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Chalmers JD, Loebinger M, Aliberti S. Challenges in the development of new therapies for bronchiectasis. Expert Opin Pharmacother 2015; 16:833-50. [DOI: 10.1517/14656566.2015.1019863] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Tildy BE, Rogers DF. Therapeutic options for hydrating airway mucus in cystic fibrosis. Pharmacology 2015; 95:117-32. [PMID: 25823699 DOI: 10.1159/000377638] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Accepted: 02/01/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND In cystic fibrosis (CF), genetic mutations in the CF transmembrane conductance regulator (CFTR) gene cause reduced chloride efflux from ciliated airway epithelial cells. This results in a reduction in periciliary liquid (PCL) depth of the airway surface liquid due to associated reduced water efflux. PCL layer dehydration reduces mucociliary clearance (MCC), leading to airway obstruction (reduced airflow and inflammation due to pathogen invasion) with mucus plug formation. SUMMARY Rehydrating mucus increases MCC. Mucus hydration can be achieved by direct hydration (administering osmotic agents to set up an osmotic gradient), using CFTR modulators to correct dysfunctional CFTR, or it can be achieved pharmacologically (targeting other ion channels on airway epithelial cells). Key Messages: The molecular mechanisms of several therapies are discussed in the context of pre-clinical and clinical trial studies. Currently, only the osmotic agent 7% hypertonic saline and the CFTR 'potentiator' VX-770 (ivacaftor) are used clinically to hydrate mucus. Emerging therapies include the osmotic agent mannitol (Bronchitol), the intracellular Ca(2+)-raising agent Moli1901/lancovutide, the CFTR potentiator sildenafil [phosphodiesterase type 5 (PDE5) inhibitor] and the CFTR 'corrector' VX-809 (lumacaftor). Other CFTR correctors (e.g. 'chemical chaperones') are also showing pre-clinical promise.
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Goss CH, MacNeill SJ, Quinton HB, Marshall BC, Elbert A, Knapp EA, Petren K, Gunn E, Osmond J, Bilton D. Children and young adults with CF in the USA have better lung function compared with the UK. Thorax 2015; 70:229-36. [PMID: 25256255 PMCID: PMC4838510 DOI: 10.1136/thoraxjnl-2014-205718] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND People with cystic fibrosis (CF) are managed differently in the USA and UK providing an opportunity to learn from differences in practice patterns. OBJECTIVES To compare cross-sectional demographics, practice patterns and clinical outcomes between US and UK CF patients. METHODS This was a cross-sectional study using 2010 data from patients in the US Cystic Fibrosis Foundation and the UK Cystic Fibrosis patient registries. The a priori outcome measures of interest were lung function and nutritional status. Descriptive statistics and two sample comparisons were performed. Stratification and multivariable linear regression were used to adjust for confounding. RESULTS The study cohort included 13 777 children and 11 058 adults from the USA and 3968 children and 3965 adults from the UK. In children, mean body mass index centiles were similar. Lung function (FEV1 and FVC% predicted) was significantly higher in US patients ages 6-25 years of age. In a regression model adjusted for only age, FEV1% predicted was on average 3.31% of predicted (95% CI 2.65 to 3.96) higher in the USA compared with the UK. When adjusted for age, age at diagnosis, gender, pancreatic insufficiency and genotype, FEV1% predicted was on average 3.03% of predicted (95% CI 2.37 to 3.69) higher in the USA compared with the UK These differences persisted despite adjustment for possible confounders. Hypertonic saline and dornase alfa were much more commonly prescribed in US children. CONCLUSIONS Children and young adults with CF have better lung function in the USA compared with the UK despite similar nutritional status.
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Affiliation(s)
- Christopher H Goss
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Stephanie J MacNeill
- Department of Occupational and Environmental Medicine, Imperial College London, London, UK
| | - Hebe B Quinton
- Value Reporting and Analytics, Dartmouth-Hitchcock Medical Center, Hanover, New Hampshire, USA
| | | | | | | | | | | | | | - Diana Bilton
- Department of Respiratory Medicine, Royal Brompton Hospital, London, UK
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Martiniano SL, Nick JA. Nontuberculous Mycobacterial Infections in Cystic Fibrosis. Clin Chest Med 2015; 36:101-15. [DOI: 10.1016/j.ccm.2014.11.003] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Sagel SD. The challenges of developing effective anti-inflammatory agents in cystic fibrosis. J Cyst Fibros 2015; 14:164-6. [DOI: 10.1016/j.jcf.2014.12.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Chopra R, Paul L, Manickam R, Aronow WS, Maguire GP. Efficacy and adverse effects of drugs used to treat adult cystic fibrosis. Expert Opin Drug Saf 2015; 14:401-11. [PMID: 25604518 DOI: 10.1517/14740338.2015.994503] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Cystic fibrosis (CF) is an autosomal recessive disease and is the most commonly seen monogenetic disease in Caucasians. The disease has various manifestations resulting from the abnormal thick secretions, most common being chronic lung infection and airway obstruction. Many new promising drugs have appeared on the horizon over the years. This review here is an attempt to bring together the various treatments being used to prolong and enhance the quality of life of CF patients. AREAS COVERED A literature review of published as well as ongoing clinical trials, meta-analysis and systematic reviews regarding the drugs used in CF management was carried out using PubMed and Ovid databases. EXPERT OPINION New concepts have been formed and some positive results in this direction have already led to the approval of cystic fibrosis transmembrane conductance regulator potentiator drug. Gene therapy and stem cell therapy are under development. The current therapies such as dornase alfa and pancreatic enzymes targeting the symptoms continue to evolve as they play an important complementary role. Development of new simple and cost-effective markers, which help assess the efficacy and safety of these constantly emerging new drugs, is also being investigated.
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Affiliation(s)
- Ravi Chopra
- New York Medical College/Westchester Medical Center, Division of Pulmonary, Critical Care and Sleep Medicine , 100 Woods Road, Valhalla, NY 10595 , USA +1 914 493 7518 ; +1 914 493 8130 ;
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Smyth AR, Bell SC, Bojcin S, Bryon M, Duff A, Flume P, Kashirskaya N, Munck A, Ratjen F, Schwarzenberg SJ, Sermet-Gaudelus I, Southern KW, Taccetti G, Ullrich G, Wolfe S. European Cystic Fibrosis Society Standards of Care: Best Practice guidelines. J Cyst Fibros 2015; 13 Suppl 1:S23-42. [PMID: 24856775 DOI: 10.1016/j.jcf.2014.03.010] [Citation(s) in RCA: 329] [Impact Index Per Article: 36.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Specialised CF care has led to a dramatic improvement in survival in CF: in the last four decades, well above what was seen in the general population over the same period. With the implementation of newborn screening in many European countries, centres are increasingly caring for a cohort of patients who have minimal lung disease at diagnosis and therefore have the potential to enjoy an excellent quality of life and an even greater life expectancy than was seen previously. To allow high quality care to be delivered throughout Europe, a landmark document was published in 2005 that sets standards of care. Our current document builds on this work, setting standards for best practice in key aspects of CF care. The objective of our document is to give a broad overview of the standards expected for screening, diagnosis, pre-emptive treatment of lung disease, nutrition, complications, transplant/end of life care and psychological support. For comprehensive details of clinical care of CF, references to the most up to date European Consensus Statements, Guidelines or Position Papers are provided in Table 1. We hope that this best practice document will be useful to clinical teams both in countries where CF care is developing and those with established CF centres.
