title: Analysis of chronic obstructive pulmonary disease exacerbations with the dual bronchodilator QVA149 compared with glycopyrronium and tiotropium (SPARK): a randomised, double-blind, parallel-group study.
abstract: BACKGROUND
  We evaluated the effect of dual, longacting inhaled bronchodilator treatment on exacerbations in patients with severe and very severe chronic obstructive pulmonary disease (COPD).
  
  
  METHODS
  In this parallel-group study, 2224 patients (aged ≥40 years, Global Initiative for Chronic Obstructive Lung Disease stages III-IV, and one or more moderate COPD exacerbation in the past year) were randomly assigned (1:1:1; via interactive voice response or web system; stratified for smoking status) to once-daily QVA149 (fixed-dose combination of indacaterol 110 μg and glycopyrronium 50 μg), glycopyrronium 50 μg, or tiotropium 18 μg for 64 weeks. Assignment to QVA149 and glycopyrronium was double-blind; tiotropium was open-label. Efficacy was assessed in all patients randomly assigned to treatment groups who received at least one dose of study drug; safety was assessed in all patients who received at least one dose whether or not they were assigned to a group. The primary objective was to show superiority of QVA149 versus glycopyrronium for rate of moderate to severe COPD exacerbations (defined by worsening symptoms and categorised by treatment requirements) during treatment. This completed trial is registered at ClinicalTrials.gov, NCT01120691.
  
  
  RESULTS
  Between April 27, 2010, and July 11, 2012, 741 patients were randomly assigned to receive QVA149, 741 to receive glycopyrronium, and 742 to receive tiotropium (729, 739, and 737 patients, respectively, analysed for efficacy). QVA149 significantly reduced the rate of moderate to severe exacerbations versus glycopyrronium by 12% (annualised rate of exacerbations 0·84 [95% CI 0·75-0·94] vs 0·95 [0·85-1·06]; rate ratio 0·88, 95% CI 0·77-0·99, p=0·038). Adverse events (including exacerbations) were reported for 678 (93%) of 729 patients on QVA149, 694 (94%) of 740 on glycopyrronium, and 686 (93%) of 737 on tiotropium. Incidence of serious adverse events was similar between groups (167 [23%] patients on QVA149, 179 [24%] on glycopyrronium, and 165 [22%] on tiotropium); COPD worsening was the most frequent serious adverse event (107 [15%] patients on QVA149, 116 [16%] on glycopyrronium, 87 [12%] on tiotropium).
  
  
  CONCLUSIONS
  The dual bronchodilator QVA149 was superior in preventing moderate to severe COPD exacerbations compared with the single longacting antimuscarinic bronchodilator glycopyrronium, with concomitant improvements in lung function and health status. These results indicate the potential of dual bronchodilation as a treatment option for patients with severe and very severe COPD.
  
  
  BACKGROUND
  Novartis Pharma AG.
authors.affiliation: Centre for Respiratory Medicine, University College London, Royal Free Campus, London, UK. Electronic address: w.wedzicha@ucl.ac.uk.
authors.forename: Jadwiga A
authors.initials: JA
authors.lastname: Wedzicha
authors.affiliation: Respiratory Division, University Hospitals, Leuven, Belgium.
authors.forename: Marc
authors.initials: M
authors.lastname: Decramer
authors.affiliation: Paracelsus Medical University Nuremberg, Nuremberg, Germany; Klinikum Nuremberg, Department of Respiratory Medicine, Allergology, and Sleep Medicine, Nuremberg, Germany.
authors.forename: Joachim H
authors.initials: JH
authors.lastname: Ficker
authors.affiliation: University of Minnesota, Minneapolis VA Health Care Center, Pulmonary Section, Minneapolis, MN, USA.
authors.forename: Dennis E
authors.initials: DE
authors.lastname: Niewoehner
authors.affiliation: Umeå University, Department of Public Health and Clinical Medicine, Umeå, Sweden.
authors.forename: Thomas
authors.initials: T
authors.lastname: Sandström
authors.affiliation: Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA.
authors.forename: Angel Fowler
authors.initials: AF
authors.lastname: Taylor
authors.affiliation: Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA.
authors.forename: Peter
authors.initials: P
authors.lastname: D'Andrea
authors.affiliation: Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA.
authors.forename: Christie
authors.initials: C
authors.lastname: Arrasate
authors.affiliation: Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA.
authors.forename: Hungta
authors.initials: H
authors.lastname: Chen
authors.affiliation: Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA.
authors.forename: Donald
authors.initials: D
authors.lastname: Banerji
mesh_terms: D000280:Administration, Inhalation; D000368:Aged; D001993:Bronchodilator Agents / Q000008:administration & dosage / Q000009:adverse effects; D018450:Disease Progression; D004305:Dose-Response Relationship, Drug; D004311:Double-Blind Method; D004338:Drug Combinations; D016903:Drug Monitoring; D005260:Female; D006024:Glycopyrrolate / Q000008:administration & dosage / Q000009:adverse effects / Q000031:analogs & derivatives*; D006801:Humans; D007189:Indans / Q000008:administration & dosage / Q000009:adverse effects; D008297:Male; D008875:Middle Aged; D029424:Pulmonary Disease, Chronic Obstructive / Q000175:diagnosis / Q000188:drug therapy* / Q000503:physiopathology; D015363:Quinolones / Q000008:administration & dosage / Q000009:adverse effects; D012129:Respiratory Function Tests / Q000379:methods; D012137:Respiratory System / Q000187:drug effects* / Q000503:physiopathology; D012602:Scopolamine Derivatives / Q000008:administration & dosage / Q000009:adverse effects; D012720:Severity of Illness Index; D000069447:Tiotropium Bromide; D016896:Treatment Outcome
chemical_list: D001993:Bronchodilator Agents; D004338:Drug Combinations; D007189:Indans; D015363:Quinolones; D012602:Scopolamine Derivatives; C554862:indacaterol-glycopyrronium combination; D006024:Glycopyrrolate; D000069447:Tiotropium Bromide