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Rollins DR, Good JT, Martin RJ. The role of atypical infections and macrolide therapy in patients with asthma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2014; 2:511-7. [PMID: 25213043 DOI: 10.1016/j.jaip.2014.06.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 04/07/2014] [Revised: 05/30/2014] [Accepted: 06/04/2014] [Indexed: 11/16/2022]
Abstract
For many years, the clinical benefit of macrolide use has been recognized in specific groups of patients with pulmonary disease. Dramatic improvement in survival of patients with diffuse panbronchiolitis is the most striking example of successful macrolide use as well as treatment of community acquired pneumonia caused by the atypical bacteria Mycoplasma, Chlamydophila, and Legionella. There also has been documentation of reduction in the exacerbation rate and of improvement in quality of life in patients with cystic fibrosis, bronchiectasis, chronic obstructive pulmonary disease, and reduction in post-lung transplantation bronchiolitis frequency. There has long been an interest in treating patients with severe asthma by using macrolides, but research results have not shown consistent clinical benefit in their use in the "general" population of patients with severe asthma. Rather, the successful use of macrolides seems to be in those patients with either documented Mycoplasma or Chlamydophila infection, or noneosinophilic asthma. Patients with neutrophil predominant phenotype severe asthma tend to show a decline in exacerbation rate, improved peak expiratory flows, and improved quality of life when treated with macrolides. This article will review the use of macrolides in the treatment of asthma.
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Affiliation(s)
- Donald R Rollins
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, National Jewish Health, Denver, Colo; Department of Medicine, National Jewish Health, Denver, Colo.
| | - James T Good
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, National Jewish Health, Denver, Colo; Department of Medicine, National Jewish Health, Denver, Colo
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52
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Newer glucocorticosteroids and corticosteroid resistance reversal in asthma. Pharm Pat Anal 2014; 2:373-85. [PMID: 24237063 DOI: 10.4155/ppa.13.14] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Inflammation is the hallmark of asthma. Glucocorticosteroids inhibit this inflammation and are the mainstay of therapy in asthma, however, they suffer from their own drawbacks. They possess high potency but their continued use has a negative influence on health. Hence, quest for a steroid with good potency but without the undesirable effects is ongoing. Besides, steroid resistance is a problem in a substantial proportion of severe asthmatics. Deeper insight into the molecular mechanism of this refractoriness has led to the successful trial of certain drugs to overcome this problem. This review attempts to discuss some of the patents related to improved glucocorticoids and those agents that have the potential to restore steroid sensitivity in severe asthmatics.
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Wong EHC, Porter JD, Edwards MR, Johnston SL. The role of macrolides in asthma: current evidence and future directions. THE LANCET RESPIRATORY MEDICINE 2014; 2:657-70. [PMID: 24948430 DOI: 10.1016/s2213-2600(14)70107-9] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Macrolides, such as clarithromycin and azithromycin, possess antimicrobial, immunomodulatory, and potential antiviral properties. They represent a potential therapeutic option for asthma, a chronic inflammatory disorder characterised by airway hyper-responsiveness that leads to recurrent episodes of wheezing, breathlessness, chest tightness, and coughing. Results from clinical trials, however, have been contentious. The findings could be confounded by many factors, including the heterogeneity of asthma, treatment duration, dose, and differing outcome measures. Recent evidence suggests improved effectiveness of macrolides in patients with sub-optimally controlled severe neutrophilic asthma and in asthma exacerbations. We examine the evidence from clinical trials and discuss macrolide properties and their relevance to the pathophysiology of asthma. At present, the use of macrolides in chronic asthma or acute exacerbations is not justified. Further work, including proteomic, genomic, and microbiome studies, will advance our knowledge of asthma phenotypes, and help to identify a macrolide-responsive subgroup. Future clinical trials should target this subgroup and place emphasis on clinically relevant outcomes such as asthma exacerbations.
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Affiliation(s)
- Ernie H C Wong
- Airway Disease Infection Section, National Heart and Lung Institute, Imperial College London, London, UK; MRC and Asthma UK Centre in Allergic Mechanisms of Asthma, London, UK; Centre for Respiratory Infection, London, UK; Imperial College Healthcare NHS Trust, London, UK
| | - James D Porter
- Airway Disease Infection Section, National Heart and Lung Institute, Imperial College London, London, UK; MRC and Asthma UK Centre in Allergic Mechanisms of Asthma, London, UK; Centre for Respiratory Infection, London, UK
| | - Michael R Edwards
- Airway Disease Infection Section, National Heart and Lung Institute, Imperial College London, London, UK; MRC and Asthma UK Centre in Allergic Mechanisms of Asthma, London, UK; Centre for Respiratory Infection, London, UK
| | - Sebastian L Johnston
- Airway Disease Infection Section, National Heart and Lung Institute, Imperial College London, London, UK; MRC and Asthma UK Centre in Allergic Mechanisms of Asthma, London, UK; Centre for Respiratory Infection, London, UK; Imperial College Healthcare NHS Trust, London, UK.
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54
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Moore WC, Hastie AT, Li X, Li H, Busse WW, Jarjour NN, Wenzel SE, Peters SP, Meyers DA, Bleecker ER. Sputum neutrophil counts are associated with more severe asthma phenotypes using cluster analysis. J Allergy Clin Immunol 2014; 133:1557-63.e5. [PMID: 24332216 PMCID: PMC4040309 DOI: 10.1016/j.jaci.2013.10.011] [Citation(s) in RCA: 429] [Impact Index Per Article: 42.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2013] [Revised: 09/04/2013] [Accepted: 10/11/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND Clinical cluster analysis from the Severe Asthma Research Program (SARP) identified 5 asthma subphenotypes that represent the severity spectrum of early-onset allergic asthma, late-onset severe asthma, and severe asthma with chronic obstructive pulmonary disease characteristics. Analysis of induced sputum from a subset of SARP subjects showed 4 sputum inflammatory cellular patterns. Subjects with concurrent increases in eosinophil (≥2%) and neutrophil (≥40%) percentages had characteristics of very severe asthma. OBJECTIVE To better understand interactions between inflammation and clinical subphenotypes, we integrated inflammatory cellular measures and clinical variables in a new cluster analysis. METHODS Participants in SARP who underwent sputum induction at 3 clinical sites were included in this analysis (n = 423). Fifteen variables, including clinical characteristics and blood and sputum inflammatory cell assessments, were selected using factor analysis for unsupervised cluster analysis. RESULTS Four phenotypic clusters were identified. Cluster A (n = 132) and B (n = 127) subjects had mild-to-moderate early-onset allergic asthma with paucigranulocytic or eosinophilic sputum inflammatory cell patterns. In contrast, these inflammatory patterns were present in only 7% of cluster C (n = 117) and D (n = 47) subjects who had moderate-to-severe asthma with frequent health care use despite treatment with high doses of inhaled or oral corticosteroids and, in cluster D, reduced lung function. The majority of these subjects (>83%) had sputum neutrophilia either alone or with concurrent sputum eosinophilia. Baseline lung function and sputum neutrophil percentages were the most important variables determining cluster assignment. CONCLUSION This multivariate approach identified 4 asthma subphenotypes representing the severity spectrum from mild-to-moderate allergic asthma with minimal or eosinophil-predominant sputum inflammation to moderate-to-severe asthma with neutrophil-predominant or mixed granulocytic inflammation.
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Affiliation(s)
- Wendy C Moore
- Wake Forest School of Medicine, Center for Genomics and Personalized Medicine Research and the Section on Pulmonary, Critical Care, Allergy and Immunologic Diseases, Winston-Salem, NC.
