Indacaterol (Onbrez) for chronic obstructive pulmonary disease

• Once-daily dosing provides symptomatic relief in COPD
  Indacaterol (Onbrez Breezhaler) once daily provides rapid-onset brochodilation in chronic obstructive pulmonary disease (COPD) lasting over 24 hours.
• Indacaterol has safety and symptom relief similar to that of twice-daily long-acting beta₂-agonist bronchodilators
  Indacaterol provides similar symptomatic improvement and greater improvement in lung function compared with salmeterol and eformoterol in COPD.
• Indacaterol is no worse than tiotropium in safety and efficacy
  Indacaterol has been demonstrated to be non-inferior in safety and efficacy (forced expiratory volume in 1 second [FEV₁] and symptom reduction) to once-daily tiotropium.
• Avoid indacaterol in people with asthma
  As with other inhaled long-acting beta₂-agonists, indacaterol may result in paradoxical bronchospasm; do not use to treat acute episodes of bronchospasm, acutely deteriorating COPD, or asthma.
• Use with caution in people with cardiovascular disease
  Use with caution in people with cardiovascular disorders and in people who are unusually responsive to beta₂-agonists.

What is known about this drug

Indacaterol is a long-acting beta₂-agonist (LABA) providing similar levels of symptom relief for people with COPD, with a similar adverse-effect profile, to that of other inhaled LABA bronchodilators.

Areas of uncertainty

The long-term clinical benefit of indacaterol is unknown, as there are no data beyond 52 weeks. There are no trials of indacaterol in combination with an inhaled corticosteroid. The safety of indacaterol in people with asthma and mixed airways disease has not been established.

What does NPS MedicineWise say?

Indacaterol is a LABA for once-daily use as maintenance treatment for symptomatic relief in people with mild to severe COPD (FEV₁ between 30% and 80% of predicted). It provides similar symptomatic relief of COPD to that of twice-daily LABAs or once-daily tiotropium and appears to cause a similar rate of adverse effects. It is not indicated for the initial treatment of acute exacerbations of COPD, i.e. as a rescue therapy. When starting indacaterol, continue inhaled corticosteroids if taken for COPD but do not use indacaterol with other LABAs. Indacaterol must not be used to treat asthma.

Restricted benefit

Indacaterol (Onbrez) is PBS listed as a Restricted Benefit for treatment of chronic obstructive pulmonary disease.¹

May be prescribed by nurse practitioners

Authorised nurse practitioners may prescribe this medicine on the PBS. See the PBS website for more information on nurse practitioner PBS prescribing.

Indacaterol (Onbrez) is a long-acting beta₂-agonist (LABA) producing bronchodilation by stimulation of intracellular adenyl cyclase. It has an onset of action within 5 minutes after inhalation and duration of effect consistent with once-daily dosing.²

Indacaterol is for maintenance bronchodilator treatment of airflow limitation in patients with mild to severe COPD (FEV₁ between 30% and 80% of predicted).* It is not indicated for people with acute exacerbations of COPD (i.e. as a rescue therapy), or in patients with acutely deteriorating COPD. Do not use in people with asthma.

* Definition according to The COPD-X Plan: Australian and New Zealand Guidelines for the Management of Chronic Obstructive Pulmonary Disease 2010.³

Do not use indacaterol in people with asthma or acute deterioration of COPD

Beta₂-agonists, particularly at high doses, are associated with excess mortality in people with asthma. Indacaterol may cause acute exacerbation. Do not use it to treat acute episodes of bronchospasm, people with acutely deteriorating COPD or in people with mixed airways disease.

Use cautiously in cardiovascular disease

Beta₂-agonists may cause clinically important cardiovascular effects in some people. Caution is required in people with cardiovascular disease (coronary artery disease, acute myocardial infarction, cardiac arrhythmias, hypertension)⁴ (see Safety issues).

Maintenance treatment for symptomatic relief in COPD

Current clinical management algorithms support regular use of an inhaled long-acting bronchodilator, in conjunction with short-acting 'rescue' bronchodilators (such as salbutamol, terbutaline and ipratropium) in patients with mild to severe COPD (FEV₁ between 30% and 80% of predicted). They may also be used in combination with inhaled corticosteroids in severe COPD (FEV₁ < 50% of predicted) if repeated exacerbations occur.^3,5

Indacaterol is PBS listed as a long-acting bronchodilator treatment option in COPD. Other long-acting inhaled bronchodilators for COPD include salmeterol, eformoterol and tiotropium, and fixed-dose combinations of fluticasone with salmeterol and budesonide with eformoterol (Table 1).

