COMMISSION OF THE EUROPEAN COMMUNITIES Brussels, 20/11/2008 SEC(2008) 2902 final COMMISSION STAFF WORKING DOCUMENT Monitoring of Pesticide Residues in Products of Plant Origin in the European Union, Norway, Iceland and Liechtenstein TABLE OF CONTENTS ABBREVIATIONS & SPECIAL TERMS USED IN THE REPORT 1. INTRODUCTION .
1elki_oa.inddThe new england journal of medicine established in 1812 january 19, 2006 A Controlled Trial of Long-Term Inhaled Hypertonic Saline in Patients with Cystic Fibrosis Mark R. Elkins, M.H.Sc., Michael Robinson, Ph.D., Barbara R. Rose, Ph.D., Colin Harbour, Ph.D.,Carmel P. Moriarty, R.N., Guy B. Marks, Ph.D., Elena G. Belousova, M.Appl.Sc., Wei Xuan, Ph.D., and Peter T.P. Bye, Ph.D., for the National Hypertonic Saline in Cystic Fibrosis (NHSCF) Study Group* Inhaled hypertonic saline acutely increases mucociliary clearance and, in short- From the Department of Respiratory Medicine, Royal Prince Alfred Hospital term trials, improves lung function in people with cystic fibrosis. We tested the (M.R.E., M.R., C.P.M., P.T.P.B.); the De- safety and efficacy of inhaled hypertonic saline in a long-term trial.
partments of Medicine (M.R.E., G.B.M., P.T.P.B.) and Microbiology and Infectious Diseases (B.R.R., C.H.), University of Sydney; and the Woolcock Institute of In this double-blind, parallel-group trial, 164 patients with stable cystic fibrosis Medical Research (G.B.M., E.G.B., W.X., who were at least six years old were randomly assigned to inhale 4 ml of either 7 per- P.T.P.B.) — all in Sydney. Address reprint requests to Dr. Bye at the Department of cent hypertonic saline or 0.9 percent (control) saline twice daily for 48 weeks, with Respiratory Medicine, Level 11 E Block, quinine sulfate (0.25 mg per milliliter) added to each solution to mask the taste. A Royal Prince Alfred Hospital, Missenden bronchodilator was given before each dose, and other standard therapies were con- Rd., Camperdown 2050, Australia, or at tinued during the trial.
*Other members of the NHSCF Study Group are listed in the Appendix.
The primary outcome measure, the rate of change (slope) in lung function (reflected N Engl J Med 2006;354:229-40.
by the forced vital capacity [FVC], forced expiratory volume in one second [FEV ], Copyright 2006 Massachusetts Medical Society. and forced expiratory flow at 25 to 75 percent of FVC [FEF ]) during the 48 weeks of treatment, did not differ significantly between groups (P = 0.79). However, the absolute difference in lung function between groups was significant (P = 0.03) when averaged across all post-randomization visits in the 48-week treatment period. As compared with the control group, the hypertonic-saline group had significantly higher FVC (by 82 ml; 95 percent confidence interval, 12 to 153) and FEV (by 68 ml; 95 percent confidence interval, 3 to 132) values, but similar FEF hypertonic-saline group also had significantly fewer pulmonary exacerbations (rela-tive reduction, 56 percent; P = 0.02) and a significantly higher percentage of patients without exacerbations (76 percent, as compared with 62 percent in the control group; P = 0.03). Hypertonic saline was not associated with worsening bacterial infection or inflammation.
Hypertonic saline preceded by a bronchodilator is an inexpensive, safe, and effec-tive additional therapy for patients with cystic fibrosis. (ClinicalTrials.gov number, NCT00271310.) n engl j med 354;3 www.nejm.org january Downloaded from www.nejm.org by on January 22, 2006 . Copyright 2006 Massachusetts Medical Society. All rights reserved. Mutations in the cystic fibrosis gators. Pfizer Pharmaceuticals provided hyper- gene result in abnormal ion transport tonic saline and normal saline but otherwise did across the respiratory epithelium.1,2 In not participate in the design and conduct of the the absence of functional cystic fibrosis trans- study; in the collection, analysis, or interpreta-
membrane conductance regulator protein, there is tion of the data; or in the writing or review of the
defective chloride secretion and excessive sodium manuscript.
