the inspiratory limb of the circuit near the patient. The nitrogen dioxide (NO2) concentration and FiO2 may also be measured at the site using calibrated and approved monitoring equipment. For patient safety, appropriate alarms may be set for iNO (±2 ppm of the prescribed dose), NO2 (0.5 ppm) and FiO2 (±0.05). The NO gas cylinder pressure may be displayed to allow timely gas cylinder replacement without inadvertent loss of therapy and backup gas cylinders may be available to provide timely replacement. iNO therapy may be available for manual ventilation such as suctioning, patient transport, and resuscitation.
In the event of a primary system failure or a wall-outlet power failure, in order to reduce the risk of rebound pulmonary hypertension, a system for nitric oxide administration may comprise backup battery power supply and two back-up systems—an integrated back-up system incorporated into the primary delivery system that allows back-up nitric oxide delivery while the patient remains mechanically ventilated, and an independent back-up system that can deliver nitric oxide while the patient is manually ventilated. Each back-up system may be able to deliver nitric oxide pneumatically in the event of primary system failure. The power supply for the monitoring equipment may be independent of the delivery device function.
The upper limit of exposure (mean exposure) to nitric oxide for personnel is 25 ppm for 8 hours (30 mg/m3) and the corresponding limit for NO2 is 2-3 ppm (4-6 mg/m3).
In one or more embodiments, the NO is administered at a dose less than 20 ppm. Exemplary dose ranges include minimum doses of about 0.1, 0.2, 0.3, 0.4, 0.5, 0.6, 0.7, 0.8, 0.9, 1, 1.5, 2, 2.5, 3, 3.5, 4, 4.5, 5, 5.5, 6, 6.5, 7, 7.5, 8, 8.5, 9 or 9.5 ppm and maximum doses of about 1, 1.5, 2, 2.5, 3, 3.5, 4, 4.5, 5, 5.5, 6, 6.5, 7, 7.5, 8, 8.5, 9, 10, 11, 12, 13, 14, 15, 20, 25, 30, 35, 40, 45 or 50 ppm. In an embodiment, the initial dose of inhaled nitric oxide may be about 5 ppm. In some embodiments, the include dose may be incrementally increased to a maximum dose. In some examples, the dose may be increased to a maximum dose of up to 10 ppm, up to 15 ppm, or up to 20 ppm. The dosage increments may be 1 ppm, 2 ppm, 5 ppm, 7 ppm, or 10 ppm. The dosage may be incremented every few minutes, such as every 1 minute, 2 minutes, 5 minutes, 10 minutes, 15 minutes, or 20 minutes. In an example, an initial dose of 2-8 ppm may be increased to 10-20 ppm, adjusting each dose after at least 10 minutes of exposure to the prior dose. The maximum dose of iNO may not exceed 20 ppm. Treatment may be discontinued if a positive response (increase in PaO2>20%) is not apparent after a 1-2 hour trial of therapy. The dose of iNO may be adjusted until adequate systemic arterial oxygenation is achieved at which time the minimum effective dose may be maintained.
After treatment, the patient may be weaned from the NO. In some embodiments, attempts to wean NO may be commenced as soon as the hemodynamics have stabilized in conjunction with weaning from a ventilator and inotropic support. The withdrawal of inhaled nitric oxide therapy may be performed in a stepwise manner. In an embodiment, the dose may be incrementally reduced to 1 ppm for 30 minutes with close observation of systemic and central pressure, and then turned off. Weaning may be attempted at least every 12 hours when the patient is stable on a low dose of NO. NO may not be stopped abruptly. Too rapid weaning from inhaled nitric oxide therapy may risk a rebound increase in pulmonary artery pressure with subsequent circulatory instability.
The nitric oxide may be administered during the patient's entire inspiration, or may be administered for only a portion of the patient's inspiration. In one or more embodiments, the NO is not administered in the last about 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85% or 90% of inspiration (i.e. the NO is administered only at the beginning of the patient's inspiration). NO administration can start and end at any point during inspiration and expiration.