Do not use indacaterol for relief of acute symptoms; concomitant short-acting beta₂-agonists can be used as needed for acute relief. If repeated exacerbations occur with indacaterol, consider introducing an inhaled corticosteroid but do not use indacaterol in combination with other LABAs.⁴

Indacaterol has similar symptom relief to that of other LABAs

In a 26-week, double-blind randomised study, people with mild to severe COPD (n = 1002) were randomised to three treatment groups (indacaterol 150 micrograms once daily, salmeterol 50 micrograms twice daily or placebo). Spirometry was improved with indacaterol, relative to both placebo and salmeterol (both p < 0.001). Symptom relief with indacaterol was:

• improved compared with placebo (reduced St George's Respiratory Questionnaire (SGRQ) score and improved transition dyspnoea index (TDI) at weeks 4, 8, 12 and 26, p < 0.001)
• equivalent to that with salmeterol, although the clinically relevant reduction in SGRQ (> 4 units from baseline) was greater with indacaterol than salmeterol at week 12 (p < 0.05).⁶

In a 52-week, randomised, double-blind parallel-group study, people with mild to severe COPD were randomised to receive indacaterol 300 or 600 micrograms once daily or eformoterol twice daily. Indacaterol groups had improved symptomatic outcomes compared with placebo (p < 0.001 for both dose levels). Although this study was not primarily powered to detect significant differences between the two active treatments, indacaterol reduced use of as-needed salbutamol and enhanced peak expiratory flow (PEF) and TDI scores compared with eformoterol.⁷

Indacaterol is no worse than tiotropium

In a 26-week study, 1683 people with moderate to severe COPD were randomised to open-label tiotropium 18 micrograms or double-blind indacaterol 150 micrograms or 300 micrograms or placebo, all once daily.⁸ Symptoms, assessed by the self-reporting measures of TDI and SGRQ, were improved relative to placebo for both active treatments over 26 weeks, although the effect on exacerbations was not consistently demonstrated; time to first exacerbation was only significantly reduced for indacaterol 150 mg (hazard ratio 0.69, 95% CI 0.51 to 0.94) but not significantly reduced for indacaterol 300 mg or tiotropium.⁸

In a randomised study of 169 patients in a double-blinded, crossover clinical comparison of the effects of indacaterol 150 micrograms and 300 micrograms once daily versus tiotropium 18 micrograms once daily or matching placebo, indacaterol at both doses satisfied the statistical criterion for non-inferiority compared with tiotropium in regard to trough FEV₁ after 14 days of treatment.⁹

No head-to-head trials of indacaterol against the combination of salmeterol with fluticasone

In a meta-analysis that compared randomised controlled studies of indacaterol versus placebo (four studies) to randomised controlled studies of salmeterol–fluticasone versus placebo (five studies), comparable efficacy outcomes were reported.¹⁰ It is important to note that, in the absence of a head-to-head comparison of indacaterol and salmeterol–fluticasone in randomised controlled studies, no conclusions can be drawn about their relative efficacy.

The most commonly reported adverse effects in a 26-week safety population were generally events that would be expected in people with COPD, and effects that would be anticipated with a beta₂-agonist.¹¹

Report suspected adverse reactions to the Therapeutic Goods Administration (TGA) online or by using the 'Blue Card' distributed three times a year with Australian Prescriber. For information about reporting adverse reactions, see the TGA website.

Similar adverse effects to those of other LABAs

The most frequent treatment-related systemic adverse effects included atrial fibrillation, ventricular tachycardia, and muscle spasms although the incidence of atrial fibrillation and cardiac arrhythmias was uncommon, with no dose response seen.¹¹

In a randomised placebo-controlled study over 1 year, class-related adverse effects of beta₂-agonists (hyperglycaemia, hypokalaemia, prolonged QTc interval) occurred no more frequently with indacaterol than in placebo control or eformoterol twice-daily comparator groups.⁷

In a post hoc analysis of pooled data from three randomised controlled studies of indacaterol 150 micrograms and 300 micrograms over 6 months, there was no increase in cardiovascular or cerebrovascular events or QT interval changes, and no relevant effect of indacaterol on development of arrhythmias.¹²

