The impact of lumacaftor/ivacaftor on the microbiological

in Figure 7A and 7B. The slope of the prevalence of S. maltophilia (p<0.001) and S.

pneumoniae (p=0.007) decreased significantly after treatment, Figure 8A. While the slope of the prevalence of C. albicans (p=0.001), Penicillium species (p=0.026) and Scedosporium apiospermum (p<0.001) increased with the treatment, Figure 8B. The slope of the prevalence of key CF pathogens such as P. aeruginosa, S. aureus and A. fumigatus did not change during the study period. The sensitivity test including CF patients who performed ≥3 bacterial and fungal cultures per year revealed a decrease in the slope of the prevalence of S. pneumoniae as well as Achromobacter species.

Figure 7A: The bacterial prevalence for each year of the study period.

Figure 8A. The slope of the probability, i.e. the prevalence, of P. aeruginosa (A), S. aureus (B), Achromobacter spp (C), S. maltophilia (D), H influenzae (E), Serratia Marcescens (F), Moraxella catarrhalis (G) and S.

pneumoniae (H), negative culture for bacteria (I).

Figure 8B: The slope of the probability, i.e. the prevalence, of A. fumigatus (A), C. albicans(B), C. dubliniensis (C), C. glabrata (D), C. parapsilosis (E), Scedosporium apiospermum (F), Exophiala dermatitidis (G) and Penicillium spp (H).

The significance (p_diff) and the 95% CI (diff_low- diff_upp) of the change in slope at the start of treatment are given. The presented slopes before (s_b) and after (s_a) the start of treatment were for the natural logarithm of the odds for outcome but predicted values have been transformed to probability for ease of interpretation.

ETHICAL CONSIDERATION

All studies included in this thesis were conducted according to the guidelines of the declaration of Helsinki.

Study I and II:

All included patients or their legal guardians signed an informed consent. The study was approved by the Regional Ethical Review Board Stockholm, reference number 2017/1493-3.

Study III:

For the Swedish subset, the study was approved by the Regional Ethical Review Board in Stockholm, reference number 2011/1782-31/2. Patients or their legal guardians signed an informed consent. For the Danish population, the study was conducted as a registry-based study. According to Danish National Committee on Health Research Ethics, registry-based studies that do not include biological material is not to be notified. However, all patients signed informed consent to be included in the national Danish CF registry for national and international research purposes.

Study IV:

Two ethical approvals are linked to this study. The one for Stockholm CF participants with reference number 2017/1493-3 allowed reviewing medical records and obtaining blood samples beyond the local routines (A. fumigatus specific antibodies). All included patients from Stockholm CF center or their guardians signed an informed consent.

Lumacaftor/ivacaftor was approved initially from 12 years of age at the time of application in 2017. The age limit was lowered to 6 years in 2018. An amendment was approved with reference number 2018/2006-32 to include patients from 6 years of age. For participant from Gothenburg and Lund, the study was performed as registry-based study and had an approval from the Regional Ethical Review Board in Stockholm, reference number 2019-00417.

Ethical consideration for all studies:

The principle of justice for non-participating patients: CF patients have a dependent position to the center. There is a risk that patients who declined participation will feel a concern about poorer care. According to the principles of justice, all patients should receive adequate care based on their needs. Patients were informed clearly that participation is based on a voluntary basis and that care will not be affected regardless the decision they have made.

Principles of autonomy: Through informed consent and careful review with patients about the procedure, the principle of autonomy was considered. No private-containing information was collected.

Nonmaleficence (the principle of not to harm): Study I and II were retrospective studies meaning no further investigation or tests were needed. All data was extracted from medical records and the Swedish National CF registry. Study III and IV were prospective studies.

However, patients were followed up according to existing routine in their respective CF center. For Stockholm patients in study IV, an extra blood sample was collected at visit 1 and 2 to follow up the levels of A. fumigatus specific antibodies. The blood volume was only 2 ml which is insignificant in relation to the total body blood volume. Moreover, the tests were planned to be performed at the same time when other mandatory blood tests were taken.

Patients in study IV received lumacaftor/ivacaftor according to the existing clinical practice.

Ethical consideration regarding the incomplete studies:

Nonmaleficence (the principle of not to harm): In the pharmacokinetic study, which was aimed to measure posaconazole in exhaled breath, three patients received an antifungal agent outside the medical indication and may be exposed to side effects. At the screening, the participants’ medical history was taken, and their clinical status was examined to ensure that they were clinically stable. Blood samples for blood, renal and liver status were taken as well as an ECG. The probability of side effects was considered to be minimal as posaconazole’s half-time is 36 hours. The side effects are often described to be transient. The patients were followed up day 1, 2 and 3.

Pros and cons of the study: The current method for measuring posaconazole concentration is through blood test, an invasive test, and the patient needs to go to a health care facility in order to have this done. This is time-consuming and for employed patients it results in loss of income. A measurement of posaconazole in exhaled breath would have been non-invasive and quicker to conduct, only 20 second and the exhalation device could be sent by post to the laboratory. However, the disadvantage of the pilot study was that the study itself was time-consuming for the participants. They needed to come three days in a row to perform the tests which meant lost income.

If measurement in exhaled breath could be replace blood tests, it would be beneficial for many patients. There would be less suffering for patients, especially children, as well as time savings as it can be done at home.

In addition, theoretically, measurement of posaconazole concentration in the exhalation could provide a better picture of the concentration in the lung tissue and thus increase the possibility of a successful treatment. These are consistent with doing good principle.

According to the double effect doctrine when all four principles are fulfilled, namely that the

saving and increased treatment efficiency, the intention is good and the evil is only a side effect and that the good effect exceeds the evil, the study is considered moral.

For the intervention study which aimed to assess the efficacy of treatment with posaconazole, patients were planned to be followed up according to the existing clinical practice. However, an extra blood test to measure the level of concentration of posaconazole was planned to be performed. We believe monitoring the concertation’s levels would have been motivated in order to achieve better outcome and prevent adverse event related to high concentration levels.

For the sub study to investigate micro- and mycobiota, patients needed to perform an extra sputum sample. Performing sputum cultures is non-invasive. Furthermore, CF patients are used to perform sputum cultures regularly.

We believe that increased knowledge about fungi in CF patients will lead to better treatment decisions and may improve the life expectancy and quality of life by reducing lung symptoms and increasing lung function in this group of patients. Furthermore, the knowledge we gain through carrying out this research may also be applied to other patients’ group, such as patients with chronic bronchitis or bronchiectasis. Findings of fungi occur in these groups of patients too; however, its relevance is unclear.

DISCUSSION