Immunologic studies in allergen-induced late-phase asthmatic reactions

Late Phase Eustachian Tube and Nasal Allergic Responses Associated with Inflammatory Mediator Elaboration

Previous work in our laboratories has documented an IgE-mediated functional obstruction of the nose and eustachian tube (ET) immediately after nasal allergen challenge. The goals of this study were to monitor changes in nasal, ET, and bronchial physiology during the 12 hours following nasal allergen challenge and to correlate these changes with the elaboration of inflammatory mediators (IM). Subjects with ragweed allergic rhinitis were challenged intranasally with 2.5 mg of ragweed/nostril, and responses were assessed by posterior rhinomanometry for the nasal airway, sonotubometry for the eustachian tube, and spirometry for the bronchial airway. Blood was obtained simultaneously for quantitating the elaboration of three functionally and metabolically distinct IM. Late nasal responses (3–12 hours postchallenge) were observed in 7 of 10 subjects, with an average decrease of 67 ± 5% in nasal conductance at an average onset time of 6.6 ± 0.8 hours postchallenge. Dual late nasal responses were observed in five subjects. Late ET responses were observed in 10 ears (50%). Two sequential late ET responses were observed in three subjects. Late bronchial responses were detected in three subjects, one of whom did not have an early response. Plasma elevations of one or more IM were detected in all late nasal responders during the late phase response period. Late nasal and ET responses in association with an allergic nasopharyngeal inflammatory process could provide an important insight into the relationship between nasal allergy and middle ear disease.

Characterisation of a murine model of the late asthmatic response

BACKGROUND

The incidence of asthma is increasing at an alarming rate. While the current available therapies are effective, there are associated side effects and they fail to adequately control symptoms in all patient subsets. In the search to understand disease pathogenesis and find effective therapies hypotheses are often tested in animal models before progressing into clinical studies. However, current dogma is that animal model data is often not predictive of clinical outcome. One possible reason for this is the end points measured such as antigen-challenge induced late asthmatic response (LAR) is often used in early clinical development, but seldom in animal model systems. As the mouse is typically selected as preferred species for pre-clinical models, we wanted to characterise and probe the validity of a murine model exhibiting an allergen induced LAR.

METHODS

C57BL/6 mice were sensitised with antigen and subsequently topically challenged with the same antigen. The role of AlumTM adjuvant, glucocorticoid, long acting muscarinic receptor antagonist (LAMA), TRPA1, CD4+ and CD8+ T cells, B cells, Mast cells and IgE were determined in the LAR using genetically modified mice and a range of pharmacological tools.

RESULTS

Our data showed that unlike other features of asthma (e.g. cellular inflammation, elevated IgE levels and airway hyper-reactivity (AHR) the LAR required AlumTMadjuvant. Furthermore, the LAR appeared to be sensitive to glucocorticoid and required CD4+ T cells. Unlike in other species studied, the LAR was not sensitive to LAMA treatment nor required the TRPA1 ion channel, suggesting that airway sensory nerves are not involved in the LAR in this species. Furthermore, the data suggested that CD8+ T cells and the mast cell-B-cell - IgE axis appear to be protective in this murine model.

CONCLUSION

Together we can conclude that this model does feature steroid sensitive, CD4+ T cell dependent, allergen induced LAR. However, collectively our data questions the validity of using the murine pre-clinical model of LAR in the assessment of future asthma therapies.

Complement in asthma: sensitivity to activation and generation of C3a and C5a via the different complement pathways

Studies in rodent models suggested that complement may play a critical role in susceptibility to airway hyperresponsiveness (AHR) and as a mediator of bronchial obstruction and inflammation in asthma. Complement may participate in susceptibility to asthma because of an intrinsic abnormality in complement activation and generation of C3a, C5a, or other products that affect cellular responses, resulting in T(H)2 predominance and asthma susceptibility. Alternatively, an intrinsic abnormality in the cellular response to complement activation products could determine susceptibility to asthma. In this study, the authors investigated whether complement in patients with atopic asthma versus nonatopic controls possesses an increased propensity to become activated. Despite reports that total complement plasma levels in unchallenged asthmatics are normal, an abnormal sensitivity of complement to activation may exist if an isoform or a polymorphic variant of a complement protein was present and resulted in gain or loss of function without associated changes in total complement levels. Therefore, complement activation was induced in vitro in plasma of asthmatics and controls using activators of the classical, alternative, and lectin pathways and measured C3a, other C3 fragments, and C5a. For each pathway, similar amounts of generated fragments, as well as C3a/C3 and C5a/C5 ratios, were found in asthmatics and controls. Also, similar basal plasma levels of C3a and C5a were found in both groups; however, mannan-binding lectin (MBL) levels were moderately elevated in asthmatics. In conclusion, the results suggest that, in asthmatic patients, complement activation does not exhibit an abnormal sensitivity to activation by any of the known activation pathways.

Effects of phenanthraquinone on allergic airway inflammation in mice

BACKGROUND

Diesel exhaust particles (DEP) enhance allergic airway inflammation in mice (Takano et al., Am J Respir Crit Care Med 1997; 156: 36-42). DEP consist of carbonaceous nuclei and a vast number of organic chemical compounds. However, it remains to be identified which component(s) from DEP are responsible for the enhancing effects. 9,10-Phenanthraquinone (PQ) is a quinone compound involved in DEP.

OBJECTIVE

To investigate the effects of PQ inoculated intratracheally on allergic airway inflammation related to ovalbumin (OVA) challenge.

MATERIALS AND METHODS

We evaluated effects of PQ on airway inflammation, local expression of cytokine proteins, and allergen-specific immunoglobulin production in mice in the presence or absence of OVA. Results In the presence of OVA, PQ (2.1 ng/animal) significantly increased the numbers of eosinophils and mononuclear cells in bronchoalveolar lavage fluid as compared with OVA alone. In contrast, the numbers of these cells around the airways were not significantly different between OVA challenge and OVA plus PQ challenge in lung histology. PQ exhibited adjuvant activity for the allergen-specific production of IgG1 and IgE. OVA challenge induced significant increases in the lung expression of IL-4, IL-5, eotaxin, macrophage chemoattractant protein-1, and keratinocyte chemoattractant as compared with vehicle challenge. However, the combination of PQ with OVA did not alter the expression levels of these proteins as compared with OVA alone.

