In bronchiectasis, how symptomatic the patient is may pick the drug

Design

post hoc analysis of two multicentre randomised controlled trials, stratified by baseline symptom burden

Population

224 patients with bronchiectasis in SAVE-BE (florensocatib) and 357 in TORNASOL (inhaled tobramycin)

Primary outcome

association between baseline QoL-B Respiratory Symptom Scale and treatment effect

Effect

florensocatib exacerbation RR 0.47 (95% CI 0.33-0.67) overall, no significant symptom improvement; tobramycin symptom improvement exceeding the 8-point threshold in high-symptom patients

A post hoc analysis of two randomised trials asked whether baseline symptom burden, measured on the Quality of Life-Bronchiectasis Respiratory Symptom Scale, predicts who responds to what. SAVE-BE (n = 224) tested florensocatib, a DPP-1 inhibitor acting on neutrophil serine proteases; TORNASOL (n = 357) tested inhaled tobramycin.

The two behaved differently. Florensocatib cut exacerbations against placebo (RR 0.47, 95% CI 0.33-0.67), with relative risks of 0.53 in high-symptom and 0.40 in low-symptom patients, but produced no significant symptomatic improvement in either. Tobramycin improved symptom scores by a clinically meaningful margin — above the 8-point threshold in high-symptom patients — and reduced bronchitic symptoms, with greater benefit the more symptomatic the patient was at baseline.

The suggested rule is that anti-inflammatory therapy prevents events while anti-infective therapy relieves symptoms, and that a simple questionnaire score might indicate which the patient in front of you needs. It is a hypothesis drawn from two separate trials analysed after the fact, not a comparison — the two drugs were never tested against each other. But the score is free, takes minutes, and is worth recording now so that the question can be asked properly later.

• Record a symptom score at baseline in bronchiectasis; it costs nothing and may become a stratification tool
• Do not expect a DPP-1 inhibitor to make the patient feel better — it reduced exacerbations without improving symptoms
• The two drugs were tested in separate trials; this is not a head-to-head comparison
• Exacerbation frequency and symptom burden are different problems and may need different answers
• Inhaled tobramycin availability and cost vary widely in Indian practice; confirm before raising it

Why it matters

It raises the possibility that a free questionnaire, not a biomarker, separates who needs an anti-inflammatory from who needs an antibiotic.

Don't overread it

Post hoc subgroup analysis across two unrelated trials — no direct comparison was made and none of this is confirmatory.

The statistics, in plain English

Comparing subgroup relative risks across two different trials is not a statistical comparison, and the authors call the findings hypothesis-generating for exactly that reason. The 8-point threshold on the symptom scale is what patients can perceive; tobramycin crossed it in the high-symptom group, meaning the improvement was noticeable rather than merely measurable.

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