absorption. Among the theories linking this ge-
netic defect to lung disease in patients with cys- settings and participants
tic fibrosis is the isotonic volume-depletion hy- Patients in clinically stable condition with a con-
pothesis. It proposes that excessive absorption of firmed diagnosis of cystic fibrosis who were at
salt from the airway lumen of patients with cystic least six years old were recruited from 16 adult
fibrosis carries water with it, dehydrating airway or pediatric hospitals in Australia. Pregnant or
mucous secretions and depleting the volume of breast-feeding women, persons colonized with
liquid on the airway surface. These changes dis- Burkholderia cepacia, and cigarette smokers were
rupt the mucociliary mechanism, with retained excluded, as were those who had used hypertonic
mucus becoming the nidus for chronic infection.3 saline or non-routine antibiotics in the previous
According to this hypothesis, the administration 14 days. The forced expiratory volume in one sec-
of hypertonic saline could be beneficial in patients ond (FEV ), measured at screening, had to be with-
with cystic fibrosis.
in 10 percent of the best value obtained during Experimental data suggest that a long-term the previous six months and at least 40 percent of clinical trial evaluating the safety and efficacy of the predicted value11,12 for height, age, and sex.
hypertonic saline as a treatment for cystic fibro- The study was conducted between September
sis is warranted. For example, short-term admin- 2000 and November 2003.
istration of hypertonic saline is reported to im-
prove the rheologic properties and transportability randomization
of sputum,4,5 hydration of the airway surface,6 At a screening visit, demographic characteristics,
and mucociliary clearance and lung function in spirometric values, and clinical data were record-
patients with cystic fibrosis.7-10 Therefore, we ed; sputum samples were collected; and patients
designed a study to test the effect of long-term filled out a questionnaire regarding their quality
inhalation of hypertonic saline in patients with of life. Eligible participants returned for a base-
cystic fibrosis. The primary aim was to determine line visit within seven days. In the interim, par-
the effect of hypertonic saline on the linear rate ticipants were assigned to a treatment group by
of change in lung function. Secondary outcome means of a concealed, computer-generated ran-
measures included the level of lung function dur- domization performed by a person not otherwise
ing treatment, the incidence of pulmonary exac- involved in the study. A minimization algorithm
erbations, the time free of pulmonary exacerba- was used to balance the two groups with respect
tions, antibiotic use, the number of days on which to age, FEV , presence or absence of long-term
patients could not participate in their usual activi- treatment with recombinant human deoxyribo-ties, results of quantitative microbiologic analy- nuclease (rhDNase), use or nonuse of physiothera-ses, the quality of life, and the body-mass index py, and study center.13 Participants, their clinicians, (the weight in kilograms divided by the square the research assistants, and the trial coordina-of the height in meters).
tor remained unaware of the treatment assign-ments throughout the study.
A parallel-group, randomized, controlled trial was Participants received 4-ml ampules of either 7 per-conducted over a 48-week period. The ethics com- cent saline (the hypertonic-saline group) or 0.9 mittee at each participating center approved the percent saline (the control group) (solutions were study. Each participant, or the legal guardian if prepared by Pfizer); quinine sulfate (0.25 mg per the patient was younger than 18 years of age, pro- milliliter) was added as a taste-masking agent. vided written informed consent. The trial was Solutions were nebulized with a Pari LC PLUS jet designed and executed by the academic investi- nebulizer and a Pari Proneb Turbo compressor. A n engl j med 354;3 www.nejm.org january Downloaded from www.nejm.org by on January 22, 2006 . Copyright 2006 Massachusetts Medical Society. All rights reserved. bronchodilator was administered before each in- second definition consisted of the presence of halation of the study solution. All other standard any 4 of the 12 signs and symptoms, regardless care was maintained throughout the trial.
of whether any treatment was given. Participants At the baseline visit, spirometry and pulse completed a weekly diary card with detailed in- oximetry were performed and participants then formation regarding changes in symptoms and inhaled their usual bronchodilator or, for those reported any unscheduled visits to a physician.
who did not routinely use one, took two 100-μg Antibiotic use was at the discretion of the puffs of albuterol (Ventolin) delivered by a attending physician in accordance with current metered-dose inhaler and Volumatic spacer (Allen practice, including the regular use of inhaled & Hanburys). After 15 minutes, spirometry was and oral antibiotics on an outpatient basis. There repeated. Participants then inhaled the assigned were no protocol-defined treatment or hospital-study solution. Participants whose oxyhemoglo- ization rules for pulmonary exacerbations.
bin saturation exceeded 90 percent and whose When a sufficient volume of sputum was avail- FEV exceeded 85 percent of its prebronchodilator able after quantitative microbiologic analysis, in- value after 15 to 30 minutes were eligible to pro- flammatory and antiinflammatory cytokines were ceed in the trial.
