Effects of theophylline, terbutaline, and prednisone on antigen-induced bronchospasm and mediator release

The Use of Antiallergic and Antiasthmatic Drugs in Viral Infections of the Upper Respiratory Tract

Despite their frequency, upper respiratory tract infections (URTIs) constitute an area with few, if any, effective treatment remedies. Asthma and airway allergies share similar pathogenetic mechanisms to URTIs and it is not surprising, therefore, that agents used to treat allergic disorders have also been studied in URTIs. Their possible effects, limitations and hypothetical modes of action in URTIs are reviewed. In controlled clinical trials of satisfactory scientific standard, symptom reductions in both experimental rhinovirus infections and natural colds have occurred with topical anticholinergics, oral antihistamines and topical chromones. Future treatment alternatives for URTIs may include the intranasal anticholinergic ipratropium bromide, new nonsedating antihistamines and sodium cromoglycate (cromolyn sodium). The latter has a record of safety and an absence of adverse effects that would make it an attractive alternative for this common but not particularly serious condition in otherwise healthy individuals.

Glucocorticoids: mechanisms of action and anti-inflammatory potential in asthma

GLUCOCORTICOIDS are potent inhibitors of inflammatory processes and are widely used in the treatment of asthma. The anti-inflammatory effects are mediated either by direct binding of the glucocorticoid/glucocorticoid receptor complex to glucocorticoid responsive elements in the promoter region of genes, or by an interaction of this complex with other transcription factors, in particular activating protein-1 or nuclear factor-kappaB. Glucocorticoids inhibit many inflammation-associated molecules such as cytokines, chemokines, arachidonic acid metabolites, and adhesion molecules. In contrast, anti-inflammatory mediators often are up-regulated by glucocorticoids. In vivo studies have shown that treatment of asthmatic patients with inhaled glucocorticoids inhibits the bronchial inflammation and simultaneously improves their lung function. In this review, our current knowledge of the mechanism of action of glucocorticoids and their anti-inflammatory potential in asthma is described. Since bronchial epithelial cells may be important targets for glucocorticoid therapy in asthma, the effects of glucocorticoids on epithelial expressed inflammatory genes will be emphasized.

Effect of dexamethasone on A23187-induced airway responses in the guinea pig

We examined the effect of dexamethasone on A23187-induced bronchospasm, pulmonary inflammation and airway responses to substance P. Guinea pigs, dosed orally once a day for 4 days with dexamethasone (3.0, 10.0 or 30.0 mg/kg) or saline, were exposed to an aerosol of A23187 for 12 min or until labored breathing began. Postmortem pulmonary gas trapping was used as an indicator of in vivo airway obstruction and changes in bronchial responses. Dexamethasone did not alter airway obstruction or inflammation 1 h after A23187 exposure. However, dexamethasone reduced the enhanced airway responses to substance P and bronchiolar/peribronchiolar inflammation 24 h post-A23187. It is possible that glucocorticosteroid suppression of A23187-induced pulmonary inflammation was important in reducing the increased airway responses to substance P.

Duration of preventive effect of inhaled salbutamol on early airway response to allergen in asthmatic subjects

Salbutamol is known to effectively prevent early asthmatic response (EAR) after specific bronchial provocation test (sBPT) in asthmatic subjects, but the time-course of this protection is not known. In this study the effects of 200 micrograms salbutamol inhaled 2 h before sBPT were compared with 200 micrograms salbutamol inhaled 10 min before sBPT in eight asthmatic subjects sensitized to Phleum pratensis (PP) or Dermatophagoides pteronyssinus (DP). All subjects showed an EAR (% decrease in FEV1 from baseline value: 30.4 +/- 11%) in a preliminary sBPT performed with cumulated doses of extracts of PP or DP titrated in biological units (BU). Each subject performed, on two different days, in a random, double-blind, cross-over study, two puffs of placebo 2 h before sBPT and two puffs of salbutamol 10 min before sBPT (treatment A) or two puffs of salbutamol 2 h before sBPT and two puffs of placebo 10 min before sBPT (treatment B). Baseline FEV1 were similar in both tests. In treatment B, 10 min, 1 h and 2 h after salbutamol inhalation, FEV1 increased significantly with respect to placebo inhalation in treatment A. Ten minutes after salbutamol inhalation in treatment A, FEV1 became similar to that obtained 2 h after salbutamol inhalation and 10 min after placebo in treatment B. Allergen inhalation induced an EAR in only one out of eight subjects after treatment A, and five of the eight subjects after treatment B.(ABSTRACT TRUNCATED AT 250 WORDS)

Theophylline. Current thoughts on the risks and benefits of its use in asthma

Theophylline and its derivatives have been used in the treatment of asthma for over 50 years, but since the advent of more potent bronchodilators their use has become cloaked in controversy. Their continued existence results from their undoubted usefulness in severe acute asthma, nocturnal asthma, childhood asthma and moderate to severe chronic airflow limitation, and because of habitual use by physicians in other situations. The precise mechanism of action of theophylline remains uncertain. The role of phosphodiesterase inhibition and adenosine antagonism has been reviewed and the clinical significance of the anti-inflammatory action of theophylline discussed. Theophylline has unpredictable metabolism when first administered, and continued monitoring of drug concentrations is essential. Commonly encountered adverse effects may occur at therapeutic serum concentrations, frequently necessitating drug withdrawal. The overlapping therapeutic and toxic theophylline serum ranges can lead to life-threatening adverse effects at the upper end of the therapeutic range, especially in the elderly in whom special precaution is required.