CONCLUSION

These results indicate that PQ can enhance the immunoglobulin production and the infiltration of inflammatory cells into alveolar spaces that are related to OVA, whereas PQ seems to be partially responsible for the DEP toxicity on the allergic airway inflammation.

Effects of nano particles on antigen-related airway inflammation in mice

Background

Particulate matter (PM) can exacerbate allergic airway diseases. Although health effects of PM with a diameter of less than 100 nm have been focused, few studies have elucidated the correlation between the sizes of particles and aggravation of allergic diseases. We investigated the effects of nano particles with a diameter of 14 nm or 56 nm on antigen-related airway inflammation.

Methods

ICR mice were divided into six experimental groups. Vehicle, two sizes of carbon nano particles, ovalbumin (OVA), and OVA + nano particles were administered intratracheally. Cellular profile of bronchoalveolar lavage (BAL) fluid, lung histology, expression of cytokines, chemokines, and 8-hydroxy-2'-deoxyguanosine (8-OHdG), and immunoglobulin production were studied.

Results

Nano particles with a diameter of 14 nm or 56 nm aggravated antigen-related airway inflammation characterized by infiltration of eosinophils, neutrophils, and mononuclear cells, and by an increase in the number of goblet cells in the bronchial epithelium. Nano particles with antigen increased protein levels of interleukin (IL)-5, IL-6, and IL-13, eotaxin, macrophage chemoattractant protein (MCP)-1, and regulated on activation and normal T cells expressed and secreted (RANTES) in the lung as compared with antigen alone. The formation of 8-OHdG, a proper marker of oxidative stress, was moderately induced by nano particles or antigen alone, and was markedly enhanced by antigen plus nano particles as compared with nano particles or antigen alone. The aggravation was more prominent with 14 nm of nano particles than with 56 nm of particles in overall trend. Particles with a diameter of 14 nm exhibited adjuvant activity for total IgE and antigen-specific IgG₁ and IgE.

Conclusion

Nano particles can aggravate antigen-related airway inflammation and immunoglobulin production, which is more prominent with smaller particles. The enhancement may be mediated, at least partly, by the increased local expression of IL-5 and eotaxin, and also by the modulated expression of IL-13, RANTES, MCP-1, and IL-6.

Exposure of Brown Norway Rats to Diesel Exhaust Particles Prior to Ovalbumin (OVA) Sensitization Elicits IgE Adjuvant Activity but Attenuates OVA-Induced Airway Inflammation

Exposure to diesel exhaust particles (DEP) during the sensitization process has been shown to increase antigen-specific IgE production and aggravate allergic airway inflammation in human and animal models. In this study, we evaluated the effect of short-term DEP exposure on ovalbumin (OVA)-mediated responses using a post-sensitization model. Brown Norway rats were first exposed to filtered air or DEP (20.6 +/- 2.7 mg/m3) for 4 h/day for five consecutive days. One day after the final air or DEP exposure (day 1), rats were sensitized with aerosolized OVA (40.5 +/- 6.3 mg/m3), and then again on days 8 and 15, challenged with OVA on day 29, and sacrificed on days 9 or 30, 24 h after the second OVA exposure or the final OVA challenge, respectively. Control animals received aerosolized saline instead of OVA. DEP were shown to elicit an adjuvant effect on the production of antigen-specific IgE and IgG on day 30. At both time points, no significant airway inflammatory responses and lung injury were found for DEP exposure alone. However, the OVA-induced inflammatory cell infiltration, acellular lactate dehydrogenase activity and albumin content in bronchoalveolar lavage (BAL) fluid, and numbers of T cells and their CD4+ and CD8+ subsets in lung-draining lymph nodes were markedly reduced by DEP on day 30 compared with the air-plus-OVA exposure group. The OVA-induced nitric oxide (NO) in the BAL fluid and production of NO, interleukin (IL)-10, and IL-12 by alveolar macrophages (AM) were also significantly lowered by DEP on day 30 as well as day 9. DEP or OVA alone decreased intracellular glutathione (GSH) in AM and lymphocytes on days 9 and 30. The combined DEP and OVA exposure resulted in further depletion of GSH in both cell types. These results show that short-term DEP exposure prior to sensitization had a delayed effect on enhancement of the sensitization in terms of allergen-specific IgE and IgG production, but caused an attenuation of the allergen-induced airway inflammatory responses.

Contribution of anaphylatoxin C5a to late airway responses after repeated exposure of antigen to allergic rats

We attempted to elucidate the contribution of complement to allergic asthma. Rat sensitized to OVA received repeated intratracheal exposures to OVA for up to 3 consecutive days, and pulmonary resistance was then estimated for up to 6 h after the last exposure. Whereas the immediate airway response (IAR) in terms of R(L) tended to decrease in proportion to the number of OVA exposures, late airway response (LAR) became prominent only after three. Although premedication with two kinds of complement inhibitors, soluble complement receptor type 1 (sCR1) or nafamostat mesylate, resulted in inhibition of the IAR after either a single or a double exposure, the LAR was inhibited after the triple. Premedication with a C5a receptor antagonist (C5aRA) before every exposure to OVA also inhibited the LAR after three. Repeated OVA exposure resulted in eosinophil and neutrophil infiltration into the bronchial submucosa which was suppressed by premedication with sCR1 or C5aRA. Up-regulation of C5aR mRNA was shown in lungs after triple OVA exposure, but almost no up-regulation of C3aR. Pretreatment with sCR1 or C5aRA suppressed the up-regulation of C5aR expression as well as cytokine messages in the lungs. The suppression of LAR by pretreatment with sCR1 was reversed by intratracheal instillation of rat C5a desArg the action of which was inhibited by C5aRA. In contrast, rat C3a desArg or cytokine-induced neutrophil chemoattractant-1 induced cellular infiltration into the bronchial submucosa by costimulation with OVA, but these had no influence on the LAR. These differences might be explained by the fact that costimulation with OVA and C5a synergistically potentiated IAR, whereas that with OVA and either C3a or cytokine-induced neutrophil chemoattractant-1 did not. C5a generated by Ag-Ab complexes helps in the production of cytokines and contributes to the LAR after repeated exposure to Ag.