Caution is required in people with cardiovascular disease

Beta₂-agonist bronchodilators can cause cardiovascular effects such as increases in pulse rate, blood pressure, and cardiovascular symptoms (such as chest pain).^4,13 Caution is required in people with cardiovascular disease (coronary artery disease, acute myocardial infarction, cardiac arrhythmias, hypertension) and if such adverse effects occur the medicine should be discontinued⁴ and alternative therapy chosen, as described in current clinical management algorithms.^3,5

Be aware of possibility of paradoxical bronchospasm

Paradoxical bronchospasm occurs rarely with any inhaled beta₂-agonist and may occur with indacaterol.¹⁴ If paradoxical bronchospasm occurs, stop indacaterol and choose an alternative therapy,⁴ as described in current clinical management algorithms.^3,5

Do not use in people with asthma

LABAs, particularly at high doses, have been associated with severe asthma exacerbations and deaths in people who use these drugs to treat asthma.¹⁵ The safety and efficacy of indacaterol in asthma has not been established; exclude asthma or mixed airways disease before initiating indacaterol treatment.⁴ Do not use indacaterol in people with acutely deteriorating COPD, or to relieve acute symptoms of COPD.⁴

Interactions with other medicines

Like other beta₂-agonists, indacaterol may potentiate the effects of drugs known to prolong the QT interval. Concomitant administration of other sympathomimetic agents may potentiate the systemic beta₂-adrenergic effects of indacaterol. Avoid using methylxanthine derivatives (such as theophylline), steroids or non-potassium-sparing diuretics with indacaterol; they may potentiate the possible hypokalaemic effect.⁴ Do not use indacaterol in people who are using beta₂-adrenergic-blocking medicines (including eye drops).⁴

Do not use in combination with other LABAs

Do not use indacaterol in conjunction with other LABAs such as salmeterol or eformoterol or with combination products that contain LABAs.

The Pharmaceutical Benefits Advisory Committee (PBAC) considered that indacaterol would be used as an alternative to both tiotropium and LABAs with corticosteroid combination therapies in COPD.^1,16 The PBAC also noted safety concerns if LABAs are used for asthma and recommended the addition of a note to the restriction that indacaterol is not PBS subsided in asthma, to minimise its use for this indication.¹

Indacaterol (Onbrez) is PBS listed as a Restricted Benefit for the treatment of chronic obstructive pulmonary disease on a cost-minimisation basis compared with fluticasone in combination with salmeterol. The equi-effective doses were considered to be indacaterol 150 micrograms daily, fluticasone with salmeterol 250/25 micrograms, two puffs twice daily and tiotropium 18 micrograms daily.¹

The recommended adult dosage of indacaterol is one 150 microgram capsule inhaled once daily. In some people one 300 microgram capsule inhaled once daily may provide additional clinical benefit. The maximum dose is 300 micrograms once daily. People who are being treated with long-term inhaled corticosteroid therapy should continue this therapy when starting indacaterol but should not use indacaterol in combination with other LABAs.⁴

Do not use indacaterol in people under 18 years of age or in people with asthma, mixed airways disease or with rapidly deteriorating COPD.⁴

Instruct patients in the proper use of the inhaler device.

For more information on managing chronic obstructive pulmonary disease, refer to NPS Case study 63 report.

No dose adjustment required in renal impairment or in mild to moderate hepatic impairment

Due to its low renal excretion, no dose adjustment is required in people with renal impairment.⁴ No dose adjustments are required in people with mild to moderate hepatic insufficiency.⁴ There are no data on people with severe hepatic impairment.

Provide patients and carers with the following information about indacaterol:

• You may cough immediately after using the indacaterol inhaler; this should only last for a short time.
• Do not swallow the capsules, use the inhalation device.
• Do not use this medicine more than once each day.
• Use this medicine every day even if you feel well.
• Talk to your healthcare professional if you think or feel that indacaterol is not working as well as it should.
• Tell your healthcare professional about any other medicines you are currently using before taking this medicine.
• If you start on any new medicine, remind your healthcare professional that you are using this medicine.
• Tell your healthcare professional as soon as possible if you do not feel well while you are using indacaterol.

Discuss the Onbrez Consumer Medicine Information (CMI) leaflet with the patient.

Medicine Update

An NPS Medicine Update article on indacaterol is available for consumers. Medicine Update helps consumers to ask the right questions about new medicines, and helps them compare the potential benefits and harms of a new medicine with those of other medicines.