Levofloxacin Inhalation Solution (MP-376) in Cystic Fibrosis Patients with
David E. Geller1, Patrick A. Flume2, Doris Staab3, Rainald Fischer4, Jeffery S. Loutit5,
Douglas J. Conrad6 for the Mpex 204 Study Group
1Nemours Children’s Clinic, Orlando, Florida; 2Medical University of South Carolina,
Charleston, South Carolina; 3Charite-University Hospital Berlin, Berlin, Germany; 4Med.
Klinik Innenstadt, Munich, Germany; 5Mpex Pharmaceuticals, San Diego, California;
6University of California, San Diego, California
Correspondence and request for reprints should be addressed to: David E. Geller, M.D.
Nemours Children’s Clinic, Divisions of Biomedical Research and Pediatric
Pulmonology, 496 South Delaney Ave., Suite 406A, Orlando, FL 32801
Fax: 407-650-7192; e-mail: firstname.lastname@example.org
Author contribution: Conception and design: DG, PF, JL, DC; Analysis and
interpretation: DG, PF, JL, DC, DS, RF; Drafting manuscript for important intellectual
content: DG, PF; Manuscript writing: DG, PF
Supported by: Mpex Pharmaceuticals, San Diego, California
Running Title: MP-376 in Cystic Fibrosis Patients
Descriptor Number:9.17 Cystic Fibrosis: Translational & Clinical Studies
Current Word Count (body of manuscript excluding abstract): 3,615
At A Glance Commentary: There is a recognized need for more treatment options for
cystic fibrosis patients with Pseudomonas aeruginosa airway infections. This study
examines the safety and efficacy of a novel formulation of inhaled levofloxacin (MP-376)
in a population of CF patients with a history of heavy exposure to other inhaled
antibiotics and chronic airway therapies. The results demonstrated significant responses
to MP-376 including reduced bacterial density in sputum, the primary endpoint of the
study, and the secondary endpoints of improved pulmonary function, prolonged time-to-
need for other antibiotics, and improved patient-reported outcome scores. Therefore,
MP-376 represents an important potential treatment option for management of airway
infections in cystic fibrosis patients.
This article has an online data supplement, which is accessible from this issue’s table of
content online at www.atsjournals.org
Page 1 of 43
AJRCCM Articles in Press. Published on February 25, 2011 as doi:10.1164/rccm.201008-1293OC
Copyright (C) 2011 by the American Thoracic Society.
Rationale: Lower respiratory tract infection with Pseudomonas aeruginosa(PA) is
associated with increased morbidity in CF patients. Current treatment guidelines for
inhaled antibiotics are not universally followed due to the perception of decreased
efficacy, increasing resistance, drug intolerance, and high treatment burden with
current aerosol antibiotics.New treatment options for CF pulmonary infections are
Objective: This study assessed the efficacy and safety of a novel aerosol formulation of
levofloxacin (MP-376, AeroquinTM) in a heavily-treated CF population with PA infection.
Methods: This study randomized 151 CF patients with chronicPA infection to one of 3
doses of MP-376 (120mg QD, 240mg QD, 240mg BID) or placebo for 28 days. The
primary efficacy endpoint was the change in sputum PA density. Secondary endpoints
included changes in pulmonary function, the need for other anti-PA antimicrobials,
changes in patient-reported symptom scores, and safety monitoring.
Results: All doses of MP-376 resulted in reduced sputum PA density at Day 28, with MP-
376 240 mg BID showing a 0.96 log differencecompared to placebo (P= 0.001). There
was a dose-dependent increase inFEV1(L) for MP-376, with a difference of 8.7% in
FEV1(L) between the 240mg BID group and placebo (P = 0.003). Significant
reductions(61% to 79%) in the needfor otheranti-PA antimicrobials were observed
withall MP-376 treatment groups compared to placebo. MP-376 was generally well
tolerated relative to placebo.
Conclusion: Nebulized MP-376was welltolerated and demonstrated significant clinical
efficacy in heavily-treated CF patients with PA lung infection.
Page 2 of 43
Word Count for Abstract: 250
Key Words for Indexing: Cystic Fibrosis, Pseudomonas aeruginosa, inhaled levofloxacin
Page 3 of 43
Progressive obstructive lung disease is the main cause of morbidity and early mortality in
cystic fibrosis (CF).(1) The lung disease is characterized by inflammation and
endobronchial infection caused by several pathogens, the most important being
Pseudomonas aeruginosa(PA) from the perspective of prevalence and pathogenicity.
Chronic infection with PA is associated with a more rapid decline in the clinical course,
(2-5)emphasizing the need for effective antimicrobial strategies that target this pathogen.
Aerosol delivery of antibiotics directly to the airways yields high concentrations at the
site of infection while minimizing systemic exposure. (6) Current options of aerosol
antibiotics are limited. Tobramycin inhalation solution (TIS) improves pulmonary
function and reduces hospital days when used as alternate-month therapy.(7)Recently
approved inhaled aztreonamlysinate (Cayston, Gilead Sciences) improved patient
reported outcomes and FEV1 after 28 days of treatment.(8)Inhaled colistimethateis not
approved in the U.S. but has been widely used in Europe for CF airway infections.
Despite current CF treatment guidelines for chronic PA infection,(9, 10) one-third of
eligible CF patients do not use TIS,(11) either because of drug intolerance, treatment
burden, or the perception that it is no longer effective. In addition, adherence is low for
TIS in children,as measured by a treatment diary,(12) and according to claims data, a
small minority of eligible patients fill at least 4 prescriptions per year.(13)Even in more
adherent patients (eg, during clinical trials) a further decline in lung function and
recurrent pulmonary exacerbations still occur with alternate month
Page 4 of 43
cycling.(14)Consequently, some clinicians prescribe continuous antibiotics or cycle
different antibiotics every other month.(15) Therefore, additional classes of inhaled
antimicrobials are needed to provide treatment options for CF patients with chronic
Levofloxacin is a fluoroquinolonewith potent activity against CF pathogens, including
PA, and is not inactivated by CF sputum.(16)The bacterial killing and clinical response to
oral and parenteral fluoroquinolones have been established, (17-19) andthey are
extensively used in CF patients for airway infections.