In one or more embodiments, the nitric oxide therapy is begun early on in the treatment of ARDS and/or prevention of ARDS. It is believed that administering nitric oxide as described herein may have a greater benefit if the nitric oxide is administered before ARDS develops or early in the development of ARDS.
In some embodiments, iNO administration may be used as an alternative to extracorporeal membrane oxygenation (ECMO) therapy for children with ARDS. A patient's respiratory and/or pulmonary parameters may be checked frequently to determine if ECMO therapy is necessary. For example, the patient's parameters may be checked multiple times per days (such as 2, 3, 4, etc. times per day) or may be checked daily or every few days (such as every 2, 3, 4, etc. days). iNO may also be administered in addition to ECMO therapy.
Administering iNO may be used in the treatment of ARDS in ventilated patients in intensive care units (ICU). The patients may be ventilated, ICU patients with ARDS in whom short-term improvements in oxygenation and MPAP represent a clinical benefit.
Treating a patient with ARDS with NO may decrease the patient's pulmonary arterial pressure, improve the patient's oxygenation, decrease the duration of mechanical ventilation, increase the number of days that the patient is alive and ventilator-free at 28 days after the start of NO administration, and/or increase extracorporeal membrane oxygenation-free (ECMO-free) survival as compared to an ARDS patient not treated with NO. In some examples the improvement may be assessed as compared to the patient's baseline measurements (e.g. a baseline pulmonary arterial pressure and/or a patient's baseline oxygenation).
In an embodiment, administering NO to a patient with ARDS may selectively decrease the patient's pulmonary arterial pressure. In an embodiment, administering NO to a patient with ARDS may improve the patient's oxygenation. The patient's oxygenation may be measured using SpO2, PaO2, and/or an oxygenation index (OI). For example, the patient may have a positive response to the NO, evidenced by an increase in PaO2>20%. In some examples, improved oxygenation may include having an arterial oxygen saturation by pulse oximetry [SpO2]≥92% or PaO2 of ≥63 mm Hg. In other examples, the patient may have an improved oxygenation index at 4 hours to 24 hours after starting administration of NO. In some embodiments, a patient administered NO may have a significantly lower oxygenation index than a patient not administered NO. The oxygenation index may be calculated as follows:
OI=[(Mean airway pressure×FiO2)÷PaO2]×100
In other embodiments, iNO may be administered for the treatment of ARDS patients with deep hypoxia, severe right ventricular dysfunction (RVD), or pulmonary hypertension.
Further provided herein are methods to selectively decrease pulmonary arterial pressure in patients with perioperative pulmonary hypertension in conjunction with heart surgery using inhaled nitric oxide.
In patients undergoing cardiac surgery, an increase in pulmonary artery pressure due to pulmonary vaso-constriction is frequently seen. Inhaled nitric oxide may selectively reduce pulmonary vascular resistance and reduce the increased pulmonary artery pressure. This may increase the right ventricular ejection fraction. These effects in turn lead to improved haemodynamics in the pulmonary circulation and oxygenation.
In some embodiments, NO may be used only after conservative support has been optimized in a cardiac surgery setting. For example, NO may be given in addition to other standard treatment regimens in the cardiac surgery setting, including inotropic and vasoactive medicinal products. NO should be administered under close monitoring of haemodynamics and oxygenation.
For patients 17 years old and under, the starting dose of inhaled nitric oxide may be 10 ppm of inhaled gas. The dose may be increased up to 20 ppm if the lower dose has not provided sufficient clinical effects. For patients over 17 years (adult patients) with pulmonary hypertension, the dose range in the context of cardiac surgery is 10-20 ppm of inhaled nitric oxide.
The lowest effective dose may be administered and the dose may be weaned down to 5 ppm provided that the clinical effect remains adequate at this lower dose.