| | - Annette T Hastie
- Wake Forest School of Medicine, Center for Genomics and Personalized Medicine Research and the Section on Pulmonary, Critical Care, Allergy and Immunologic Diseases, Winston-Salem, NC
| | - Xingnan Li
- Wake Forest School of Medicine, Center for Genomics and Personalized Medicine Research and the Section on Pulmonary, Critical Care, Allergy and Immunologic Diseases, Winston-Salem, NC
| | - Huashi Li
- Wake Forest School of Medicine, Center for Genomics and Personalized Medicine Research and the Section on Pulmonary, Critical Care, Allergy and Immunologic Diseases, Winston-Salem, NC
| | - William W Busse
- University of Wisconsin School of Medicine and Public Health, Allergy, Pulmonary and Critical Care Division, Madison, Wis
| | - Nizar N Jarjour
- University of Wisconsin School of Medicine and Public Health, Allergy, Pulmonary and Critical Care Division, Madison, Wis
| | - Sally E Wenzel
- University of Pittsburgh School of Medicine, Pulmonary, Allergy and Critical Care Medicine, Pittsburgh, Pa
| | - Stephen P Peters
- Wake Forest School of Medicine, Center for Genomics and Personalized Medicine Research and the Section on Pulmonary, Critical Care, Allergy and Immunologic Diseases, Winston-Salem, NC
| | - Deborah A Meyers
- Wake Forest School of Medicine, Center for Genomics and Personalized Medicine Research and the Section on Pulmonary, Critical Care, Allergy and Immunologic Diseases, Winston-Salem, NC
| | - Eugene R Bleecker
- Wake Forest School of Medicine, Center for Genomics and Personalized Medicine Research and the Section on Pulmonary, Critical Care, Allergy and Immunologic Diseases, Winston-Salem, NC
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Kim TH. Respiratory reviews in asthma 2013. Tuberc Respir Dis (Seoul) 2014; 76:105-13. [PMID: 24734097 PMCID: PMC3982236 DOI: 10.4046/trd.2014.76.3.105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2014] [Revised: 02/21/2014] [Accepted: 02/28/2014] [Indexed: 11/24/2022] Open
Abstract
From January 2012 up until March 2013, many articles with huge clinical importance in asthma were published based on large numbered clinical trials or meta-analysis. The main subjects of these studies were the new therapeutic plan based on the asthma phenotype or efficacy along with the safety issues regarding the current treatment guidelines. For efficacy and safety issues, inhaled corticosteroid tapering strategy or continued long-acting beta agonists use was the major concern. As new therapeutic trials, monoclonal antibodies or macrolide antibiotics based on inflammatory phenotypes have been under investigation, with promising preliminary results. There were other issues on the disease susceptibility or genetic background of asthma, particularly for the "severe asthma" phenotype. In the era of genome and pharmacogenetics, there have been extensive studies to identify susceptible candidate genes based on the results of genome wide association studies (GWAS). However, for severe asthma, which is where most of the mortality or medical costs develop, it is very unclear. Moreover, there have been some efforts to find important genetic information in order to predict the possible disease progression, but with few significant results up until now. In conclusion, there are new on-going aspects in the phenotypic classification of asthma and therapeutic strategy according to the phenotypic variations. With more pharmacogenomic information and clear identification of the "severe asthma" group even before disease progression from GWAS data, more adequate and individualized therapeutic strategy could be realized in the future.
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Affiliation(s)
- Tae-Hyung Kim
- Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Seoul, Korea
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57
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Jouneau S, Desrues B. [Long-term macrolide treatment in adult chronic bronchial diseases: benefits and limits]. Presse Med 2014; 43:510-9. [PMID: 24631048 DOI: 10.1016/j.lpm.2013.08.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2013] [Revised: 07/03/2013] [Accepted: 08/19/2013] [Indexed: 10/25/2022] Open
Abstract
Decreased frequency of pulmonary exacerbations, mainly related to immunomodulatory effects of macrolide antibiotics, has been demonstrated in bronchiectasis and chronic obstructive pulmonary diseases (COPD). Due to its tolerance, azithromycin is the antibiotic of choice for maintenance therapy at the dose of 250 mg per day or 500 mg × 3 per week (for body weight >55 kg). Maintenance therapy with macrolide could be proposed in selected patients with bronchiectasis or COPD with more than 3 acute exacerbations in the previous year or decreased lung function despite compliance with optimum treatment. The risk of sudden cardiac death with azithromycin is rare and controversial. It should be avoided in patients with a high baseline risk of cardiovascular disease, QT>450 msec, pulse rate>100 bpm and potential drug interactions, particularly those known to cause QT prolongation. It is recommended to search for hearing deficit (audiometry) and sputum culture positive for mycobacteria. Patients must also be aware that it can rapidly lead to macrolide resistance in commensal or pathogenic flora. Follow-up evaluation every 3 month can be proposed with medical history (hearing deficit) and electrocardiography. After one year, the treatment should be stopped in the absence of reduction in the frequency of exacerbations.
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Affiliation(s)
- Stéphane Jouneau
- Centre hospitalier universitaire de Rennes, hôpital Pontchaillou, service de pneumologie, 35033 Rennes cedex 9, France; IRSET-UMR Inserm U1085, 35043 Rennes cedex, France
| | - Benoît Desrues
- Centre hospitalier universitaire de Rennes, hôpital Pontchaillou, service de pneumologie, 35033 Rennes cedex 9, France.
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Sutherland ER, Busse WW. Designing clinical trials to address the needs of childhood and adult asthma: the National Heart, Lung, and Blood Institute's AsthmaNet. J Allergy Clin Immunol 2014; 133:34-8.e1. [PMID: 24369797 DOI: 10.1016/j.jaci.2013.10.025] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Revised: 10/09/2013] [Accepted: 10/14/2013] [Indexed: 10/25/2022]
Abstract
In 2008, the National Heart, Lung, and Blood Institute announced its intent to support a new asthma network known as AsthmaNet. This clinical trials consortium, now in its fifth year, has been charged with developing and executing clinical trials to address the most important asthma management questions and identify new treatment approaches in pediatric and adult patients. This review will discuss the organization of AsthmaNet and the scientific context in which the network was developed and began its work, report the results of an internal priority-setting exercise designed to guide the network's scientific strategy, and highlight the portfolio of clinical trials, proof-of-concept studies, and mechanistic studies planned for the 7-year period of the network to update the global asthma community regarding the progress and processes of the network.
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Affiliation(s)
- E Rand Sutherland
- Department of Medicine, National Jewish Health, the University of Colorado School of Medicine, Denver, Colo.
| | - William W Busse
- Department of Medicine, University of Wisconsin, Madison, Wis
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Abstract
The pathogenetic mechanisms leading to asthma are likely to be diverse, influenced by multiple genetic polymorphisms as well as elements of the environment. Recent data on the microbiome of the airway have revealed intriguing differences between the number and diversity of microbial populations in healthy persons and asthmatics. There is convincing evidence that early viral infections, particularly with human rhinovirus and respiratory syncytial virus, are often associated with the development of chronic asthma and with exacerbations. Recent studies suggest that two unrelated types of atypical bacteria, Mycoplasma pneumoniae (Mpn) and Chlamydia pneumoniae, are present in the airways of a substantial proportion of the population, bringing up the possibility that the persistent presence of the organism may contribute to the asthmatic phenotype in a subset of patients. This review will examine the current data regarding a possible role for infection in chronic asthma with a particular focus on atypical bacterial infections.
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Affiliation(s)
- T Prescott Atkinson
- Children's of Alabama CPP M220, 1601 4th Ave South, Birmingham, AL, 35233, USA,
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60
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Sumino K, Sugar EA, Irvin CG, Kaminsky DA, Shade D, Wei CY, Holbrook JT, Wise RA, Castro M. Variability of methacholine bronchoprovocation and the effect of inhaled corticosteroids in mild asthma. Ann Allergy Asthma Immunol 2014; 112:354-60.e1. [PMID: 24507830 DOI: 10.1016/j.anai.2014.01.013] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Revised: 01/09/2014] [Accepted: 01/13/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND The methacholine challenge test quantifies airway hyper-responsiveness, which is measured by the provocative concentration of methacholine causing a 20% decrease in forced expiration volume in 1 second (PC20). The dose-response effect of inhaled corticosteroids (ICS) on PC20 has been inconsistent and within-patient variability of PC20 is not well established. OBJECTIVE To determine the effect of high- vs low-dose ICS on PC20 and within-patient variability in those with repeated measurements of PC20. METHODS A randomized, double-masked, crossover trial was conducted in patients with asthma on controller medications with PC20 of 8 mg/mL or lower (n = 64) to evaluate the effect of high-dose (1,000 μg/d) vs low-dose (250 μg/d) fluticasone for 4 weeks on PC20. In addition, the variability of PC20 was assessed in participants who underwent 2 or 3 PC20 measurements on the same dose of ICS (n = 27) over a 4-week interval. RESULTS Because there was a significant period effect, dose comparison of the change in PC20 was assessed in the first treatment period. There was no significant difference in the change in PC20 for high- vs low-dose ICS (39% vs 30% increase, respectively; P = .87). The within- and between-participant variances for log PC20 were 0.84 and 0.96, respectively, with an intra-class correlation of 0.53, and 37% of participants had more than 2 doubling dose changes in PC20 in those with repeated measurements. CONCLUSION The effect of ICS on PC20 is not dose dependent at fluticasone levels of 250 and 1,000 μg/d. Interpersonal variability for PC20 is large. A lack of precise measurements should be taken into account when interpreting any change in PC20.