A novel formulation of levofloxacin (MP-376, Aeroquin™, Mpex Pharmaceuticals, Inc.
San Diego, CA) has been developed for aerosolization to treat endobronchial infections
in CF. MP-376 contains high concentrations of levofloxacin along with magnesium
chloride that enables rapid administration using a customized, vibrating-perforated-
membrane eFlow® nebulizer (PARI Pharma, Germany). Ascending-dose studies of MP-
376 in CF patients for up to 14 days of treatment demonstrated dose-related increases of
levofloxacin in serum and sputum, good safety and tolerability, and early evidence of
clinical effectiveness compared to placebo.(20, 21) MP-376 produced very high sputum
concentrations with low serum exposure. Based on these promising initial results, a
randomized, placebo-controlled study was conducted to evaluate the efficacy, safety and
tolerability of three doses of MP-376 administered for 28 days in a CF population with
significant prior exposure to inhaled antibiotics as well as other chronic treatments for
Page 5 of 43
health maintenance in CF. The results of this study have been previously published in
abstract form.(22, 23)
Study Design. This randomized, double-blind study was conducted at 51 CF Centers in
the United States and Europe (June 2008 - June 2009). The Institutional Review Board
for each site approved the study and all patients or their guardians provided written
Following a 14-day screening period, eligible patients were randomly assigned (1:1:1:1)
to either one of three MP-376 dosing regimens [120 mg (1.2 mL) QD, 240 mg (2.4 mL)
QD, 240 mg (2.4 mL) BID] or a placebo group that was subdivided to match the volume
and dosing frequency of one of the MP-376 regimens (Figure 1). MP-376 had a 100
mg/mL concentration of levofloxacin, and study drug was delivered with an
investigational eFlow® nebulizer. The first dose of MP-376 or placebo was administered
at the study site to monitor for drug intolerance, defined as a decline from baseline in
FEV1 of ≥ 20% at 30 minutes post-dose, oxygen saturation <90% within 30 minutes
post-dose, severe coughing, chest tightness, throat discomfort, or moderate to severe
dyspnea. Patients self-administered study drug for the remainder of the treatment period
and returned for monitoring on days 7, 14, and 28. Patients were followed for an
additional 28 days after the last dose. (Figure 1)
Page 6 of 43
Patient Eligibility.Inclusion criteria includeddiagnosis of CF, age ≥16 years, FEV1≥25%
and ≤85% predicted values,(24) clinically stable, and a sputum specimen positive for PA
at screening and within the past 18 months. Patients must have received ≥3 courses of
inhaled antimicrobials over the preceding year and with completion of at least one course
in the 30-56 days prior to visit 1. Exclusion criteria included use of any investigational
agents or anti-pseudomonal antibiotics, or changes in the CF medical regimen within 30
days prior to visit 1. Detailed inclusion and exclusion criteria are provided in the online
Evaluation of Efficacy
Procedures performed at various study visits included interval history, physical exam,
spirometry (post-bronchodilator), collection of sputum for qualitative and quantitative
culture, and administration of the Cystic Fibrosis Questionnaire – Revised (CFQ-R). The
primary efficacy endpoint was change in sputum PA density (colony-forming units
[CFU] / g sputum, log10 transformed) from day 1 to day 28. Major secondary efficacy
endpoints included changes in pulmonary function, time to need for other anti-
pseudomonal antimicrobials, and changes in clinical symptoms [respiratory domain of
CFQ-R].(25)Patients received additional anti-PA antimicrobials at the discretion of the
PI, however use of anti-PA antimicrobials was only captured as an event in the time to
anti-PA analysis if they also met 1 of 4 symptoms as defined by Rosenfeld, increase in
cough, increase in sputum production/chest congestion, decrease in exercise tolerance or
decrease in appetite. (26)
Page 7 of 43
Evaluation of Safety
Safety was assessed by monitoring adverse events, changes in clinical laboratory values,
vital signs, abnormal physical examination findings, electrocardiograms, and acute
change in pulmonary function after dosing.
Analyses are reported on a modified intent to treat (MITT/Safety) patient population
(Figure 1), defined as any randomized patient who received a dose of study drug. Placebo
patients were pooled for the purpose of analysis after demonstrating that the groups were
not statistically different. Comparisons between the active drug and placebo during the
28-day treatment phase used a repeated measures mixed model that included treatment
group, visit, treatment by visit interaction, geographical region, baseline values, and visit
by baseline interaction.
Comparisons of the time to need for other anti-pseudomonal antimicrobials between
active drug and placebo was assessed using a Cox proportional hazards regression model.
Patients that did not require anti-pseudomonal antimicrobials prior to discontinuation
from the study were censored at the date of discontinuation. The proportion of patients
that required anti-pseudomonal antimicrobials was also compared among treatment
groups using Fisher’s exact test.
A sample size of 128 patients was estimated as providing 80% power to detect a
difference between treatment arms using a 2-sided ANOVA, with α = 0.05. This
Page 8 of 43
estimate assumed a SD of 1.5 and a mean log CFU change in P. aeruginosa of - 0.75, -
0.75, no change, and 0.25 increase for the MP-376 240mg BID, MP-376 240mg QD,
MP-376 120mg QD, and placebo arms, respectively.
Of 180 patients screened, 151 patients were randomized into the study and 143 (95%)
completed the study. The reasons for most of the screen failures were that subjects did
not satisfy all of the inclusion and exclusion criteria, or they had a respiratory
exacerbation during the screening period. Five patients (2 in the placebo group and 3 in
MP-376 groups) discontinued the study due to adverse events during the 28-day
treatment period (Figure 1).