Asthma pathogenesis and the implications for therapy in children

Gaining greater insight into the pathogenesis of asthma has redefined the approach to treatment of children with asthma. Clearly, the Expert Panel of the National Heart, Lung, and Blood Institute National Education Program has played a major role in taking the message to a wide audience of health care providers. Although only early trends are evident at this point in time, within several years therapeutic trends underway currently will be more commonplace, and we may observe how asthma continues to impact society and our health care system. The approach to therapy will continue to evolve and most likely be controversial for years to come.

Theophylline inhibits late asthmatic reactions induced by toluene diisocyanate in sensitised subjects

Toluene diisocyanate (TDI)-induced asthma is a frequent occupational airway disease. To determine whether a calibrated dosage of oral slow-release theophylline inhibits asthmatic reactions and the associated increase of airway responsiveness to methacholine induced by TDI, we examined six asthmatic subjects who developed a late or a dual asthmatic reaction after TDI inhalation challenge. We administered oral slow-release theophylline or placebo to each subject for 7 days according to a double-blind, randomized, cross-over study design. When the subjects received a placebo, TDI caused a late or a dual asthmatic reaction. When the subjects received theophylline. TDI caused significantly reduced late asthmatic reactions. Mean serum theophylline concentrations were within the therapeutic range. Theophylline neither modified the baseline airway responsiveness to methacholine, nor the increase of airway responsiveness to methacholine induced by TDI. These results suggest that slow-release theophylline may improve TDI-induced late asthmatic reactions, but it does not change the baseline airway responsiveness to methacholine and the increase of airway responsiveness to methacholine induced by TDI.

Salbutamol plus beclomethasone dipropionate, but not salbutamol alone, completely prevent early and late asthmatic responses to allergen

The effect of a week treatment with inhaled salbutamol plus placebo (S+P) vs. salbutamol combined with beclomethasone dipropionate (S+BDP) on early and late asthmatic responses to inhaled allergen was studied in ten atopic patients in a randomized, double-blind, cross-over study. All patients had previously shown a dual type response to the specific bronchial provocative test (sBPT). Each patient performed two periods of treatment for a week, with a 15 day interval between them: (a) salbutamol 0.3 mg, tid + placebo; (b) salbutamol 0.3 mg+BDP 0.2 mg, tid; at the end of each treatment period, sBPT was performed and the last treatments were given 1.5-2 h before and 3-4 h after allergen challenge. S + BDP completely prevented both early and late responses to allergen, while S + P reduced but did not completely inhibit early and late responses. The difference between the two treatments was significant for early and late asthmatic responses. Non-specific bronchial hyperresponsiveness to methacholine was performed before each treatment period, after 6 days of treatment before sBPT and the day after sBPT at the end of the treatment period; there was only a mild increase in PD15FEV1 methacholine after 6 days of treatment with S + BDP in comparison with S + P treatment. These results suggest that salbutamol plus beclomethasone may be used effectively in the prophylaxis of early and late asthmatic reactions induced by allergen in sensitized subjects.

The effect of a beta 2-adrenergic agonist and a histamine H1-receptor antagonist on the late asthmatic response to inhaled antigen

In this double-blind, randomized, cross-over trial, the role of histamine and the possible protective effect of a beta 2-adrenergic agonist in the later asthmatic response to inhaled antigen was investigated in nine atopic asthmatic patients. On four study days, 2-4 weeks apart, patients were given either: placebo; salbutamol aerosol 400 micrograms before and 200 micrograms 2-hourly after challenge; oral terfenadine 120 mg 2 h before and 10 h after challenge; and, on the final day, lung function was monitored without medication or antigen challenge. A nebuliser-dosimeter system was used to deliver a predetermined, single dose of antigen aerosol. Response was assessed by specific airways conductance (SGAW) measured in a body plethysmograph; FEV1 and PEFR were measured with a Pocket Spirometer. All measurements were made for 10 h in the clinic and then the patients continued to record PEFR and FEV1 at home for at least 2 more hours. Similar findings were obtained with all three lung function parameters. After challenge, the early response (ER) was small when compared with the late response (LR). All patients had a definite LR on the placebo day when FEV1 was compared with 'no challenge day'. Neither drugs had much effect on the small ER. The LR was not altered by terfenadine but was very significantly attenuated by salbutamol; the mean maximum fall in FEV1 during LR being 31, 29 and 12% after placebo, terfenadine and salbutamol, respectively. It is unlikely that histamine plays an important role in the LR to inhaled antigen but beta 2-adrenergic stimulants can attenuate LR, probably by directly preventing bronchial smooth muscle constriction and also by stabilising bronchial mast cells.