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Affiliation(s)
- Kaharu Sumino
- Washington University School of Medicine, St Louis, Missouri; St Louis VA Medical Center, St Louis, Missouri.
| | - Elizabeth A Sugar
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland; Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Charles G Irvin
- University of Vermont College of Medicine, Burlington, Vermont
| | | | - Dave Shade
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Christine Y Wei
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Janet T Holbrook
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Robert A Wise
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mario Castro
- Washington University School of Medicine, St Louis, Missouri
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Cameron EJ, Chaudhuri R, Mair F, McSharry C, Greenlaw N, Weir CJ, Jolly L, Donnelly I, Gallacher K, Morrison D, Spears M, Evans TJ, Anderson K, Thomson NC. Randomised controlled trial of azithromycin in smokers with asthma. Eur Respir J 2013; 42:1412-5. [PMID: 24036246 PMCID: PMC3814414 DOI: 10.1183/09031936.00093913] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Euan J Cameron
- Immunity and Inflammation, University of Glasgow, Glasgow
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New treatments for severe treatment-resistant asthma: targeting the right patient. THE LANCET RESPIRATORY MEDICINE 2013; 1:639-652. [PMID: 24461667 DOI: 10.1016/s2213-2600(13)70128-0] [Citation(s) in RCA: 70] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Guidelines for asthma management focus on the use of combination inhaled treatment with corticosteroids and longacting β-agonists for symptomatic asthma. In more severe disease, other drugs such as leukotriene blockers and slow-release oral theophylline are added, with oral corticosteroids and anti-immunoglobulin E treatment with omalizumab for the most severe cases of asthma. Once-daily longacting β-agonists and inhaled corticosteroids are being developed. Longacting muscarinic antagonists might also provide additive benefit. New approaches are needed for the treatment of severe asthma, but patients need to be endotyped so that they can be directed for specific treatments. This Review focuses on the role of eosinophilic and neutrophilic inflammation, the attributes of chronic airflow obstruction, and the notion of corticosteroid insensitivity because potential targets for treatment have started to emerge from such analyses. How the best phenotypic or even better, the best endotypic responder with each new treatment, can be established will also be discussed. Newer treatments for asthma will emerge from better endotyping, leading to personalised medicine in asthma.
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Reiter J, Demirel N, Mendy A, Gasana J, Vieira ER, Colin AA, Quizon A, Forno E. Macrolides for the long-term management of asthma--a meta-analysis of randomized clinical trials. Allergy 2013; 68:1040-9. [PMID: 23895667 DOI: 10.1111/all.12199] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/06/2013] [Indexed: 11/26/2022]
Abstract
BACKGROUND Macrolide antibiotics, which have anti-inflammatory and immune modulatory effects, have been studied as adjuncts for the management of asthma. However, results have been contradictory and trials underpowered. We therefore sought to conduct a meta-analysis of randomized controlled trials (RCT). METHODS All RCT of prolonged macrolides (3+ weeks) for asthma treatment, published up to January 2013 in MEDLINE, Scopus, CINAHL, Highwire, and The Cochrane Collaboration Library, were included. Fixed- or random-effects models were used to calculate pooled weighted or standard mean differences (WMD or SMD, respectively). RESULTS A total of 12 studies were included for analysis. The pooled effect of macrolides on FEV1 (eight trials, 381 subjects) was not significant (SMD 0.05, 95% CI -0.14-0.25), but there was a significant increase in peak expiratory flow (four trials, 419 subjects; WMD 6.7, 95% CI 1.35-12.06). Pooled analysis also showed significant improvements in symptom scores (eight studies, 478 subjects; WMD -0.46, 95% CI -0.60 to -0.32), quality of life (five trials, 346 subjects; WMD 0.18, 95% CI 0.001-0.37), and airway hyper-reactivity (two trials, 131 subjects; SMD 1.99, 95% CI 0.46-3.52). Post hoc evaluation showed limited statistical power to detect significant differences in FEV1. CONCLUSIONS Macrolide administration for asthma for three or more weeks was not associated with improvement in FEV1, but produced significant improvements in peak expiratory flow, symptoms, quality of life, and airway hyper-reactivity. Macrolides may therefore be beneficial as adjunct asthma therapy. Future trials, focusing on long-term safety and effectiveness, should use standardized outcomes and procedures.
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Affiliation(s)
| | | | - A. Mendy
- Department of Epidemiology; College of Public Health; University of Iowa; Iowa City; IA; USA
| | - J. Gasana
- South Florida Asthma Consortium; Ft Lauderdale; FL; USA
| | - E. R. Vieira
- Department of Physical Therapy; Florida International University; Miami; FL; USA
| | - A. A. Colin
- Division of Pediatric Pulmonology; Department of Pediatrics; University of Miami; Miami; FL; USA
| | - A. Quizon
- Division of Pediatric Pulmonology; Department of Pediatrics; University of Miami; Miami; FL; USA
| | - E. Forno
- Division of Pulmonary Medicine; Department of Pediatrics; Children's Hospital of Pittsburgh of UPMC; Pittsburgh; PA; USA
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Abstract
A significant number of older asthmatics, more often than in previous ages, have poorly controlled asthma, leading to increased morbidity and mortality. On the other hand, current guidelines suggest that most asthmatics can obtain achievement and maintenance of disease control and do not include sections specific to the management of asthma in the elderly so that it is more evident the contrast between poor control of asthma in the elderly and the lack of specific guidance from guidelines on asthma management in older asthmatics. Inhaled corticosteroids are the cornerstone for older asthmatics, eventually with add-on inhaled long-acting beta-agonists; inhaled short acting beta-agonists can be used as rescue medications. Triggers exacerbating asthma are similar for all ages, but inhaled viruses and drug interactions have greater clinical significance in the elderly. Older asthmatics have an increased likelihood of comorbidities and polypharmacy, with possible worsening of asthma control and reduced treatment adherence. Physicians and older asthmatics probably either do not perceive or accept a poor asthma control. We conclude that specific instruments addressed to evaluate asthma control in the elderly with concomitant comorbidities and measurements for improving self-management and adherence could assure better disease control in older asthmatics.
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Affiliation(s)
- Andrea S Melani
- Fisiopatologia e Riabilitazione Respiratoria, Dipartimento Vasi, Cuore e Torace, Policlinico Le Scotte, Azienda Ospedaliera Universitaria Senese, 53100 Siena, Italy.
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Abstract
Asthma is one of the most common conditions seen in clinical practice and carries both a significant disease burden in terms of patient morbidity and a high economic burden in both direct and indirect costs. Despite this, it remains a comparatively poorly understood disease, with only modest advances in treatment over the past decade. Corticosteroids remain the cornerstone of therapy. Both patient compliance with medications and physician adherence to evidence-based guidelines are often poor, and a high percentage of patients continue to have inadequately controlled disease even with optimal therapy. Following a contextual overview of the current treatment guidelines, this review focuses on novel asthma therapies, beginning with the introduction of the leukotriene receptor antagonist zafirlukast in the 1990s, continuing through advanced endoscopic therapy and into cytokine-directed biologic agents currently in development. Along with clinically relevant biochemistry and pharmacology, the evidence supporting the place of these therapies in current guidelines will be highlighted along with data comparing these agents with more conventional treatment. A brief discussion of other drugs, such as those developed for unrelated conditions and subsequently examined as potential asthma therapies, is included.
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Dzhindzhikhashvili MS, Joks R, Smith-Norowitz T, Durkin HG, Chotikanatis K, Estrella E, Hammerschlag MR, Kohlhoff SA. Doxycycline suppresses Chlamydia pneumoniae-mediated increases in ongoing immunoglobulin E and interleukin-4 responses by peripheral blood mononuclear cells of patients with allergic asthma. J Antimicrob Chemother 2013; 68:2363-8. [PMID: 23749949 DOI: 10.1093/jac/dkt179] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Chlamydia pneumoniae, an obligate intracellular bacterium, has been associated with asthma and the induction of immunoglobulin E (IgE) responses. Whereas tetracyclines have anti-chlamydial activity, their effect on human IgE responses to C. pneumoniae has not been studied. METHODS Peripheral blood mononuclear cells (PBMCs) from serum IgE+ allergic asthmatic subjects (n = 11) and healthy controls (n = 12) were infected with C. pneumoniae and cultured for 12 days with or without doxycycline (0.01-1.0 mg/L). IgE, interferon (IFN)-γ and interleukin (IL)-4 levels in supernatants were determined on days 1-12 post-infection, and C. pneumoniae DNA copy numbers in PBMC culture were measured on day 2 (quantitative PCR). RESULTS C. pneumoniae-infected PBMCs from allergic asthmatic individuals had increased levels of IgE in supernatants compared with uninfected PBMCs (520% on day 10 post-infection, P = 0.008). IgE levels in PBMC cultures from controls were undetectable (<0.3 ng/mL). Increases in C. pneumoniae-induced IgE in asthmatics correlated with those of C. pneumoniae-induced IL-4 (r = 0.98; P < 0.001), but not with IFN-γ. The addition of doxycycline (1.0 mg/L) to the culture strongly suppressed the production of IgE (>70%, P = 0.04) and IL-4 (75%, P = 0.018), but not IFN-γ. The suppressive effect on IL-4 production remained significant even at concentrations of doxycycline that were subinhibitory (0.01 mg/L) for C. pneumoniae. In both asthmatic participants and controls, no significant effect of doxycycline on DNA copy numbers of C. pneumoniae was observed. CONCLUSIONS Doxycycline suppressed the C. pneumoniae-induced production of IgE and IL-4, but not IFN-γ, in PBMCs from IgE+ allergic asthmatic subjects. These findings resulted from the immunomodulatory anti-allergic properties of tetracyclines.