measured to assess the effect of hypertonic sa-line on airway inflammation. Sputum samples assessment of trial outcomes
were liquified and homogenized according to the Monitoring visits were scheduled at 4, 12, 24, and methods of Wolter et al.17 and then frozen for 36 weeks, and two visits were scheduled within batch processing. Enzyme-linked immunosorbent 7 days of each other at 48 weeks. At each visit, assay kits were used with automated standard participants filled out questionnaires regarding laboratory methods to measure interleukin-6, their quality of life, spirometry and a clinical as- interleukin-8, interleukin-10, and tumor necrosis sessment were performed, and sputum was col- factor α (TNF-α).
lected. At all visits, a sputum sample was sent to The quality of life was measured with the use the local laboratory for routine qualitative micro- of a general health-related tool, the Medical Out-biologic analysis. A second sputum sample was comes Study 36-item Short-Form General Health collected at screening, baseline, and 4, 24, and 48 Survey (SF-36).18 The SF-36 consists of 36 items, weeks and shipped on ice to a central laboratory 35 of which are aggregated to evaluate eight for quantitative microbiologic analysis. Samples dimensions of health: physical function, pain, were handled according to protocols established general and mental health, vitality, social func-for the North American Cystic Fibrosis Therapeu- tion, and physical and emotional health. Scores tics Development Network Core Laboratory.14 Or- on each subscale range from 0 to 10, and the ganisms were identified with the use of standard summary scores range from 0 to 100, with high-microbiologic techniques, including the API 20 er scores indicating better health. The quality of NE system (BioMerieux Vitek). Quantification of life was also measured with the use of a ques-pathogens was performed with the use of the tionnaire specific to cystic fibrosis: the Cystic modifications of Wong et al.15 Fibrosis Questionnaire for Adults and for Par- Two definitions of a pulmonary exacerbation ents.19 Each instrument yields a score of 0 to 100, were used. The first16 was the clinical need for with higher numbers indicating better function
the intravenous administration of antibiotics, as for a number of quality-of-life domains related
indicated by the presence of 4 of 12 possible to health.
signs or symptoms: a change in sputum volume
or color; new or increased hemoptysis; increased statistical analysis
cough; increased dyspnea; malaise, fatigue, or Data were analyzed according to the intention-
lethargy; a temperature above 38°C; anorexia or to-treat priniciple. The primary outcome measure
weight loss; sinus pain or tenderness; a change — the linear rate of change in lung function
in sinus discharge; a change in findings on from baseline — was assessed with the use of
physical examination of the chest; a decrease in values obtained 0, 4, 12, 24, 36, and 48 weeks
pulmonary function by 10 percent or more from after randomization. The effect of the interven-
a previously recorded value; or radiographic tion was tested and estimated with the use of the
changes indicative of pulmonary infection. The time-by-treatment-group interaction term from
n engl j med 354;3 www.nejm.org january Downloaded from www.nejm.org by on January 22, 2006 . Copyright 2006 Massachusetts Medical Society. All rights reserved. a mixed-effects model,20 which included age, sex, isms in the hypertonic-saline and control groups and height as covariates. Participants were treat- were compared with the use of the chi-square ed as a random effect, and all other effects were test or, in cases in which subgroups were small, fixed. As a secondary analysis, the absolute dif- Fisher's exact test. No adjustments for multiplicity ference in lung function during the treatment were made across secondary outcomes, with nom-period was compared between groups with the inal P values being reported. Interaction terms use of the treatment-effect term from the mixed- were used to conduct prespecified tests for dif-effects model including the same covariates plus ferences in treatment-group effects according to baseline lung function. Values obtained before age group, the FEV at baseline, the use or non- the administration of a bronchodilator were used use of rhDNase, and the use or nonuse of physio-for spirometric outcomes. P values of less than therapy.
0.05 were considered to indicate statistical sig- We calculated that 164 participants would be nificance. To reduce the risk of a type I error required to give the study a statistical power of related to multiple comparisons, we used the 80 percent to detect a change from baseline in multivariate mixed-effects model with the three FEV equal to 10 percent of the predicted value measurements of lung function (FEV , forced between the hypertonic-saline and control groups vital capacity [FVC], and forced expiratory flow at the 5 percent level. This estimation was based at 25 to 75 percent of FVC [FEF ]) included on published estimates of the standard deviation simultaneously as dependent variables and re- of the change in FEV from baseline expressed ported a single P value derived by this analysis. as a percentage of the predicted value (19 per-For the analysis of the linear rate of change in cent)22 and the attrition rate (30 percent)23 in lung function, in which follow-up time was treat- similar trials.