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Affiliation(s)
- Alan R Smyth
- Division of Child Health, Obstetrics & Gynaecology (COG), School of Medicine, University of Nottingham, UK.
| | - Scott C Bell
- Department of Thoracic Medicine, The Prince Charles Hospital, Australia; Queensland Children's Medical Research Institute, Brisbane, Australia
| | - Snezana Bojcin
- Cystic Fibrosis Europe, Denmark; Macedonian Cystic Fibrosis Association, Misko Mihajlovski 15, 1000 Skopje, Republic of Macedonia
| | - Mandy Bryon
- Cystic Fibrosis Unit, Great Ormond Street Hospital for Children, London, UK
| | - Alistair Duff
- Regional Paediatric CF Unit, The Leeds Children's Hospital, Belmont Grove, Leeds LS2 9NS, UK
| | - Patrick Flume
- Medical University of South Carolina, Charleston, SC, USA
| | - Nataliya Kashirskaya
- Department of Cystic Fibrosis, Research Centre for Medical Genetics, RAMS, Moscow, Russia
| | - Anne Munck
- Assistance publique-Hôpitaux de Paris, Hôpital Robert Debré, Paediatric Gastroenterology and Respiratory Department, CF Centre, Université Paris 7, 75019, Paris, France; Association française pour le dépistage et la prévention des handicaps de l'enfant (AFDPHE), France
| | - Felix Ratjen
- Division of Respiratory Medicine, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Canada; Physiology and Experimental Medicine, Research Institute, The Hospital for Sick Children, University of Toronto, Canada
| | - Sarah Jane Schwarzenberg
- Pediatric Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Amplatz Children's Hospital, Minneapolis, MN, USA
| | - Isabelle Sermet-Gaudelus
- INSERM U1151, France; Université René Descartes Paris 5, France; Unité fonctionnelle de Mucoviscidose, Service de Pneumo-Pédiatrie, Hôpital Necker-Enfants Malades, 149 rue de Sèvres, 75743, Paris, France
| | - Kevin W Southern
- Department of Women's and Children's Health, University of Liverpool, UK
| | - Giovanni Taccetti
- Institute of Child Health, Alder Hey Children's Hospital, Eaton Road, Liverpool L12 2AP, UK; Cystic Fibrosis Centre, Department of Paediatric Medicine, Anna Meyer Children's University Hospital, Florence, Italy
| | | | - Sue Wolfe
- Paediatric Cystic Fibrosis, Regional Paediatric CF Unit, The Leeds Children's Hospital, Belmont Grove, Leeds LS2 9NS, UK
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Hurt K, Bilton D. Inhaled Interventions in Cystic Fibrosis: Mucoactive and Antibiotic Therapies. Respiration 2014; 88:441-8. [DOI: 10.1159/000369533] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Middleton A, Robinson PD, McKay K, Jaffe A, Selvadurai H. A pilot study of inhaled dry-powder mannitol during cystic fibrosis-related pulmonary exacerbation. Eur Respir J 2014; 45:541-4. [DOI: 10.1183/09031936.00137814] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Birket SE, Chu KK, Liu L, Houser GH, Diephuis BJ, Wilsterman EJ, Dierksen G, Mazur M, Shastry S, Li Y, Watson JD, Smith AT, Schuster BS, Hanes J, Grizzle WE, Sorscher EJ, Tearney GJ, Rowe SM. A functional anatomic defect of the cystic fibrosis airway. Am J Respir Crit Care Med 2014; 190:421-32. [PMID: 25029666 DOI: 10.1164/rccm.201404-0670oc] [Citation(s) in RCA: 117] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE The mechanisms underlying cystic fibrosis (CF) lung disease pathogenesis are unknown. OBJECTIVES To establish mechanisms linking anion transport with the functional microanatomy, we evaluated normal and CF piglet trachea as well as adult swine trachea in the presence of selective anion inhibitors. METHODS We investigated airway functional microanatomy using microoptical coherence tomography, a new imaging modality that concurrently quantifies multiple functional parameters of airway epithelium in a colocalized fashion. MEASUREMENTS AND MAIN RESULTS Tracheal explants from wild-type swine demonstrated a direct link between periciliary liquid (PCL) hydration and mucociliary transport (MCT) rates, a relationship frequently invoked but never experimentally confirmed. However, in CF airways this relationship was completely disrupted, with greater PCL depths associated with slowest transport rates. This disrupted relationship was recapitulated by selectively inhibiting bicarbonate transport in vitro and ex vivo. CF mucus exhibited increased viscosity in situ due to the absence of bicarbonate transport, explaining defective MCT that occurs even in the presence of adequate PCL hydration. CONCLUSIONS An inherent defect in CF airway surface liquid contributes to delayed MCT beyond that caused by airway dehydration alone and identifies a fundamental mechanism underlying the pathogenesis of CF lung disease in the absence of antecedent infection or inflammation.
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Bilton D, Tino G, Barker AF, Chambers DC, De Soyza A, Dupont LJA, O'Dochartaigh C, van Haren EHJ, Vidal LO, Welte T, Fox HG, Wu J, Charlton B. Inhaled mannitol for non-cystic fibrosis bronchiectasis: a randomised, controlled trial. Thorax 2014; 69:1073-9. [PMID: 25246664 DOI: 10.1136/thoraxjnl-2014-205587] [Citation(s) in RCA: 104] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
RATIONALE Bronchiectasis is characterised by excessive production of mucus and pulmonary exacerbations. Inhaled osmotic agents may enhance mucociliary clearance, but few long-term clinical trials have been conducted. OBJECTIVES To determine the impact of inhaled mannitol on exacerbation rates in patients with non-cystic fibrosis (CF) bronchiectasis. Secondary endpoints included time to first exacerbation, duration of exacerbations, antibiotic use for exacerbations and quality of life (QOL) (St George's Respiratory Questionnaire, SGRQ). METHODS Patients with non-CF bronchiectasis and a history of chronic excess production of sputum and ≥2 pulmonary exacerbations in the previous 12 months were randomised (1:1) to 52 weeks treatment with inhaled mannitol 400 mg or low-dose mannitol control twice a day. Patients were 18-85 years of age, baseline FEV1 ≥40% and ≤85% predicted and a baseline SGRQ score ≥30. MAIN RESULTS 461 patients (233 in the mannitol and 228 in the control arm) were treated. Baseline demographics were similar in the two arms. The exacerbation rate was not significantly reduced on mannitol (rate ratio 0.92, p=0.31). However, time to first exacerbation was increased on mannitol (HR 0.78, p=0.022). SGRQ score was improved on mannitol compared with low-dose mannitol control (-2.4 units, p=0.046). Adverse events were similar between groups. CONCLUSIONS Mannitol 400 mg inhaled twice daily for 12 months in patients with clinically significant bronchiectasis did not significantly reduce exacerbation rates. There were statistically significant improvements in time to first exacerbation and QOL. Mannitol therapy was safe and well tolerated. TRIAL REGISTRATION NUMBER NCT00669331.