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Affiliation(s)
- M S Dzhindzhikhashvili
- Center for Allergy and Asthma Research at SUNY Downstate, State University of New York (SUNY) Downstate Medical Center, 450 Clarkson Ave., Brooklyn, NY 11203, USA
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Biomarker surrogates do not accurately predict sputum eosinophil and neutrophil percentages in asthmatic subjects. J Allergy Clin Immunol 2013; 132:72-80. [PMID: 23706399 DOI: 10.1016/j.jaci.2013.03.044] [Citation(s) in RCA: 189] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2012] [Revised: 03/05/2013] [Accepted: 03/13/2013] [Indexed: 01/21/2023]
Abstract
BACKGROUND Sputum eosinophil percentages are a strong predictor of airway inflammation and exacerbations and aid asthma management, whereas sputum neutrophil percentages indicate a different severe asthma phenotype that is potentially less responsive to TH2-targeted therapy. Variables, such as blood eosinophil counts, total IgE levels, fraction of exhaled nitric oxide (Feno) levels, or FEV1 percent predicted, might predict airway eosinophil percentages, whereas age, FEV1 percent predicted, or blood neutrophil counts might predict sputum neutrophil percentages. Availability and ease of measurement are useful characteristics, but accuracy in predicting airway eosinophil and neutrophil percentages either individually or combined is not established. OBJECTIVES We sought to determine whether blood eosinophil counts, Feno levels, and IgE levels accurately predict sputum eosinophil percentages and whether age, FEV1 percent predicted, and blood neutrophil counts accurately predict sputum neutrophil percentages. METHODS Subjects in the Wake Forest Severe Asthma Research Program (n = 328) were characterized by blood and sputum cell counts, health care use, lung function, Feno levels, and IgE levels. Multiple analytic techniques were used. RESULTS Despite significant association with sputum eosinophil percentages, blood eosinophil counts, Feno levels, and total IgE levels did not accurately predict sputum eosinophil percentages, and combinations of these variables did not improve prediction. Age, FEV1 percent predicted, and blood neutrophil counts were similarly unsatisfactory for the prediction of sputum neutrophil percentages. Factor analysis and stepwise selection found Feno levels, IgE levels, and FEV1 percent predicted, but not blood eosinophil counts, correctly predicted 69% of sputum eosinophil percentages of less than 2% or 2% and greater. Likewise, age, asthma duration, and blood neutrophil counts correctly predicted 64% of sputum neutrophil percentages of less than 40% or 40% and greater. A model to predict both sputum eosinophil and neutrophil percentages accurately assigned only 41% of samples. CONCLUSION Despite statistically significant associations, Feno levels, IgE levels, blood eosinophil and neutrophil counts, FEV1 percent predicted, and age are poor surrogates, both separately and combined, for accurately predicting sputum eosinophil and neutrophil percentages.
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69
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Serisier DJ. Risks of population antimicrobial resistance associated with chronic macrolide use for inflammatory airway diseases. THE LANCET RESPIRATORY MEDICINE 2013; 1:262-74. [PMID: 24429132 DOI: 10.1016/s2213-2600(13)70038-9] [Citation(s) in RCA: 117] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Macrolide antibiotics have established efficacy in the management of cystic fibrosis and diffuse panbronchiolitis-uncommon lung diseases with substantial morbidity and the potential for rapid progression to death. Emerging evidence suggests benefits of maintenance macrolide treatment in more indolent respiratory diseases including chronic obstructive pulmonary disease and non-cystic fibrosis bronchiectasis. In view of the greater patient population affected by these disorders (and potential for macrolide use to spread to disorders such as chronic cough), widespread use of macrolides, particularly azithromycin, has the potential to substantially influence antimicrobial resistance rates of a range of respiratory microbes. In this Personal View, I explore theories around population (rather than patient) macrolide resistance, appraise evidence linking macrolide use with development of resistance, and highlight the risks posed by injudicious broadening of their use, particularly of azithromycin. These risks are weighed against the potential benefits of macrolides in less aggressive inflammatory airway disorders. A far-sighted approach to maintenance macrolide use in non-cystic fibrosis inflammatory airway diseases is needed, which minimises risks of adversely affecting community macrolide resistance: combining preferential use of erythromycin and restriction of macrolide use to those patients at greatest risk represents an appropriately cautious management approach.
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Affiliation(s)
- David J Serisier
- Department of Respiratory Medicine, Mater Adult Hospital, South Brisbane, QLD, Australia; University of Queensland and Mater Medical Research Institute, Mater Health Services, South Brisbane, QLD, Australia.
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Wood PR, Hill VL, Burks ML, Peters JI, Singh H, Kannan TR, Vale S, Cagle MP, Principe MFR, Baseman JB, Brooks EG. Mycoplasma pneumoniae in children with acute and refractory asthma. Ann Allergy Asthma Immunol 2013; 110:328-334.e1. [PMID: 23622002 DOI: 10.1016/j.anai.2013.01.022] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2012] [Revised: 01/26/2013] [Accepted: 01/28/2013] [Indexed: 11/28/2022]
Abstract
BACKGROUND The presence of Mycoplasma pneumoniae has been associated with worsening asthma in children. Sensitive assays have been developed to detect M pneumoniae-derived community-acquired respiratory distress syndrome (CARDS) toxin. OBJECTIVES To identify the frequency and persistence of M pneumoniae detection in respiratory secretions of children with and without asthma and to evaluate antibody responses to M pneumoniae and the impact of M pneumoniae on biological markers, asthma control, and quality of life. METHODS We enrolled 143 pediatric patients (53 patients with acute asthma, 26 patients with refractory asthma, and 64 healthy controls; age range, 5-17 years) during a 20-month period with 2 to 5 follow-up visits. We detected M pneumoniae using CARDS toxin antigen capture and polymerase chain reaction and P1 adhesin polymerase chain reaction. Immune responses to M pneumoniae were determined by IgG and IgM levels directed against CARDS toxin and P1 adhesin. pH was measured in exhaled breath condensates, and asthma control and quality of life were assessed using the Asthma Control Test and Pediatric Asthma Quality of Life Questionnaire. RESULTS M pneumoniae was detected in 64% of patients with acute asthma, 65% with refractory asthma, and 56% of healthy controls. Children with asthma had lower antibody levels to M pneumoniae compared with healthy controls. Exhaled breath condensate pHs and asthma control and quality of life scores were lower in M pneumoniae-positive patients with asthma. CONCLUSION The results suggest that M pneumoniae detection is common in children, M pneumoniae detection is associated with worsening asthma, and children with asthma may have poor humoral immune responses to M pneumoniae.
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Affiliation(s)
- Pamela R Wood
- Department of Pediatrics, University of Texas Health Science Center at San Antonio, San Antonio, TX 78229-3900, USA.
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Cameron EJ, McSharry C, Chaudhuri R, Farrow S, Thomson NC. Long-term macrolide treatment of chronic inflammatory airway diseases: risks, benefits and future developments. Clin Exp Allergy 2013; 42:1302-12. [PMID: 22925316 DOI: 10.1111/j.1365-2222.2012.03979.x] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Macrolide antibiotics were discovered over 50 years ago and following their use as antimicrobials it became apparent that this group of antibiotics also possessed anti-inflammatory properties. Subsequent clinical trials showed benefits of macrolides as long-term adjuncts in the treatment of a spectrum of chronic inflammatory respiratory diseases, particularly diffuse panbronchiolitis, cystic fibrosis, post-transplant bronchiolitis obliterans and more recently chronic obstructive pulmonary disease (COPD). The evidence for efficacy of macrolides in the long-term treatment of chronic asthma and bronchiectasis is less well established. The mechanism(s) of action of macrolides in the treatment of these diseases remains unexplained, but may be due to their antibacterial and/or anti-inflammatory actions, which include reductions in interleukin-8 production, neutrophil migration and/or function. Macrolides have additional potentially beneficial properties including anti-viral actions and an ability to restore corticosteroid sensitivity. The increased prescribing of macrolides for long-term treatment could result in the development of microbial resistance and adverse drug effects. New macrolides have been developed which do not possess any antimicrobial activity and hence lack the ability to produce microbial resistance, but which still retain immunomodulatory effects. Potentially novel macrolides may overcome a significant barrier to the use of this type of drug for the long-term treatment of chronic inflammatory airway diseases.