Inhaled nitric oxide has a rapid onset of action; decrease in pulmonary artery pressure and improved oxygenation may be seen within 5-20 minutes. In case of insufficient response, the dose may be titrated after a minimum of 10 minutes.
Consideration should be given to discontinuation of treatment if no beneficial physiological effects are apparent after a 30 minute trial of therapy. The procedure for weaning, outlined above, should be followed when reductions in NO dose are needed.
Treatment may be initiated at any time point in the peri-operative course to lower pulmonary pressure. In some embodiments, administration of NO may be initiated before separation from Cardio Pulmonary Bypass. Inhaled NO may be given for time periods up to 7 days in the peri- and post-operative setting. In some examples, the treatment duration may be 24-48 hours.
Inhaled nitric oxide (iNO) is a vasodilator indicated for treatment of term and near-term neonates with hypoxic respiratory failure associated with clinical or echocardiographic evidence of pulmonary hypertension. In these patients, iNO has been shown to improve oxygenation and reduce the need for extracorporeal membrane oxygenation therapy. NO binds to and activates cytosolic guanylate cyclase, thereby increasing intracellular levels of cyclic guanosine 3′,5′-monophosphate (cGMP). This, in turn, relaxes vascular smooth muscle, leading to vasodilatation. Inhaled NO selectively dilates the pulmonary vasculature, with minimal systemic vasculature effect as a result of efficient hemoglobin scavenging. In acute lung injury (ALI) and acute respiratory distress syndrome (ARDS), increases in partial pressure of arterial oxygen (PaO2) are believed to occur secondary to pulmonary vessel dilation in better-ventilated lung regions. As a result, pulmonary blood flow is redistributed away from lung regions with low ventilation/perfusion ratios toward regions with normal ratios.
[Many pharmacologic treatments have been investigated in ARDS patients, including alprostadil, acetylcysteine, corticosteroids, surfactant, dazoxiben, and acyclovir. A meta-analysis of trials completed through 2004 indicated no statistically significant mortality benefit with any of the above-mentioned treatments.
A large-scale, randomized, blinded, placebo-controlled study was carried out in the Intensive Care Units (ICUs) of 46 US hospitals to evaluate the efficacy of low-dose (5 ppm) iNO in 385 patients with moderately severe Acute Lung Injury (ALI). The primary endpoint of this study was number of days alive and off assisted breathing. Results of an intent-to-treat analysis revealed that inhaled NO (iNO) had no significant benefit versus control (nitrogen gas) as it related to mortality, days alive and off assisted breathing, or days alive and meeting oxygenation criteria for extubation. However, iNO treatment did result in a significant increase (p<0.05) in partial pressure of arterial oxygen (PaO2) during the initial 24 hours of treatment that resolved by 48 hours.
Safety results for the initial 28-day study period have been reported and are summarized briefly here. A total of 630 adverse events (AEs) were reported for patients treated with iNO versus 666 events for those who received placebo. Respiratory system AEs occurred in 51% versus 61% of patients receiving iNO and placebo, respectively, primarily due to higher frequencies of pneumonia, pneumothorax, and apnea in the placebo group. Frequency of other AEs was similar in both groups.
Patients had acute lung injury (ALI), defined by a modification of American-European Consensus Conference criteria (PaO2/inspired oxygen concentration [FiO2] ratio of 250 mm Hg), due to causes other than severe sepsis. Patients with evidence of non-pulmonary system failure at the time of randomization and sepsis-induced ARDS were excluded. Patients were also excluded if they had sustained hypotension requiring vasopressor support, hemodynamic profiles supporting severe sepsis, severe head injury, severe burns, or evidence of other significant organ system dysfunction at baseline.
Patients were randomly assigned to receive either inhaled placebo gas (nitrogen) or 5 ppm of iNO (INO Therapeutics Inc., Port Allen, La.). All patients, healthcare professionals, and investigators were blinded to the assigned treatment. Inhaled NO was administered via INOvent® delivery system (Datex-Ohmeda, Madison, Wis.) that blended treatment gas (nitrogen or NO at 100-ppm balance nitrogen) 1:20 with ventilator gases to achieve a target ppm value in the inspiratory limb of the ventilator.