Histamine stimulates alveolar macrophages to release neutrophil and monocyte chemotactic activity

Histamine and serotonin are important inflammatory mediators in the pathophysiology of asthma, and asthmatic patients have higher plasma histamine and serotonin levels than non-asthmatic control subjects. Alveolar macrophages (AMs) synthesize and secrete a large number of substances that play a key role in acute and chronic inflammation including asthma. We postulated that AMs might release chemotactic activity for neutrophils and monocytes in response to histamine or serotonin. To test this hypothesis, bovine AMs were cultured, and the supernatant fluids were evaluated for neutrophil chemotactic activity (NCA) and monocyte chemotactic activity (MCA) by a blind well chamber technique. AMs released chemotactic activity in response to histamine and serotonin in a dose- and time-dependent manner (P <.05). Partial characterization and molecular sieve column chromatography revealed that low-molecular-weight lipid-soluble activity was predominant. Lipoxygenase inhibitors significantly blocked the release of chemotactic activity. Leukotriene B(4) receptor antagonists blocked the chemotactic activity. Immunoreactive leukotriene B(4) significantly increased in supernatant fluids in response to histamine and serotonin. The receptor responsible for the release of chemotactic activity in response to histamine was the H2 receptor. These data demonstrate that AMs release NCA and MCA in response to histamine or serotonin (or both) and may modulate the inflammatory cell recruitment into the lung.

Antigen-specific IgE and IgA antibodies in bronchoalveolar lavage fluid are associated with stronger antigen-induced late phase reactions

The mechanism(s) leading to the development of late phase allergic reactions is (are) unknown. Previous studies have indicated that a relationship between serum IgE and the late phase exists. To explore the relationships between allergen-specific immunoglobulins in bronchoalveolar lavage (BAL) fluids and the magnitude of airflow limitation during the late phase response to inhaled allergen. Ragweed-specific IgE, IgA, secretory IgA (sIgA) and IgG were measured in BAL fluid and in the serum 1-5 weeks before whole lung antigen challenge with ragweed extract, in 16 ragweed allergic asthmatics. In addition, BAL and serum eosinophil cationic protein (ECP) and BAL fibrinogen levels were determined and BAL cells counted and differentiated. The latter procedures were repeated in a second BAL performed 24 h after the end of the ragweed challenge. After the challenge, lung function was monitored hourly for 8 h, to record the magnitude of airflow limitation. Ragweed-specific immunoglobulins were detected in 25% to 37.5% of BAL samples. Compared to the subjects with undetectable BAL fluid ragweed-specific IgE levels at baseline, those with detectable antibodies had stronger late phase reactions as determined by the nadir of FEV1 between hours 4 and 8 after the ragweed inhalation challenge (P = 0.0007). Allergen-induced changes in BAL ECP and fibrinogen levels were also higher in those subjects with detectable ragweed-specific IgE in baseline fluids (P = 0.03 and P = 0.005, respectively). Significant relationships between BAL antigen-specific IgA, serum ragweed-specific IgE and IgA and the late phase reaction were also found. The results of this study point towards the possibility that allergen-specific IgE and IgA may be independently involved in the pathogenesis of the late phase reaction. This notion merits further exploration.

Mucous-cell metaplasia and inflammatory-cell recruitment are dissociated in allergic mice after antibody- and drug-dependent cell depletion in a murine model of asthma

Inflammatory-cell infiltration and epithelial modifications are prominent lesions of the bronchial mucosa in asthma and in experimental allergic bronchopulmonary inflammation. However, the recruitment of inflammatory cells and their relationship to the epithelial modifications and to functional alterations such as bronchopulmonary hyperreactivity (BHR) are less known. We studied the mechanisms of antigen-dependent inflammatory-cell recruitment to the lungs and the associated lesions and their relationship using drug- and antibody-dependent cell-depletion procedures. A single intranasal ovalbumin challenge in BP2 mice was found to induce hyperreactivity within 1 h after challenge, followed by the massive infiltration of immunoglobulin (Ig)E-bearing polymorphonuclear leukocytes (PMN), and eosinophils, and by a mucous-cell metaplasia of the bronchiolar epithelium. Similarly challenged BALB/c mice did not exhibit BHR, despite a moderate recruitment of inflammatory cells and mucous-cell metaplasia. Inflammatory-cell recruitment, mucous-cell metaplasia, and BHR were prevented by prior antibody-dependent depletion of CD3(+) lymphocytes and partially inhibited by the depletion of CD4(+) lymphocytes. Treatment with the granulocytopenic drug vinblastine before challenge completely abolished the recruitment of granulocytes without affecting the antigen-induced mucous-cell metaplasia. In this study two new key elements of the murine model of allergic pulmonary inflammation are described: the recruitment of IgE-bearing PMN between 3 and 72 h after challenge, and the dissociation between granulocytes and mucous-cell metaplasia.

National guidelines needed to manage rhinitis and prevent complications

OBJECTIVES

Rhinitis is an extremely common disease worldwide and nasal allergies are one of the major causes of the condition. Allergic rhinitis not only produces a range of nasal and non-nasal symptoms, but it has been closely associated with other chronic airways diseases, such as asthma and sinusitis. This review was undertaken to evaluate the relationship of allergic rhinitis to these diseases and to provide support for proposing national guidelines for managing rhinitis.

