A Crossover, Randomized, Controlled Trial of Dornase Alfa Before Versus After Physiotherapy in Cystic Fibrosis

Abstract

ABSTRACT. Objective. Although dornase alfa is a widely used, aerosolized, mucolytic agent in patients with cystic fibrosis (CF), its efficacy in relation to the timing of physiotherapy has not been tested. We sought to determine whether dornase alfa is more efficacious when it is administered 30 minutes before versus 30 minutes after physiotherapy/positive expiratory pressure (PEP) therapy in clinically stable children.Methods. Using a crossover, randomized, doubleblind, and placebo-controlled trial, we undertook a 6-week study of the efficacy of dornase alfa in relation to the timing of physiotherapy at home. There were 2 treatment orders. Dornase alfa before ؉ placebo after physiotherapy/PEP for 2 weeks was followed by a 2-week washout and then the reverse order placebo before and dornase alfa after physiotherapy/PEP for the final 2 weeks. The second treatment order reversed the placebo and dornase alfa therapy for the first and last 2-week blocks. The main outcome measures used included the change in predicted percentage of forced expiratory volume in 1 second (FEV 1 ), a composite quality of wellbeing score (QWB), and a measure of aerobic fitness (maximal oxygen consumption, [VO 2max ]), determined using shuttle testing.Results. Fifty-two patients who had CF (27 female) with mild to moderate suppurative lung disease, were a mean ؎ SD age of 10.7 ؎ 3.2 years, had Shwachman scores of 86 ؎ 11.8, had predicted FEV 1 of 83% ؎ 18%, had quality of well-being score of 0.76 ؎ 0.08, and had VO 2max of 42.6 ؎ 6.3 ml/kg per min were enrolled. Fifty patients completed the study. Intention-to-treat analysis was used. Nonsignificant mean (95% confidence interval) differences in FEV 1 ABBREVIATIONS. CF, cystic fibrosis; FEV 1 , forced expiratory volume in 1 second; PEP, positive expiratory pressure; VO 2max , maximal oxygen consumption; QWB, quality of well-being score; CI, confidence interval; FEF , mid expiratory flow rate. P hysiotherapy and systemic and nebulized antibiotics have been the cornerstones of treatment in cystic fibrosis (CF) for many years. [1][2][3] The introduction of the nebulized mucolytic agent dornase alfa (Pulmozyme [Hoffman-La Roche, Dee Why, Sydney, Australia]) in the 1990s proved to be an innovative adjunct to the management of lung disease in terms of reduced pulmonary exacerbations, improved lung function, and quality-of-life measures. 3-5 Dornase alfa use varies from country to country, on the basis of patient preference, physician prescribing practices, measured benefit in an individual, and health funding arrangements. In Australia, most recent figures indicate that dornase alfa is used by 22.1% of school-aged children (5-18 years), all of whom have demonstrated a Ͼ10% improvement in forced expiratory volume in 1 second (FEV 1 ) after 4 weeks of therapy. 6 However, despite the evaluation of dornase alfa in Ͼ15 years of clinical trials, there is no evidence as to whether dornase alfa is more efficacious when delivered before or after physiotherapy. As has been shown in adults who are prescri...

Neutrophil Elastase, Proteinase 3, and Cathepsin G as Therapeutic Targets in Human Diseases

“…Hypertonic saline disrupts glycosaminoglycans-LL-37 complexes thus promoting antimicrobial effects (Bergsson et al, 2009) but free LL-37 is then degraded by HNE and cathepsin D (Bergsson et al, 2009). The large amounts of DNA released by lysed neutrophils in the respiratory tract of patients with CF in response to infection can be disrupted through therapeutic DNase administration, thus resulting in the liquefaction of viscous mucus, a reduction of the viscoelasticity of purulent lung secretions, an airflow increase, and a consequently decreased risk of infection (Fitzgerald et al, 2005). DNase increases the amount of LL-37 peptide detected in the supernatant of CF sputum dissolved from DNA/actin bundles (Bucki et al, 2007).…”

Enzymes Approved for Human Therapy: Indications, Mechanisms and Adverse Effects

“…Mucus containing significant amounts of extracellular DNA from degenerating leukocytes is also a problem in bronchiectasis patients [78], patients with respiratory syncytial virus bronchiolitis [79], and in non-cystic fibrosis pediatric patients with atelectasis [80]. Dornase alfa ( Table 2) converts extracellular DNA to 5 0 -phosphonucleotide end products, reducing both sputum viscosity in the airways and adhesiveness of lung secretions without affecting intracellular DNA and has proven to be an effective treatment in cystic fibrosis [81][82][83] and the other conditions mentioned.…”

Inhaled Therapy in Children

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