All patients using the iNO delivery system received mechanical ventilatory support. Treatment continued with active or placebo gas until one of the following criteria were met: [1] end of trial (28 days); [2] death; or [3] adequate oxygenation (arterial oxygen saturation by pulse oximetry [SpO2]≥92% or PaO2 of ≥63 mm Hg) without treatment gas at ventilator settings of FiO2≤0.4 and positive end-expiratory pressure (PEEP) of ≤5 cm H2O. Decreases in treatment gas continued in 20% decrements (titrated down by 1 ppm for inhaled NO) every 30 minutes until either the treatment gas concentration reached 0% or oxygenation criteria were not satisfied. If oxygenation criteria were not met, treatment gas concentration was titrated up until they were again achieved. Increments of upward titration were determined by the clinician, based on degree of arterial desaturation.
Baseline oxygenation measures included PaO2, arterial partial pressure of CO2 (PaCO2), SpO2, FiO2, PEEP, PaO2/FiO2 ratio, ventricular rate, tidal volume, and mean airway pressure. Respiratory parameters (FiO2, PEEP, and PaO2/FiO2 ratio) were recorded on case report forms every 12 hours during mechanical ventilation.
Between-group differences in baseline clinical and demographic characteristics were assessed with the Fisher's exact test and the chi-square test for categorical variables and with the Wilcoxon rank sum test for continuous variables. Baseline oxygenation and respiratory/oxygenation parameters in the two groups were compared using Wilcoxon rank sum tests. The areas under the curve (AUCs) of FiO2, PEEP, and PaO2/FiO2 ratio were calculated using the trapezoidal rule. The null hypothesis that the respective AUCs were normally distributed was rejected employing the Shapiro-Wilk test. A Wilcoxon rank sum test was utilized to assess the differences in each median AUC between treatment groups. A p value <0.05 was considered significant.
Final disposition of all subjects in the original study and 6-month follow-up is shown in
Baseline oxygenation parameters, including PaO2, PaCO2, SpO2, FiO2, PEEP, and PaO2/FiO2 ratio, are summarized in Table 2. The patients included in this analysis were severely ill with mean baseline PaO2/FiO2 ratios of 140.5±43.4 (iNO) and 136.1±40.4 (placebo). Except for a clinically insignificant difference in SpO2, there were no significant between-group differences with respect to baseline oxygenation parameters.
Baseline respiratory parameters, including ventilator rate, tidal volume, and mean airway pressure are summarized in Table 3. There were no significant differences between groups for any of these measures.
There were no significant differences between groups for aggregate per-patient changes from baseline parameters in supplemental oxygen, PEEP, or PaO2/FiO2 ratio. However, when calculating the duration of exposure over the length of mechanical ventilation for total FiO2 (6.3+4.5 days versus 7.6+4.7 days for iNO and placebo groups, respectively; p=0.151), total PEEP (96.3+75.9 versus 113.4+81.1 mm Hg, p=0.261) and total PaO2/FiO2 ratio (2637+1729 versus 2950+1774, p=0.358), the iNO group had less cumulative exposure to all three variables (Table 4).
Clinical trials evaluating numerous interventions have repeatedly failed to demonstrate significant benefit in decreasing mortality in ARDS patients. This clinical trial, as well as a meta-analysis of 12 randomized controlled trials in ALI or ARDS patients indicated no significant benefit of iNO in decreasing mortality.
Inhaled NO did not improve short-term mortality in patients with ARDS
Table 1 is a summary of baseline demographic and clinical characteristics of the study group.
Table 2 is a summary of baseline oxygenation parameters of the study group (placebo versus treated).
Table 3 is a summary of baseline respiratory parameters of the study group (placebo versus treated).