Pathogenesis of asthma: therapeutic implications

The current knowledge of asthma, specifically an appreciation of the contributing mechanisms leading to its development as well as its clinical features, has increased vastly in recent years. A better understanding of asthma's inflammatory nature has resulted in wider use of antiinflammatory agents. Specific effects of available antiasthma medications have been better elucidated, thereby helping to focus the development of newer drugs and improve the use of currently available therapeutic agents. The purpose of this article is to further understanding of asthma by providing the pathologic and physiologic basis of this disease. This is vitally important information as it is shaping the directions of the therapeutic approach to asthma care.

Long-term drug treatment of asthma in children

In this short review the pharmacologic and clinical effect of antiasthma drugs in children that is, beta 2-agonists, theophylline, anticholinergics, disodiumcromoglycate/nedocromil sodium, and inhaled corticosteroids are described. Furthermore, a medication plan for maintenance treatment is presented.

New assessment of airway responsiveness. Effect of pretreatment with procaterol on allergen-induced bronchoconstriction

We examined airway responsiveness to allergen inhalation using a novel technique by which dynamic compliance (Cdyn) and pulmonary resistance (Rl) are simultaneously calculated by Fourier-series analysis of flow and transpulmonary pressure during tidal breathing. C0 and C0.5 (Cdyn at the frequency of zero and 0.5 Hz, respectively) were computed using the regression line of Cdyn versus frequency measured at the fundamental and first three harmonics in each breathing cycle. First, the validity of this system was tested by comparing Rl, C0 and C0.5 during five consecutive breaths with those obtained by the conventional method. A good correlation was seen in Rl, C0 and C0.5 between the two methods. Second, we studied airway response to allergen inhalation before and after oral administration of a long-acting beta 2-stimulant (procaterol, 50 micrograms or 100 micrograms) or placebo in a double-blind crossover trial in six atopic asthmatic subjects. In control allergen inhalation tests by administration of placebo, Rl increased progressively, and C0.5, expressed as percentage of control compliance at zero frequency (C0.5/COcont), decreased progressively. After 100 micrograms procaterol, Rl response to allergen was almost completely inhibited. However, a decrease in C0.5/C0cont was still observed. These findings suggest that pretreatment of asthmatic patients with procaterol can release allergen-induced bronchoconstriction of the central airways, but cannot release that of the peripheral airways.

Effect of nedocromil sodium on early and late phase responses to allergen challenge in the guinea-pig

We have developed a model of asthma in conscious guinea-pigs in which inhalation challenge with specific allergen induces both early and late phase reductions in specific airways conductance. Analysis of cells removed from the airways by bronchoalveolar lavage showed the presence of a neutrophilia, which reached a maximum at 17 hours, and an eosinophilia which developed more slowly, still increasing at 72 hours. Nedocromil sodium inhaled before challenge inhibited both the early and late phase responses. In contrast, the beta-adrenoceptor stimulant, salbutamol, inhibited only the early phase. When inhaled 6 hours after challenge, i.e. between the early and late phase responses, the late phase bronchoconstriction was prevented by nedocromil sodium but only partially by salbutamol. Evidence that the neutrophilia was not functionally associated with the late response was gained from the observations that it was inhibited by both nedocromil sodium and salbutamol, whereas only nedocromil sodium blocked the late phase airways response. When administered 6 hours after challenge, nedocromil sodium reduced eosinophil accumulation at 72 hours in parallel with inhibiting a secondary late response at this time. These results demonstrate that nedocromil sodium is able to prevent both early and late phase reductions in airways function in an animal model of allergic asthma. Whereas inhibition of the early response may reflect an effect on mast cell mediator release, the effects of nedocromil sodium on the late response and on eosinophil accumulation are strongly suggestive of an anti-inflammatory effect within the lung.

Allergy or inflammation? From neuropeptide stimulation of human skin mast cells to studies on the mechanism of the late asthmatic response

This short review examines two examples of studies into the mechanisms of allergic responses which have particular relevance to inflammation research. The first is the ability of human skin mast cells, but not those derived from lung, adenoids, tonsils or intestine, to release histamine in response to stimulation by neuropeptides including substance P, vasoactive intestinal polypeptide (VIP) and somatostatin. The neuropeptide activation site does not appear to be a classical tachykinin receptor but rather a binding site of low affinity and low specificity capable of interacting with neuropeptides and compounds with similar physicochemical characteristics. In contrast to IgE-dependent activation, neuropeptide stimulation of skin mast cells induces a rapid release of histamine with minimal generation of PGD2 and LTC4. This pseudo-allergic reaction is thought to underlie the weal and flare response in the skin and may have a role in urticaria. The second example describes studies to elucidate the mechanisms of the late asthmatic response by use of a guinea-pig model. As in man, both early and late phase responses in the guinea-pig are inhibited by sodium cromoglycate whereas only the early response is inhibited by the beta-adrenoceptor stimulant drug salbutamol. Examination of bronchoalveolar fluid has shown a temporal relationship between an airways neutrophilia and the late response. However, pharmacological manipulation and the use of an anti-neutrophil serum has shown that these events are not interdependent. The role of the airways eosinophilia requires further investigation.