DATA SOURCES

Relevant studies in English were searched for using MEDLINE, bibliographies from obtained articles, and consultation with experts.

STUDY SELECTION

All major studies related to the epidemiology and effects of allergic rhinitis and the relationship between allergic rhinitis and asthma, sinusitis, and other airways diseases were reviewed.

DATA SYNTHESIS

There is substantial scientific and clinical evidence that allergic rhinitis frequently coexists with asthma, and sinusitis and may be a predisposing factor for both. In addition, a number of studies have demonstrated that nasal inflammation and obstruction directly affect pulmonary function and clinical symptoms of asthma. Finally, it has been clearly demonstrated that treating allergic rhinitis with antihistamines, nasal corticosteroids, immunotherapy, and allergen avoidance have a significant, positive effect on lung function and asthma symptomology.

CONCLUSIONS

The prevalence of allergic rhinitis, asthma, and sinusitis are increasing. Asthma and sinusitis can be debilitating conditions. Asthma alone can be life threatening and costly to treat. The timely and optimal treatment of allergic rhinitis may help prevent these conditions or, at least, prevent them from worsening. Consequently, there is an immediate need to establish national, evidence-based, practice guidelines to assist primary care physicians in diagnosing and managing rhinitis and in evaluating and managing rhinitis and in evaluating and managing allergic rhinitis coexisting with other airways diseases.

Urinary excretion of inflammatory mediators during allergen-induced early and late phase asthmatic reactions

BACKGROUND

It is generally accepted that the early asthmatic response to inhaled allergen is a result of IgE-mediated mast cell activation. In contrast, the underlying mechanism of the late asthmatic response is much less clear.

OBJECTIVE

In order to investigate the pattern of mediator release during the early and late asthmatic responses to allergen, measurements of the urinary excretion of the mast cell markers 9alpha,11beta-PGF2 and Ntau-methylhistamine were made. In addition, urinary levels of eosinophil protein X (EPX) and leukotriene E4 (LTE4) were measured.

METHODS

Twelve mild atopic asthmatics participated in the study. On the study day, pulmonary function was recorded at baseline and for 12 h after inhalation of allergen. Urine was collected prior to challenge and thereafter at 1 h intervals. Measurements of 9alpha, 11beta-PGF2 and LTE4 were made with enzyme-immunoassay, and levels of Ntau-methylhistamine and EPX were analysed with radioimmunoassay.

RESULTS

All subjects developed both an early and late phase airway response. Within 1 h of the early peak airway response, there was a significant increase in the urinary concentrations (AUC/h) of 9alpha, 11beta-PGF2 (49.3 +/- 9.2 to 142.5 +/- 49.2; P < 0.001) Ntau-methylhistamine (10.4 +/- 1.4 to 19.5 +/- 1.4; P < 0.001) and LTE4 (43.7 +/- 5.9 to 105.9 +/- 21.3; P < 0.001). Levels of all three mediators were also significantly increased above baseline during the LAR to 79.4 +/- 9.5 (P < 0.01), 19.8 +/- 1.9 (P < 0.001) and 85.6 +/- 10.4 (P < 0.001), respectively. Levels of EPX remained unchanged during the early and late responses (39.2 +/- 10.2 to 37.5 +/- 18.5, 33.9 +/- 6.8).

CONCLUSIONS

These results indicate that mast cell activation is a feature not only of the early but also the late asthmatic response. Finally, increased LTE4 supports the contribution of the leukotrienes to airway obstruction during both phases of the asthmatic response to allergen.

Murine strain differences in allergic airway inflammation and immunoglobulin production by a combination of antigen and diesel exhaust particles

To clarify the relationship between the manifestations of allergic airway inflammation modulated by diesel exhaust particles (DEP) and immunoglobulin production in response to an antigen, airway inflammation characterized by the infiltration of eosinophils, goblet cell proliferation, and antigen-specific immunoglobulin (Ig) production was investigated in five strains of mice after immunization with ovalbumin (OA). Mice were injected intratracheally with OA (1 microg) or OA (1 microg) + DEP (50 microg) four times at 3-week intervals. The order of antigen-specific IgG1 production in plasma of mouse strains treated with OA alone was CBA/2N <BDF/1 <C57BL/6 < ICR <C3H/He. The adjuvant effect of DEP on IgG1 production was observed in CBA/2N, BDF/1, ICR, and C57BL/6 mice. The immune activity in BDF/1 mice was significantly elevated (P < 0.01). The OA-specific IgE in plasma was unaffected by antigen challenge with or without DEP in any strain. The degree of eosinophilic inflammation and goblet cell proliferation in the airway induced by OA alone or OA + DEP corresponded well with the antigen-specific IgG1 production. These results suggest that the manifestations of allergic airway inflammation modulated by DEP were closely related to the immunoglobulin production response to OA, especially with regard to enhanced IgG1 production.

Diesel exhaust particles enhance antigen-induced airway inflammation and local cytokine expression in mice

Previous experimental studies have suggested that nasal instillation of diesel exhaust particles (DEP) can enhance nasal IgE response and cytokine production. However, there is no experimental evidence for the relation of DEP to allergic asthma. We investigated the effects of DEP inoculated intratracheally on antigen-induced airway inflammation, local expression of cytokine proteins, and antigen-specific immunoglobulin production in mice. DEP aggravated ovalbumin-induced airway inflammation characterized by infiltration of eosinophils and lymphocytes and an increase in goblet cells in bronchial epithelium. DEP with antigen markedly increased interleukin-5 (IL-5) protein levels in lung tissue and bronchoalveolar lavage supernatants compared with either antigen or DEP alone. The combination of DEP and antigen induced significant increases in local expression of IL-4, granulocyte macrophage-colony stimulating factor (GM-CSF), and IL-2, whereas expression of interferon-gamma was not affected. In addition, DEP exhibited adjuvant activity for the antigen-specific production of IgG and IgE. These results provide the first experimental evidence that DEP can enhance the manifestations of allergic asthma. The enhancement may be mediated mainly by the increased local expression of IL-5, and also by the modulated expression of IL-4, GM-CSF, and IL-2.