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Affiliation(s)
- Diana Bilton
- Department of Respiratory Medicine, Royal Brompton Hospital, London, UK
| | - Gregory Tino
- Department of Pulmonary, Allergy and Critical Care Division, University of Pennsylvania Medical Centre, Philadelphia, Pennsylvania, USA
| | - Alan F Barker
- Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, Oregon, USA
| | - Daniel C Chambers
- Queensland Lung Transplant Service, The Prince Charles Hospital, Chermside, Queensland, Australia School of Medicine, The University of Queensland, Herston, Queensland, Australia
| | - Anthony De Soyza
- Institute of Cellular Medicine Newcastle University & Sir William Leech Centre, Freeman Hospital, Newcastle-upon-Tyne, UK
| | | | - Conor O'Dochartaigh
- Department of Respiratory Medicine, Middlemore Hospital, Auckland, New Zealand
| | | | - Luis Otero Vidal
- Hospital Interzonal Especializado en Agudos y Cronicos "Dr Antonio A. Cetrangolo", Partido de Vicente Lopez Provincia de Buenos Aires, Buenos Aires, Argentina
| | - Tobias Welte
- Medizinische Hochschule Hannover, Klinik fur Pneumologie, Hannover, Germany
| | - Howard G Fox
- Pharmaxis Ltd, Frenchs Forest, Sydney, NSW, Australia
| | - Jian Wu
- Pharmaxis Ltd, Frenchs Forest, Sydney, NSW, Australia
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Bradley JM, Koker P, Deng Q, Moroni-Zentgraf P, Ratjen F, Geller DE, Elborn JS. Testing two different doses of tiotropium Respimat® in cystic fibrosis: phase 2 randomized trial results. PLoS One 2014; 9:e106195. [PMID: 25188297 PMCID: PMC4154718 DOI: 10.1371/journal.pone.0106195] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Accepted: 07/25/2014] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Tiotropium is a once-daily, long-acting anticholinergic bronchodilator with the potential to alleviate airway obstruction in cystic fibrosis. Our objective was to evaluate the efficacy and safety of 2.5 and 5 µg once-daily tiotropium delivered via the Respimat Soft Mist Inhaler vs. placebo in people with cystic fibrosis. METHODS This phase 2, 12-week, randomized, double-blind, placebo-controlled parallel-group study of tiotropium Respimat as add-on to usual cystic fibrosis maintenance therapy included people with cystic fibrosis with pre-bronchodilator forced expiratory volume in 1 second (FEV1) ≥ 25% predicted. Co-primary efficacy end points were change from baseline in percent-predicted FEV1 area under the curve from 0 to 4 hours (FEV1 AUC0-4h), and trough FEV1 at the end of week 12. FINDINGS A total of 510 subjects with cystic fibrosis aged 5-69 years were randomized. Both doses of tiotropium resulted in significant improvement compared with placebo in the co-primary efficacy end points at the end of week 12 (change from baseline in percent-predicted FEV1 AUC0-4h: 2.5 µg: 2.94%, 95% confidence interval 1.19-4.70, p = 0.001; 5 µg: 3.39%, 95% confidence interval 1.67-5.12, p = 0.0001; in percent-predicted trough FEV1 ∶ 2.5 µg: 2.24%, p = 0.2; 5 µg: 2.22%, p = 0.02). There was a greater benefit with tiotropium 5 vs. 2.5 µg. No treatment-related adverse events or unexpected safety findings were observed in patients taking tiotropium. CONCLUSIONS Tiotropium significantly improved lung function in people with cystic fibrosis. The improvement was greater with the higher dose than the lower dose, with no difference in adverse events. TRIAL REGISTRATION ClinicalTrials.gov NCT00737100 EudraCT 2008-001156-43.
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Affiliation(s)
- Judy M. Bradley
- Institute of Nursing and Health Research, University of Ulster, Ulster, Northern Ireland
| | - Paul Koker
- Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, Connecticut, United States of America
| | - Qiqi Deng
- Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, Connecticut, United States of America
| | | | - Felix Ratjen
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | - David E. Geller
- Florida State University College of Medicine, Orlando, Florida, United States of America
| | - J. Stuart Elborn
- Centre for Infection and Immunity, Queen’s University Belfast, Belfast, Northern Ireland
- * E-mail:
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Martiniano SL, Hoppe JE, Sagel SD, Zemanick ET. Advances in the diagnosis and treatment of cystic fibrosis. Adv Pediatr 2014; 61:225-43. [PMID: 25037130 DOI: 10.1016/j.yapd.2014.03.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
CF is a genetic, life-shortening, multisystem disease that is most commonly diagnosed through newborn screen performed in all 50 states in the United States. In the past, therapies for CF lung disease have primarily targeted the downstream effects of a dysfunctional CFTR protein. Newer CFTR modulator therapies, targeting the basic defect in CF, are available for a limited group of people with CF, and offer the hope of improved treatment options for many more people with CF in the near future. Best practice is directed by consensus clinical care guidelines from the CFF and is provided with a multidisciplinary approach by the team at the CF care center and the primary care office.