ed as a continuous variable, we assumed that the model had a compound-symmetry variance– covariance structure. For the analysis of the level of lung function, the variance–covariance struc- Between September 2000 and December 2002, ture was defined by the Kronecker product,21 which 164 patients underwent randomization (Fig. 1). assumes an autoregressive correlation structure The baseline characteristics of the patients are between follow-up visits and an unstructured cor- shown in Table 1; domain scores reflecting the relation matrix across the three measurements quality of life are shown in Table 4 of the Supple-of lung function.
mentary Appendix (available with the full text of Other secondary outcomes, including the qual- this article at www.nejm.org).
ity of life, results of quantitative microbiologic After the administration of a bronchodilator analyses, and cytokine concentrations, were also for tolerance testing, both groups had a mean assessed with the use of a mixed-effects model. improvement in the FEV of 60 ml. After the sub- Data across all measurement points, with adjust- sequent inhalation of the assigned solution, the ment for baseline values as a covariate, were used. FEV fell by a mean of 94 ml in the hypertonic- The mean of the screening-day values and base- saline group and 16 ml in the control group (see line values was used as the baseline.
Fig. 5 in the Supplementary Appendix). Two par- The number of exacerbations and other events ticipants had a decrease in their FEV of more during treatment was compared between groups than 15 percent after the inhalation of hyper-with the use of the Wilcoxon rank-sum test, and tonic saline. However, on retesting, both sub-the interval in which participants remained free sequently passed the test and began taking the of exacerbations was compared with the use of trial solution.
Cox proportional-hazards regression. The number Inspection of the data showed that the FVC of events, such as hospitalizations or exacerba- and FEV appeared to increase during the first tions, was adjusted for time spent in the study four weeks of treatment with hypertonic saline by multiplying the observed number of events but remained essentially unchanged in the con-by 336, which was the total number of days of trol group (Fig. 2). Thereafter, lung function study participation possible, divided by the num- plateaued in the hypertonic-saline group, and a ber of days that the patient actually participated difference in lung function favoring hypertonic in the study. The rates of acquisitions of organ- saline persisted at all subsequent times. The test n engl j med 354;3 www.nejm.org january Downloaded from www.nejm.org by on January 22, 2006 . Copyright 2006 Massachusetts Medical Society. All rights reserved. 168 Screened for eligibility 4 Did not meet inclusion 164 Underwent randomization 83 Assigned to hypertonic 81 Assigned to control 1 Voluntarily withdrew 1 Voluntarily withdrew 80 Received 1st dose 82 Received 1st dose 10 Lost to follow-up 7 Lost to follow-up 5 Owing to time constraints 2 Owing to time constraints 3 Owing to insufficient perceived 2 Owing to insufficient perceived benefit from trial solution benefit from trial solution 1 Failed to attend 2 Owing to adverse reaction 1 Provided no reason to trial solution (cough) 1 Provided no reason 7 Stopped inhalations but con- 8 Stopped inhalations but con- 3 Owing to time constraints 2 Had adverse reaction to trial 4 Had adverse reaction to trial solution (tonsillitis in 1 and 1 Had cough and vomiting 1 Had insufficient benefit from 1 Had pharyngitis and wheezing 1 Had voice changes 1 Provided no reason 1 Had chest tightness 2 Could not tolerate taste of trial 1 Had insufficient benefit from 80 Included in analysis 82 Included in analysis 1 Voluntarily withdrew 1 Voluntarily withdrew before 1st dose and before 1st dose and Figure 1. Enrollment and Outcome.
n engl j med 354;3 www.nejm.org january Downloaded from www.nejm.org by on January 22, 2006 . Copyright 2006 Massachusetts Medical Society. All rights reserved. Table 1. Baseline Characteristics of the 164 Participants.*
Control (N = 81)
Hypertonic Saline (N = 83)
FEV (% of the predicted value) FVC (% of the predicted value) (% of the predicted value) Regular use of bronchodilator (%) Regular use of rhDNase (%) Regular use of antibiotic (%) Regular use of inhaled tobramycin (%) Regular use of inhaled colistin (%) Regular use of oral antibiotic (%) Regular use of azithromycin (%) Regular use of physiotherapy (%) Previous inhalation of a dose of hypertonic saline (%) Pseudomonas aeruginosa in sputum (%) Density (log CFU/g) Staphylococcus aureus in sputum (%) Density (log CFU/g) * Plus–minus values are means ±SD. The body-mass index is the weight in kilograms divided by the square of the height in meters. Baseline refers to the mean of the screening-day values and baseline values. FEV denotes forced expiratory volume in one second; FVC forced vital capacity; FEF forced expiratory flow at 25 to 75 percent of the forced vital ca- pacity; rhDNase recombinant human deoxyribonuclease; and CFU/g colony-forming units per gram of sputum, expressed as log values on a base 10 scale.