Blood markers of early and late airway responses to allergen in asthmatic subjects. Relationship with functional findings

We evaluated the relationship between blood markers of mast-cell (plasma histamine and serum level of heat-stable neutrophil chemotactic activity [NCA]) and eosinophil (serum eosinophil cationic protein [ECP]) activation during early airway response (EAR) and late airway response (LAR) to allergen inhalation in 24 asthmatic subjects. After EAR, 14 subjects showed significant LAR (FEV1 fall: > or = 25%), while 10 subjects showed equivocal LAR (FEV1 fall: 15-20%). A significant increase from baseline value was observed in plasma histamine and in serum NCA during both EAR and LAR, while serum ECP significantly increased only during LAR. The sensitivity of different markers to detect significant FEV1 fall during EAR and LAR was low, except for NCA. Changes in blood mediators were similar in both groups with significant and equivocal LAR. There was a significant relationship between the increase in NCA during EAR and the severity of LAR. Stepwise regression between changes in different blood markers showed a significant relationship between histamine increase during EAR and ECP increase during LAR. Thus, serum NCA is a more sensitive marker of EAR and LAR than plasma histamine and serum ECP, and its increase during EAR seems predictive of the severity of the subsequent LAR.

Antihistamines in the treatment of asthma

Antihistamines were investigated for use in asthma shortly after discovery over fifty years ago. Earlier compounds proved ineffective because of side effects: this class of drugs was not thought useful for asthma, and were actually considered contraindicated. More recent drugs have greater potency, fewer side-effects, and no evidence of adverse effects in asthma. There are some studies showing second generation antihistamines, especially cetirizine, improve certain parameters of asthma.

Measurement of interleukin-4 and histamine in superficial cells of conjunctiva in patients with allergic conjunctivitis

Interleukin 4 (IL-4) may play a role in the development of allergic disease. We questioned whether IL-4 related phenomenon occurred on the surface of the conjunctiva during allergic conjunctivitis. Ten patients with cedar pollen-allergic conjunctivitis and 10 patients with postsurgical conjunctivitis were enrolled in this study. Cells were collected by brush cytology from the upper palpebral conjunctiva. After the cells were cultured for 24 hours, the levels of IL-4, IgE, and histamine were measured in the supernatants. An ELISA was used for histamine and a highly sensitive sandwich ELISA for IL-4 and IgE. Conjunctival cells were also stained and fixed by May-Grunwalds stain solution. The number of superficial cells, especially lymphocytes, were compared in the two groups. The total number of cells collected by brush cytology did not differ in allergic vs., postsurgical conjunctivitis. Lymphocytes were similarly present in such specimens. The levels of IL-4 (p = 0.01) and histamine (p = 0.02) significantly increased in the specimens from patients with allergic conjunctivitis, although IgE was not detected in both groups. There was a correlation between the level of IL-4 and histamine (p = 0.0001). Conjunctival cells in allergic conjunctivitis produced a larger amount of IL-4 and histamine for cedar pollen compared to the postsurgical conjunctivitis. As with other allergic diseases, IL-4 may play a role similar to that of histamine in the development of allergic conjunctivitis.

A double-blind, placebo controlled study of the effect of the specific histamine H1-receptor antagonist, terfenadine, in chronic severe asthma

1. The characteristic changes seen in asthma are widely regarded as being caused by local mediator release in the airways, with histamine the first putative mediator in asthma to be identified. 2. We performed a double-blind, randomised, placebo-controlled crossover trial of the effect of 4 weeks treatment with terfenadine 120 mg twice daily in chronic severe asthma. 3. Forty-two subjects (20 male and 22 female) completed the 10 week study. 4. Terfenadine had no significant treatment effect on the primary efficacy variables measured. Mean (95% CI) measurements for terfenadine vs placebo treatment periods were 1.5 vs 1.5 (-0.3, 0.3) l for FEV1, 259 vs 260 (-42, 40) l min-1 for morning PEF and 0.8 vs 0.8 (-0.3, 0.3) for global symptom scores. 5. Bronchodilator use and sleep disturbance, the secondary efficacy variables studied, showed an improvement during terfenadine treatment but this only reached statistical significance for the number of times subjects awoke from sleep (P = 0.04). 6. There was a similar frequency of minor adverse effects reported during placebo (13.6%) and terfenadine (16.7%) treatments. 7. Addition of the potent and specific histamine H1-receptor antagonist terfenadine to maintenance asthma treatment had no significant therapeutic benefit in this group of chronic severe asthmatics.

Allergen-specific IgG1 and IgG3 through Fc gamma RII induce eosinophil degranulation

Evidence suggests that eosinophils contribute to inflammation in bronchial asthma by releasing chemical mediators and cytotoxic granule proteins. To investigate the mechanism of eosinophil degranulation in asthma, we established an in vitro model of allergen-induced degranulation. We treated tissue culture plates with short ragweed pollen (SRW) extract and sera from either normal donors or SRW-sensitive patients with asthma. Eosinophils were incubated in the wells and degranulation was assessed by measurement of eosinophil-derived neurotoxin in supernatants. We detected degranulation only when sera from SRW-sensitive patients were reacted with SRW. Anti-IgG and anti-Fc gamma RII mAb, but not anti-IgE or anti-Fc epsilon RII mAb, abolished the degranulation. IgG-depleted serum did not induce degranulation; IgE-depleted serum triggered as much degranulation as untreated serum. Furthermore, serum levels of SRW-specific IgG1 or IgG3 correlated with the amounts of released eosinophil-derived neurotoxin. When eosinophils were cultured in wells coated with purified IgG or IgE, eosinophil degranulation was observed only with IgG. Finally, human IgG1 and IgG3, and less consistently IgG2, but not IgG4, induced degranulation. Thus, sera from patients with SRW-sensitive asthma induce eosinophil degranulation in vitro through antigen-specific IgG1 and IgG3 antibodies. These antibodies may be responsible for degranulation of eosinophils in inflammatory reactions, such as bronchial asthma.