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Affiliation(s)
- E J Cameron
- Respiratory Medicine, Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK.
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72
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Abstract
Asthma in the adult patient is a complex clinical syndrome. Multiple patient phenotypes and subphenotypes exist that contribute to disease heterogeneity. Whether adult asthma begins in utero, develops in childhood, or manifests for the first time in adulthood is not completely understood, nor are the mechanisms fully delineated. In this chapter, we update definitions that apply to this group, emphasize epidemiologic factors and pathogenic mechanisms, diagnosis, therapeutic options, and controversies regarding drug safety. Finally, we provide a brief discussion of biomarker technologies and novel therapies with the potential to impact adult-onset asthma outcomes.
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Affiliation(s)
- Amir A Zeki
- UC Davis School of Medicine, Davis, CA, USA.
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Roulis E, Polkinghorne A, Timms P. Chlamydia pneumoniae: modern insights into an ancient pathogen. Trends Microbiol 2012; 21:120-8. [PMID: 23218799 DOI: 10.1016/j.tim.2012.10.009] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2012] [Revised: 10/28/2012] [Accepted: 10/31/2012] [Indexed: 01/11/2023]
Abstract
Chlamydia pneumoniae is an enigmatic human and animal pathogen. Originally discovered in association with acute human respiratory disease, it is now associated with a remarkably wide range of chronic diseases as well as having a cosmopolitan distribution within the animal kingdom. Molecular typing studies suggest that animal strains are ancestral to human strains and that C. pneumoniae crossed from animals to humans as the result of at least one relatively recent zoonotic event. Whole genome analyses appear to support this concept - the human strains are highly conserved whereas the single animal strain that has been fully sequenced has a larger genome with several notable differences. When compared to the other, better known chlamydial species that is implicated in human infection, Chlamydia trachomatis, C. pneumoniae demonstrates pertinent differences in its cell biology, development, and genome structure. Here, we examine the characteristic facets of C. pneumoniae biology, offering insights into the diversity and evolution of this silent and ancient pathogen.
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Affiliation(s)
- Eileen Roulis
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane 4059, Australia
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74
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Denlinger LC, Manthei DM, Seibold MA, Ahn K, Bleecker E, Boushey HA, Calhoun WJ, Castro M, Chinchili VM, Fahy JV, Hawkins GA, Icitovic N, Israel E, Jarjour NN, King T, Kraft M, Lazarus SC, Lehman E, Martin RJ, Meyers DA, Peters SP, Sheerar D, Shi L, Sutherland ER, Szefler SJ, Wechsler ME, Sorkness CA, Lemanske RF. P2X7-regulated protection from exacerbations and loss of control is independent of asthma maintenance therapy. Am J Respir Crit Care Med 2012; 187:28-33. [PMID: 23144325 DOI: 10.1164/rccm.201204-0750oc] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE The function of the P2X(7) nucleotide receptor protects against exacerbation in people with mild-intermittent asthma during viral illnesses, but the impact of disease severity and maintenance therapy has not been studied. OBJECTIVES To evaluate the association between P2X(7), asthma exacerbations, and incomplete symptom control in a more diverse population. METHODS A matched P2RX7 genetic case-control was performed with samples from Asthma Clinical Research Network trial participants enrolled before July 2006, and P2X(7) pore activity was determined in whole blood samples as an ancillary study to two trials completed subsequently. MEASUREMENTS AND MAIN RESULTS A total of 187 exacerbations were studied in 742 subjects, and the change in asthma symptom burden was studied in an additional 110 subjects during a trial of inhaled corticosteroids (ICS) dose optimization. African American carriers of the minor G allele of the rs2230911 loss-of-function single nucleotide polymorphism were more likely to have a history of prednisone use in the previous 12 months, with adjustment for ICS and long-acting β(2)-agonists use (odds ratio, 2.7; 95% confidence interval, 1.2-6.2; P = 0.018). Despite medium-dose ICS, attenuated pore function predicted earlier exacerbations in incompletely controlled patients with moderate asthma (hazard ratio, 3.2; confidence interval, 1.1-9.3; P = 0.033). After establishing control with low-dose ICS in patients with mild asthma, those with attenuated pore function had more asthma symptoms, rescue albuterol use, and FEV(1) reversal (P < 0.001, 0.03, and 0.03, respectively) during the ICS adjustment phase. CONCLUSIONS P2X(7) pore function protects against exacerbations of asthma and loss of control, independent of baseline severity and the maintenance therapy.
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Affiliation(s)
- Loren C Denlinger
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA.
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75
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James KM, Peebles RS, Hartert TV. Response to infections in patients with asthma and atopic disease: an epiphenomenon or reflection of host susceptibility? J Allergy Clin Immunol 2012; 130:343-51. [PMID: 22846746 PMCID: PMC3410318 DOI: 10.1016/j.jaci.2012.05.056] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2012] [Revised: 05/12/2012] [Accepted: 05/15/2012] [Indexed: 01/22/2023]
Abstract
Associations between respiratory tract infections and asthma inception and exacerbations are well established. Infant respiratory syncytial virus and rhinovirus infections are known to be associated with an increased risk of asthma development, and among children with prevalent asthma, 85% of asthma exacerbations are associated with viral infections. However, the exact nature of this relationship remains unclear. Is the increase in severity of infections an epiphenomenon, meaning respiratory tract infections just appear to be more severe in patients with underlying respiratory disease, or instead a reflection of altered host susceptibility among persons with asthma and atopic disease? The main focus of this review is to summarize the available levels of evidence supporting or refuting the notion that patients with asthma or atopic disease have an altered susceptibility to selected pathogens, as well as discussing the biological mechanism or mechanisms that might explain such associations. Finally, we will outline areas in need of further research because understanding the relationships between infections and asthma has important implications for asthma prevention and treatment, including potential new pathways that might target the host immune response to select pathogens.
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Affiliation(s)
- Kristina M James
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN 37232-8300, USA
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76
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Szefler SJ, Chinchilli VM, Israel E, Denlinger LC, Lemanske RF, Calhoun W, Peters SP. Key observations from the NHLBI Asthma Clinical Research Network. Thorax 2012; 67:450-5. [PMID: 22514237 DOI: 10.1136/thoraxjnl-2012-201876] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
The National Heart, Lung and Blood Institute (NHLBI) Asthma Clinical Research Network (ACRN) recently completed its work after 20 years of collaboration as a multicentre clinical trial network. When formed, its stated mission was to perform multiple controlled clinical trials for treating patients with asthma by dispassionately examining new and existing therapies, and to rapidly communicate its findings to the medical community. The ACRN conducted 15 major clinical trials. In addition, clinical data, manual of operations, protocols and template informed consents from all ACRN trials are available via NHLBI BioLINCC (https://biolincc.nhlbi.nih.gov/studies/). This network contributed major insights into the use of inhaled corticosteroids, short-acting and long-acting ß-adrenergic agonists, leukotriene receptor antagonists, and novel agents (tiotropium, colchicine and macrolide antibiotics). They also pioneered studies of the variability in drug response, predictors of treatment response and pharmacogenetics. This review highlights the major research observations from the ACRN that have impacted the current management of asthma.
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Affiliation(s)
- Stanley J Szefler
- Department of Pediatrics, National Jewish Health and University of Colorado Denver, School of Medicine, Denver, Colorado 80206, USA.
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Caramori G, Papadopoulos N, Contoli M, Marku B, Forini G, Pauletti A, Johnston SL, Papi A. Asthma: a chronic infectious disease? Clin Chest Med 2012; 33:473-84. [PMID: 22929096 DOI: 10.1016/j.ccm.2012.06.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
There are increasing data to support the "hygiene" and "microbiota" hypotheses of a protective role of infections in modulating the risk of subsequent development of asthma. There is less evidence that respiratory infections can actually cause the development of asthma. There is some evidence that rhinovirus respiratory infections are associated with the development of asthma, particularly in childhood, whereas these infections in later life seem to have a weaker association with the development of asthma. The role of bacterial infections in chronic asthma remains unclear. This article reviews the available evidence indicating that asthma may be considered as a chronic infectious disease.