Effect of salbutamol and inhaled sodium cromoglycate on the airway and neutrophil chemotactic activity in "fog"induced bronchospasm

To investigate whether salbutamol and sodium cromoglycate (SCG) inhibit airway response and the associated mediator release induced by ultrasonic nebulation of distilled water (UNDW, "fog"), we measured the serum neutrophil chemotactic activity (NCA) during bronchial challenge with "fog" with and without premedication with placebo, salbutamol, or SCG in 10 subjects with asthma, in four sets of studies. To assess changes in airway caliber, we measured FEV1. To assess changes in NCA, we measured the maximal distance reached by neutrophils in a filter when neutrophils were challenged with the subject's serum in a Boyden chamber. Treatment with placebo did not change baseline FEV1 or serum NCA; however, FEV1 decreased and serum NCA increased (p less than 0.05) after inhalation of "fog". Treatment with SCG did not affect either FEV1 and baseline serum NCA. After inhalation of "fog", no significant bronchoconstriction nor NCA increase was observed in eight of 10 patients with maximal mean percent decrease in FEV1 of -4.26, SEM 0.99, and maximal mean percent increase in NCA of +8.6, SEM 5.28. In the two patients who developed a bronchoconstriction after challenge with SCG pretreatment, an associated significant increase in NCA was observed but did not affect baseline NCA. After inhalation of "fog", no significant decrease in FEV1 (maximal mean percent decrease FEV1, -6.71, SEM 0.17) nor significant increase in serum NCA (maximal mean percent increase NCA, +3.6, SEM 7.1) was observed in nine of 10 patients. After salbutamol, only one patient developed a bronchoconstrictive response to "fog" associated with a significant increase in serum NCA. These results suggest that both SCG and salbutamol may prevent the bronchoconstriction induced by "fog" by inhibiting mediator release.

Sustained release theophylline preparations. Practical recommendations for prescribing and therapeutic drug monitoring

Theophylline is an important antiasthmatic medication which has bronchodilator properties. With increased understanding of the relationships of serum theophylline concentration and effect, both adverse and beneficial, oral dosage forms were developed to provide consistent serum theophylline concentrations with the benefit of convenient dosage intervals for long term use. Since factors such as concurrent disease states, drug interactions and age have a profound effect on theophylline disposition, relatively sophisticated dosage guidelines have evolved. Theophylline is in fact a model drug for the application of pharmacokinetic principles to the individualization of a treatment regimen. The purpose of this discussion is to review the relationship of serum theophylline concentration and pharmacodynamic effect and the special properties of oral sustained release theophylline formulations, and to provide a practical approach to prescribing theophylline. Guidelines are provided on the use of serum theophylline concentrations to individualize the theophylline dose, with an analysis of available techniques to monitor theophylline.

Release of leukotrienes in patients with bronchial asthma

To investigate whether leukotrienes (LTs) are released into the bronchial fluid of patients with symptomatic asthma, bronchial lavage was carried out in 17 patients with mild to severe asthma and nine healthy subjects without asthma. LTE4 was detected in 15 of the 17 patients with asthma with reverse-phase high-performance liquid chromatography. The identify of LTE4 was confirmed by ultraviolet spectrometry and by positive ion fast atom-bombardment mass spectrometry. LTD4 was found in two patients and 20-OH-LTB4 in 12 patients. No LTs were detectable in the lavage fluid from any of the healthy subjects without asthma. The finding of LTs in bronchial lavage fluid from the patients with asthma despite bronchodilator and/or corticosteroid therapy suggests that these compounds may be important in asthma. However, the presence of significant quantities of LTE4 in patients with mild asthma requiring only intermittent bronchodilator therapy for control and the lack of correlation between LTE4 and pulmonary function also suggests that other factors may be important in determining the net end organ response. The present study points to the importance of studying the whole spectrum of mediators that are released. Analysis of bronchial lavage fluid may be useful in determining the relative role of these mediators and the effect of pharmacologic intervention.

Heat-labile neutrophil chemotactic activity in subjects with asthma after allergen inhalation: relation to the late asthmatic reaction and effects of asthma medication

Neutrophil chemotactic activity (NCA) in serum is raised in subjects with asthma after inhalation of an allergen. Two kinds of NCA have been demonstrated, heat-stable and heat-labile. In addition, inhibitory activity is generated after inhalation challenge. In the present study we have investigated the relationship of heat-labile NCA to the development of the late asthmatic reaction (LAR) in 13 subjects with asthma after allergen challenge and the effects of asthma medication on the formation of this activity. Heat-labile NCA peaked 120 to 240 minutes after challenge and demonstrated at this time significant (p less than 0.001) quantitative relationships to the ensuing LAR. The inhalant corticosteroid, budesonide, significantly inhibited (p less than 0.001) the generation of heat-labile NCA and the development of LAR both after a single dose and after 4 weeks of pretreatment. Single-dose disodium cromoglycate pretreatment, initially, slightly enhanced (p less than 0.05) heat-labile NCA but, after 120 minutes, slightly inhibited (p less than 0.05) the activity. Disodium cromoglycate also slightly abrogated the development of LAR. Single-dose pretreatment with the beta 2-agonist, terbutaline, inhibited generation of heat-labile NCA (p less than 0.001) but was without effect on LAR. It is concluded that the generation of heat-labile NCA is related to the development of the LAR and may be of importance for the attraction of inflammatory cells to the lung in the development of the inflammatory reaction probably responsible for LAR. However, the pharmacologic control of heat-labile NCA indicates that the process is multifactorial and not solely dependent on the generation of NCAs detected in serum.