Patient Characteristics.Baseline characteristics of all patients were similar in each
treatment arm (Table 1). Patients were an average of 28.7 years of age and were
predominantly Caucasian. At baseline, mean FEV1 percent predicted was 52.3%. The
average number of inhaled antibiotic courses per patient used in the prior year was 4.8,
with 59 patients (39%) having received ≥6 courses. Other important respiratory
medications used at baseline and continued throughout the study were dornasealfa (78%),
azithromycin (74%), and hypertonic saline (46%). Importantly, at baseline 62% of PA
isolates were not susceptible to levofloxacin based on an MIC >2µg/ml, the breakpoint
used for systemic dosing with levofloxacin.
Page 9 of 43
Adherence and Nebulization Time.Empty returned vials were counted and compared to
the number of vials that should have been used during the timeframe of the study. Over
the 28 day treatment period, 86.5% of the placebo group and 92.3%-97.3% of MP-376
groups took >80% of the required doses. For the 240 mg groups, the time of nebulization
averaged between 4 – 6 minutes.
Efficacy.Adjusted mean sputum PA density decreased from baseline for the MP-376
patients at day 28 but increased for placebo-treated patients (Figure 2, top panel). At day
28 the greatest treatment effect was observed in the MP-376 240 mg BID group
(placebo, 0.23 log CFU/g sputum increase; MP-376 240 mg BID, 0.73 log decrease;
treatment difference of -0.96 log10 CFU/g ; 95% CI, -1.54 to -0.38; P = 0.001). More
patients in the MP-376 240 mg groups experienced a significant change of ≥1 log
decrease in PA density compared to placebo [placebo, 8%; MP-376 240 mg QD, 32% (P
= 0.004); MP-376 240 mg BID, 36% (P = 0.004)]. PA density returned towards baseline
levels in all treatment groups by the end of follow up (day 56).
Many patients had bacteria other than Pseudomonas cultured from their sputum at
baseline. Nearly half of the patients had Staphylococcus aureus, while other pathogens
like Stenotrophomonasmaltophiliaand Achromobacterxylosoxidans were present in much
smaller numbers. There was no consistent change in the number of patients with these
organisms present during the study (Table E2, online supplement), suggesting no
selection of any pathogens in this brief treatment period. Also, whether or not S. aureus
was present at baseline, the change in sputum PA density and percent change in FEV1
Page 10 of 43
was similar within the treatment groups (data not shown). No correlation between
baseline MIC values for levofloxacin against PA and change in sputum PA density and
percent change in FEV1 at day 28 was observed (combined Spearman’s correlation
r=0.18 and r=-0.0836 respectively; Figures E1-E2, online supplement). Importantly there
were no significant changes in levofloxacin MIC50 or MIC90 values for PA during the 28-
day treatment or the follow-up period of the study (Table E3 in online supplement).
Mean FEV1 values improved with increasing doses of MP-376 and decreased in placebo
recipients (Figure 2, middle panel). The mean changes in absolute FEV1 for the MITT
population at day 28 were -50, +40, +40, and +90 mL for the placebo, MP-376 120 mg
QD, MP-376 240 mg QD, and MP-376 240 mg BID groups respectively.Percent change
from baseline in FEV1 (L) at day 28 for placebo and MP-376 240 mg BID were
significantly different (placebo, -2.36%; MP-376 240 mg BID, 6.25%; treatment
difference of 8.6%; 95% CI, 3.05 to 14.17; P= 0.003). There was still statistically
significant improvement in FEV1 (L) at day 42 for the MP-376 240 mg BID group, but
values returned to baseline by day 56. More patients in the MP-376 treatment groups
experienced a >10% increase in adjusted FEV1(L) on day 28 compared to the placebo
group [placebo, 27%; MP-376 120 mg QD, 59%; MP-376 240 QD, 54%; MP-376 240
mg BID, 72%(P= 0.001 vs. placebo)]. Results for other pulmonary function tests (FEV1
percent predicted, FVC, and FEF 25-75) followed a similar, dose-dependent trend
(Figures E3-E6,online supplement). As with FEV1 (L), the relative change in percent
predicted FEV1 values at day 28 for placebo and MP-376 240 mg BID were significantly
Page 11 of 43
different (placebo, -2.4%; MP-376 240 mg BID 8.6%; treatment difference of 10.9%; P=
CFQ-R-Respiratory symptom scores improved in MP-376 treated patients (Figure 2,
lower panel), with the changes being statistically significant in the MP-376 240 mg BID
group at day 14, but not at day 28. At day 28 placebo patients experienced a mean
decrease of 0.44 points while the MP-376 240 mg BID patient group showed
improvements from baseline of 4.06 points. Although the treatment difference of 4.5
points was not statistically significant (P = 0.22), it exceed the prospectively defined
minimal clinically important difference of 4 points. (25) During the 28-day treatment
period, 43%-49% of MP-376 treated patients experienced ≥4 point increases in
respiratory scores compared to 30% in the placebo group. By day 56, scores had returned
to near-baseline levels.
MP-376 treatment resulted in a reduction in the need for other anti-pseudomonal
antimicrobials compared to placebo over the 56-day study period (Figure 3). A clinically
and statistically significant reduction in risk for needing additional antibiotics was
observed for the MP-376 120 mg QD (71%, P= 0.007), 240 mg QD (61%, P = 0.021)
and 240 mg BID (79%, P <0.001) treatment groups, respectively. The median time to
antibiotic need could not be determined for any group; however, the 25th percentile was
31 days for the placebo group, compared to 56 days and 59 days for the MP-376 240 mg
QD and BID groups, respectively.
