Therapeutic Effects of Intranasal Tofacitinib on Chronic Rhinosinusitis with Nasal Polyps in Mice

Antibody-based therapeutics for chronic rhinosinusitis with nasal polyps

INTRODUCTION

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a prevalent inflammatory condition with heterogenous underlying endotypes, the most common being type 2 mediated inflammation. Several biologics have been developed to target specific pro-inflammatory cytokines and their receptors with proven efficacy in both quantitative and qualitative outcomes in patients with severe uncontrolled disease. However, there is an ongoing debate on the role of biologics relative to conventional therapies for CRSwNP and their efficacy in patient subgroups with non-polyp type 2 disease.

AREAS COVERED

This review examines the evidence on the efficacy and safety of biologics in CRSwNP, recommendations for their use, and discusses the broader economic factors influencing their application in clinical practice.

EXPERT OPINION

Emerging real-life data demonstrating the variable efficacy of the available biologics for patients with CRSwNP, coupled with the high cost compared to conventional therapies such as surgery, renders biologics to be considered as an add-on therapy in the majority of cases. However, ongoing research into increasing biologic dose intervals and novel therapies targeting alternative pathways may offer a more cost-effective and sustainable option in future.

Dupilumab-Associated Arthritis: A Dermatology-Rheumatology Perspective

Dupilumab is an interleukin (IL)-4/13 inhibitor approved by the US FDA for multiple atopic indications. It is well-known to have favorable efficacy and safety profiles; however, emerging reports of dupilumab-associated arthritis suggest an underrecognized potential adverse effect. In this article, we summarize the literature to date to better characterize this clinical phenomenon. Arthritic symptoms were most commonly peripheral, generalized, and symmetric. Onset was generally within 4 months following initiation of dupilumab, and most patients resolved fully after a matter of weeks following discontinuation. Mechanistic insights suggest that suppression of IL-4 may lead to increased activity of IL-17, a prominent cytokine in inflammatory arthritis. We propose a treatment algorithm that stratifies patients by severity, recommending that patients with more mild disease continue dupilumab and treat through symptoms, while patients with more severe disease discontinue dupilumab and consider switching to another class (e.g., Janus kinase inhibitors). Lastly, we discuss important ongoing questions that should be addressed in future studies.

Which are the best murine models to study Eosinophilic Chronic Rhinosinusitis? A contemporary review

OBJECTIVE

Mechanisms that lead to Eosinophilic Chronic Rhinosinusitis (ECRS) are not fully established in the literature. It is desirable to assess ECRS in a model that embraces most of the related events. This article reviewed the murine models for ECRS and compared them regarding eosinophilic polypoid formation.

METHODS

The authors reviewed the articles that included the terms "chronic rhinosinusitis" OR "chronic sinusitis" AND "animal model". We analyzed articles in English that evaluated both the number of polyps and the number of eosinophils in the sinus mucosa of mouse models.

RESULTS

We identified a total of 15 articles describing different models of ECRS that used BALB/c or C57BL/6 mice, and different triggers/stimulants such as Staphylococcus aureus Enterotoxin B (SEB) + Ovalbumin (OVA); House Dust Mite (HDM) ± Ovalbumin (OVA); and Aspergillus oryzae Protease (AP) + Ovalbumin (OVA). OVA associated with SEB was the commonest protocol to induce ECRS in both BALB/c and C57BL/6 mice, and it produced a robust response of eosinophilic nasal polyps in both. AP + OVA protocol also led to a good ECRS response. The other models were not considered adequate to produce eosinophilic polyps in mice.

CONCLUSION

In conclusion, OVA associated with SEB seems to produce the most robust eosinophilic sinonasal inflammation.