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Affiliation(s)
- Stacey L Martiniano
- Department of Pediatrics, Children's Hospital Colorado, University of Colorado Denver, 13123 East 16th Avenue, B-395, Aurora, CO 80045, USA.
| | - Jordana E Hoppe
- Department of Pediatrics, Children's Hospital Colorado, University of Colorado Denver, 13123 East 16th Avenue, B-395, Aurora, CO 80045, USA
| | - Scott D Sagel
- Department of Pediatrics, Children's Hospital Colorado, University of Colorado Denver, 13123 East 16th Avenue, B-395, Aurora, CO 80045, USA
| | - Edith T Zemanick
- Department of Pediatrics, Children's Hospital Colorado, University of Colorado Denver, 13123 East 16th Avenue, B-395, Aurora, CO 80045, USA
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Dubus JC, Bassinet L, Chedevergne F, Delaisi B, Desmazes-Dufeu N, Reychler G, Vecellio L. Mucoviscidose et traitements inhalés : quoi de neuf en 2013 ? Rev Mal Respir 2014; 31:336-46. [DOI: 10.1016/j.rmr.2013.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2013] [Accepted: 10/13/2013] [Indexed: 10/25/2022]
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Abstract
INTRODUCTION Cystic fibrosis is an autosomal recessive disease, which is the result of a genetic defect in the cystic fibrosis transmembrane conductance regulator (CFTR) gene. Pulmonary disease accounts for over 90% of the morbidity and mortality associated with the disease. Conventionally, CF treatment has focused on symptomatic therapy. AREAS COVERED In the past, the emphasis for the development of CF therapeutics has previously been on addressing complications of the manifestations rather than on the underlying disease process. However, in the past few decades there has been a paradigm shift with new attention on the underlying biological mechanisms and therapies targeted at curing the disease rather than simply controlling it. This review summarizes the current CF therapeutics pipeline. These developing therapies include CFTR gene therapy, CFTR pharmacotherapeutics, osmotically active agents and anti-inflammatory therapies, as well as novel inhaled antibiotics. EXPERT OPINION The CF therapeutics pipeline currently holds great promise both for novel therapies directly targeting the underlying biological mechanisms of CFTR dysfunction and new symptomatic therapies. While CFTR-directed therapy has the highest potential to improve patients' outcome, it is important to continue to develop better treatment options for all aspects of CF lung disease.
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Affiliation(s)
- Reshma Amin
- University of Toronto, The Hospital for Sick Children, Division of Respiratory Medicine, Department of Pediatrics, Physiology and Experimental Medicine , 555 University Avenue, Toronto, ON, M5G 1X8 , Canada +416 813 6346 ; +416 813 6246 ;
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Elkins MR, Robinson P, Anderson SD, Perry CP, Daviskas E, Charlton B. Inspiratory flows and volumes in subjects with cystic fibrosis using a new dry powder inhaler device. Open Respir Med J 2014; 8:1-7. [PMID: 24570763 PMCID: PMC3933773 DOI: 10.2174/1874306401408010001] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2013] [Revised: 11/26/2013] [Accepted: 11/26/2013] [Indexed: 11/24/2022] Open
Abstract
Introduction: Drug inhalation via a dry-powder inhaler (DPI) is a convenient, time efficient alternative to
nebulizers in the treatment of cystic fibrosis (CF). Efficient drug administration via DPIs depends on the device resistance
and adequate (≥ 45L/min) inspiratory flows and volumes generated by individuals. Dry-powder mannitol is delivered
using a RS01 breath-actuated device developed by Plastiape, for Pharmaxis. The study aim was to determine in vivo if CF
patients’ inspiratory flows and volumes are adequate to use the RS01 DPI device. Materials and Methodology: An open, non-interventional study; enrolled 25 CF subjects, aged ≥ 6 years with FEV1 ≥ 30
to < 90‰ predicted. Inspiratory flows and volumes were measured when subjects inhaled in a controlled manner through
the RS01 device in series with a spirometer. Results: The mean inspiratory volume (IV) of CF subjects was 1.83L ± 0.97. Their achieved mean ± SD peak inspiratory
flow (PIF) was 75.5 ± 27.2L/min. Twenty-three subjects (92%) achieved PIF of > 45L/min with the inhaler device;
eighteen of those subjects (78%) had a baseline FEV1 of > 1L. Conclusion: Use of the RS01 DPI device allowed adequate inspiratory flow and volume for dispersion of dry-powder
mannitol in CF patients.
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Affiliation(s)
| | - Philip Robinson
- Murdock Children's Research Institute and University of Melbourne, Royal Children's Hospital, Melbourne, Australia
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Durupt S, Nove Josserand R, Durieu I. [Therapeutic update in cystic fibrosis]. Rev Med Interne 2013; 35:388-92. [PMID: 24309546 DOI: 10.1016/j.revmed.2013.11.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2013] [Revised: 08/27/2013] [Accepted: 11/02/2013] [Indexed: 10/25/2022]
Abstract
We present the recent therapeutic advances in the cystic fibrosis care. It concerns improvements in symptomatic treatment with the development of dry powder inhaled antibiotics that improved quality of life, and innovative treatments namely the modulators of the cystic fibrosis transmembrane protein conductance regulator (CFTR), molecules which act specifically at the level of the defective mechanisms implied in the disease. The life expectancy of cystic fibrosis patients born after 2000, is estimated now to be about 50 years. This improvement of survival was obtained with the organization of the care within the specialized centers for cystic fibrosis (Centre de ressource et de compétences de la mucoviscidose) and remains still based on heavy symptomatic treatments. Dry powder inhaled antibiotics constitute a significant time saving for patients to whom all the care can achieve two hours daily. Since 2012, the modulators of CFTR, molecules allowing a pharmacological approach targeted according to the type of the mutations, allows a more specific approach of the disease. Ivacaftor (Kalydeco(®)) which potentialises the function of the CFTR protein expressed on the cellular surface is now available for patients with the G551D mutation. Lumacaftor is going to be tested in association with ivacaftor in patients with the F508del mutation, that is present in at least 75% of the patients. The ataluren which allows the production of a functional protein CFTR in patients with a no sense mutation is the third representing of this new therapeutic class. We presently have numerous symptomatic treatments for the cystic fibrosis care. The development of CFTR modulators, today available to a restricted number of patients treated with ivacaftor represents a very promising therapeutic avenue. It will represent probably the first step to a personalized treatment according to CFTR genotype.
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Affiliation(s)
- S Durupt
- Service de médecine interne, service adulte du centre de référence national de Lyon, centre de ressource et de compétences de la mucoviscidose, centre hospitalier Lyon-Sud, 69495 Pierre-Bénite cedex, France.