Page 12 of 43
Safety.The incidence of adverse events was similar for MP-376 and placebo patients
during the 28-day treatment period. (Table 2) On-treatment adverse events were
generally mild to moderate. Those events reported with the highest frequency in MP-376
treated patients were complaint about taste, (45 patients; 40%), cough (18 patients; 16%),
and headache (9 patients; 8%). Theonly adverse event that was statistically more
prevalent in the MP-376 groups was the complaint of taste, and while all taste eventswere
thought by the investigators to be related to study drug, only 5 (3.3%) and 3 (2.0%) of
cough and headache episodes, respectively, were considered related to study drug. Taste
complaints were predominantly mild in severity, and no patients discontinued treatment
orwithdrew from the study because of it. Two cases of drug intolerance in MP-376
patients led to early discontinuation from the study at day 1; a third case of drug
intolerance was reported by a patient given MP-376 240 mg QD who experienced ≥20%
decline in FEV1 but remained asymptomatic and continued in the study. There were a
total of 4 serious adverse events during the 28-day treatment period: 2 cases of acute
pulmonary exacerbation in the placebo group, one occurrence of bronchitis in another
placebo patient, and one case of appendicitis unrelated to study drug in a patient
administered MP-376 120 mg QD. There were no complaints related to joints, tendons, or
In general, laboratory parameters and ECG results remained stable through the study and
any shifts from baseline did not correlate with receipt of placebo or dose of MP-376.
Twelve patients (8%) required hospitalization during the study, with no differences
among treatment groups in hospitalizations.
Page 13 of 43
This study demonstrates the efficacy and safety of aerosolized MP-376 compared to
placebo in a population of CF patients receiving extensive treatment for maintenance of
respiratory health. MP-376 significantly reduced the density of PA in sputum,the primary
endpoint of the study, after 28 days at all doses tested, consistent with its antibacterial
effect. MP-376 also substantially reduced the need for systemic or inhaled anti-
pseudomonal antimicrobials, and producedimprovements in pulmonary function,
specifically FEV1, FVC, and FEF25-75. An increase in the respiratory score of the CFQ-R
was observed with MP-376 administration in the highest dose group. Following 28 days
of treatment, the differences between the MP-376 240 mg BID group and the placebo
group were statistically significant for all endpoints described above, except CFQ-R.
There was a strong trend of greater improvement with increasing dose of MP-376 for
most of these endpoints, consistent with a dose response. These improvements in clinical
endpoints were seen despite the PA in the majority of the baseline sputum cultures having
an MIC higher than 2 µg/mL for levofloxacin, demonstrating the irrelevance of parenteral
breakpoints for resistance when using inhaled antibiotics.(27)
Study conduct was very good, with only 8 (5%) patients discontinuing the study and MP-
376 was found to be safe and generally well-tolerated.Most of the adverse events were
mild or moderate in severity and did not increase in frequency or severity with increasing
doses of MP-376. Although there was a high incidence of taste complaints, importantly
no patients discontinued from study drug or from the study due to these complaints.
Page 14 of 43
There were no treatment-related SAEs reported in any of theMP-376 groups. Other than
complaints about the taste of MP-376, the adverse events noted during the study were
typical for the underlying CF sinopulmonary disease. No significant increase
inlevofloxacin MICs in PA was observed after 28-days of exposure in any of the MP-376
or placebo groups.
It was important to design this study to include patients with significant prior exposure to
other inhaled antibiotics to assess the treatment effect with MP-376. Recently published
guidelines establish the long-term use of inhaled antibiotics as a standard of care for
chronic PAinfection. (9, 10) Inhaled TIS and colistin have been used for many years, and
AZLI was recently approved for treatment of chronic PA infection. It is also notable that
these patients used other chronic medications including dornasealfa, azithromycin, and
inhaled hypertonic saline, all of which are now recommended for chronic use in CF
patients with PA. (9)As these therapies have been incorporated into CF treatment
regimens over the past few years, lung health has improved and there has been a lesser
degree of improvement with added therapies; that is, the magnitude of the response to
medications with respect to relevant endpoints such as PAdensity and FEV1 has
diminished compared to earlier studies of inhaled tobramycin when it was first
introduced. (28)Indeed, the recent pivotal studies of inhaled aztreonam, showed that those
patients with more intensive treatment with chronic medicationsat baselinehad less
response to aztreonam with regard to P. aeruginosadensity, FEV1, and CFQ-R respiratory
scores compared to those patients on less intensive baseline therapy.(8, 29)Similarly, the
effect of TIS on bacterial density was reduced in older, more antibiotic-exposed
Page 15 of 43
patients.(7) The patients in the current study were an average 8 years older than those in
the TIS study and had a more extensive exposure to chronic maintenance therapies
compared to those reported in any other study of inhaled antibiotics. Despite this, MP-
376 resulted in a significant reduction in PAdensity (the primary endpoint) and
improvement in the secondary endpoints, adding confidence that MP-376 offers clinically
important improvement for CF patients who already take several therapies for the
maintenance of lung health.
This study showed that MP-376 significantly reduced the proportion of subjects requiring
additional systemic or inhaled antibiotics, with a 79% risk reduction being observed in
the 240 mg BID group. The study period was too short to capture the median time to need
for additional antibiotics however an extended follow-up period of greater than 28 days
post-study drug was considered too long to have patients off standard–of–care therapy.
Prevention of exacerbations is a very important component in preserving lung function as
recent data demonstrate that lung function does not return to pre-exacerbation levels in
about 25% of patients who experience an exacerbation. (30)
Though use of aerosolized antibiotics for suppression of chronic airways infection is the
standard of care for patients with CF, there is evidence that they are underutilized. TIS
has been available since 1998, yet according to US CF Registry data, a third of eligible
patients are not receiving long-term TIS therapy. (11) Further, of those patients who had
TIS prescribed, almost 75% used 2 cycles or less. (13) Possible explanations for this
deviation from accepted guidelines include decreased clinical response, (7, 14, 29)
Page 16 of 43
concerns about resistance or cumulative toxicity, (31) drug intolerance, and treatment
burden; specifically the 15-20 minutes per dose administration time. The recently
approved inhaled aztreonam has a much shorter administration time but requires more
frequent dosing than TIS. Inhaled colistimethateis recommended in the European
consensus statement, (10) but not in the U.S. guidelines, nor is it approved in the U.S.