Quantification of histamine in plasma and pulmonary fluids from horses with chronic obstructive pulmonary disease, before and after 'natural (hay and straw) challenges'

A commercial radioimmunoassay kit was used to quantify histamine concentrations of plasma, bronchoalveolar lavage fluid (BALF) and pulmonary epithelial lining fluid (PELF) of normal horses and horses with chronic obstructive pulmonary disease (COPD), before and after 'natural (hay and straw) challenge' (NC). There were no significant changes in the concentrations of histamine in plasma or BALF at 0.5 or 5 h after NC, but the PELF histamine concentration of COPD affected horses was significantly increased at 5 h, but not at 0.5 h, following NC. As the histamine concentrations of whole BALF lysates were significantly correlated with the numbers of metachromatically staining cells, presumed to be mast cells and/or basophils, these findings support involvement of a late phase, IgE mediated, hypersensitivity reaction in the pathogenesis of equine COPD.

Bronchial lavage and bronchoalveolar lavage in allergen-induced single early and dual asthmatic responders

The phenotypic cellular profile of bronchial lavage (BL) and bronchoalveolar lavage (BAL) was studied in 7 single early (SR) and 10 dual asthmatic responders (DR). Lavage was performed, after previously having determined bronchial hyperresponsiveness to histamine and the response to house dust mite (HDM) challenge. The recovered lavage fluid was separated in two fractions, BL and BAL. Total fluid recovery and cell number from the BL and BAL were comparable in both patient groups. Differential cell counting and immunocytochemistry were performed. DR had a significantly higher number of eosinophils and EG2+ cells in BL but not in their BAL. No differences could be found in CD4+, CD8+, and HLA-DR+ cells. A strong correlation was found between eosinophils in the BL+ and EG2+ cells in the BL (r = 0.79, p < 0.001) and between eosinophils in the BL and peripheral blood eosinophils (r = 0.70, p < 0.0025). The number of EG2+ cells and the number of epithelial cells in both BL and BAL showed a correlation (r = 0.55, p < 0.05). Dual responders had a higher total IgE (p < 0.01), and total serum IgE correlated well with the eosinophils in the BL (r = 0.85, p < 0.0001). Our observations demonstrate cellular differences in the lung on mainly a bronchial level between single early and dual asthmatic responders. A bronchial lavage eosinophil and EG2+ cell count and higher blood total IgE level are associated with the tendency to develop a dual asthmatic response.

Increases in activated T lymphocytes, eosinophils, and cytokine mRNA expression for interleukin-5 and granulocyte/macrophage colony-stimulating factor in bronchial biopsies after allergen inhalation challenge in atopic asthmatics

Immunohistology and in situ hybridization were used to evaluate the presence, activation status, and cytokine mRNA profile of cells in the bronchial mucosa during human allergen-induced asthma. Fifteen atopic asthmatic subjects underwent inhalation challenge with allergen and with allergen diluent, performed in random order separated by an interval of at least 3 wk. Bronchial biopsies were obtained 24 h after challenge. Immunostaining revealed increases in the numbers of secreting eosinophils (EG2+; P < 0.05) and in interleukin-2 receptor (IL-2R)-positive cells (CD25+; P < 0.01) after allergen compared with diluent challenge. No differences were observed in the numbers of total leukocytes (CD45+), T lymphocytes (CD3+, CD4+, and CD8+), elastase-positive neutrophils, macrophages (CD68+), or mast cell subtypes (MCT+ or MCTC+). In situ hybridization revealed significant increases in the numbers of cells expressing mRNA for IL-5 (P < 0.02) and granulocyte/macrophage colony-stimulating factor (P < 0.01) after allergen compared with diluent challenge. A significant inverse relationship was observed between the number of cells expressing mRNA for IL-4 and for interferon-gamma (r = -0.75, P < 0.02). The results support the view that cytokines possibly from activated T lymphocytes may contribute to local eosinophil accumulation during allergen-induced asthma.

Allergic inflammation

A greater understanding of the basic mechanisms of allergic inflammation is pertinent to the development of new treatments. Previous studies have focused on the role of mediators of hypersensitivity and effector cells, including mast cells and eosinophils. Recent evidence suggests that IgE-dependent activation and tissue eosinophilia are under the local regulation of distinct cytokines. Originally described as products from T lymphocytes, these peptide messengers are produced by alternative cells, including mast cells, eosinophils and the respiratory epithelium. In vitro studies in murine models and using cloned human T lymphocytes indicate the preferential production of "Th2-type" cytokines, including interleukin-4 (IL-4) and IL-5. This review considers the evidence from in vivo studies in humans that "Th2-type" cytokines have a primary role in orchestrating both IgE-dependent events and local tissue eosinophilia. Novel therapeutic approaches might include a broad strategy directed against T lymphocytes, including the use of immunosuppressive agents or anti CD4 antibodies or more precise targeting of IL-4 and/or IL-5.