Table 4 is a summary of the duration of exposure parameters during gas administration.
This was a prospective, multicenter, randomized, double-blind, placebo-controlled, parallel-group study of the safety and efficacy of inhaled nitric oxide in pediatric subjects with acute hypoxemic respiratory failure (AHRF). The subjects were randomized to receive either 5 ppm inhaled nitric oxide or placebo.
350 total subjects (175 per treatment arm) were planned. Because of low enrollment (and not for safety reasons) the trial was ended when 55 subjects were enrolled. A summary of the study population is provided in
Pediatric subjects admitted to the Pediatric Intensive Care Unit (PICU) with AHRF requiring intubation.
Nitric Oxide for inhalation at 5 ppm was administered continuously into the inspiratory limb of the ventilator circuit in mechanically ventilated subjects using a blinded version of the INOvent® delivery system.
Subjects received 100% treatment gas (nitric oxide 5 ppm or placebo [nitrogen gas]) until Day 28 or extubation, whichever occurred first.
Placebo consisting of 100% Grade 5 nitrogen gas was administered continuously into the inspiratory limb of the ventilator circuit in mechanically ventilated subjects using a blinded version of the INOvent® delivery system at a rate equivalent to a 5 ppm dose of nitric oxide.
Efficacy data were collected and summarized in place of a full efficacy analysis. The mean duration of intubation, days in the PICU, and frequencies of high frequency oscillatory ventilation, extracorporeal membrane oxygenation, and pneumothorax were lower for the nitric oxide group than for the placebo group, whereas the duration of supplemental oxygen and the frequency of ventilator-associated pneumonia at discharge were higher for the nitric oxide group than for the placebo group.
29 patients received placebo and 26 iNO. A summary of the patient randomization and disposition is shown in
Subjects who received inhaled nitric oxide were no more likely to experience adverse events (AEs) than were those who received placebo, with 21 subjects in the placebo group (72.4%) reporting 93 AEs and 16 subjects in the nitric oxide group (61.5%) reporting 52 AEs. Four AEs, reported by 2 subjects in the placebo group, were suspected to have a relationship to treatment. The frequencies of treatment discontinuation due to AEs were 6.9% for the placebo group and 3.9% for the nitric oxide group. Compared with subjects treated with placebo, subjects treated with nitric oxide reported fewer serious AEs during the study (27.6% vs. 3.9%) and had a higher survival rate (72.4% vs. 88.5%). No death, serious AE, severe AE, or AE resulting in treatment discontinuation was suspected to be related to study treatment. The percent methemoglobin levels were within normal limits in both the placebo and the nitric oxide groups. These levels were well below levels that would have necessitated discontinuation of treatment.
The safety profile of inhaled nitric oxide 5 ppm appears to compare favorably with that of placebo, with regard to methemoglobin levels, frequency of AEs and, particularly, mortality rates. No serious concerns about the use of inhaled nitric oxide were generated by the results of this study, and it appears that inhaled nitric oxide 5 ppm is safe and well tolerated by children with AHRF.
Unexpectedly, iNO shortened the duration of mechanical ventilation (MV) and improved the rate of survival, both of which approached statistical significance. The rate of ECMO free survival was significantly greater in those randomized to iNO. It is believed that this is the first randomized, non-crossover study to evaluate the impact of iNO on outcomes in pediatric ARDS. Previous studies incorporated a crossover design, precluding an analysis of outcomes.
This was a prospective, multicenter, randomized, double-blind, placebo-controlled, Phase III study to assess the effects of nitric oxide for inhalation in the treatment of acute hypoxic respiratory failure (AHRF) in pediatric subjects. The study population consisted of male and female pediatric subjects, aged 44 weeks postconceptional age to 16 years age, who were admitted to the pediatric intensive care unit (PICU) and who required intubation because of AHRF. The inclusion/exclusion criteria are described in the Patients section below.