The relationship between mast cell-mediator release and bronchial reactivity in allergic asthma

The relationship between mast cell-mediator release and nonspecific bronchial reactivity was investigated in allergen-induced asthma. Two groups of subjects with asthma, one group with markedly reactive airways (provocative concentration of methacholine causing a 20% fall in FEV1, 0.07 mg/ml) and the other group with less reactive airways (provocative concentration of methacholine causing a 20% fall in FEV1, 3.83 mg/ml), had allergen bronchoprovocation. After challenge, bronchoconstriction was measured as change in specific airway conductance (SGaw), and mast cell-mediator release was measured as change in both plasma histamine and serum neutrophil chemotactic activity (NCA). In the group with more reactive airways, allergen challenge, while it produced a mean fall in SGaw of 58.1%, was not associated with any significant increase in plasma histamine from a mean resting level of 3.69 nmol/L-1. In contrast, a comparable mean fall in SGaw of 52.4% in the group with less reactive airways was associated with a significant (p less than 0.005) increase in plasma histamine from 1.17 to 3.60 nmol/L-1, maximal 5 minutes after allergen challenge. There were, however, significant increments in serum NCA in both groups with asthma after allergen challenge. The changes in NCA in the group with less reactive airways (136.7 +/- 38.1% above baseline; p less than 0.01; 1% sera dilution) were significantly greater (p less than 0.05) than changes identified in the group with more reactive airways (68.3% above baseline; p less than 0.01; 20% sera dilution). These findings directly support the concept that both mast cell-mediator release and nonspecific bronchial reactivity are separate factors that influence the airway response to inhaled allergen in asthma.(ABSTRACT TRUNCATED AT 250 WORDS)

Inhibition of IgE-dependent histamine release from human dispersed lung mast cells by anti-allergic drugs and salbutamol

The ability of the anti-allergic drugs, sodium cromoglycate (SCG), lodoxamide, traxanox, RU31156 and the beta-adrenoceptor agonist salbutamol to inhibit IgE-dependent histamine and prostaglandin D2 (PGD2) release was assessed using human dispersed lung mast cells. The anti-allergic drugs were weak inhibitors of histamine release, high concentrations (100-1000 microM) producing less than 35% inhibition. Salbutamol produced 39% inhibition at 10 microM. The efficacy of both SCG and salbutamol was inversely related to the concentration of anti-IgE used for challenge and to the degree of histamine release. Rapid tachyphylaxis was observed with all anti-allergic drugs but not with salbutamol. Cross-tachyphylaxis was observed between SCG and the other anti-allergic drugs, suggesting a common mechanism of action. No cross-tachyphylaxis was observed between SCG and salbutamol. SCG was significantly (P less than 0.001) more effective in inhibiting PGD2 than it was histamine release. Preferential inhibition of PGD2 compared with histamine release was less marked (P less than 0.05) with salbutamol and not significant with the other anti-allergic drugs. Mast cells dispersed by enzymatic digestion of human lung released more histamine on immunological challenge than mechanically dispersed cells obtained by fine chopping of tissue. Enzyme treatment of mechanically dispersed cells removed this difference. Enzymatically and mechanically dispersed cells responded similarly to the inhibitory effects of SCG and salbutamol. Our results suggest that salbutamol is a more effective inhibitor of mediator release from human lung mast cells than anti-allergic drugs. However, with the low levels of mediator release achieved during an allergic reaction in man in vivo, both salbutamol and SCG are likely to be effective inhibitors of both preformed and newly generated mediators.

Treatment of nocturnal asthma: the role of sustained-release theophylline and oral beta-2-mimetics

In two double-blind, multiple-dose cross-over studies the therapeutic effects of SR theophylline preparations given once each night (mean 11.2 mg/kg per day) versus twice daily in equal doses (mean 10.3 mg/kg per day) (study I) and SR-terbutaline in equal doses (mean 0.25 mg/kg per day) versus SR theophylline in unequally divided daily doses (mean 5.3 mg/kg morning dose, 10.6 mg/kg evening dose) study II) were compared in 19 patients with nocturnal asthma. At the end of each treatment period drug serum concentrations and PEFR were measured every 2 hr over a 24-hr period. With the twice-daily, equally divided regimen, serum theophylline concentrations were lower at night than during the day (mean 9.4 +/- 0.9 versus 11.3 +/- 1.0 mg/l). With the single evening administration, serum theophylline concentrations were considerably higher at night (Cmax 16.3 +/- 1.4 mg/l) and the circadian variation of PEFR was significantly reduced. PEFR was higher during night and early morning (283 +/- 14 versus 217 +/- 11 l/min, P less than 0.005). During daytime in study II, PEFR values were slightly higher with theophylline than terbutaline. There was no significant difference in peak flow between either treatment during the night and early morning. However, additional use of inhaled beta-2-mimetics because of asthmatic attacks occurred more often during terbutaline (79 times in 8/10 patients) than theophylline treatment (29 times in 5/10 patients). Symptom scores, number of attacks and side-effects clearly favor the theophylline regimen. We conclude that for patients with nocturnal asthma a once-nightly dose of SR theophylline can be sufficient for stabilization of the airways.