Inflammation and the allergic response

The atopic diseases--allergic rhinitis, asthma, and atopic dermatitis--are chronic inflammatory diseases characterized by an exacerbating and remitting course and can only rarely be associated causally with allergen exposure. The challenge to ascribe an allergic basis to these diseases is derived from the apparent inability to reconcile these chronic inflammatory features with a process thought to be initiated by the rapid release of mediators after the interaction of allergen with IgE-coated mast cells. The traditional understanding has been that mast cell activation results in the release of a series of preformed and rapidly synthesized substances that mediate the immediate onset of vasodilatation, vascular leakage, smooth muscle contraction, and irritant nerve receptor stimulation. These mediators, however, are rapidly degraded and are not thought to be associated with a significant inflammatory component. Recent studies, however, have established that the interaction of allergen with the immune system is, in fact, far more complex (Fig. 4). In addition to mast cell activation, allergen can interact with and activate T-lymphocytes and mononuclear phagocytic cells, leading to the secretion of cytokines and other inflammatory substances. Furthermore, the interaction of allergen with the mast cell may be far more complex, with the potential to stimulate the delayed release of newly synthesized cytokines. The interaction of allergen with the immune system also promotes the secondary release of inflammatory neuropeptides. Thus, the known spectrum of mediators released after allergen exposure has vastly been expanded. These include numerous still uncharacterized chemotactic and activating peptides; eicosanoids such as 5-HETE, 12-HETE, and leukotriene B4; platelet-activating factor; several proteases; neuropeptides and, most importantly, the cytokines. These mediators recruit and activate neutrophils, monocytes, basophils, and eosinophils, attract additional lymphocytes and mononuclear phagocytic cells, and induce mast cell proliferation with further mast cell degranulation. A vicious cycle subsequently develops, with further inflammation and tissue destruction. Thus, the interaction of allergen with the immune system has become a complex cascade capable of producing the chronic inflammatory changes characteristic of allergic diseases.

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.

Expression of endothelial-leukocyte adhesion molecule-1 in elicited late phase allergic reactions

To better understand the events involved in the local migration of inflammatory cells into sites of allergic reactions, we studied expression of the cytokine inducible endothelial cell (EC) neutrophil adhesion molecule, endothelial-leukocyte adhesion molecule (ELAM-1), in sequential skin biopsies from patients with respiratory allergy during the late phase reaction (LPR) between 20 min and until 24 h after intradermal allergen (ragweed or dust mites) injection. In 7 of 7 atopic patients but in only 1 of 4 apparently normal controls, allergen induced appearance of ELAM-1 on EC. ELAM-1 expression occurred concurrently with the development of inflammatory cell infiltrates by 3-4 h after intradermal injection. Saline injected sites in all subjects were negative. Skin organ cultures demonstrated that allergen could produce the same EC changes in vitro whether allergen was injected in vivo 20 min before culture or added during skin culture. These EC changes in organ culture were inhibited by the presence of combined anti-sera to both TNF-alpha and IL-1, but not by antisera to either cytokine alone. We conclude that EC activation occurs in elicited LPR and suggest that cytokine-induced EC activation may play a role in the migration of inflammatory cells into allergic skin reactions. Furthermore, resident cells in the skin rather than infiltrating leukocytes appear to be the source of the cytokines that mediate endothelial activation.

The significance of late responses in asthma

There is good evidence to suggest that the late response is a valid clinical model of asthma. The factors which predict late responses in individual subjects are unknown although recent studies suggest that the level of IgE sensitivity and allergen dose are two important variables. Recent placebo-controlled pharmacological studies support earlier work and vindicate the use of late responses as a preclinical screening test in the evaluation of new therapeutic agents. In addition to putative pro-inflammatory mechanisms we should evaluate possible protective mechanisms which might prevent the development of late responses in individual subjects. In this regard, altered adrenal responses as reflected by serum cortisol concentrations did not appear to play a role, protective or otherwise in the development of late asthmatic responses. In conclusion, the development of symptomatic late responses and associated increased bronchial responsiveness are relevant to day-to-day asthma. As suggested by Cockcroft, repeated allergen exposure may result in a vicious cycle of ongoing bronchial inflammation. This emphasizes the importance of allergen avoidance and the need for earlier intervention in mild to moderate asthma with effective prophylactic agents which are known to inhibit late responses.

The pharmacology of airway hyperresponsiveness and inflammation

Hyperresponsiveness is a key abnormality in asthma and deserves recognition both in the clinical presentation of asthma and its pathogenesis. Available evidence strongly suggests that inflammatory processes are important in producing this aspect of disordered airway physiology. Pharmacologic studies have greatly increased our knowledge of mechanisms involved in hyperresponsiveness but fall short of a complete explanation of the phenomenon. It is most likely that hyperresponsiveness, as measured in the laboratory, has many different components and that any single mechanism will be an insufficient explanation.

Histamine-releasing factors and heterogeneity of IgE

The duration and severity of the allergic response are variable. Even though antigens are rapidly cleared from the individual, an acute allergic response is frequently followed by a recrudescence of symptoms hours or even days after the initial exposure. Experimentally, the cellular infiltrates and mediators released during this late response resemble those associated with chronic inflammatory disease. Although basophils are present in this late reaction, the stimuli for their activation remain unknown. A heterogeneous group of unique cytokines called histamine-releasing factors (HRF), discovered over a decade ago, may well play a role in stimulating basophils during this late-phase reaction. These factors have been reported from a variety of cell sources including alveolar macrophages, platelets, vascular endothelial cells, B and T lymphocytes, mononuclear cell cultures, the U937 monocyte/macrophage-like cell line and the RPMI 8866 B cell line. These ubiquitous factors cause non-cytotoxic, calcium-dependent mediator release from human basophils in vitro and are also present and active in vivo. Purification attempts have revealed that HRF exists in at least three forms, based on molecular weight. In our hands, the mechanism of mediator release by one of the forms of HRF is IgE dependent. Since only about 50% of allergic donors' basophils respond to HRF, a heretofore unappreciated heterogeneity of IgE was revealed. The presence of HRF has been shown to correlate with severity of allergic disease in children with food allergies, with symptoms in the late-phase response in adults and with severity of the allergic response to an inhaled antigen. Thus, the study of HRF has evolved over the last decade and may lead to better understanding of the complex allergic response.