of the linear slope of lung function, incorporat- points (95 percent confidence interval, 0.1 to 6.2 ing FEV , FVC, and FEF into a single model, percentage points) higher in the hypertonic-saline through all times from 0 weeks (baseline) to 48 group than the control group and the FVC was weeks revealed no significant difference between 2.8 percentage points (95 percent confidence in-the two groups (P = 0.79) (Table 2). However, the terval, 0.4 to 5.2 percentage points) higher in the absolute level of lung function, averaged over the hypertonic-saline group.
period from 4 weeks to 48 weeks after random- The effect of treatment on the linear rate of ization, was higher in the hypertonic-saline group change in lung function did not differ signifi-than the control group (P = 0.03) (Table 2). Ex- cantly according to the baseline FEV , the use or pressing the absolute differences in lung func- nonuse of rhDNase, age group, or the use or non-tion during this period as a percentage of indi- use of physiotherapy. The effect of treatment on vidual baseline values, the FEV was 3.2 percentage the absolute level of the FVC and FEV during the n engl j med 354;3 www.nejm.org january Downloaded from www.nejm.org by on January 22, 2006 . Copyright 2006 Massachusetts Medical Society. All rights reserved. post-randomization period did not differ sig- nificantly according to the baseline FEV , the use or nonuse of rhDNase, or the use or nonuse of physiotherapy. The effect of treatment on the absolute level of FVC, but not of FEV , did differ significantly between adults and children (P = 0.01). For participants who were at least 18 years of age, the absolute level of FVC during the treatment period was 175 ml higher (95 percent confidence interval, 56 to 294; P = 0.004) in the hypertonic-saline group than in the control group, whereas among participants who were younger than 18 years of age, the FVC did not differ sig- nificantly between groups (1 ml higher in the Absolute Change in FVC from Baseline (ml)
control group; 95 percent confidence interval, −72 to 70; P = 0.98).
There were fewer exacerbations requiring in- travenous antibiotic therapy in the hypertonic-saline group than in the control group. The mean number of exacerbations per participant in the control group was 0.89, as compared with 0.39 in the hypertonic-saline group (difference, 0.5; 95 percent confidence interval, 0.14 to 0.86; P = 0.02). The mean number of days on which participants from Baseline (ml)
met this exacerbation definition was 17 days in the control group and 6 days in the hypertonic-saline group (difference, 11 days; 95 percent con- fidence interval, 3 to 19; P = 0.02). The interval during which participants remained free of exac- erbations was significantly longer in the hyperton-ic-saline group than in the control group (P = 0.03), Absolute Change in FEV ¡150
with a 48-week exacerbation-free survival rate of 76 percent in the hypertonic-saline group and 62 percent in the control group (Fig. 3A).
Figure 2. Absolute Change from Baseline in Forced Vital Capacity (FVC)
When exacerbations were defined according (Panel A) and the Forced Expiratory Volume in One Second (FEV ) (Panel B).
to signs and symptoms alone, regardless of treat- Values are adjusted for baseline FEV and for age, height, and sex as covari- ment, results again favored the hypertonic- saline ates. Means and 95 percent confidence intervals are shown.
group. The mean number of exacerbations de-fined in this way was 2.74 per participant in the control group and 1.32 in the hypertonic-saline (Fig. 3B). The effects of hypertonic saline on exac-group (difference, 1.42; 95 percent confidence in- erbations did not differ significantly between terval, 0.86 to 1.99; P<0.001). The mean number participants who used rhDNase and those who of days during which participants met criteria did not use rhDNase.