Further treatment options are necessary to address the concerns of microbial resistance,
new emerging organisms, loss of efficacy over time, and treatment burden.
Levofloxacin appears to have several pharmacologic properties that would be
advantageous for treating CF airway infections. While PAis the pathogen most frequently
associated with pulmonary morbidity in CF, the microbiologic environment of the CF
lung is complex, often including many microbe species, biofilm formation, and
microenvironments with low oxygen tension. A series of in vitro studies demonstrated
that levofloxacin was more potent than tobramycin, amikacin or aztreonam when tested
against clinical isolates of PA, Stenotrophomonasmaltophilia,
Achromobacterxylosoxidans,Burkholderiacepaciacomplex, and Staphylococcus
aureus(sensitive and resistant to methicillin).(16)The activity of levofloxacin was not
reduced by exposure to sputum from CF patients, whereas tobramycin activity was
significantly impaired.(16)Pseudomonas biofilms did not affect the MIC of levofloxacin,
whereas the MICs increased several-fold for tobramycin and aztreonam. (16) Further,
while anaerobic conditions significantly reduced the potency of tobramycin, amikacin
and aztreonam, the potency of levofloxacin was relatively maintained. (32)These data
support the clinical findings that MP-376 has significant potential for the control of
Page 17 of 43
current and emerging CF pathogens. MP-376 also has features that reduce the time
burden for CF patients, including use of a fast, efficient, customized eFlow nebulizer (33)
requiring only 4-6 minutes to nebulize a 240 mg dose. MP-376is also provided as a
premixed solution in single-use ampule that provides for patient convenience.
This large clinical study shows that MP-376 given for 28 days reduces PA density and
the need for other antibiotics, while improving respiratory symptoms and pulmonary
function in heavily-treated CF patients. MP-376 was tolerated well and did not lead to
increased levofloxacin resistance in sputum PA isolates. Further studies will be needed to
define the appropriate strategy for incorporating MP-376 use into the long-term treatment
of chronic airway infection in CF.
Page 18 of 43
Acknowledgement: The authors thank the patients and their families who participated in
this study, as well as the principal investigators (PI) and study coordinators (SC) for each
study site, as listed below. Statistical analyses were performed by Synteract, Carlsbad,
CA. The authors would also like to thank Dr Alexandra Quittner for the use of the CFQ-
R, and the Protocol Review Committee of the Cystic Fibrosis Foundation Therapeutic
Development Network for their thorough review of the protocol.
Valhalla NY- PI: Allen Dozor; SC: Ingrid Gherson; Little Rock, AR – PI: Ariel
Berlinski; SC: Patricia Brady; Park Ridge IL – PI: Avery Stone; SC: Suellen Moen;
Sacramento CA – PI: Brian Morrissey; SC: Ellen Vlastelin; Orange CA – PI: Bruce
Nickerson; SC: NozomiYagi; Palo Alto CA – PI: Carol Conrad; SC: Colleen Dunn, Zoe
Davis; Tucson AZ – PI: Cori Daines; SC: Osmara Molina; Las Vegas NV – PI: Craig
Nakamura; SC: Teresa Melvin, Ryan Yoshikawa; Columbia SC – PI: David Brown; SC:
Betty Johnson; Orlando FL – PI: David Geller; SC: Bert Kesser, Angie Price; Memphis
TN – PI: Dennis Stokes; SC: Barbara Culbreath, Stefani Vatter; San Diego CA – PI:
Douglas Conrad; SC: Bobbie Munden; Kalamazoo MI – PI: Douglas Homnick; SC:
Nancy Wallace, Esther Wyman; Oakland CA – PI: Gregory Shay; SC: Julie Lee;
Cincinnati OH – PI: James Acton; SC: Lorrie Duan; Oklahoma City OK – PI: James
Royall; SC: Jodie Groff; Philadelphia PA - PI: Jeffrey Hoag; SC: Judy Hillman;
Minneapolis MN – PI: Joanne Billings; SC: Trisha Grover; Albany NY – PI: Jonathen
Rosen; SC: Kathy Mokhiber; Columbus OH - PI: Karen McCoy; SC: Laura Raterman;
Mobile AL – PI: Lawrence Sindel; SC: Tony Cowan, Michelle Hemphill; Los Angeles
CA – PI: Marilyn Woo, Thomas Keens; SC: Lynn Fukushima, Kelsey Maloy; Miami FL
– PI: Matthias Salathe; SC: Fernando Cubillos; Pittsburgh PA – PI: Patricia Dubin; SC:
Elizabeth Hartigan, Sandy Hurban; Charleston SC – PI: Patrick Flume; SC: Terry Byars;
San Antonio TX – PI: Peter Fornos; SC: Teresa Phillips; Tyler TX – PI: Rodolfo Amaro-
Glavez; SC: Jan Hoeft; Louisville KY – PI: Ronald Morton; SCs: Kara Richardson; Ann
Arbor MI – PI: Samya Nasr; SCs: Dawn Kruse; Oklahoma City OK – PI: Santiago
Reyes; SC: Teresa Orf; Morristown NJ – PI: Stanley Fiel; SC: Carol Cahill; Glenview IL
– PI: Steven Boas; SC: Clarice Jernagin; Salt Lake City UT – PI: Ted Liou; SC: Kristyn
Packer; Boston MA – PI: Terry Spencer; SC: Erin Leone.