| | - R Nove Josserand
- Service de médecine interne, service adulte du centre de référence national de Lyon, centre de ressource et de compétences de la mucoviscidose, centre hospitalier Lyon-Sud, 69495 Pierre-Bénite cedex, France
| | - I Durieu
- Service de médecine interne, service adulte du centre de référence national de Lyon, centre de ressource et de compétences de la mucoviscidose, centre hospitalier Lyon-Sud, 69495 Pierre-Bénite cedex, France
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Graeber SY, Zhou-Suckow Z, Schatterny J, Hirtz S, Boucher RC, Mall MA. Hypertonic saline is effective in the prevention and treatment of mucus obstruction, but not airway inflammation, in mice with chronic obstructive lung disease. Am J Respir Cell Mol Biol 2013; 49:410-7. [PMID: 23590312 DOI: 10.1165/rcmb.2013-0050oc] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Recent evidence suggests that inadequate hydration of airway surfaces is a common mechanism in the pathogenesis of airway mucus obstruction. Inhaled hypertonic saline (HS) induces osmotic water flux, improving hydration of airway surfaces. However, trials in patients with obstructive lung diseases are limited. The aim of this study was to investigate effects of HS on mucus obstruction and airway inflammation in the prevention and treatment of obstructive lung disease in vivo. We, therefore, used the β-epithelial Na(+) channel (βENaC)-overexpressing mouse as a model of chronic obstructive lung disease and determined effects of preventive and late therapy with 3% HS and 7% HS on pulmonary mortality, airway mucus obstruction, and inflammation. We found that preventive treatment with 3% HS and 7% HS improved growth, reduced mortality, and reduced mucus obstruction in neonatal βENaC-overexpressing mice. In adult βENaC-overexpressing mice with chronic lung disease, mucus obstruction was significantly reduced by 7% HS, but not by 3% HS. Treatment with HS triggered airway inflammation with elevated keratinocyte chemoattractant levels and neutrophils in airways from wild-type mice, but reduced keratinocyte chemoattractant in chronic neutrophilic inflammation in adult βENaC-overexpressing mice. Our data demonstrate that airway surface rehydration with HS provides an effective preventive and late therapy of mucus obstruction with no consistent effects on inflammation in chronic lung disease. These results suggest that, through mucokinetic effects, HS may be beneficial for patients with a spectrum of obstructive lung diseases, and that additional strategies are required for effective treatment of associated airway inflammation.
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Affiliation(s)
- Simon Y Graeber
- Department of Translational Pulmonology, Translational Lung Research Center, University of Heidelberg, Im Neuenheimer Feld 350, Heidelberg, Germany
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72
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Fedan JS, Thompson JA, Ismailoglu UB, Jing Y. Tracheal epithelium cell volume responses to hyperosmolar, isosmolar and hypoosmolar solutions: relation to epithelium-derived relaxing factor (EpDRF) effects. Front Physiol 2013; 4:287. [PMID: 24130533 PMCID: PMC3795350 DOI: 10.3389/fphys.2013.00287] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2013] [Accepted: 09/21/2013] [Indexed: 11/16/2022] Open
Abstract
In asthmatic patients, inhalation of hyperosmolar saline or D-mannitol (D-M) elicits bronchoconstriction, but in healthy subjects exercise causes bronchodilation. Hyperventilation causes drying of airway surface liquid (ASL) and increases its osmolarity. Hyperosmolar challenge of airway epithelium releases epithelium-derived relaxing factor (EpDRF), which relaxes the airway smooth muscle. This pathway could be involved in exercise-induced bronchodilation. Little is known of ASL hyperosmolarity effects on epithelial function. We investigated the effects of osmolar challenge maneuvers on dispersed and adherent guinea-pig tracheal epithelial cells to examine the hypothesis that EpDRF-mediated relaxation is associated with epithelial cell shrinkage. Enzymatically-dispersed cells shrank when challenged with ≥10 mOsM added D-M, urea or NaCl with a concentration-dependence that mimics relaxation of the of isolated perfused tracheas (IPT). Cells shrank when incubated in isosmolar N-methyl-D-glucamine (NMDG) chloride, Na gluconate (Glu), NMDG-Glu, K-Glu and K2SO4, and swelled in isosmolar KBr and KCl. However, isosmolar challenge is not a strong stimulus of relaxation in IPTs. In previous studies amiloride and 4,4'-diisothiocyano-2,2'-stilbenedisulfonic acid (DIDS) inhibited relaxation of IPT to hyperosmolar challenge, but had little effect on shrinkage of dispersed cells. Confocal microscopy in tracheal segments showed that adherent epithelium is refractory to low hyperosmolar concentrations that induce dispersed cell shrinkage and relaxation of IPT. Except for gadolinium and erythro-9-(2-hydroxy-3-nonyl)adenine (EHNA), actin and microtubule inhibitors and membrane permeabilizing agents did not affect on ion transport by adherent epithelium or shrinkage responses of dispersed cells. Our studies dissociate relaxation of IPT from cell shrinkage after hyperosmolar challenge of airway epithelium.
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Affiliation(s)
- Jeffrey S. Fedan
- Pathology and Physiology Research Branch, National Institute for Occupational Safety and HealthMorgantown, WV, USA
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73
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Bilton D, Daviskas E, Anderson SD, Kolbe J, King G, Stirling RG, Thompson BR, Milne D, Charlton B. Phase 3 randomized study of the efficacy and safety of inhaled dry powder mannitol for the symptomatic treatment of non-cystic fibrosis bronchiectasis. Chest 2013; 144:215-225. [PMID: 23429964 DOI: 10.1378/chest.12-1763] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Inhaled dry powder mannitol enhanced mucus clearance and improved quality of life over 2 weeks in non-cystic fibrosis bronchiectasis. This study's objective was to investigate the efficacy and safety of dry powder mannitol over 12 weeks. METHODS Patients with bronchiectasis confirmed by high-resolution CT (HRCT) scan, aged 15 to 80 years, with FEV1≥50% predicted and ≥1 L participated in a randomized, placebo-controlled, double-blind study. Patients with a negative mannitol provocation test were randomized to inhale 320 mg mannitol (n=231) or placebo (n=112) bid for 12 weeks. To further assess safety, the same mannitol dose/frequency was administered to a patient subset in an open-label extension over 52 weeks. Primary end points were changes from baseline at 12 weeks in 24-h sputum weight and St. George's Respiratory Questionnaire (SGRQ) score. RESULTS There was a significant difference of 4.3 g in terms of change in sputum weight over 12 weeks (95% CI, 1.64-7.00; P=.002) between mannitol and placebo; however, this was largely driven by a decrease in sputum weight in the placebo group. This was associated, in turn, with more antibiotic use in the placebo group (50 of 112 [45%]) than in the inhaled mannitol group (85 of 231 [37%]). There was no statistical difference between the groups (P=.304) in total SGRQ score (mannitol, -3.4 points [95% CI, -4.81 to -1.94] vs placebo, -2.1 points [95% CI, -4.12 to -0.09]). In a subgroup study (n=82), patients receiving mannitol showed less small airway mucus plugging on HRCT scan at 12 weeks compared with patients receiving placebo (P=.048). Compliance rates were high, and mannitol was well tolerated with adverse events similar to those of placebo. CONCLUSION Because the difference in sputum weights appears to be associated with increased antibiotic use in the placebo group, a larger controlled study is now required to investigate the long-term mannitol effect on pulmonary exacerbations and antibiotic use. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT0027753; URL: www.clinicaltrials.gov.
