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Inhaled Fluticasone Effects on Upper Airway Patency in Obstructive Lung Disease (InFLOW)

The safety and scientific validity of this study is the responsibility of the study sponsor and investigators. Listing a study does not mean it has been evaluated by the U.S. Federal Government. Read our disclaimer for details. Identifier: NCT01554488
Recruitment Status : Terminated (Low subject accrual)
First Posted : March 15, 2012
Last Update Posted : February 25, 2016
Information provided by (Responsible Party):
VA Office of Research and Development

Brief Summary:
The Chairman of the Veterans' Disability Benefits Commission reported at a recent US Senate hearing that asthma, chronic obstructive pulmonary disease (COPD), and sleep apnea are among the top 13 most frequent diagnoses leading to disability under the Department of Defense and the VA system statutes. Recent research finds that sleep apnea is more common among asthma and COPD individuals, and this may be caused by inhaled corticosteroid use. Many Veterans are currently using inhaled corticosteroids, and many more will be prescribed such medications, given their recent inclusion in international treatment guidelines. As such, this study addresses a critical need by researching the role of a potent inhaled corticosteroid in promoting sleep apnea, the determinants of this response, and the ways through which it occurs. Results from this study will form the foundation for future research aimed at expanding understanding of the effects of inhaled corticosteroids on the upper airway, as well as developing means to prevent or counteract them.

Condition or disease Intervention/treatment Phase
Asthma Chronic Obstructive Pulmonary Disease Obstructive Sleep Apnea Drug: Inhaled Fluticasone Propionate Not Applicable

Detailed Description:

BACKGROUND: Growing data suggest that patients with obstructive lung disease (OLD) such as asthma and chronic obstructive pulmonary disease (COPD) have an increased predisposition for obstructive sleep apnea, but the mechanism(s) remain unknown. One characteristic these patients share is use of inhaled corticosteroid (ICS). The investigators recently found a dose-dependent relationship of ICS use with high OSA risk. Furthermore, in a 16-week observational inhaled fluticasone (FP) treatment study, the investigators observed increased upper airway (UAW) collapsibility during sleep, as measured by the critical closing pressure (Pcrit), paralleling the improvement in lower airways obstruction, with the largest Pcrit deterioration in the subject with most sleep-disordered breathing (SDB) at baseline. These findings suggest an effect of ICS on the "unified airway" of steroid responsive patients and of those with more collapsible upper airways at baseline. The investigators also found a dose-dependent relationship of ICS with obesity. Based on their known effects, ICSs could deleteriously affect UAW collapsibility through inducing dilators' myopathy and fat deposition around the UAW. FP is the most potent and commonly used ICS.

HYPOTHESIS/AIMS: The central hypothesis is that FP will increase UAW collapsibility (less negative Pcrit) and worsen SDB in steroid responsive patients with OLD and those with UAWs more susceptible to collapse at baseline, through alterations in tongue muscle function and fat accumulation in the UAW surrounding structures. To address this hypothesis, the investigators propose to test the effects of inhaled FP on: 1) UAW collapsibility during sleep and SDB severity, assessed by Pcrit and polysomnographic (PSG) measures. Exploratory aims will test the role of steroid responsiveness and baseline collapsibility as determinants of FP effects on Pcrit and SDB; 2) tongue strength and fatigability, and fat accumulation (fraction and volume, measured on MRI) in the surrounding UAW structures. Exploratory aims will test whether these effects underlie the increase in UAW collapsibility and the role of steroid responsiveness status as a mediator of these FP effects.

DESIGN: The investigators propose a proof-of-concept and mechanistic, randomized-controlled, parallel groups study of high (220 mcg, 4 puffs twice a day) vs. low (44 mcg twice a day) dose inhaled FP, followed by an 8-week wash-out period, in 58 steroid-naive subjects with OLD. Following baseline Pcrit, PSG, MRI and tongue function (using the Iowa Oral Performance Instrument) measurements, subjects will enter a 2-week low-dose FP run-in, with subsequent randomization to either high- vs. low-dose FP, for 16 weeks. At mid-period, Pcrit, tongue function and steroid responsiveness status (defined as 5% improvement from baseline in FEV1%) will be determined. At the end of treatment, Pcrit, PSG, MRI and tongue measurements will be taken. Then, subjects will enter an 8-week wash-out that ends with repeat Pcrit and tongue function assessments.

