Roflumilast or Azithromycin to Prevent COPD Exacerbations (RELIANCE)

  • End date
    Feb 10, 2024
  • participants needed
  • sponsor
    Johns Hopkins University
Updated on 10 April 2021
pulmonary disease
muscarinic antagonist


A multi-center, randomized, 36-month, parallel- group, non-inferiority, phase III study to compare the effectiveness of roflumilast (Daliresp, 500 mcg quaque die (QD) or alternate regimen) therapy versus azithromycin (250 mg QD, 500 mg QD three times per week, or alternate regimen) to prevent hospitalization or death in a patients at high risk for COPD exacerbations.


RELIANCE is a U.S.-based pragmatic clinical trial funded by the Patient-Centered Outcomes Research Institute (PCORI) to compare long-term use of roflumilast vs. azithromycin in up to 3,200 patients. It is intended to support hospital efforts to reduce the risk of all-cause hospitalization and reduce pre-mature deaths in individuals with chronic obstructive pulmonary disease (COPD) who have been hospitalized in the prior year for a COPD exacerbation. The COPD Patient Powered Research Network (PPRN) and affiliated investigators will conduct the trial in sites in the U.S.

Both roflumilast and azithromycin have been shown to reduce the risk of COPD exacerbations compared to placebo. However, there has not been a head-to-head comparison of the two medications. So, the relative harms and benefits of the two medications are unknown. Eligible patients will be randomized (1:1) to receive either a prescription for roflumilast or a prescription for azithromycin, and will be followed for at least 6 and up to 36 months. The primary endpoint is the combined outcome of all-cause hospitalization or death; the secondary endpoints include premature treatment discontinuation, patient-reported adverse effects, and physical, social, and emotional health. Patients will be enrolled at participating clinical sites and follow up data will be collected via an online patient portal or via a call center. Baseline and outcome data will also be collected from site medical records and administrative/claims databases.

Pragmatic, non-inferiority trial using an intention-to-treat analysis to evaluate whether daily azithromycin is non-inferior to daily roflumilast in patients at high risk of COPD exacerbations. The investigators will randomize individual patients to receive prescriptions for roflumilast or azithromycin (1:1 ratio), stratified by site and current smoking status (yes/no).

Condition Chronic bronchitis, Chronic Obstructive Pulmonary Disease Severe, Severe Chronic Obstructive Pulmonary Disease
Treatment Azithromycin, Roflumilast
Clinical Study IdentifierNCT04069312
SponsorJohns Hopkins University
Last Modified on10 April 2021


Yes No Not Sure

Inclusion Criteria

Patient and treating clinician considering treatment intensification with roflumilast or azithromycin to reduce the risk of COPD exacerbations
Age 40 years
Current or past smoker of at least 10 pack-years
Diagnosis of severe COPD and associated chronic bronchitis
Hospitalized with a diagnosis of COPD exacerbation in the past 12 months
Current medications include inhaled Long Acting Muscarinic Antagonist (LAMA), Long Acting Beta Agonist (LABA) /LAMA, or Inhaled Corticosteroids (ICS) /LABA
English or Spanish speaking

Exclusion Criteria

Unable or declines to provide informed consent
Declines to provide social security number or health insurance claims number (as applicable)
History of intolerance to azithromycin or roflumilast that the patient or patient's treating clinician considers sufficiently serious to avoid either treatment option
Current treatment with long-term (more than 30 days) roflumilast or azithromycin (previous treatment with 1 or more doses of azithromycin or roflumilast is not an exclusion criterion, as long as the patient and clinician are seeking treatment intensification options and would be willing to use azithromycin or roflumilast, as per randomized treatment assignment.)
Known hypersensitivity to azithromycin, erythromycin, any macrolide or ketolide antibiotic
History of cholestatic jaundice/hepatic dysfunction associated with prior use of azithromycin
Moderate to severe liver impairment (Child-Pugh B or C)
Current pregnancy
Any other clinician-determined exclusion as per the clinician's clinical practice
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