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Affiliation(s)
- Gaetano Caramori
- Section of Respiratory Diseases, Department of Medical Sciences, Centro per lo Studio delle Malattie Infiammatorie Croniche delle Vie Aeree e Patologie Fumo Correlate dell'Apparato Respiratorio, University of Ferrara, via Savonarola 9, 44121, Ferrara, Italy
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Barnes PJ. Severe asthma: advances in current management and future therapy. J Allergy Clin Immunol 2012; 129:48-59. [PMID: 22196524 DOI: 10.1016/j.jaci.2011.11.006] [Citation(s) in RCA: 127] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2011] [Revised: 11/08/2011] [Accepted: 11/10/2011] [Indexed: 12/17/2022]
Abstract
Effective treatment of severe asthma is a major unmet need because patients' symptoms are not controlled on maximum treatment with inhaled therapy. Asthma symptoms can be poorly controlled because of poor adherence to controller therapy, and this might be addressed by using combination inhalers that contain a corticosteroid and long-acting β(2)-agonist as reliever therapy in addition to maintenance treatment. New bronchodilators with a longer duration of action are in development, and recent studies have demonstrated the benefit of a long-acting anticholinergic bronchodilator in addition to β(2)-agonists in patients with severe asthma. Anti-IgE therapy is beneficial in selected patients with severe asthma. Several new blockers of specific mediators, including prostaglandin D(2), IL-5, IL-9, and IL-13, are also in clinical trials and might benefit patients with subtypes of severe asthma. Several broad-spectrum anti-inflammatory therapies that target neutrophilic inflammation are in clinical development for the treatment of severe asthma, but adverse effects after oral administration might necessitate inhaled delivery. Macrolides might benefit some patients with infection by atypical bacteria, but recent results are not encouraging, although there could be an effect in patients with predominant neutrophilic asthma. Corticosteroid resistance is a major problem in patients with severe asthma, and several molecular mechanisms have been described that might lead to novel therapeutic approaches, including drugs that could reverse this resistance, such as theophylline and nortriptyline. In selected patients with severe asthma, bronchial thermoplasty might be beneficial, but thus far, clinical studies have not been encouraging. Finally, several subtypes of severe asthma are now recognized, and in the future, it will be necessary to find biomarkers that predict responses to specific forms of therapy.
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Affiliation(s)
- Peter J Barnes
- National Heart and Lung Institute, Imperial College, London, United Kingdom.
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79
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Just J, Gouvis-Echraghi R, Couderc R, Guillemot-Lambert N, Saint-Pierre P. Novel severe wheezy young children phenotypes: boys atopic multiple-trigger and girls nonatopic uncontrolled wheeze. J Allergy Clin Immunol 2012; 130:103-10.e8. [PMID: 22502798 DOI: 10.1016/j.jaci.2012.02.041] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2011] [Revised: 02/09/2012] [Accepted: 02/13/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND Recurrent wheezing during infancy is a heterogeneous disorder that has been associated with early-onset asthma. OBJECTIVE To identify phenotypes of severe recurrent wheezing and therapeutic approaches. METHODS We performed cluster analysis with 20 variables of 551 children with active asthma, younger than 36 months old, and enrolled in the Trousseau Asthma Program. RESULTS We identified 3 independent clusters of children with wheezing. Cluster 1, mild episodic viral wheeze (n= 327), consisted of children with wheezing related only to colds (71%), mild disease (76%), and mainly normal chest x-ray results. Cluster 2, nonatopic uncontrolled wheeze (n = 157), was characterized by moderate to severe disease (91%), uncontrolled wheezing despite high doses of inhaled corticosteroids (55%), parents with asthma, and increased levels of ferritine. Cluster 3, atopic multiple-trigger wheeze (n = 67), included more children with multiple-trigger wheeze (68%) than did clusters 1 or 2; eczema (75%); a positive result from the Phadiatop Infant test (90%); increased levels of IgE, IgA, and IgG; and abnormal results from chest x-rays. In separate analysis, 1 parameter for boys (increased total level of IgE) and 2 parameters for girls (wheezing severity and increased total level of IgE) properly classified 90% of boys and 83% of girls in the appropriate cluster. Significant associations were found between overcrowding, molds and cockroaches at home, and atopic multiple-trigger wheeze and between day-care attendance and nonatopic uncontrolled wheeze in other parts. CONCLUSION We identified different phenotypes of recurrent wheezing in young children by using cluster analysis with usual variables. These phenotypes require confirmation in longer, follow-up studies.
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Affiliation(s)
- Jocelyne Just
- Centre de l'Asthme et des Allergies, Groupe Hospitalier Trousseau-La Roche Guyon, University Paris 06, Paris, France.
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80
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Sumino K, Sugar EA, Irvin CG, Kaminsky DA, Shade D, Wei CY, Holbrook JT, Wise RA, Castro M. Methacholine challenge test: diagnostic characteristics in asthmatic patients receiving controller medications. J Allergy Clin Immunol 2012; 130:69-75.e6. [PMID: 22465214 DOI: 10.1016/j.jaci.2012.02.025] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2011] [Revised: 02/15/2012] [Accepted: 02/21/2012] [Indexed: 11/25/2022]
Abstract
BACKGROUND The methacholine challenge test (MCT) is commonly used to assess airway hyperresponsiveness, but the diagnostic characteristics have not been well studied in asthmatic patients receiving controller medications after the use of high-potency inhaled corticosteroids became common. OBJECTIVES We investigated the ability of the MCT to differentiate participants with a physician's diagnosis of asthma from nonasthmatic participants. METHODS We conducted a cohort-control study in asthmatic participants (n= 126) who were receiving regular controller medications and nonasthmatic control participants (n= 93) to evaluate the sensitivity and specificity of the MCT. RESULTS The overall sensitivity was 77% and the specificity was 96% with a threshold PC(20) (the provocative concentration of methacholine that results in a 20% drop in FEV(1)) of 8 mg/mL. The sensitivity was significantly lower in white than in African American participants (69% vs 95%, P= .015) and higher in atopic compared with nonatopic (82% vs 52%, P= .005). Increasing the PC(20) threshold from 8 to 16 mg/mL did not noticeably improve the performance characteristics of the test. African American race, presence of atopy, and lower percent predicted FEV(1) were associated with a positive test result. CONCLUSIONS The utility of the MCT to rule out a diagnosis of asthma depends on racial and atopic characteristics. Clinicians should take into account the reduced sensitivity of the MCT in white and nonatopic asthmatic patients when using this test for the diagnosis of asthma.
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Affiliation(s)
- Kaharu Sumino
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St Louis, MO 63110, USA.
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Abstract
INTRODUCTION Chlamydiae are obligate intracellular bacterial pathogens whose entry into mucosal epithelial cells is required for intracellular survival and subsequent growth. The life cycle of Chlamydia spp. and the ability to cause persistent, often subclinical infection, has major ramifications for diagnosis and treatment of C. trachomatis and C. pneumoniae infections in humans. AREAS COVERED This up-to-date review describes the current state of knowledge of antimicrobial susceptibilities and treatment of genital infections due to C. trachomatis and respiratory infections due to C. pneumoniae. EXPERT OPINION Chlamydiae are susceptible to antibiotics that interfere with DNA and protein synthesis, including tetracyclines, macrolides and quinolones, which are the compounds that have been most extensively studied and used for treatment of human infection. Treatment of individuals with C. trachomatis genital infection prevents sexual transmission and complications, including pelvic inflammatory disease. Treatment of pregnant women will prevent the transmission of infection to infants during delivery. The benefits of treatment of respiratory infections due to C. pneumoniae are more difficult to assess, primarily because of the lack of FDA-approved, specific diagnostic tests for detection of the organism in clinical samples. The majority of published studies have relied on serology for diagnosis, making it difficult to assess microbiologic efficacy.
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Affiliation(s)
- Margaret R Hammerschlag
- SUNY Downstate Medical Center, Division of Infectious Diseases, Department of Pediatrics, 450 Clarkson Avenue, Brooklyn, NY 11203-2098, USA.
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Hörmannsperger G, Clavel T, Haller D. Gut matters: microbe-host interactions in allergic diseases. J Allergy Clin Immunol 2012; 129:1452-9. [PMID: 22322009 DOI: 10.1016/j.jaci.2011.12.993] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2011] [Revised: 12/09/2011] [Accepted: 12/21/2011] [Indexed: 02/07/2023]
Abstract
The human body can be considered a metaorganism made up of its own eukaryotic cells and trillions of microbes that colonize superficial body sites, such as the skin, airways, and gastrointestinal tract. The coevolution of host and microbes brought about a variety of molecular mechanisms, which ensure a peaceful relationship. The mammalian barrier and immune functions warrant simultaneous protection of the host against deleterious infections, as well as tolerance toward harmless commensals. Because these pivotal host functions evolved under high microbial pressure, they obviously depend on a complex network of microbe-host interactions. The rapid spread of immune-mediated disorders, such as autoimmune diseases, inflammatory bowel diseases, and allergies, in westernized countries is thus thought to be due to environmentally mediated disturbances of this microbe-host interaction network. The aim of the present review is to highlight the importance of the intestinal microbiota in shaping host immune mechanisms, with particular emphasis on allergic diseases and possible intervention strategies.