SIGNIFICANCE: Millions of people, including many Veterans, are treated with ICS for OLD, and among those with COPD, these numbers are likely to escalate. However, do these medications alter UAW collapsibility and predispose to OSA in some individuals, as the investigators' preliminary observations suggest? This research is innovative because it will directly evaluate the effects of ICS on the UAW structure and function during sleep and wakefulness. At the study completion, it is the investigators expectation that they will have elucidated the effects and governing mechanisms of ICS on UAW patency and SDB severity. Data generated will form the foundation for future research aimed at expanding the investigators' understanding of ICS's effects on UAW and means to mitigate/prevent them. The clinical implication of these findings will be experimental-based verification of deleterious effects of ICS on UAW and risk for OSA, which will ultimately be of enormous financial benefit to the VA and OLD management programs.

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Study Type : Interventional  (Clinical Trial)
Estimated Enrollment : 58 participants
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)
Official Title: Inhaled Fluticasone Effects on Upper Airway Patency in Obstructive Lung Disease
Study Start Date : March 2013
Estimated Primary Completion Date : March 2016
Estimated Study Completion Date : March 2016

Resource links provided by the National Library of Medicine

MedlinePlus related topics: Lung Diseases

Arm Intervention/treatment
Experimental: Arm 1
High dose inhaled fluticasone (1760mcg/day)
Drug: Inhaled Fluticasone Propionate
Inhaled corticosteroid

Active Comparator: Arm 2
Low dose inhaled fluticasone (88mcg/day)
Drug: Inhaled Fluticasone Propionate
Inhaled corticosteroid

Primary Outcome Measures :
  1. Upper airway critical closing pressure [ Time Frame: 16 weeks ]
    Pressure at which the pharyngeal upper airway closes.

Information from the National Library of Medicine

Choosing to participate in a study is an important personal decision. Talk with your doctor and family members or friends about deciding to join a study. To learn more about this study, you or your doctor may contact the study research staff using the contacts provided below. For general information, Learn About Clinical Studies.

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Ages Eligible for Study:   18 Years and older   (Adult, Older Adult)
Sexes Eligible for Study:   All
Accepts Healthy Volunteers:   No

Inclusion Criteria:

  • American Veterans
  • age 18 and above
  • diagnosis of asthma and COPD per guidelines
  • for asthma, persistent symptoms per guidelines
  • for asthma, a pre-bronchodilator FEV1 55-90% and DLCO 80% predicted
  • for asthma, physiologic confirmation by bronchodilator or methacholine challenge
  • for COPD, a post-bronchodilator ratio of FEV1/FVC 70% and FEV1 50%
  • overall smoking history of <10 pack-years for asthma and 10 pack-years for COPD.

Exclusion Criteria:

  • any use of inhaled corticosteroid for >2 weeks at a time during the last 6 months, or any use in the last 6 weeks;
  • as needed use of nasal steroids in the prior 6 months
  • select medications
  • recent exacerbation requiring oral or systemic steroids in the past 6 months
  • diagnosed vocal cords dysfunction
  • other lung diseases (lung cancer, sarcoidosis, tuberculosis, lung fibrosis) or known 1-antitrypsin deficiency
  • significant or actively unstable medical or psychiatric illnesses
  • diagnosed osteopenia or osteoporosis
  • established diagnosis of neuromuscular disease
  • BMI 45 kg/m2 and higher
  • treated OSA
  • pregnancy (confirmed on urine test) or desire to get pregnant in the upcoming 6 months.
  • smoking in the past 6 months
  • metallic or electronic implants
  • claustrophobia

Information from the National Library of Medicine

To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor.

Please refer to this study by its identifier (NCT number): NCT01554488

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United States, Wisconsin
William S. Middleton Memorial Veterans Hospital, Madison, WI
Madison, Wisconsin, United States, 53705
Sponsors and Collaborators
VA Office of Research and Development
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Principal Investigator: Mihaela Teodorescu, MD William S. Middleton Memorial Veterans Hospital, Madison, WI

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Responsible Party: VA Office of Research and Development Identifier: NCT01554488     History of Changes
Other Study ID Numbers: CLIN-20-11S
First Posted: March 15, 2012    Key Record Dates
Last Update Posted: February 25, 2016
Last Verified: February 2016
Keywords provided by VA Office of Research and Development:
sleep apnea, obstructive
Additional relevant MeSH terms:
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Lung Diseases
Sleep Apnea Syndromes
Lung Diseases, Obstructive
Pulmonary Disease, Chronic Obstructive
Sleep Apnea, Obstructive
Respiratory Tract Diseases
Respiration Disorders
Sleep Disorders, Intrinsic
Sleep Wake Disorders
Nervous System Diseases
Anti-Inflammatory Agents
Bronchodilator Agents
Autonomic Agents
Peripheral Nervous System Agents
Physiological Effects of Drugs
Anti-Asthmatic Agents
Respiratory System Agents
Dermatologic Agents
Anti-Allergic Agents