Protective effects of ketotifen on allergen-induced bronchoconstriction and skin weal

A single-blind cross-over method was used to investigate the effects of ketotifen on the total respiratory resistance response curve to inhalation of a high concentration of allergen (1:5 w/v house dust or 1:10 w/v Japanese cedar pollen) and the weal response to intradermal injection of serially diluted allergen (1:10(3)-1:10(6) w/v). Five subjects received 2 mg of ketotifen every 12 hr for the first week and an inactive placebo in the same manner for the second week. The remaining five subjects received the placebo for the first week and ketotifen for the second week. Ketotifen did not alter base-line pulmonary function, but significantly delayed the time from the start of allergen exposure to the beginning of elevation of total respiratory resistance (P less than 0.02), and the time from the start of allergen exposure to the point at which total respiratory conductance decreased by 35% from the base-line value (P less than 0.01). Ketotifen also decreased skin test sensitivity significantly (P less than 0.01).

The glucocorticosteroid, budesonide, partially blocks histamine release from human lung tissue in vitro

IgE-receptor dependent, but not A23187-induced, histamine release from passively sensitized chopped human lung tissue, or from a dispersed lung cell population obtained from the tissue after enzymatic digestion, is reduced after incubation overnight of cells/tissue with the glucocorticosteroid budesonide (10(-7) M). Since the inhibitory effect of budesonide is reduced in the continuous presence of diluted reagin-rich serum used for passive sensitization, but not in the presence of heat-inactivated serum, it is suggested that the glucocorticosteroid acts by reducing the binding of IgE-antibody to the target cell(s).

Antigen-induced bronchial anaphylaxis in actively sensitized SD rats. Effects of glucocorticoid treatment

We examined the effects of glucocorticosteroids (GCS) on antigen-induced bronchial anaphylactic reactions (BAR) in SD rats immunized with ovalbumin (OA) and alum. The animals were treated with vehicle, budesonide (BUD), dexamethasone (DEX), or hydrocortisone (HC) at various times before intravenous (i.v.) antigen challenge. The drugs were administered either intraperitoneally (i.p.) or intratracheally (i.t.); the BAR was elicited by a low or by a high challenge dose of antigen. A BAR elicited by a low challenge dose of antigen was reduced in a dose-dependent way by all GCS after i.p. administration; at 1 mg/kg, BUD and DEX significantly reduced BAR and at 50 mg/kg all three of the examined compounds inhibited the BAR by 50% or more. For BUD, maximum effect was recorded when it was given 12 h before test. There was only a slight variation in the inhibitory effects of the GCS with immunization conditions of test animals. I.t. instillation of the drugs did not markedly increase their inhibitory capacity as compared to i.p. administration. BAR elicited by a high antigen dose was at best marginally affected by the GCS when given either i.p. or i.t. Thus, antigen-induced airway reactivity in rats can be reduced by GCS treatment provided that this is performed sufficiently long before the test and that the challenge dose of antigen is not too high.

Histopathological support of antagonism of allergen-induced mast cell mediator release in human skin by a beta-2-agonist

The site of antagonistic action on allergen-induced early skin reactions by the beta 2-agonist terbutaline was studied by light microscopy in 10 atopic subjects. Pretreatment with 1 microgram terbutaline intradermally 5 min prior to challenge with horse dander allergen produced an approximate inhibition of 85 and 55% of flare and wheal responses respectively (P less than 0.001). Biopsy specimens obtained from skin sites injected with allergen alone showed a reduced number of remaining stainable mast cells as compared to sites injected with terbutaline prior to allergen (P less than 0.05, Sign test). The data support the concept of in vivo inhibition of the mast cell mediator release reaction in atopic skin by terbutaline.

Theophylline reduces the response to nasal challenge with antigen

A nasal challenge model of allergic rhinitis was used to determine if pretreatment with oral theophylline reduces histamine release in vivo. Ten subjects were entered into a double-blind, cross-over trial. The results showed that both the physiologic response (sneezing) (p = 0.02) and the amount of mediators (histamine, kinins, toluene sulfonyl arginine methyl ester esterase activity) (p less than 0.01 for all) released into nasal secretions were significantly reduced after one week of pretreatment with theophylline. At the time of challenge, the serum concentrations of theophylline were between 8 and 22 micrograms/ml. It is speculated that the ability of theophylline to block the clinical response to antigen challenge and to decrease the release of mast cell mediators contributes to its clinical efficacy in the treatment of asthma.

Mechanisms of glucocorticosteroid action in bronchial asthma

Although their precise mechanisms of action are undefined, the usefulness of CCS in the treatment of asthma is unquestioned. It is clear that they act at multiple sites. Among the general actions of CCS felt to be applicable to asthma are their ability to facilitate beta-adrenergic responsiveness and to suppress inflammation. More specific actions relevant to asthma are their inhibition of eicosanoid formation (e.g., reduction in leukotriene formation), prevention and reversal of LPR (probably through CCS anti-inflammatory effects), and reduction in mucus secretion. Actions that have not yet been clarified but that may be useful include possible reductions in airway hyperreactivity (or at least the prevention of increases in reactivity superimposed upon overreactive airways) and suppression of basophil (but not mast cell) mediator release.