Standardized ventilatory management and weaning procedures were used. Ventilatory management was used based on an “open lung approach” using positive end-expiratory pressure (PEEP) to increase lung volume and limiting tidal volumes to reduce plateau pressures. Subjects received nitric oxide for inhalation at 5 ppm or placebo (100% Grade 5 nitrogen gas) into the inspiratory limb of the ventilator circuit using a blinded version of the INOvent® delivery system. The subjects were treated until Day 28 or extubation, whichever occurred first. Subjects were assessed daily using a spontaneous breathing trial, according to the institution's standard of care. Arterial blood gases (ABG), ventilator settings, methemoglobin, oxygenation index, systolic blood pressure, diastolic blood pressure, Pediatric Risk of Mortality (PRISM) III score, and subject positioning (prone or supine) were performed/recorded at specified times during the study. Selected centers also performed plasma cytokine assays, bronchoalveolar lavage fluid (BALF) assays, and a 6-month follow-up assessment.
Inclusion criteria for patients were as follows:
Exclusion criteria for patients were as follows:
The following assessments were made at baseline: arterial blood gases, ventilator settings, methemoglobin, prone position, PRISM III score, oxygenation index, systolic and diastolic blood pressure, bronchoalveolar lavage fluid assay and plasma cytokine.
The following assessments were made at 4 hours ±1 hour after the start of therapy: arterial blood gases, ventilator settings and methemoglobin.
The following assessments were made at 12 hours ±2 hours after the start of therapy: arterial blood gases and ventilator settings.
The following assessments were made at 24 hours ±2 hours after the start of therapy: arterial blood gases, ventilator settings, methemoglobin, systolic and diastolic blood pressure and plasma cytokine.
The following assessments were made at 48 hours after the start of therapy: bronchoalveolar lavage fluid assay.
The following assessments were made at 72 hours after the start of therapy: plasma cytokine.
The following assessments were made on Day 5 after the start of therapy: bronchoalveolar lavage fluid assay.
The following assessments were made on Day 7 after the start of therapy: plasma cytokine.
Prone positioning was evaluated daily to determine whether prone 8 hours within a 24-hour period.
The following assessments were made at the end of treatment: plasma cytokine.
The following assessments were made during the follow-up visit: pulmonary function tests (subjects >6 years of age), vital signs (respiratory rate and spot oxygen saturation), and chest X-ray.
Extubation was considered when:
Extubation occurred within 12 hours of meeting the above criteria. If a patient met the above criteria but was not extubated within 12 hours, the reason (i.e. airway protection, surgery, secretions clearance, etc.) was documented.
Fifty-five subjects were enrolled and randomized to treatment. The intent-to-treat population consisted of 30 subjects randomized to treatment with placebo and 25 subjects randomized to treatment with nitric oxide 5 ppm. One subject, who was originally randomized to receive placebo, received nitric oxide in error. This subject was allowed to continue treatment with nitric oxide throughout the trial. Therefore, the safety population consisted of 29 subjects who received placebo and 26 subjects who received nitric oxide.
Of the 55 subjects enrolled, 21 (72.4%) in the placebo group and 21 (80.8%) in the nitric oxide group either completed 28 days of the study or were successfully extubated. Of the remaining subjects, 8 (27.6%) in the placebo group and 2 (7.7%) in the nitric oxide group died, and 3 subjects in the nitric oxide group discontinued treatment for reasons other than death. Subject outcome is summarized in Table 5.
The baseline characteristics of the study population are summarized in Table 6.
The medical history of the study population is summarized in Table 7.
The concomitant corticosteroid medications are summarized in Table 8.
Full efficacy analyses were not performed. However, efficacy data were collected and summarized. As shown in Table 9, the mean number of days of intubation, days in the PICU, and frequencies of high-frequency oscillatory ventilation (HFOV), extracorporeal membrane oxygenation (ECMO), and pneumothorax were lower for the nitric oxide group than for the placebo group, whereas the mean number of days of supplemental oxygen and the frequency of VAP at discharge were higher for the nitric oxide group than for the placebo group. The survival rate was 72.4% for the placebo group and 88.5% for the nitric oxide group.