Page 19 of 43
Giessen – PI: Daniel Schuler, Christina Geidel; SC: Claudia Ruckes-Nilges; Berlin – PI:
Doris Staab; SC: Christine Nagel; Tubingen – PI: Joachim Riethmuller; SC: Andrea
Evers-Bischoff; Munchen – PI: Rainald Fischer; SC: Maria Kerscher; Frankfurt – PI:
Thomas Wagner; SC: IngeWortmann; Gerlingen – PI: Martin Kohlhaeufl; SC: Iris
Strecker; Kiel – PI: BurkhardBewig; SC: Sonja Rohweder; Essen – PI: Helmut Teschler;
SC: Cordula Conrad – Kabbe.
Groesbeek - PI: Monique Reijers; SC: FemkeCuppen; Amsterdam – PI: ElsWeersink;
SC: Gerrit-Jan Illbrink
Page 20 of 43
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J, Vasiljev KM, Borowitz D, Bowman CM, Marshall BC, et al. Intermittent
administration of inhaled tobramycin in patients with cystic fibrosis. Cystic fibrosis
inhaled tobramycin study group. N Engl J Med 1999;340:23-30.
8. Retsch-Bogart GZ, Quittner AL, Gibson RL, Oermann CM, McCoy KS,
Montgomery AB, Cooper PJ. Efficacy and safety of inhaled aztreonam lysine for airway
pseudomonas in cystic fibrosis. Chest 2009;135:1223-1232.
9. Flume PA, O'Sullivan BP, Robinson KA, Goss CH, Mogayzel PJ, Jr., Willey-
Courand DB, Bujan J, Finder J, Lester M, Quittell L, et al. Cystic fibrosis pulmonary
guidelines: Chronic medications for maintenance of lung health. Am J Respir Crit Care
10. Heijerman H, Westerman E, Conway S, Touw D, Doring G. Inhaled medication
and inhalation devices for lung disease in patients with cystic fibrosis: A european
consensus. J Cyst Fibros 2009;8:295-315.
11. Cystic fibrosis foundation patient registry. 2008 annual data report. Bethesda,
12. Modi AC, Lim CS, Yu N, Geller D, Wagner MH, Quittner AL. A multi-method
assessment of treatment adherence for children with cystic fibrosis. J Cyst Fibros
13. Briesacher B, Quittner A, Saiman L, Fouayzi H, Sacco P, Quittell L. Adherence
to tobramycin inhaled solution and health care utilization. Am J Respir Crit Care Med
2009;179; Abstract A1183.
14. Bowman CM. The long-term use of inhaled tobramycin in patients with cystic
fibrosis. J Cyst Fibros 2002;1:194-198.
Gibson RL, Burns JL, Ramsey BW. Pathophysiology and management of
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DJ. Antibiotic therapy against pseudomonas aeruginosa in cystic fibrosis: A european
consensus. Eur Respir J 2000;16:749-767.
16. King P, Lomovskaya O, Griffith DC, Burns JL, Dudley MN. In vitro
pharmacodynamics of levofloxacin and other aerosolized antibiotics under multiple
conditions relevant to chronic pulmonary infection in cystic fibrosis. Antimicrob Agents
17. Jumbe N, Louie A, Leary R, Liu W, Deziel MR, Tam VH, Bachhawat R,
Freeman C, Kahn JB, Bush K, et al. Application of a mathematical model to prevent in
vivo amplification of antibiotic-resistant bacterial populations during therapy. J Clin
18. Griffith DC, Corcoran E, Lofland D, Lee A, Cho D, Lomovskaya O, Dudley MN.
Pharmacodynamics of levofloxacin against pseudomonas aeruginosa with reduced
susceptibility due to different efflux pumps: Do elevated mics always predict reduced in
vivo efficacy? Antimicrob Agents Chemother 2006;50:1628-1632.
19. Preston SL, Drusano GL, Berman AL, Fowler CL, Chow AT, Dornseif B, Reichl
V, Natarajan J, Corrado M. Pharmacodynamics of levofloxacin: A new paradigm for
early clinical trials. JAMA 1998;279:125-129.
20. Griffith DC, Hansen C, Pressler T, Balchen T, Jensen TJ, Geller DE, Kesser KC,
Rock J, Surber M, Bostian, K., et al. Single-dose pharmacokinetics of aerosol mp-376
(levofloxacin solution for inhalation) in cystic fibrosis patients: Pk-pd implications. J
Cystic Fibrosis 2008;7, Suppl 2:S26 [poster 104].
21. Geller DE, Flume PA, Schwabl R, Fornos P, Conrad DJ, Morgan E, D. G,
Lomovskaya O, Loutit J, Dudley MN. A phase i safety, tolerability and pharmacokinetic
(pk) study of mp-376 (levofloxacin solution for inhalation) in stable cystic fibrosis (cf)
patients. Pediatr Pulmonol 2008;Suppl 31:315 [poster 321].
22. Flume PA, Geller D, Sindel L, Staab D, Fischer R, Reithmuller J, Loutit J, Conrad
DJ. Inhaled mp-376 (aeroquin, levofloxacin inhalation solution) improves lung function
in stable cystic fibrosis (cf) patients with chronic pseudomonas aeruginosa (pa) lung
infection. J Cyst Fibros 2010;9 [Suppl 1]:S23 [abstract 86].
23. Geller D, Flume PA, Sindel L, Staab D, Fischer R, Loutit J, Conrad DJ. Effects of
inhaled mp-376 (aeroquin, levofloxacin inhalation solution) on need for other anti-
pseudomonal antibiomicrobials in stable cystic fibrosis (cf) patients with chronic
pseudomonas aeruginosa (pa) lung infection. Pediatr Pulmonol 2010;Suppl 33:301
24. Hankinson JL, Odencrantz JR, Fedan KB. Spirometric reference values from a
sample of the general u.S. Population. Am J Respir Crit Care Med 1999;159:179-187.