Targeting Epithelium Dysfunction and Impaired Nasal Biofilms to Treat Immunological, Functional, and Structural Abnormalities of Chronic Rhinosinusitis

Chronic rhinosinusitis (CRS) with (CRSwNP) or without (CRSsNP) nasal polyps is a prevalent and heterogeneous disorder existing as a spectrum of clinical conditions with complex underlying pathomechanisms. CRS comprises a broad syndrome characterized by multiple immunological features involving complex interactions between the genes, the microbiome, host- and microbiota-derived exosomes, the epithelial barrier, and environmental and micromilieu exposures. The main pathophysiological feature is an epithelial barrier disruption, accompanied by microbiome alterations and unpredictable and multifactorial immunologic overreactions. Extrinsic pathogens and irritants interact with multiple epithelial receptors, which show distinct expression patterns, activate numerous signaling pathways, and lead to diverse antipathogen responses. CRSsNP is mainly characterized by fibrosis and mild inflammation and is often associated with Th1 or Th17 immunological profiles. CRSwNP appears to be associated with moderate or severe type 2 (T2) or Th2 eosinophilic inflammation. The diagnosis is based on clinical, endoscopic, and imaging findings. Possible CRS biomarkers from the peripheral blood, nasal secretions, tissue biopsies, and nasally exhaled air are studied to subgroup different CRS endotypes. The primary goal of CRS management is to maintain clinical control by nasal douching with isotonic or hypertonic saline solutions, administration of nasal and systemic steroids, antibiotics, biologic agents, or, in persistent and more severe cases, appropriate surgical procedures.

Murine model for chronic rhinosinusitis: an interventional study

BACKGROUND

Chronic rhinosinusitis (CRS) is a complex inflammatory disease of the sinonasal tract. To understand this disease entity and develop targeted treatments, a reproducible animal model is paramount.

AIMS/OBJECTIVES

To optimize a murine model of eosinophilic CRS by establishing benchmark histological markers and validate its fidelity in evaluating intranasal treatments.

MATERIAL AND METHODS

Forty-five Balb/c mice were included in the 7-week protocol. Experimental animals (n = 20) were induced a CRS disease state upon receiving intraperitoneal sensitization with ovalbumin (OVA), followed by intranasal OVA with Aspergillus oryzae protease. Analysis of complete blood count with differential, peripheral blood smear, and histological markers from the nasal cavity mucosa were performed. CRS mice were additionally treated with intranasal saline (n = 5) or mometasone (n = 10) and compared with control groups of untreated CRS (n = 5) and healthy (n = 5) mice after week 7.

RESULTS

Histological analysis of experimental animal nasal mucosa revealed significantly higher levels of eosinophilic tissue infiltration/degranulation, hyaline droplets, Charcot-Leyden crystals, and respiratory epithelial thickness compared to healthy controls. Treatment with mometasone significantly reversed the histopathological changes observed in CRS mice.

CONCLUSION AND SIGNIFICANCE

This murine model induced substantial local eosinophilic inflammation within sinonasal mucosa, that was reversible with mometasone. This model may be used to evaluate the efficacy of therapeutics designed to target CRS.

The Efficacy of Functional Endoscopic Sinus Surgery Combined With Triamcinolone Acetonide Aqueous Nasal Spray for the Treatment of Chronic Rhinosinusitis

Objective

We aimed to investigate the efficacy of functional endoscopic sinus surgery (FESS) combined with triamcinolone acetonide aqueous nasal spray (TAA AQ) for the treatment of chronic rhinosinusitis.

Methods

From December 2019 to June 2021, 109 patients with chronic rhinosinusitis were classified into a control group (n = 50) and an experimental group (n = 59) according to the method of treatment. Subjects in the control group were treated with FESS while those in the experimental group were treated with FESS + TAA AQ. We then compared clinical indices, total effective rate, and the clinical symptoms of patients between the two groups. The pre- and postoperative serum levels of inflammatory cytokines were also determined. Before and 12 months after surgery, we analyzed the recovery of the nasal mucosa, olfactory function, and mucociliary transport rate of each patient. Postoperative complications were observed and recorded and the quality-of-life 12 months after surgery was ascertained.

Results

Clinical indices and total effective rate were higher in the experimental group. After treatment, the VAS score and serum levels of inflammatory cytokines in the two groups both decreased, although the experimental group had lower VAS scores and inflammatory cytokine levels. Six months after treatment, olfactory function, and the recovery of nasal mucosa were improved, MTR had increased, and the total incidence of complications had reduced in the experimental group when compared with the control group. No significant difference was found between the two groups in terms of quality-of-life (P > 0.05).