Bronchorelaxation and plasma histamine after salbutamol inhalation

Plasma histamine in 8 normal subjects was measured before and after inhalation of carbachol to induce a 50% fall in specific airway conductance (SGaw). The measurements were repeated 5 min after inhalation of salbutamol or placebo. No significant change in plasma histamine occurred after placebo or carbachol inhalation, despite the persistent induced bronchospasm after the latter treatment. In contrast, plasma histamine was significantly increased from 0.25 to 0.43 ng/ml after salbutamol inhalation. Simultaneously, induced bronchospasm was relieved, from 51% to 103% of baseline SGaw. Thus, the relief of carbachol-induced bronchospasm by salbutamol was associated with a rise in plasma histamine. Since salbutamol itself is a potent inhibitor of mast cell degranulation and histamine release, the present findings suggest that histamine may be released and sequestered within the lungs during carbachol-induced-bronchospasm, and also that desequestration of bronchoconstrictor mediators accumulated at the point of contact of bronchial smooth muscle may contribute to the relief of bronchospasm by salbutamol.

Urinary N tau-methylhistamine during early and late allergen-induced bronchial-obstructive reactions

Urinary N tau-methylhistamine, a unique histamine metabolite, was determined in 29 patients with bronchial asthma before and after inhalation of a control solution on 1 day and before and after allergen inhalation on another day. Twenty-eight patients had an early bronchial-obstructive reaction, defined by a decrease in FEV1 of 20% or more within 1 hr after allergen inhalation. A late bronchial-obstructive reaction, 3 to 8 hr after allergen inhalation, was found in 16 patients. The early bronchial-obstructive reaction was attended with a significantly increased N tau-methylhistamine excretion. The fall in FEV1 was correlated with the degree of bronchial hyperreactivity to histamine, but no significant correlation was found with the increase in urinary N tau-methylhistamine excretion. During the late reaction there was no significant difference in the change in N tau-methylhistamine excretion when the change was compared with that of the control day. These results suggest that a renewed degranulation of lung mast cells during the late bronchial-obstructive reaction is unlikely.

Sustained inhibition of antigen-induced histamine release from human lung by the beta 2-adrenoceptor agonist terbutaline

Antigen-induced histamine release from passively sensitized human lung tissue was inhibited in the presence of the beta 2-adrenoceptor agonist, terbutaline. A sustained and statistically significant suppression was detected in the concentration interval 3 X 10(-8)-1 X 10(-6) M. Fifty per cent inhibition IC50, was obtained at an interpolated concentration of 5.3 X 10(-8) +/- 0.4 X 10(-8) M (n = 13), when the histamine secretion was elicited with optimum concentration of antigen. Histamine release induced with a suboptimum concentration of antigen was inhibited to a greater extent than release initiated with optimum concentration. The data in the present investigation support the concept that terbutaline-induced inhibition of mediator release from human lung tissue can contribute to the clinical effectiveness of the drug during treatment of allergic asthma.

Inhibitory effect of glucocorticosteroids on anti-IgE-induced histamine release from human basophilic leukocytes: evidence for a dual mechanism of action

Anti-IgE-induced histamine release from human leukocytes is inhibited when the cells before challenge are cultured overnight in the presence of glucocorticoids (GCSs). The present report suggests that the GCSs might exert their effect by at least a dual mechanism of action. Histamine release was induced by a suboptimum concentration of anti-IgE. When the release recorded in the presence of the steroid is plotted against the release recorded in its absence, the data points of several experiments fit a regression line characterized by two parameters: its slope and its intercept with the abscissa. Structure-activity examination with selected GCSs indicates that the orders of potency for affecting these two parameters are not identical. Furthermore, pulse experiments suggest that the cells require different times of contact with the steroid to express inhibition according to the two parameters. The removal of adherent cells or platelets did not markedly affect the degree of leukocyte histamine release or its inhibition by a given GCS, suggesting that the steroid interacts directly with the basophil. Finally, steroid-induced inhibition was not affected by the putative phospholipase A2-inhibitor p-bromophenacylbromide (BPB) or the 5-lipoxygenase inhibitor nordihydroguaiaretic acid (NDGA).

Influence of glucocorticoids on histamine release and 45calcium uptake by isolated rat mast cells

Hydrocortisone and prednisolone inhibited the histamine release from isolated rat mast cells induced by antigen, the ionophore A23187, and compound 48/80 in the absence and in the presence of calcium. Hydrocortisone reduced the response to the different releasing agents by 50% in the concentration range 2-6 X 10(-4) M, whereas prednisolone was about 1.5 times more potent. The inhibitory effect of hydrocortisone had a rapid onset of action and maximal inhibition was observed after preincubation for 20 minutes. The effect of hydrocortisone was reversed by including 2 mM glucose in the medium. The reversal was only partial with antigen and the ionophore A23187, indicating a greater energy requirement of these releasing agents compared with compound 48/80. The inhibition of the histamine release was accompanied by a concentration-related inhibition of the 45Ca uptake, except with the ionophore. The inhibition of the 45Ca uptake was also reversed by glucose, but differences were noted concerning the influence of preincubation time. The observations are explained by an association of 45Ca to cellular material, e.g. granules, secondary to the release process. The effects of hydrocortisone and prednisolone were qualitatively identical and were not observed with estriol. The glucocorticoid inhibition of histamine release does not seem to be caused by effects on phospholipase activity or cyclic AMP metabolism. The present observations are fully consistent with an impaired mitochondrial function as the mechanism for the mast cell effects of the glucocorticoids.