25. Quittner AL, Modi AC, Wainwright C, Otto K, Kirihara J, Montgomery AB.
Determination of the minimal clinically important difference scores for the cystic fibrosis
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AB, Ramsey B. Defining a pulmonary exacerbation in cystic fibrosis. J Pediatr
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Montgomery AB, Albers GM, Ramsey BW, Smith AL. Effect of chronic intermittent
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MW, Wagener JS. Trends in the clinical characteristics of the u.S. Cystic fibrosis patient
population from 1995 to 2005. Pediatr Pulmonol 2008;43:739-744.
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Montgomery AB. Inhaled aztreonam lysine for chronic airway pseudomonas aeruginosa
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Burns JL, Van Dalfsen JM, Shawar RM, Otto KL, Garber RL, Quan JM,
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Table 1. Patient Characteristics at Baseline
120 mg QD
240 mg QD
240 mg BID
Age, mean yr (SD)
Male, n (%)
Caucasian, n (%)
19 (51.4%) 20 (52.6%)
36 (97.3%) 37 (97.4%) 37 (100.0%) 39 (100.0%) 149 (98.7%)
28.0 (6.9) 27.5 (9.1)
US, n (%)
FEV1 % predicted, mean (SD)
BMI, mean kg/m2 (SD)
Other Respiratory Medications
Dornase Alpha, n (%)
Azithromycin, n (%)
Salbutamol, n (%)
Hypertonic Saline, n (%)
Inhaled Antibiotic Courses Previous 12 months
30 (81.1%) 32 (84.2%)
52.4 (13.4) 52.9 (17.7)
13 (35.1 %)
4.5 (1.6) *
MIC of levofloxacin for PA
Number of PA isolates tested
MIC 50, µg/mL
MIC 90, µg/mL
% not susceptible to levofloxicin**
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* p = 0.042 compared to placebo
**based on an MIC >2µg/mL
Table 2. Number of Patients Reporting Adverse Events During 28-Day Treatment Period
120 mg QD
240 mg QD
240 mg BID
Patients reporting ≥1 AE 27 (73.0%) 27 (71.1%) 31 (83.8%) 26 (66.7%) 84 (73.7%)
Patients reporting ≥1 SAE 3 (8.1%) 1 (2.6%) 0 (0.0%) 0 (0.0%) 1 (0.9%)
Cough 4 (10.8%) 6 (15.8%) 6 (16.2%) 6 (15.4%) 18 (15.8%)
Diarrhea 2 (5.4%) 2 (5.3%) 4 (10.8%) 1 (2.6%) 7 (6.1%)
Disease progression* 7 (18.9%) 2 (5.3%) 1 (2.7%) 2 (5.1%) 5 (4.4%)
Dysgeusia** 1 (2.7%) 14 (36.8%) 18 (48.6%) 13 (33.3%) 45(39.5%)
Headache 0 4 (10.5%) 1 (2.7%) 4 (10.3%) 9 (7.9%)
Hemoptysis 4 (10.8%) 1 (2.6%) 2 (5.4%) 1 (2.6%) 4 (3.5%)
Intolerability 0 1 (2.6%) 1 (2.7%) 1 (2.6%) 3 (2.6%)
*acute CF exacerbation **taste complaint
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Figure 1. Study Design and Patient Disposition
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Figure 2.Changes in Pseudomonas aeruginosa (PA) density in sputum, FEV1, and CFQ-
*P<0.05; **P<0.01 vs Placebo
Days on Treatment Days Followup
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Figure 3.Time to need for additional antipseudomonal antibiotics.
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Geller et al.
Levofloxacin Inhalation Solution (MP-376) in Cystic Fibrosis Patients with
David E. Geller1, Patrick A. Flume2, Doris Staab3, Rainald Fischer4, Jeffery S. Loutit5, Douglas
J. Conrad6 for the Mpex 204 Study Group
All patients who met inclusion/exclusion criteria were randomized into the trial at Visit 1
(Day 1). Randomization was via a centralized voice response system with patients stratified by
geographic region (US vs. ex-US). Patients were randomized 1:1:1:1 to receive 1 of the 3 MP-
376 treatment regimens or placebo. Patients in the placebo treatment group were further
subdivided (0.33:0.33:0.33) to match the number and frequency of ampules in the MP-376
Patients were included in the study if they met all of the following criteria:
1. Were at least 16 years of age (at least 18 years of age in Germany and the Netherlands)
2. Had a clinical diagnosis of CF based on the following criteria:
a. positive sweat chloride ≥ 60 mEq/liter (by pilocarpine iontophoresis) and/or
b. a genotype with 2 identifiable mutations consistent with CF, and
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Geller et al.
c. accompanied by 1 or more clinical features consistent with the CF phenotype
3. Were able to elicit an FEV1 ≥ 25% but ≤ 85% predicted value at Screening based on
Hankinson/National Health and Nutrition Examination Survey (NHANES)criteria 1
4. Had received at least 3 courses of inhaled antimicrobials over the preceding 12 months and
had received at least 1 course of inhaled tobramycin/(TOBI®)/colistin in the 2 months prior
to Visit 1 (Day 1), but none in the 28 days prior to Visit 1 (Day 1)
5. Must have had a sputum specimen at Screening positive for P. aeruginosa and a history of at
least 1 positive sputum culture positive for P. aeruginosa within the last 18 months
6. Clinically stable with no significant changes in health status within the last 30 days
7. Were able to perform spirometry reproducibly
8. Had not smoked tobacco within 30 days prior to Visit 1 (Day 1) and agreed not to smoke for
the duration of the study
9. Were able to reproducibly expectorate sputum
10. Were able to and had given written informed assent/consent in a manner approved by the
IRB/IEC and were willing to comply with the requirements of the stud
Patients were excluded from the study if they met any of the following criteria:
1. Had used an investigational agent within 30 days prior to Visit 1 (Day 1)
2. Had used any nebulized or systemic antibiotics active against P. aeruginosa within 28 days
prior to Visit 1 (Day 1), other than maintenance oral azithromycin, which must have been
initiated at least 30 days prior to Visit 1 (Day 1)
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Geller et al.