for a symptom-defined exacerbation was 69 days As an index of total antibiotic use for symp- in the control group and 22 days in the hyper- tom-defined exacerbations, the number of "anti-tonic-saline group (difference, 47 days; 95 per- biotic-days for exacerbations" was calculated by cent confidence interval, 30 to 63; P<0.001). The summing the number of days spent taking each time participants remained free of exacerbations antibiotic prescribed for an exacerbation, regard-was significantly longer in the hypertonic-saline less of any overlap of different antibiotics. The group (P<0.001), with a 48-week exacerbation- median number of antibiotic-days for exacerba-free survival rate of 41 percent in the hypertonic- tions was 50 (interquartile range, 6 to 144) in saline group and 16 percent in the control group the control group, whereas it was significantly n engl j med 354;3 www.nejm.org january Downloaded from www.nejm.org by on January 22, 2006 . Copyright 2006 Massachusetts Medical Society. All rights reserved. Table 2. Effect of Hypertonic Saline on Lung Function.*
Difference in Linear Rate of Change
Absolute Difference in Lung Function
of Lung Function from 0–48 Wk
Across Wk 4 to 48†
ml/wk (95% CI) ml (95% CI) 0.3 (−1.3 to 1.8) 0.5 (−1.3 to 2.3) −1.5 (−4.2 to 1.2) 39 (−67 to 146) * The differences shown are those between the hypertonic-saline and control groups. Positive values represent a benefit from hypertonic saline. Values were adjusted for age, height, and sex. CI denotes confidence interval, FEV forced expi- ratory volume in one second, FVC forced vital capacity, and FEF forced expiratory flow at 25 to 75 percent of the forced vital capacity.
† Four weeks is the first post-baseline measurement. The analysis was adjusted for baseline values.
lower, at 11 (interquartile range, 0 to 49) in the The difference between groups in all other do-hypertonic-saline group (P<0.001). The two groups mains was not significant.
did not differ significantly in the number of Overall, hypertonic saline did not significant- antibiotic-days for any reason (median number in ly alter the concentration of Pseudomonas aerugi-the control group, 167; interquartile range, 56 to nosa in sputum (Fig. 4A). Among participants who 388; and median number in the hypertonic-saline were younger than 18 years of age, the concen-group, 144; interquartile range, 36 to 351; P = 0.29) tration of P. aeruginosa in sputum was lower in the or in the number of intravenous-antibiotic-days control group than in the hypertonic-saline group for any reason (0 in the control group; interquar- (P = 0.04), reflecting a single, unsustained drop in tile range, 0 to 34; and 0 in the hypertonic-saline values in the control group at four weeks (Fig. 4B). group; interquartile range, 0 to 25; P = 0.46).
Hypertonic saline did not significantly alter the Participants in the hypertonic-saline group concentration of Staphylococcus aureus in sputum had significantly fewer days on which they were (Fig. 4C). The prevalence of P. aeruginosa and S. au-absent from school or work or unable to partici- reus did not differ significantly between groups.
pate in other, usual activities: 7 days (interquartile The incidence of acquisition of P. aeruginosa, range, 0 to 21), as compared with 24 (interquar- S. aureus, B. cepacia, Stenotrophomonas maltophilia, tile range, 12 to 48) in the control group (P<0.001). Candida albicans, aspergillus species, and Haemo-There was no significant difference in weight philus influenzae did not differ significantly be-or body-mass index between the groups. The num- tween groups. There were five new acquisitions ber of hospitalizations and unscheduled visits to of coliform bacteria in the control group and the hospital also did not differ significantly be- none in the hypertonic-saline group (P = 0.03).
tween the groups.
There was no significant difference between The mental health domain of the SF-36 was a groups in the concentration of interleukin-6 mean of 5.2 points higher in the hypertonic- (P = 0.94), interleukin-8 (P = 0.36), interleukin-10 saline group than the control group (P = 0.02). For (P = 0.81), or TNF-α (P = 0.38) across the post-ran-participants who were at least 14 years old, there domization measurements, after adjustment for were significant differences between groups in baseline values.
favor of hypertonic saline in the role domain (7.3 Adverse events included respiratory exacerba- points, P = 0.04), the emotional domain (4.8 points, tions, chest pain, gastrointestinal symptoms, P = 0.03), and the health domain (5.3 points, headache, joint pains, pharyngitis, and tonsilli-P = 0.01) of the Cystic Fibrosis Questionnaire for tis. There were significantly fewer adverse events Adults. For participants who were younger than in the hypertonic-saline group than the control 14 years of age, the digestion domain of the Cystic group (mean, 2.89 vs. 5.17 per 336 days; P<0.001). Fibrosis Questionnaire for Parents was a mean Adverse drug reactions (i.e., adverse events that of 6.4 points higher (better) in the control group in the opinion of the examining investigator than in the hypertonic-saline group (P = 0.02). were directly and temporally related to the inha- n engl j med 354;3 www.nejm.org january Downloaded from www.nejm.org by on January 22, 2006 . Copyright 2006 Massachusetts Medical Society. All rights reserved. lation of the trial solution) were significantly A
more common in the hypertonic-saline group (P = 0.001) (Table 3). Six of these resolved when the participants elected to stop taking the trial solution permanently. The remainder resolved af-ter a mean of 15 days, with no interruption of the treatment regimen, temporary cessation of treat- ment, or reduction of the dosing frequency.