Conclusion

The combination of FESS and TAA AQ exerted a certain therapeutic effect on chronic rhinosinusitis.

Punicalagin Alleviates Aged Bronchial Asthma by Inhibiting Th2 Differentiation through IL-4/STAT6 and Jagged1/Notch Pathways

OBJECTIVE

To explore the therapeutic effect and mechanism of punicalagin on bronchial asthma in the elderly.

METHODS

Peripheral venous blood was collected from healthy people and elderly patients with bronchial asthma. Peripheral blood mononuclear cells (PBMCs) were isolated and cultured. PBMCs in the patient group were treated with different concentrations (0, 50, 100, and 200 mg/L) of punicalagin (PUN). MTT assay was used to detect cell activity, ELISA was used to detect the levels of IFN-γ, IL-2, IL-4, and IL-5, and Western blotting was used to detect the protein levels of p-STAT6, Jagged1, and GATA3.

RESULT

MTT results showed that 50-200 mg/L PUN had no cytotoxicity to PBMCs within 24 h. ELISA results showed that the levels of IFN-γ and IL-2 in the serum of the patients were significantly lower than those of healthy people, and the levels of IL-4 and IL-5 were significantly higher than those of the healthy people. PUN treatment significantly increased the levels of IFN-γ and IL-2 in the supernatant of PBMCs culture, while significantly decreased the levels of IL-4 and IL-5, and the change was proportional to the concentration of PUN. Western blotting results showed that the levels of p-STAT6, Jagged1, and GATA3 protein in PBMCs of patients were significantly higher than those of the healthy people. PUN treatment could significantly reduce the expression of p-STAT6, Jagged1, and GATA3 protein in PBMCs of patients, and the reduction level was proportional to PUN concentration.

CONCLUSION

PUN can inhibit Th2 differentiation and regulate Th1/Th2 balance by regulating IL-4/STAT6 and Jagged1/Notch pathways to alleviate the progress of bronchial asthma in the elderly.

Activation of STAT6 by intranasal allergens correlated with the development of eosinophilic chronic rhinosinusitis in a mouse model

Eosinophilic chronic rhinosinusitis (ECRS) is a chronic inflammatory disease characterized by prominent eosinophilic infiltration along with a T-helper-2 (Th2) response. It has been well documented that signal transducer and activator of transcription 6 (STAT6) is a nuclear transcription factor that mediates Th2-type immunity and is implicatory of STAT1 and STAT3 in the pathogenesis of allergic airway diseases. However, little is known about the association between STATs and ECRS. Here, we explored the relationship between STAT1, STAT3, and/or STAT6 and eosinophilic inflammation accompanied by Th2-type immunity in a mouse model of ECRS. An ovalbumin (OVA)-staphylococcal enterotoxin B (SEB)-induced ECRS murine model was first established. The mucosal histological alterations were determined using hematoxylin and eosin staining. The number of eosinophils in peripheral blood was measured using a blood cell analyzer. The cytokine (IL-4, IL-5, IL17 A and IFN-γ) expression levels in the sinonasal mucosa and total and OVA-specific IgE from serum were measured using ELISA. Then, the protein levels of STAT1, STAT3, STAT6, phosphorylated STAT1 (p-STAT1), p-STAT3, p-STAT6, T-box expressed in T-cells (T-bet), GATA binding protein 3 (GATA-3), and retinoic acid receptor-related orphan receptor γ (RORγt) in the sinonasal mucosa were examined by immunohistochemical staining or Western blotting. Local administration of OVA combined with SEB (OVA + SEB) induced multiple polyp-like lesions, accompanied by prominent eosinophilic infiltration in the sinonasal mucosa. The OVA- and OVA+SEB-treated groups showed significantly higher eosinophil counts from peripheral blood and total and OVA-specific IgE levels from serum than those in the PBS- and SEB-treated groups. The levels of p-STAT6 were markedly increased by OVA + SEB exposure, as well as GATA-3, IL-4, and IL-5, but did not affect STAT6, p-STAT1, p-STAT3, T-bet, RORγt, IFN-γ, or IL-17A. Furthermore, an eosinophil count in the sinonasal mucosa showed a positive correlation with the level of p-STAT6 in the ECRS mouse model. Signal transducer and activator of transcription 6 signaling could be activated in the OVA+SEB-induced ECRS model and might be a crucial signal transducer in the development of Th2-skewed ECRS.