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Affiliation(s)
- Diana Bilton
- Department of Respiratory Medicine, Royal Brompton Hospital, London, England.
| | - Evangelia Daviskas
- Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Sandra D Anderson
- Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - John Kolbe
- Department of Medicine, University of Auckland, Auckland, New Zealand
| | - Gregory King
- Department of Respiratory Medicine, The Royal North Shore Hospital, Sydney, NSW, Australia
| | - Rob G Stirling
- Department of Allergy Immunology and Respiratory Medicine, The Alfred Hospital, Melbourne, VIC, Australia
| | - Bruce R Thompson
- Department of Allergy Immunology and Respiratory Medicine, The Alfred Hospital, Melbourne, VIC, Australia
| | - David Milne
- Department of Radiology, Auckland District Health Board, Auckland, New Zealand
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74
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Rowe SM, Reeves G, Hathorne H, Solomon GM, Abbi S, Renard D, Lock R, Zhou P, Danahay H, Clancy JP, Waltz DA. Reduced sodium transport with nasal administration of the prostasin inhibitor camostat in subjects with cystic fibrosis. Chest 2013; 144:200-207. [PMID: 23412700 DOI: 10.1378/chest.12-2431] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Prostasin, a trypsin-like serine protease, is a channel-activating protease and major regulator of epithelial sodium channel-mediated sodium absorption. Its direct inhibition by camostat represents a potential approach to inhibiting sodium transport in cystic fibrosis (CF). METHODS To determine whether a topical formulation of camostat represents an efficacious and tolerable approach to reducing Na+ transport in the CF airway, we conducted a two-part randomized, double-blind, placebo-controlled, crossover, ascending single-dose study to evaluate the pharmacodynamics, safety, and pharmacokinetics of camostat administered through a nasal spray pump in subjects with CF. Nasal potential difference (PD) was measured before and after treatment, and safety and pharmacokinetics were assessed by a standardized approach. RESULTS In part 1, nine subjects were enrolled, and six completed crossover dosing at the maximally tolerated dose. The change in maximal (most polarizing) basal PD 2 h following administration of camostat was +13.1 mV (1.6-mg dose group) compared with -8.6 mV following placebo (P<.005). Intrasubject change in Ringer and amiloride-sensitive PDs exhibited similar and consistent responses. Bayesian analysis in an additional six subjects in part 2 estimated a dose of 18 μg/mL to provide 50% of the maximum effect. There was no significant change in chloride transport or total nasal symptom score, nasal examination rating, and laboratory parameters. CONCLUSIONS This study establishes the proof of concept that a reduction in sodium transport in the human CF airway can be achieved through inhibition of prostasin activity, identifying a potential therapeutic target in the disease. TRIAL REGISTRATION ClinicalTrials.gov; No.: NCT00506792; URL: www.clinicaltrials.gov.
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Affiliation(s)
- Steven M Rowe
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL; Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL; Department of Physiology and Biophysics, University of Alabama at Birmingham, Birmingham, AL; Cystic Fibrosis Research Center, University of Alabama at Birmingham, Birmingham, AL.
| | - Ginger Reeves
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL; Cystic Fibrosis Research Center, University of Alabama at Birmingham, Birmingham, AL
| | - Heather Hathorne
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL; Cystic Fibrosis Research Center, University of Alabama at Birmingham, Birmingham, AL
| | - G Martin Solomon
- Cystic Fibrosis Research Center, University of Alabama at Birmingham, Birmingham, AL
| | - Smita Abbi
- Novartis Institutes for BioMedical Research, East Hanover, NJ
| | - Didier Renard
- Novartis Institutes for BioMedical Research, Basel, Switzerland
| | - Ruth Lock
- Novartis Institutes for BioMedical Research, Horsham, England
| | - Ping Zhou
- Novartis Institutes for BioMedical Research, Horsham, England
| | - Henry Danahay
- Novartis Institutes for BioMedical Research, Horsham, England
| | - John P Clancy
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, and University of Cincinnati, Cincinnati, OH
| | - David A Waltz
- Novartis Institutes for BioMedical Research, Cambridge, MA
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Griese M, Kappler M, Eismann C, Ballmann M, Junge S, Rietschel E, van Koningsbruggen-Rietschel S, Staab D, Rolinck-Werninghaus C, Mellies U, Köhnlein T, Wagner T, König S, Teschler H, Heuer HE, Kopp M, Heyder S, Hammermann J, Küster P, Honer M, Mansmann U, Beck-Speier I, Hartl D, Fuchs C, Hector A. Inhalation treatment with glutathione in patients with cystic fibrosis. A randomized clinical trial. Am J Respir Crit Care Med 2013; 188:83-9. [PMID: 23631796 DOI: 10.1164/rccm.201303-0427oc] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
RATIONALE Glutathione is the major antioxidant in the extracellular lining fluid of the lungs and depleted in patients with cystic fibrosis (CF). OBJECTIVES We aimed to assess glutathione delivered by inhalation as a potential treatment for CF lung disease. METHODS This randomized, double-blind, placebo-controlled trial evaluated inhaled glutathione in subjects with CF 8 years of age and older and FEV1 of 40-90% of predicted. Subjects were randomized to receive 646 mg glutathione in 4 ml (n = 73) or placebo (n = 80) via an investigational eFlow nebulizer every 12 hours for 6 months. MEASUREMENTS AND MAIN RESULTS FEV1 (absolute values), both as pre-post differences (P = 0.180) and as area under the curves (P = 0.205), were the primary efficacy endpoints, and were not different between the glutathione group and the placebo group over the 6-month treatment period. Exploratory analysis showed an increase of FEV1 from baseline over placebo of 100 ml or 2.2% predicted; this was significant at 3 months, but not later. Subjects receiving glutathione had neither fewer pulmonary exacerbations, nor better scores for quality of life. Whereas increased glutathione and metabolites in sputum demonstrated significant delivery to the lungs, there was no indication of diminished oxidative stress to proteins or lipids, and no evidence for anti-inflammatory or antiproteolytic actions of glutathione supplemented to the airways. The adverse event incidence was similar between glutathione and placebo. CONCLUSIONS Inhaled glutathione in the dose administered did not demonstrate clinically relevant improvements in lung function, pulmonary exacerbation frequency, or patient-reported outcomes. Glutathione delivery to the airways was not associated with changes in markers of oxidation, proteolysis, or inflammation. Clinical trial registered with www.clinicaltrials.gov (NCT00506688) and https://eudract.ema.europa.eu/index.html (EudraCT 2005-003870-88).
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Affiliation(s)
- Matthias Griese
- Children's Hospital, Ludwig-Maximilians-University, Munich, Germany.