Compliance with treatment, as judged by the number of returned ampules, was 63 percent in the control group and 64 percent in the hyper- Exacerbation-free Survival (%)
tonic-saline group. Quarterly data are presented in Table 5 of the Supplementary Appendix. Only 38 percent of participants (49 percent of the hypertonic-saline group and 27 percent of the control group) were able to guess their treatment assignment correctly. Most attributed their choice to the perceived therapeutic effect.
In this long-term trial, we compared the safety and efficacy of hypertonic saline with those of isotonic saline in patients with cystic fibrosis. Treatment with hypertonic saline for approxi- Survival Free of Symptom-Defined
mately one year had no significant effect on the rate of change in lung function, but it was associ- ated with a moderate yet sustained improvement in the level of lung function. More dramatic, how- Figure 3. Percentage of Participants in Each Group Remaining Free of Exac-
erbations during the Trial.
ever, were the reductions in the number of exac- The dotted lines represent the median values, which were greater than 48 erbations, antibiotic use for exacerbations, and weeks for both groups in Panel A and 9.2 weeks for the control group and absenteeism from school or work or the inability 36 weeks for the hypertonic-saline group in Panel B. In Panel A, exacerba- to engage in other, usual activities that were as- tions are defined according to the criteria of Fuchs et al.,16 which involve sociated with the use of hypertonic saline.
the clinical need for the intravenous administration of antibiotics, as indi- This apparent divergence between small im- cated by the presence of 4 of 12 possible signs or symptoms: a change in sputum volume or color; new or increased hemoptysis; increased cough; provements in lung function and large reduc- increased dyspnea; malaise, fatigue, or lethargy; a temperature above 38°C; tions in the frequency of exacerbations has been anorexia or weight loss; sinus pain or tenderness; a change in sinus discharge; observed in other studies of patients with cystic a change in findings on physical examination of the chest; a decrease in pul- fibrosis.17,24 A possible mechanism for this di- monary function by 10 percent or more from a previously recorded value; chotomy is presented in an article by Donaldson or radiographic changes indicative of pulmonary infection. In Panel B, exac-erbations are defined according to the presence of any 4 of the 12 signs and colleagues in this issue of the Journal.25 A and symptoms, regardless of whether any treatment was given. decrease in exacerbations is an important out-come for patients with cystic fibrosis with respect to the quality of life, days absent from normal tive to that of other proven therapies for cystic activities, and cost. Furthermore, exacerbations fibrosis,27 it is an attractive addition to the thera-associated with infections typically worsen the peutic armamentarium. Furthermore, treatment progression of lung disease in these patients. with hypertonic saline reduced indirect costs to Accordingly, the frequency of exacerbations is a patients and the community by reducing absen-strong predictor of morbidity and mortality.26 teeism.
Thus, a treatment that reduces exacerbations is The beneficial effects of hypertonic saline of major clinical relevance. Because hypertonic could be due to increased clearance of mucus as saline achieves this outcome at a low cost rela- a result of increased hydration of the airway n engl j med 354;3 www.nejm.org january Downloaded from www.nejm.org by on January 22, 2006 . Copyright 2006 Massachusetts Medical Society. All rights reserved. A All Participants
Figure 4. Absolute Changes in the Density of P. aerugi-
nosa in Sputum in All Patients (Panel A) and in Those
Younger Than 18 Years of Age (Panel B) and in the
Density of S. aureus in Sputum in All Patients (Panel C).
Means and 95 percent confidence intervals are shown. P values are for the difference between groups after P. aeruginosa CFU/g)
randomization. CFU denotes colony-forming units (per gram of sputum) and are expressed as log values on a base 10 scale.
in Sputum (log
hypertonic saline promoted sustained increases in mucociliary clearance in patients with cystic Change in Density of
fibrosis and provided in vitro data describing a possible mechanism — namely, slow diffusion of hypertonic saline from airway surfaces from such patients.
B Participants Younger Than 18 Years of Age
Given the hypothesis that hypertonic saline could inactivate endogenous antimicrobial com- pounds in patients with cystic fibrosis,28,29 our finding that there was no convincing evidence of enhanced bacterial growth with hypertonic sa- P. aeruginosa CFU/g)
line was reassuring. The significant difference between groups in the concentration of P. aerugi- nosa in sputum in the subgroup of patients who were younger than 18 years of age was due pri- marily to a single data point representing an un- in Sputum (log
explained and unsustained drop in the concen- Change in Density of
tration in the control group at four weeks. This drop did not appear to indicate a clinically im- portant detrimental effect of hypertonic saline. The absence of an increase in the rate of acquisi-tion of common organisms in the hypertonic- C All Participants
saline group also provides reassurance. Further- more, the analysis of sputum cytokines, including interleukin-8, which is considered to be a key marker of inflammation in patients with cystic fibrosis,30,31 revealed no evidence that hypertonic saline induced airway inflammation.