The mean duration of treatment was 13 days for subjects in both treatment groups (Table 10). Note that one subject from the placebo group and one subject who received nitric oxide were excluded from this table because their study drug end date and time were unknown.
There were 93 AEs reported in 21 of the 29 subjects who received placebo (72.4%). A total of 52 AEs were reported in 16 of the 26 subjects who received nitric oxide (61.5%). Four of the AEs (reported in 2 subjects in the placebo group) were suspected to have a relationship to treatment.
There were 21 serious adverse events (SAEs) reported in 8 of the 29 subjects who received placebo (27.6%) and 2 SAEs reported in 1 of the 26 subjects who received nitric oxide (3.9%). There were 27 severe AEs reported in 10 subjects who received placebo (34.5%) and 4 severe AEs reported in 2 subjects who received nitric oxide (7.7%). Two AEs reported in 2 subjects who received placebo (6.9%) and 2 AEs reported in 1 subject who received nitric oxide (3.9%) resulted in discontinuation of study treatment. None of the serious or severe AEs was suspected to be related to study treatment. An overall summary of AEs is presented in Table 12.
.0
indicates data missing or illegible when filed
The most frequently reported AEs were hypokalemia and pneumothorax for the placebo group and bradycardia and hypotension for the nitric oxide group. All AEs are presented in Table 14. Adverse events that occurred in 3 or more subjects in either treatment group are summarized in Table 13.
Four AEs, reported in 2 subjects in the placebo group, were suspected to be related to study treatment (one subject had agitation and hyperlipidemia; another subject had hyperammonemia and increased C-reactive protein). All of these were non-serious AEs that were mild, and all but hyperammonemia had resolved by the end of the study (see Table 15).
.0 (0.0)
indicates data missing or illegible when filed
Eleven subjects died during the study or follow-up period. Eight died during treatment with placebo, 2 died during treatment with nitric oxide, and 1 died during the follow-up period after treatment with nitric oxide. All subjects who died are identified in Table 16. Four subjects who died had no AE listed where “death” was the outcome, and 1 of these subjects died after the treatment period. A summary of AEs in which death was the outcome is provided in Table 17. None of the AEs in which death was the outcome was suspected of being related to the study treatment (Table 18).
a(All AEs in which death was the outcome were SAEs.
bDeath was not listed as the outcome of this SAE.
cThe subject died after the treatment period.
Pneumonia,
aspergillus
Pneumonia,
aspergillus
There were 21 SAEs reported in 8 of the 29 subjects who received placebo (27.6%) and 2 SAEs reported in 1 of the 26 subjects who received nitric oxide (3.9%). All subjects with SAEs are identified in Table 19. No SAE was reported by more than 1 subject in either treatment group (Table 20), and no SAE had a suspected relationship to study treatment (Table 21).
Pneumonia
Aspergillus
Pneumonia,
aspergillus
Pneumonia,
aspergillus
Two AEs reported in 2 of the 29 subjects who received placebo (6.9%) and 2 AEs reported in 1 of the 26 subjects who received nitric oxide (3.9%) resulted in discontinuation of study treatment. All subjects in whom study treatment was discontinued because of one or more AEs are identified in Table 22. No AE that resulted in treatment discontinuation was reported by more than 1 subject in either treatment group (Table 23), and none had a suspected relationship to study treatment (Table 24).
Percent methemoglobin levels were obtained at baseline and at Hours 4 and 24. The percent methemoglobin levels were within normal limits in both the placebo and the nitric oxide groups. These levels were well below levels that would have necessitated discontinuation of treatment. Percent methemoglobin levels are summarized in Table 25.
Mean systolic and diastolic blood pressure increased slightly from baseline in both groups at 24 hours. Descriptive statistics for systolic and diastolic blood pressure, which were taken both at baseline and at 24 hours, are summarized Table 26.