Revisiting Asian chronic rhinosinusitis in the era of type 2 biologics

Chronic rhinosinusitis (CRS) is a highly heterogeneous disorder exhibiting considerable epidemiological, clinical and immunopathological variations across patients with distinct ethnic backgrounds and in different geographic locations. Asian CRS patients present less eosinophilic and type 2 (T2) inflammation, but more prominent neutrophilic inflammation compared with patients in Western countries. Although several biologics targeting important elements of T2 inflammation, such as IL-4, IL-5, IL-13 and IgE, demonstrate promising benefit for Caucasian patients with recurrent nasal polyps, their efficacy in Asian patients remains poorly defined. The distinct endotypes in Asian patients warrant the identification and selection of patients who would benefit from T2 biologics in Asian countries. Additionally, developing novel treatments targeting neutrophilic, type 1, and type 3 inflammation may benefit approximately 50% of Asian CRS patients with non-T2 inflammation. In this review, we summarized and discussed recent progress in the study of Asian CRS endotypes in comparison with those in patients in Western countries, and the methods of identifying Asian patients with eosinophilic or T2 inflammation. T2 biologic treatment of Asian CRS patients, potential therapeutic candidates targeting non-T2 inflammation in Asian CRS patients and the progress on developing other T2 biologics were discussed.

Strategies Targeting Type 2 Inflammation: From Monoclonal Antibodies to JAK-Inhibitors

Bronchial asthma and its frequent comorbidity chronic rhinosinusitis (CRS), are characterized by an inflammatory process at lower and upper respiratory tract, with a variability in terms of clinical presentations (phenotypes) and distinct underpin pathophysiological mechanisms (endotypes). Based on the characteristics of inflammation, bronchial asthma can be distinguished into type 2 (eosinophilic) or nontype 2 (noneosinophilic) endotypes. In type 2 asthma endotype, the pathogenic mechanism is sustained by an inflammatory process driven by Th2 cells, type 2 innate lymphoid cells (ILC2) and type 2 cytokines, which include interleukin (IL)-4, IL-5, IL-9 and IL-13. The definition of asthma and chronic rhinusinusitis phenotype/endotype is crucial, taking into account the availability of novel biologic agents, such as monoclonal antibodies targeting the classical type 2 cytokines. Recently, new therapeutic strategies have been proposed and analyzed in preliminary clinical trials. Among them Janus kinase (JAK) inhibitors, now largely used for the treatment of other chronic inflammatory diseases such as rheumatoid arthritis and inflammatory bowel diseases, is receiving great relevance. The rationale of this strategy derives from the data that JAK is a tyrosine kinase involved in the signaling of T cell receptor and of several cytokines that play a role in allergic respiratory disease, such as IL-2, IL-4 and IL-9. In this review, we discuss whether treatment with biological agents and JAK inhibitors may be equally effective in controlling type 2 inflammatory process in both asthma and CRS.

JAK inhibitors for asthma

Asthma is an inflammatory disease of the airways characterized by intermittent episodes of wheezing, chest tightness, and cough. Many of the inflammatory pathways implicated in asthma involve cytokines and growth factors that activate Janus kinases (JAKs). The discovery of the JAK/signal transducer and activator of transcription (STAT) signaling pathway was a major breakthrough that revolutionized our understanding of cell growth and differentiation. JAK inhibitors are under active investigation for immune and inflammatory diseases, and they have demonstrated clinical efficacy in diseases such as rheumatoid arthritis and atopic dermatitis. Substantial preclinical data support the idea that inhibiting JAKs will ameliorate airway inflammation and hyperreactivity in asthma. Here, we review the rationale for use of JAK inhibitors in different asthma endotypes as well as the preclinical and early clinical evidence supporting such use. We review preclinical data from the use of systemic and inhaled JAK inhibitors in animal models of asthma and safety data based on the use of JAK inhibitors in other diseases. We conclude that JAK inhibitors have the potential to usher in a new era of anti-inflammatory treatment for asthma.