Adverse events, which often reflect the effects of the disease in patients with cystic fibrosis, were less common in the hypertonic-saline group, a in Sputum (log
finding consistent with the efficacy described Change in Density of
above. Immediate adverse reactions to the admin-istration of hypertonic saline resolved rapidly in the few patients who had them. Cough can be expected with the introduction of this therapy, but in our experience, it typically decreases over time. We should also stress the fact that to pre- surface6 or to ionic or electrostatic effects on vent or minimize airway narrowing, a broncho-secretions4,5 and the induction of cough.7,8 Don- dilator must be given before the administration aldson et al.25 report evidence in support of the of hypertonic saline.
first mechanism. Specifically, they showed that In conclusion, our results provide proof of n engl j med 354;3 www.nejm.org january Downloaded from www.nejm.org by on January 22, 2006 . Copyright 2006 Massachusetts Medical Society. All rights reserved. quency of exacerbations, and reduced absentee- Table 3. Adverse Reactions Considered to Be Related
ism in both children and adults. Hypertonic sa-line was associated with few treatment-related adverse events and improved important domains related to the quality of life, and its benefits were independent of treatment with rhDNase. Hyper-tonic saline preceded by a bronchodilator is an inexpensive, safe, additional therapy in patients with cystic fibrosis.
Supported by the U.S. Cystic Fibrosis Foundation, the Na- tional Health & Medical Research Council of Australia, and the Australian Cystic Fibrosis Research Trust.
No potential conflict of interest relevant to this article was We are indebted to the patients and parents who volunteered to participate in the study; to Pfizer Australia for manufacturing the saline solutions; to Pari Germany and Technipro Australia for supplying the compressors and nebulizers; to Allen & Han-burys, a Division of Glaxo Wellcome Australia, for supplying principle that adding salt (and water) to the air- albuterol metered-dose inhalers and spacers; to Prof. Richard way surfaces of patients with cystic fibrosis is Boucher and Dr. Scott Donaldson for their careful review of this article; to Dr. Lisa LaVange for her advice regarding the statisti- beneficial. Long-term treatment with hypertonic cal analysis; and to Profs. Malcolm King and Warrick Britton for saline improved lung function, reduced the fre- their helpful advice.
In addition to the authors, the following investigators participated in the National Hypertonic Saline in Cystic Fibrosis Study (all in Australia): D. Agaliotis, Royal Prince Alfred Hospital; S. Sheridan, M. Roberts, P. Robinson, Royal Children's Hospital Melbourne; K. McKay, L. Smith, K. Covil, A. Ratcliffe, P. Cooper, Children's Hospital at Westmead; K. Terrell, M. Hurwitz, Canberra Hospital; R. O'Donnell, K. Here-wane, H. Greville, Royal Adelaide Hospital; V. McDonald, P. Gibson, P. Wark, John Hunter Hospital; B. Button, L. Francis, J. Wilson, T. Kotsimbos, Alfred Hospital; M. McElrea, S. Bell, Prince Charles Hospital; K. Rogers, J. Hilton, B. Whitehead, John Hunter Children's Hospital; K. Spanner, G. Smith, Adelaide Women's and Children's Hospital; P. Mitchell, C. Wainwright, P. Francis, Royal Children's Hospital Brisbane; D. Kepert, L. Blackwell, D. Armstrong, P. Solin, Monash Medical Centre; E. Balding, K. Winfield, S. Brennan, P. Sly, Princess Margaret Hospital for Children; C. Dias, G. Ryan, Sir Charles Gairdner Hospital; J. Studdert, S. Dixon, J. Morton, Sydney Children's Hospital; M. Zimmerman, I. Feather, Gold Coast Hospital; M. Pegler, M. Anthony, H. Service, K. Thamotharampillai, V. Nguyen, J. Gilchrist, C. Lee, M. Singh, G. Punch, D. Hill, M. Whitnall, W. Chin, University of Sydney; J. Zhou, Centenary Institute Sydney; J.P. Seale (chair), I. Marschner, P. Taylor, S.K. Lo, Data and Safety Monitoring Board.
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