Descriptive statistics for the PRISM III Worksheet values taken at baseline (systolic blood pressure, temperature, heart rate, pupil reactivity, Glasgow Coma Scale, pH, carbon dioxide pressure [pCO2], total carbon dioxide, partial pressure of oxygen [PaO2], glucose, potassium, blood urea nitrogen, creatinine, white blood cell count, platelet count, prothrombin time, and partial thromboplastin time) are summarized in Table 27.
Descriptive statistics for the respiratory values are summarized in Table 28. Oxygen status was determined at screening only. Respiratory values in the HFOV category were obtained at baseline, 4 hours, 12 hours, and 24 hours. Respiratory values in the categories conventional mechanical ventilation [CMV] and ABG were obtained at baseline, 4 hours, 12 hours, 24 hours, and at extubation.
Of 6 subjects in whom a chest x-ray was performed, 4 (13.8%), all of whom were in the placebo group, had evidence of chronic changes/persistent infiltrates.
Subjects who received inhaled nitric oxide were no more likely to experience AEs than were those who received placebo, with 21 subjects in the placebo group (72.4%) reporting 93 AEs and 16 subjects in the nitric oxide group (61.5%) reporting 52 AEs. Four AEs, reported by 2 subjects in the placebo group, were suspected to have a relationship to treatment.
The frequencies of treatment discontinuation due to AEs were 6.9% for the placebo group and 3.9% for the nitric oxide group. Compared with subjects treated with placebo, subjects treated with nitric oxide reported fewer serious AEs during the study (27.6% vs. 3.9%) and had a higher survival rate (72.4% vs. 88.5%). No death, serious AE, severe AE, or AE resulting in treatment discontinuation was suspected to be related to study treatment.
Percent methemoglobin levels for subjects who inhaled nitric oxide 5 ppm were equal to or less than those for subjects in the placebo group at most time points during the study, indicating that inhaled nitric oxide is well tolerated and is unlikely to be associated with high levels of methemoglobin at the low dose used in this study.
The safety profile of inhaled nitric oxide 5 ppm appears to compare favorably with that of placebo, with regard to methemoglobin levels, frequency of AEs and, particularly, mortality rates. No serious concerns about the use of inhaled nitricoxide were generated by the results of this study, and it appears that inhaled nitric oxide 5 ppm is safe and well tolerated by children with acute hypoxemic respiratory failure.
This application is a continuation-in-part application of U.S. application Ser. No. 17/458,202, filed on Aug. 26, 2021, which is a re-issue application of U.S. Pat. No. 10,391,120, filed on Dec. 12, 2018, which is a continuation U.S. application Ser. No. 15/170,130, now U.S. Pat. No. 10,201,564, filed on Jun. 1, 2016, which is a continuation of U.S. application Ser. No. 14/593,085, now U.S. Pat. No. 9,381,212, filed Jan. 9, 2015, which claims the benefit under 35 U.S.C. § 119(e) to U.S. Provisional Application No. 61/925,925, filed Jan. 10, 2014. This Application also claims the benefit of U.S. Provisional Application No. 63/222,092, filed Jul. 15, 2021. The entire contents of each of which are incorporated herein by reference in their entirety.
| Number | Date | Country | |
|---|---|---|---|
| 61925925 | Jan 2014 | US | |
| 63222092 | Jul 2021 | US |
| Number | Date | Country | |
|---|---|---|---|
| Parent | 15170130 | Jun 2016 | US |
| Child | 16217981 | US | |
| Parent | 14593085 | Jan 2015 | US |
| Child | 15170130 | US |
| Number | Date | Country | |
|---|---|---|---|
| Parent | 17458202 | Aug 2021 | US |
| Child | 17865707 | US |
| Number | Date | Country | |
|---|---|---|---|
| Parent | 16217981 | Dec 2018 | US |
| Child | 17458202 | US |