3. History of hypersensitivity to fluoroquinolones or excipients of MP-376 (magnesium
4. History of intolerance to bronchodilators or unwilling to use a bronchodilator during the
5. Current use of oral corticosteroids in doses exceeding the equivalent of 10 mg
prednisone/day or 20 mg prednisone every other day
6. Changes in physiotherapy technique or schedule within 14 days prior to Visit 1 (Day 1)
7. Changes in medical regimen for treatment of CF (e.g., introduction, dose escalation, or
elimination of therapies such as dornase alfa, nonsteroidal anti-inflammatory agents,
azithromycin, hypertonic saline, or inhaled corticosteroids) within 30 days of Visit 1 (Day 1)
8. History of lung transplantation
9. Evidence of acute upper respiratory tract infection within 10 days or lower respiratory tract
infection within 30 days prior to Visit 1 (Day 1)
10. Were pregnant, breastfeeding, or unwilling to practice birth control or abstinence during
participation in the study (women only)
11. Had a history of seizures or low seizure threshold (e.g., epilepsy)
12. Had renal dysfunction (calculated creatinine clearance [CrCl] < 50 mL/min) at Screening
13. Had aspartate aminotransferase (AST), alanine aminotransferase (ALT), or total bilirubin
≥ 3 x upper limit of normal (ULN) at Screening or evidence of severe liver disease (e.g.,
cirrhosis, portal hypertension)
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Geller et al.
14. Known history of human immunodeficiency virus (HIV), hepatitis B, or hepatitis C
infection/seropositivity (based on medical history, Screening laboratory evaluations were
15. Had a history of hemoptysis ≥ 30 mL over any 24-hour period during the 30 days prior to
16. Had an oxygen saturation < 90% on room air at Screening or Visit 1 (Day 1)
17. Had a > 15% relative decline in FEV1 (L) from Screening to Visit 1 (Day 1)
18. Were a dependent (as an employee or relative) of the Sponsor, CRO, or Principal
19. Had a present condition, or abnormality in Screening laboratory tests or physical
examination findings, that in the opinion of the Principal Investigator or Medical Monitor
would have compromised the safety of the patient or the quality of the data
The timing of efficacy and safety measurements takenduring the study is shown in table E1.
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Geller et al.
Table E1. Measurements by Study Visit
MP-376 or Placebo Treatment Period
(28 Days of Treatment)
(28 Days of Follow-up)
X X X X X X X
Obtain Vital Signsc X X X X X X X
Obtain ECG X X X
Conduct PFTs X XX X X X
Obtain Sputum for
X X X X X X
Record Adverse Events X X X X X X
XX – pre and post dose
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Geller et al.
Final visit procedures were conducted on all patients who completed all treatments or if the patient was prematurely
withdrawn from the study.
b A complete physical examination was completed at Screening,Visit 4, and Final Visit. A focused physical examination
(pulmonary system only)was completed at Visits 1, 2, 3, and 5. A more detailed examination was conducted at the discretion
of the Principal Investigator.
Vital signs included temperature, respiration rate, blood pressure, heart rate, and pulse oximetry. During treatment period,
vital signs were collected pre-dose and 30 minutes after the start of nebulization (± 5 minutes) during Visits 1, 2, 3, and 4.
Evaluation of Efficacy
Pulmonary function testing was performed according to American Thoracic Society (ATS) and
European Respiratory Society (ERS) Spirometry Standards 2. All patients underwentPFTs to
determine their forced vital capacity (FVC), forced expiratory flow between 25% and 75% of the
FVC (FEF 25-75), and FEV1. Up to 8 efforts were performed to obtain 3 acceptable and
reproducible test results. Prior to performance of any PFT at any study visit, all patients received
a dose of a short-acting β2-agonist (eg, albuterol, salbutamol) within 30 minutes to 2 hours prior
to testing or a long-acting bronchodilator agent (eg, salmeterol) 30 minutes to 6 hours prior to
Pre-dose PFTs were performed 30 minutes (± 5 minutes) prior to the patient administering the
Study Drug. Post-dose PFTs (Visit 1, Day 1 only) were performed 30 minutes (± 5 minutes)
from the start of Study Drug administration.
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Geller et al.
Analyses of the primary and secondary efficacy endpoints used the last observation carried
forward convention, wherein patients who received IV, oral, or inhaled antipseudomonal
antibiotics other than MP-376 had the last value prior to receipt of antipseudomonal antibiotics
carried forward to subsequent visits whether the patient has missing or non-missing values at the
subsequent visits. All other missing values were left as missing.
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Geller et al.
Figure E1. Change in PADensity by Baseline Highest MIC of Levofloxacin to
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Geller et al.
Figure E2. Change in FEV1 by Baseline Highest MIC of Levofloxacin to PA
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Geller et al.
Figure E3. Changes in FEV1 percent predicted
Error! Reference source not found.
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E4. Changes in FVC (L L)
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Figure E5. Changes in FVC percent predicted
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Geller et al.
Figure E6. Changes in FEF 25-75
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Geller et al.
Table E2. Presence of colonization growth by visit
MP-376 120 mg QD MP-376 240 mg QD MP-376 240 mg BID
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Geller et al.
Table E3. Change in MIC of P. aeruginosina to Levofloxacin
N = 37
120 mg QD
N = 38
240 mg QD
N = 37
240 mg BID
N = 39
Day 1 (Baseline)
Day 28 (End of Treatment)
Day 56 (End of Study)
Crit Care Med 159:179‐87, 1999
E2. Miller MR, Hankinson J, Brusasco V, et al: Standardisation of spirometry. Eur Respir J 26:319‐38, 2005
E1. Hankinson JL, Odencrantz JR, Fedan KB: Spirometric reference values from a sample of the general U.S. population. Am J Respir
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