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Affiliation(s)
- Gabriele Hörmannsperger
- Biofunctionality, ZIEL-Research Center for Nutrition and Food Science, CDD Center for Diet and Disease, Technische Universität München, Freising-Weihenstephan, Germany
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Abstract
PURPOSE OF REVIEW This review summarizes the importance of macrolide therapy in the treatment of asthma, discusses macrolide mechanisms of action, and outlines new clinical data supporting their use. The effects of macrolides on both the innate and adaptive immune responses are discussed. RECENT FINDINGS Subacute bacterial infection with both typical and atypical organisms contributes to poor asthma control. Identification of pathogens using polymerase chain reaction (PCR) and cultures from bronchoscopic samples directs antibiotic therapy and improves asthma control. PCR identification of Mycoplasma pneumoniae and Chlamydophila pneumoniae in asthmatics best identifies the macrolide responsive phenotype. SUMMARY Because of their effect on protein synthesis, macrolides have both antimicrobial and anti-inflammatory properties. Both mechanisms appear to be important in their clinical efficacy in treating a wide variety of pulmonary disorders, including asthma.
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84
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McGrath KW, Icitovic N, Boushey HA, Lazarus SC, Sutherland ER, Chinchilli VM, Fahy JV. A large subgroup of mild-to-moderate asthma is persistently noneosinophilic. Am J Respir Crit Care Med 2012; 185:612-9. [PMID: 22268133 DOI: 10.1164/rccm.201109-1640oc] [Citation(s) in RCA: 373] [Impact Index Per Article: 31.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
RATIONALE Airway eosinophilia is typical of asthma, and many controller treatments target eosinophilic disease. Asthma is clinically heterogeneous, however, and a subgroup of people with asthma do not have airway eosinophilia. The size of this subgroup is uncertain because prior studies have not examined repeated measures of sputum cytology to determine when people with asthma have intermittent versus persistent sputum eosinophila and when they are persistently noneosinophilic. OBJECTIVES To determine the prevalence and clinical characteristics of the noneosinophilic asthma phenotype. METHODS We analyzed sputum cytology data from 995 subjects with asthma enrolled in clinical trials in the Asthma Clinical Research Network where they had undergone sputum induction and measures of sputum cytology, often repeatedly, and assessment of responses to standardized asthma treatments. MEASUREMENTS AND MAIN RESULTS In cross-sectional analyses, sputum eosinophilia (≥2% eosinophils) was found in only 36% of subjects with asthma not taking an inhaled corticosteroid (ICS) and 17% of ICS-treated subjects with asthma; an absence of eosinophilia was noted frequently, even in subjects with asthma whose disease was suboptimally controlled. In repeated measures analyses of people with asthma not taking an ICS, 22% of subjects had sputum eosinophilia on every occasion (persistent eosinophilia); 31% had eosinophilia on at least one occasion (intermittent eosinophilia); and 47% had no eosinophilia on every occasion (persistently noneosinophilic). Two weeks of combined antiinflammatory therapy caused significant improvements in airflow obstruction in eosinophilic asthma, but not in persistently noneosinophilic asthma. In contrast, bronchodilator responses to albuterol were similar in eosinophilic and noneosinophilic asthma. CONCLUSIONS Approximately half of patients with mild-to-moderate asthma have persistently noneosinophilic disease, a disease phenotype that responds poorly to currently available antiinflammatory therapy.
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Affiliation(s)
- Kelly Wong McGrath
- Cardiovascular Research Institute, University of California San Francisco, San Francisco, CA 94143, USA
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85
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Craig T, Quinn L. Asthma Clinical Research Network: lessons learned. ACTA ACUST UNITED AC 2012; 78:671-82. [PMID: 21913198 DOI: 10.1002/msj.20282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
The Asthma Clinical Research Network was created by the National Heart, Lung, and Blood Institute to improve public health by rapidly evaluating novel and existing therapeutic approaches to asthma. The multicenter clinical research network has greatly contributed to the healthcare community's understanding of asthma by conducting clinical trials independent of the pharmaceutical industry. The following manuscript reviews the experimental design and major findings of noteworthy studies performed in this network. All of the network's publications were reviewed, and 19 were selected for summary. As shown in these publications, the research performed by the Asthma Clinical Research Network has produced significant data with important implications that should impact the way the healthcare community treats asthma at the present time.
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86
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Zarogoulidis P, Papanas N, Kioumis I, Chatzaki E, Maltezos E, Zarogoulidis K. Macrolides: from in vitro anti-inflammatory and immunomodulatory properties to clinical practice in respiratory diseases. Eur J Clin Pharmacol 2011; 68:479-503. [PMID: 22105373 DOI: 10.1007/s00228-011-1161-x] [Citation(s) in RCA: 187] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2011] [Accepted: 10/25/2011] [Indexed: 12/12/2022]
Abstract
BACKGROUND Macrolides have long been recognised to exert immunomodulary and anti-inflammatory actions. They are able to suppress the "cytokine storm" of inflammation and to confer an additional clinical benefit through their immunomodulatory properties. METHODS A search of electronic journal articles was performed using combinations of the following keywords: macrolides, COPD, asthma, bronchitis, bronchiolitis obliterans, cystic fibrosis, immunomodulation, anti-inflammatory effect, diabetes, side effects and systemic diseases. RESULTS Macrolide effects are time- and dose-dependent, and the mechanisms underlying these effects remain incompletely understood. Both in vitro and in vivo studies have provided ample evidence of their immunomodulary and anti-inflammatory actions. Importantly, this class of antibiotics is efficacious with respect to controlling exacerbations of underlying respiratory problems, such as cystic fibrosis, asthma, bronchiectasis, panbrochiolitis and cryptogenic organising pneumonia. Macrolides have also been reported to reduce airway hyper-responsiveness and improve pulmonary function. CONCLUSION This review provides an overview on the properties of macrolides (erythromycin, clarithromycin, roxithromycin, azithromycin), their efficacy in various respiratory diseases and their adverse effects.
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Affiliation(s)
- P Zarogoulidis
- Pulmonary Department, G. Papanikolaou Hospital, Aristotle University of Thessaloniki, Thessaloniki 57010, Greece.
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87
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Dulek DE, Peebles RS. Bacteria and asthma: more there than we thought. Expert Rev Respir Med 2011; 5:329-32. [PMID: 21702654 DOI: 10.1586/ers.11.33] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
In a recently performed case-control study, characteristics of the airway microbiota in suboptimally controlled adult asthmatics were compared with those of healthy, nonasthmatic adult subjects. Bacterial burden was significantly greater in asthmatic subjects. Further, increased airway microbiota variability and diversity were correlated with increased bronchial hyper-responsiveness. Although several limitations are present, this study provides an intriguing initial insight into the possible relationship between the airway microbiota and asthma pathogenesis.
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Affiliation(s)
- Daniel E Dulek
- Department of Pediatrics, Division of Pediatric Infectious Diseases, Monroe Carell Jr, Children's Hospital at Vanderbilt, Vanderbilt University Medical Center, Nashville, TN, USA
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88
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Affiliation(s)
- Shamsah Kazani
- Department of Medicine, Pulmonary and Critical Care Division, Brigham and Women's Hospital, Boston, MA 02115, USA
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89
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Pakhale S, Mulpuru S, Boyd M. Optimal management of severe/refractory asthma. CLINICAL MEDICINE INSIGHTS-CIRCULATORY RESPIRATORY AND PULMONARY MEDICINE 2011; 5:37-47. [PMID: 21912491 PMCID: PMC3165919 DOI: 10.4137/ccrpm.s5535] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Asthma is a chronic inflammatory disease of the airways, affecting approximately 300 million people worldwide. Asthma results in airway hyperresponsiveness, leading to paroxysmal symptoms of wheeze, cough, shortness of breath, and chest tightness. When these symptoms remain uncontrolled, despite treatment with high doses of inhaled and ingested corticosteroids, asthmatic patients are predisposed to greater morbidity and require more health care support. Treating patients with severe asthma can be difficult and often poses a challenge to physicians when providing ongoing management. This clinical review aims to discuss the definition, prevalence and evaluation of severe asthmatics, and provides a review of the existing pharmacologic and non-pharmacologic treatment options.