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76
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He SN, Li YL, Yan JJ, Zhang W, Du YZ, Yu HY, Hu FQ, Yuan H. Ternary nanoparticles composed of cationic solid lipid nanoparticles, protamine, and DNA for gene delivery. Int J Nanomedicine 2013; 8:2859-69. [PMID: 23990715 PMCID: PMC3753151 DOI: 10.2147/ijn.s47967] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background The objective of this research was to design an effective gene delivery system composed of cationic solid lipid nanoparticles (SLNs), protamine, and Deoxyribonucleic acid DNA. Methods Cationic SLNs were prepared using an aqueous solvent diffusion method with octadecylamine as the cationic lipid material. First, protamine was combined with DNA to form binary protamine/DNA nanoparticles, and the ternary nanoparticle gene delivery system was then obtained by combining binary protamine/DNA nanoparticles with cationic SLNs. The size, zeta potential, and ability of the binary and ternary nanoparticles to compact and protect DNA were characterized. The effect of octadecylamine content in SLNs and the SLNS/DNA ratios on transfection efficiency, cellular uptake and cytotoxicity of the ternary nanoparticles were also assessed using HEK293 cells. Results When the weight ratio of protamine to DNA reached 1.5:1, the plasmid DNA could be effectively compacted and protected. The average hydrodynamic diameter of the ternary nanoparticles when combined with protamine increased from 188.50 ± 0.26 nm to 259.33 ± 3.44 nm, and the zeta potential increased from 25.50 ± 3.30 mV to 33.40 ± 2.80 mV when the weight ratio of SLNs to DNA increased from 16/3 to 80/3. The ternary nanoparticles showed high gene transfection efficiency compared with Lipofectamine™ 2000/DNA nanoparticles. Several factors that might affect gene transfection efficiency, such as content and composition of SLNs, post-transfection time, and serum were examined. The ternary nanoparticles composed of SLNs with 15 wt% octadecylamine (50/3 weight ratio of SLNs to DNA) showed the best transfection efficiency (26.13% ± 5.22%) in the presence of serum. It was also found that cellular uptake of the ternary nanoparticles was better than that of the SLN/DNA and binary protamine/DNA nanoparticle systems, and DNA could be transported to the nucleus. Conclusion SLNs enhanced entry of binary protamine/DNA nanoparticles into the cell, and protamine protected DNA from enzyme degradation and transported DNA into the nucleus. Compared with Lipofectamine 2000/DNA nanoparticles, these cationic ternary nanoparticles showed relatively durable and stable gene transfection in the presence of serum.
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Affiliation(s)
- Sai-Nan He
- Women's Hospital, Zhejiang University, Hangzhou, People's Republic of China
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77
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Daviskas E, Rubin BK. Effect of inhaled dry powder mannitol on mucus and its clearance. Expert Rev Respir Med 2013; 7:65-75. [PMID: 23362816 DOI: 10.1586/ers.12.72] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Insufficient hydration at the airway surface can make mucus adherent and poorly cleared. Cough, the major mechanism of mucus clearance in disease, is ineffective when mucus is adhesive. Inhaled mannitol creates an osmotic drive for water to move into the airway lumen. The consequent increased hydration of the airway surface decreases the adherence of mucus to the epithelium, facilitates the coupling of mucus and cilia thereby increasing mucus clearance. Inhaled mannitol also promotes effective coughing and stimulates mucociliary clearance. The beneficial effect of mannitol on mucus and its clearance has been demonstrated in patients with asthma, bronchiectasis and cystic fibrosis. Inhaled dry powder mannitol (Bronchitol™) is promising to be an effective treatment for the clearance of retained airway secretions.
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Affiliation(s)
- Evangelia Daviskas
- Department of Respiratory and Sleep Medicine, E11 West, Royal Prince Alfred Hospital, Missenden Road, Camperdown, Sydney, NSW 2050, Australia.
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78
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Affiliation(s)
- Christopher H Goss
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington, Seattle, WA, USA.
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79
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Bucior I, Abbott J, Song Y, Matthay MA, Engel JN. Sugar administration is an effective adjunctive therapy in the treatment of Pseudomonas aeruginosa pneumonia. Am J Physiol Lung Cell Mol Physiol 2013; 305:L352-63. [PMID: 23792737 DOI: 10.1152/ajplung.00387.2012] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Treatment of acute and chronic pulmonary infections caused by opportunistic pathogen Pseudomonas aeruginosa is limited by the increasing frequency of multidrug bacterial resistance. Here, we describe a novel adjunctive therapy in which administration of a mix of simple sugars-mannose, fucose, and galactose-inhibits bacterial attachment, limits lung damage, and potentiates conventional antibiotic therapy. The sugar mixture inhibits adhesion of nonmucoid and mucoid P. aeruginosa strains to bronchial epithelial cells in vitro. In a murine model of acute pneumonia, treatment with the sugar mixture alone diminishes lung damage, bacterial dissemination to the subpleural alveoli, and neutrophil- and IL-8-driven inflammatory responses. Remarkably, the sugars act synergistically with anti-Pseudomonas antibiotics, including β-lactams and quinolones, to further reduce bacterial lung colonization and damage. To probe the mechanism, we examined the effects of sugars in the presence or absence of antibiotics during growth in liquid culture and in an ex vivo infection model utilizing freshly dissected mouse tracheas and lungs. We demonstrate that the sugar mixture induces rapid but reversible formation of bacterial clusters that exhibited enhanced susceptibility to antibiotics compared with individual bacteria. Our findings reveal that sugar inhalation, an inexpensive and safe therapeutic, could be used in combination with conventional antibiotic therapy to more effectively treat P. aeruginosa lung infections.
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Affiliation(s)
- Iwona Bucior
- Department of Medicine, University of California, San Francisco, CA, USA
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80
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Abstract
This paper reviews a personal selection of three potentially important cystic fibrosis (CF) interventional studies that have been published in the 12 month period preceding the November 2012 RSM CF conference. The review highlights the difficulties in the interpretation of outcome measures in CF.
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Affiliation(s)
- Iolo Doull
- Department of Paediatric Respiratory Medicine and Paediatric Cystic Fibrosis Centre, Children's Hospital for Wales, Cardiff CF14 4XN, UK.
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Abstract
A great deal of excitement and hope has followed the successful trials and US Food and Drug Administration approval of the drug ivacaftor (Kalydeco), the first therapy available that targets the underlying defect that causes cystic fibrosis (CF). Although this drug has currently demonstrated a clinical benefit for a small minority of the CF population, the developmental pathway established by ivacaftor paves the way for other CF transmembrane conductance regulator (CFTR) modulators that may benefit many more patients. In addition to investigating CFTR modulators, researchers are actively developing numerous other innovative CF therapies. In this review, we use the catalog of treatments currently under evaluation with the support of the Cystic Fibrosis Foundation, known as the Cystic Fibrosis Foundation Therapeutics Pipeline, as a platform to discuss the variety of candidate treatments for CF lung disease that promise to improve CF care. Many of these approaches target the individual components of the relentless cycle of airway obstruction, inflammation, and infection characteristic of lung disease in CF, whereas others are aimed directly at the gene defect, or the resulting dysfunctional protein, that instigates this cycle. We discuss how new findings from the laboratory have informed not only the development of novel therapeutics, but also the rationales for their use and the outcomes used to measure their effects. By reviewing the breadth of candidate treatments currently in development, as well as the recent progress in CF therapies reflected by the evolution of the therapeutics pipeline over the past few years, we hope to build upon the optimism and anticipation generated by the recent success of Kalydeco.