Plasma histamine concentrations and complement activation during house dust mite-provoked bronchial obstructive reactions

Lung function and histamine levels in peripheral venous plasma samples were followed after challenge with house dust mite allergen. In eight patients the mean maximal histamine concentration showed a significant rise during the early obstructive reaction when compared with the concentrations at similar time intervals after inhalation of a control solution. In nine other patients treatment with disodium cromoglycate (DSCG) caused a significant fall in plasma histamine concentrations indicating that histamine liberation plays a role during the early obstructive reaction and was released from the lung compartment. Histamine during early obstructive reactions compared with the pre-inhalation values did show a rise in mean maximal histamine concentration (1.5-4.1 ng/ml) but this was statistically not significant. During the late reaction neither significant increase in histamine nor inhibition by DSCG was found. Measurement of complement degradation products did not support the role of complement activation during either early or late bronchial obstructive reactions.

Theophylline. A "state of the art" review

Theophylline is a bronchodilator and respiratory stimulant that is effective in the treatment of acute and chronic asthma, Cheyne-Stokes respirations, and apnea/bradycardia episodes in newborns. It is also used as an adjunct in the treatment of congestive heart failure and acute pulmonary edema, but it has no established efficacy in patients with chronic irreversible airways obstruction. Benefits and risks from theophylline relate directly to serum concentration, which is a function of both dose and elimination characteristics of the drug in an individual patient. When used to treat acute symptoms, an initial loading dose based on a mean volume of distribution is required to rapidly obtain maximum bronchodilator effect. Because of large interpatient differences in elimination, constant intravenous infusion rates for continued therapy must be guided by monitoring serum theophylline concentration at intervals until a steady-state serum concentration is reached within the 10-20 micrograms/ml therapeutic range. Intravenous, oral or rectal solutions and plain uncoated tablets are appropriate for acute therapy, while reliably absorbed slow-release formulations offer therapeutic advantages for the management of chronic asthma, particularly in patients with rapid elimination. Dosage for long-term therapy is determined by starting with low doses that allow virtually complete acceptance of the medication followed by gradual increases, if tolerated, at three day intervals until mean age-specific doses are reached. Subsequent adjustment in dosage regimens are then based upon serum concentration measurements. Most clinical laboratories now measure theophylline, and newer systems have been developed to provide emergency results within minutes at a reasonable cost. In cases of theophylline poisoning, the drug must be rapidly removed to prevent life-threatening toxicity. When serum concentrations are in excess of 60 micrograms/ml charcoal hemoperfusion dialysis may be indicated, even in the absence of obvious signs of toxicity.

Antigen-induced neutrophil chemotactic activity from sensitized lung

We have used the model of ovalbumin-sensitized guinea pigs to define the source of antigen-derived, high-molecular-weight neutrophil chemotactic activity (NCA). Incubating sensitized lung fragments with specific antigen (ovalbumin) but not irrelevant antigen (bovine serum albumin) or buffer resulted in the release of high-molecular-weight NCA and histamine, suggesting a lung mast cell origin for NCA. High-molecular-weight NCA accounted for greater than 90% of the NCA observed after antigen-lung incubation. The importance of high-molecular-weight NCA in recruitment of neutrophilic leukocytes to the site of allergic inflammatory reactions is emphasized.

Double-blind trials of inhaled beclomethasone diproprionate and fluocortin butyl ester in allergen-induced immediate and late asthmatic reactions

The blocking effects of inhaled beclomethasone dipropionate (BDP) and fluocortin butyl ester (FCB) on the immediate and late asthmatic reactions induced by inhaled allergen were studied in two trials. In the first, a double-blind cross-over trial compared BDP (800 micrograms daily as powder) with FCB 8 mg daily (1:20 by wt.-Formulation 1). The second trial was identical in design and compared FCB 8 mg daily (1:20) with FCB 8 mg daily as Formulation 2 (1:40). Known BDP, 400 micrograms daily by pressurized aerosol was studied at the end of the second trial. Allergen provocation was performed before and after 7 days treatment with each drug, with a 2-week interval between each drug. Overall, a blocking index for the immediate reaction of greater than 50% was obtained in ten of twenty patients (50%) using BDP, and five of twenty-one (25%) using FCB (P less than 0.01). The late reaction was blocked in nine of eleven (82%) instances on BDP, and four of fourteen (33%) on FCB. Contrary to earlier reports, inhaled corticosteroid agents used for several days prior to bronchial challenge, were found to block both the immediate as well as the late reaction in many individuals.