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Affiliation(s)
- Smita Pakhale
- The Ottawa Hospital at the University of Ottawa, Ottawa, ON, Canada
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90
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Busse WW. Asthma diagnosis and treatment: filling in the information gaps. J Allergy Clin Immunol 2011; 128:740-50. [PMID: 21875745 DOI: 10.1016/j.jaci.2011.08.014] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2011] [Accepted: 08/15/2011] [Indexed: 01/18/2023]
Abstract
Current approaches to the diagnosis and management of asthma are based on guideline recommendations, which have provided a framework for the efforts. Asthma, however, is emerging as a heterogeneous disease, and these features need to be considered in both the diagnosis and management of this disease in individual patients. These diverse or phenotypic features add complexity to the diagnosis of asthma, as well as attempts to achieve control with treatment. Although the diagnosis of asthma is often based on clinical information, it is important to pursue objective criteria as well, including an evaluation for reversibility of airflow obstruction and bronchial hyperresponsiveness, an area with new diagnostic approaches. Furthermore, there exist a number of treatment gaps (ie, exacerbations, step-down care, use of antibiotics, and severe disease) in which new direction is needed to improve care. A major morbidity in asthmatic patients occurs with exacerbations and in patients with severe disease. Novel approaches to treatment for these conditions will be an important advance to reduce the morbidity associated with asthma.
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Affiliation(s)
- William W Busse
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI 53792, USA.
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91
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Peters J, Singh H, Brooks EG, Diaz J, Kannan TR, Coalson JJ, Baseman JG, Cagle M, Baseman JB. Persistence of community-acquired respiratory distress syndrome toxin-producing Mycoplasma pneumoniae in refractory asthma. Chest 2011; 140:401-407. [PMID: 21622549 PMCID: PMC3148797 DOI: 10.1378/chest.11-0221] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2011] [Accepted: 04/13/2011] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND The role of Mycoplasma pneumoniae (Mp) in the initiation and persistence of asthma remains elusive. Mp community-acquired respiratory distress syndrome toxin (CARDS Tx) is a unique virulence factor that induces an intense lymphocytic response and exacerbates asthma in animal models. We sought to determine the incidence of Mp infection and the presence of CARDS Tx in subjects with refractory asthma (RA). METHODS We conducted a prospective observational study in 64 subjects with RA. Respiratory secretions (sputum, nasal lavage, and throat swab) and blood were analyzed for the presence of CARDS Tx and P1 adhesin (P1) DNA by polymerase chain reaction (PCR), and CARDS Tx by antigen capture. Serum IgM and IgG antibodies to CARDS Tx were determined by enzyme-linked immunosorbent assay (ELISA). RESULTS Thirty-three of 64 subjects (52%) tested positive for Mp: 29 of 33 by CARDS Tx vs 10 of 33 by P1 assays. Ten subjects followed longitudinally for up to 633 days tested persistently positive for Mp. There were no significant differences in Mp-specific IgG responses between Mp-positive and Mp-negative groups. Eight of 10 subjects who tested persistently positive failed to mount a substantial IgG response to CARDS Tx, and up to 8 weeks of clarithromycin failed to eradicate Mp in five subjects. CONCLUSIONS Subjects with RA may be chronically infected with Mp. PCR for CARDS Tx appears to be the most sensitive method of identifying Mp infection. Despite the persistence of Mp in subjects with RA, some subjects failed to mount an IgG response, and macrolide therapy was insufficient to eradicate Mp.
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Affiliation(s)
- Jay Peters
- Department of Medicine, University of Texas Health Science Center at San Antonio, TX.
| | - Harjinder Singh
- Department of Medicine, University of Texas Health Science Center at San Antonio, TX
| | - Edward G Brooks
- Department of Pediatrics, University of Texas Health Science Center at San Antonio, TX
| | - Joseph Diaz
- Asthma and Allergy Associates of South Texas, San Antonio, TX
| | - Thirumalai R Kannan
- Department of Microbiology and Immunology, University of Texas Health Science Center at San Antonio, TX
| | - Jacqueline J Coalson
- Department of Pathology, University of Texas Health Science Center at San Antonio, TX
| | - Janet G Baseman
- Department of Microbiology and Immunology, University of Texas Health Science Center at San Antonio, TX
| | - Marianna Cagle
- Department of Microbiology and Immunology, University of Texas Health Science Center at San Antonio, TX
| | - Joel B Baseman
- Department of Microbiology and Immunology, University of Texas Health Science Center at San Antonio, TX; Department of Epidemiology, University of Washington School of Public Health, Seattle, WA
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92
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Maselli DJ, Adams S, Peters J. The role of anti-infectives in the treatment of refractory asthma. Ther Adv Respir Dis 2011; 5:387-96. [PMID: 21459926 DOI: 10.1177/1753465811402534] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Refractory asthma not only has a significant effect on quality of life, but also imposes an economic burden on society. Increasing evidence suggests that there is a pathophysiologic interaction between infection and allergic disease in patients with severe or refractory asthma. Therapeutic trials of macrolides and azoles are being utilized in some patients with refractory asthma who fail to respond to standard therapy. In this article we review the definition of refractory asthma and the potential pathophysiologic interactions between infection and allergic disease. Emerging data suggest that microorganisms and their byproducts may be a therapeutic target in the therapy of patients with severe or refractory asthma.
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Affiliation(s)
- Diego Jose Maselli
- Division of Pulmonary Diseases & Critical Care,University of Texas Health Science Center at San Antonio, TX, USA
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Huang YJ, Nelson CE, Brodie EL, Desantis TZ, Baek MS, Liu J, Woyke T, Allgaier M, Bristow J, Wiener-Kronish JP, Sutherland ER, King TS, Icitovic N, Martin RJ, Calhoun WJ, Castro M, Denlinger LC, Dimango E, Kraft M, Peters SP, Wasserman SI, Wechsler ME, Boushey HA, Lynch SV. Airway microbiota and bronchial hyperresponsiveness in patients with suboptimally controlled asthma. J Allergy Clin Immunol 2010; 127:372-381.e1-3. [PMID: 21194740 DOI: 10.1016/j.jaci.2010.10.048] [Citation(s) in RCA: 509] [Impact Index Per Article: 36.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2010] [Revised: 10/08/2010] [Accepted: 10/27/2010] [Indexed: 02/01/2023]
Abstract
BACKGROUND Improvement in lung function after macrolide antibiotic therapy has been attributed to reduction in bronchial infection by specific bacteria. However, the airway might be populated by a more diverse microbiota, and clinical features of asthma might be associated with characteristics of the airway microbiota present. OBJECTIVE We sought to determine whether relationships exist between the composition of the airway bacterial microbiota and clinical features of asthma using culture-independent tools capable of detecting the presence and relative abundance of most known bacteria. METHODS In this pilot study bronchial epithelial brushings were collected from 65 adults with suboptimally controlled asthma participating in a multicenter study of the effects of clarithromycin on asthma control and 10 healthy control subjects. A combination of high-density 16S ribosomal RNA microarray and parallel clone library-sequencing analysis was used to profile the microbiota and examine relationships with clinical measurements. RESULTS Compared with control subjects, 16S ribosomal RNA amplicon concentrations (a proxy for bacterial burden) and bacterial diversity were significantly higher among asthmatic patients. In multivariate analyses airway microbiota composition and diversity were significantly correlated with bronchial hyperresponsiveness. Specifically, the relative abundance of particular phylotypes, including members of the Comamonadaceae, Sphingomonadaceae, Oxalobacteraceae, and other bacterial families were highly correlated with the degree of bronchial hyperresponsiveness. CONCLUSION The composition of bronchial airway microbiota is associated with the degree of bronchial hyperresponsiveness among patients with suboptimally controlled asthma. These findings support the need for further functional studies to examine the potential contribution of members of the airway microbiota in asthma pathogenesis.
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Affiliation(s)
- Yvonne J Huang
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California, San Francisco, Calif, USA
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Lai JF, Zindl CL, Duffy LB, Atkinson TP, Jung YW, van Rooijen N, Waites KB, Krause DC, Chaplin DD. Critical role of macrophages and their activation via MyD88-NFκB signaling in lung innate immunity to Mycoplasma pneumoniae. PLoS One 2010; 5:e14417. [PMID: 21203444 PMCID: PMC3009709 DOI: 10.1371/journal.pone.0014417] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2010] [Accepted: 11/29/2010] [Indexed: 01/07/2023] Open
Abstract
Mycoplasma pneumoniae (Mp), a common cause of pneumonia, is associated with asthma; however, the mechanisms underlying this association remain unclear. We investigated the cellular immune response to Mp in mice. Intranasal inoculation with Mp elicited infiltration of the lungs with neutrophils, monocytes and macrophages. Systemic depletion of macrophages, but not neutrophils, resulted in impaired clearance of Mp from the lungs. Accumulation and activation of macrophages were decreased in the lungs of MyD88(-/-) mice and clearance of Mp was impaired, indicating that MyD88 is a key signaling protein in the anti-Mp response. MyD88-dependent signaling was also required for the Mp-induced activation of NFκB, which was essential for macrophages to eliminate the microbe in vitro. Thus, MyD88-NFκB signaling in macrophages is essential for clearance of Mp from the lungs.
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Affiliation(s)
- Jen-Feng Lai
- Department of Microbiology, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
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