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Affiliation(s)
- Lucas R Hoffman
- Seattle Children's Hospital and the University of Washington School of Medicine, Seattle, WA.
| | - Bonnie W Ramsey
- Seattle Children's Hospital and the University of Washington School of Medicine, Seattle, WA
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83
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Moss RB. Pitfalls of drug development: lessons learned from trials of denufosol in cystic fibrosis. J Pediatr 2013; 162:676-80. [PMID: 23290508 DOI: 10.1016/j.jpeds.2012.11.034] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2012] [Revised: 10/08/2012] [Accepted: 11/12/2012] [Indexed: 10/27/2022]
Affiliation(s)
- Richard B Moss
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA.
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84
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Plant BJ, Goss CH, Plant WD, Bell SC. Management of comorbidities in older patients with cystic fibrosis. THE LANCET RESPIRATORY MEDICINE 2013; 1:164-74. [DOI: 10.1016/s2213-2600(13)70025-0] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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85
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Jennings G, Jonsson PF, George E, Adler AI. NICE guidance on inhaled mannitol for treatment of cystic fibrosis. THE LANCET. RESPIRATORY MEDICINE 2013; 1:e19-e20. [PMID: 24321814 DOI: 10.1016/s2213-2600(12)70054-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Affiliation(s)
- Grace Jennings
- National Institute for Health and Clinical Excellence, MidCity Place, London, UK
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86
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Prayle AP, Smyth AR. From pipeline to patient: new developments in cystic fibrosis therapeutics. Expert Opin Pharmacother 2013; 14:323-9. [DOI: 10.1517/14656566.2013.769958] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Evolution of Mycobacterium tuberculosis. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2013; 783:81-91. [DOI: 10.1007/978-1-4614-6111-1_4] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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Bilton D, Bellon G, Charlton B, Cooper P, De Boeck K, Flume PA, Fox HG, Gallagher CG, Geller DE, Haarman EG, Hebestreit HU, Kolbe J, Lapey A, Robinson P, Wu J, Zuckerman JB, Aitken ML. Pooled analysis of two large randomised phase III inhaled mannitol studies in cystic fibrosis. J Cyst Fibros 2012; 12:367-76. [PMID: 23234802 DOI: 10.1016/j.jcf.2012.11.002] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2012] [Revised: 10/27/2012] [Accepted: 11/02/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND To evaluate safety and efficacy of inhaled mannitol treatment in subgroups of a large global CF population. METHODS Data were pooled from two multicentre, double-blind, randomised, controlled, parallel group phase III studies in which 600 patients inhaled either mannitol (400 mg) or control (mannitol 50 mg) twice a day for 26 weeks. RESULTS Both the mean absolute change in FEV(1) (mL) and relative change in FEV(1) by % predicted from baseline for mannitol (400 mg) versus control were statistically significant (73.42 mL, 3.56%, both p<0.001). Increases in FEV(1) were observed irrespective of rhDNase use. Significant improvements in FEV1 occurred in adults but not children (6-11) or adolescents (aged 12-17). Pulmonary exacerbation incidence was reduced by 29% (p=0.039) in the mannitol (400 mg) group. CONCLUSIONS Sustained six-month improvements in lung function and decreased pulmonary exacerbation incidence indicate that inhaled mannitol is an important additional drug in the treatment of CF.
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Affiliation(s)
- Diana Bilton
- Royal Brompton Hospital, London, United Kingdom.
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Hurley M, Smyth A. Fluoroquinolones in the treatment of bronchopulmonary disease in cystic fibrosis. Ther Adv Respir Dis 2012; 6:363-73. [PMID: 22968160 PMCID: PMC3509170 DOI: 10.1177/1753465812459899] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Fluoroquinolones are commonly used to treat lung infections in patients with cystic fibrosis. These patients are susceptible to lung infection with common bacteria such as Staphylococcus aureus and Haemophilus influenzae, but are also prone to infection by opportunistic bacteria, including Pseudomonas aeruginosa. The good oral bioavailability and broad antimicrobial spectrum of activity, including antipseudomonal properties, make this class of antimicrobial attractive. We review the evidence assessing the use of fluoroquinolones in the context of preventing and eradicating early lung infection and in managing chronic lung infection and pulmonary exacerbations. The safety of fluoroquinolones and the use of newer agents in the class are also discussed.
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Affiliation(s)
- Matthew Hurley
- Division of Child Health, University of Nottingham, Queens Medical Centre, Nottingham, UK.
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Rowe SM, Borowitz DS, Burns JL, Clancy JP, Donaldson SH, Retsch-Bogart G, Sagel SD, Ramsey BW. Progress in cystic fibrosis and the CF Therapeutics Development Network. Thorax 2012; 67:882-90. [PMID: 22960984 PMCID: PMC3787701 DOI: 10.1136/thoraxjnl-2012-202550] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Cystic fibrosis (CF), the most common life-shortening genetic disorder in Caucasians, affects approximately 70 000 individuals worldwide. In 1998, the Cystic Fibrosis Foundation (CFF) launched the CF Therapeutics Development Network (CF-TDN) as a central element of its Therapeutics Development Programme. Designed to accelerate the clinical evaluation of new therapies needed to fulfil the CFF mission to control and cure CF, the CF-TDN has conducted 75 clinical trials since its inception, and has contributed to studies as varied as initial safety and proof of concept trials to pivotal programmes required for regulatory approval. This review highlights recent and significant research efforts of the CF-TDN, including a summary of contributions to studies involving CF transmembrane conductance regulator (CFTR) modulators, airway surface liquid hydrators and mucus modifiers, anti-infectives, anti-inflammatories, and nutritional therapies. Efforts to advance CF biomarkers, necessary to accelerate the therapeutic goals of the network, are also summarised.
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Affiliation(s)
- Steven M Rowe
- Department of Medicine, University of Alabama at Birmingham, 1819 University Boulevard (MCLM 768), Birmingham, AL 35294, USA.
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Flume PA, Van Devanter DR. State of progress in treating cystic fibrosis respiratory disease. BMC Med 2012; 10:88. [PMID: 22883684 PMCID: PMC3425089 DOI: 10.1186/1741-7015-10-88] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2012] [Accepted: 08/10/2012] [Indexed: 12/12/2022] Open
Abstract
Since the discovery of the gene associated with cystic fibrosis (CF), there has been tremendous progress in the care of patients with this disease. New therapies have entered the market and are part of the standard treatment of patients with CF, and have been associated with marked improvement in survival. Now there are even more promising therapies directed at different components of the pathophysiology of this disease. In this review, our current knowledge of the pathophysiology of lung disease in patients with CF is described, along with the current treatment of CF lung disease, and the therapies in development that offer great promise to our patients.
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