Terfenadine, a potent histamine H1-receptor antagonist in the treatment of grass pollen sensitive asthma

1. We have assessed the effect of a specific histamine H1-receptor antagonist, terfenadine, in the treatment of atopic asthmatics during the grass pollen season. 2. Eighteen mild, grass pollen sensitive asthmatics (10F, 8M, mean +/- s.e. mean age 34.7 +/- 5.6 years), all of whom were controlled on inhaled beta 2-adrenoceptor agonists alone, took part in a 9 week, double-blind, crossover study using terfenadine 180 mg three times daily and placebo. Throughout the study patients recorded peak expiratory flow rate (PEFR) twice daily, symptoms of cough, wheeze, breathlessness and chest tightness (scored 0-3), and their use of bronchodilators. Methacholine inhalation challenge tests were performed each week. Data were analysed by a method suitable for a two group, two period crossover trial with baseline measurements. 3. Terfenadine significantly reduced symptoms of cough by 76.9% (P less than 0.05) and wheeze by 46.9% (P less than 0.02). Symptoms of breathlessness and chest tightness were reduced by 16.8 and 30.3% respectively but these were not statistically significant. Morning and evening PEFR rose by 5.5 (P less than 0.001) and 6.2% (P less than 0.003) respectively on treatment with terfenadine and bronchodilator use fell by 40.3%. A progressive increase in methacholine sensitivity was seen in both treatment groups throughout the study but did not reach statistical significance. 4. We conclude that treatment with terfenadine during the grass pollen season in sensitive asthmatics reduced their symptoms and bronchodilator requirements and produced a modest improvement in their lung function without affecting the development of increased methacholine sensitivity that occurred during the grass pollen season.

Histamine and asthma: an appraisal based on specific H1-receptor antagonism

H1-receptor antagonists have been utilized, following their initial chemical synthesis in 1933, both in the treatment of conditions in which histamine is considered to be of pathogenic importance and conversely to help elucidate the role of histamine in disease, through an evaluation of their influence on disease expression. While there is considerable indirect evidence to implicate histamine in the pathogenesis of asthma, a critical evaluation of H1-receptor antagonism in this condition has, until recently, proved difficult, as many of the early H1-receptor antagonists possessed additional actions, such as anti-cholinergic, local anaesthetic, alpha-adrenoceptor antagonistic and anti-serotonin activity. In addition, H1-receptor antagonists have been shown to have effects on mast cell function. In low concentrations in vitro, antihistamines have been found to inhibit immunologically stimulated mast cell mediator release, with the IC50 in the nanomolar to micromolar range, while at higher concentrations they induce histamine release. The potency of these drugs in producing such effects is unrelated to their H1-receptor blocking activity. Furthermore the sedative effects of these therapeutic agents limit the tolerable administrable dose and thus the degree of H1-receptor blockade achievable within the airways. The recent development of H1-receptor antagonists devoid of clinical sedative effects has enabled the administration of doses of H1-antihistamines which achieve a greater degree of H1-receptor blockade within the airways, thus permitting a better appraisal of the role of histamine in this condition. Furthermore, the receptor specificity of many of these agents has been focused such that terfenadine, astemizole, loratadine and cetirizine are devoid of anticholinergic activity and exhibit little alpha-antagonistic or anti-serotonin activity of clinical relevance. However, of these agents both loratadine and cetirizine possess additional actions likely to be of relevance to asthma. Pretreatment with loratadine has been shown to reduce the recovery of both histamine and prostaglandin D2 (PGD2) in nasal lavage fluid following nasal allergen challenge, a finding interpreted as indicative of in vivo mast cell stabilization, and cetirizine has been shown in vivo at therapeutic doses to inhibit allergen-induced eosinophil chemotaxis. Thus while both these agents offer the potential of an oral therapy for asthma based on an H1-receptor antagonist, their additional actions do not make them ideally suited to the exploration of the role of histamine in asthma.(ABSTRACT TRUNCATED AT 400 WORDS)

Release of histamine and tryptase during continuous and interrupted cutaneous challenge with allergen in humans

To help in understanding the patterns of in vivo mediator release in human allergic skin reactions, we have used a skin chamber model to challenge the denuded bases of skin blisters of 11 sensitive subjects with pollen antigens (Ags) and codeine (C), a mast cell degranulator. Challenges were performed either (1) continuously for 6 hours or (2) in an intermittent fashion that is, Ag or C for the first hour, buffer for the next 4 hours, and then Ag or C during the sixth hour. Fluids in the overlying chamber were assayed for levels of the mast cell components, histamine and tryptase. There was peak release of both histamine and tryptase during the first hour of Ag incubation (89 +/- 11 ng/ml and 1428 +/- 260 ng/ml, respectively). At continuous Ag-challenge sites, there was a plateau of histamine levels (8.0 to 9.5 ng/ml) during the next 4 hours, whereas tryptase levels decreased progressively to baseline levels. Challenge of continuous Ag-incubation sites with C, a mast cell activator, led to another peak release of both histamine and tryptase. At interrupted Ag-challenge sites, histamine levels decreased abruptly, and tryptase levels decreased progressively after the first hour. Rechallenge of such sites with Ag during the sixth hour induced a peak release of histamine but no increase in tryptase levels. Continuous challenge with C for up to 5 hours in other sites induced an initial peak histamine release without a subsequent plateau. However, such a plateau of histamine (but not tryptase) release occurred after an initial C challenge if Ag was subsequently incubated in a continuous fashion.(ABSTRACT TRUNCATED AT 250 WORDS)

Change in airway responsiveness to inhaled house dust from childhood to adulthood

Between 1966 and 1969, housedust (HD) inhalation provocation tests were performed in 119 children with asthma. Between 1984 and 1987, 101 of the 119 subjects (85%) were reinvestigated. Thirty-one of these 101 adults who participated in a study on the outcome of childhood asthma were rechallenged with HD after a mean interval of 16 years to establish the change in airway responsiveness to HD from childhood to adult life. In the childhood study in these 31 subjects, six had no response (NAR); six, an early response (EAR); eight, a late (LAR); and eleven subjects, an EAR followed by an LAR (dual asthmatic response [DAR]) to the inhalation of HD. In the second survey, two of the subjects with NAR in the first study had a bronchoconstrictor response to HD. Five subjects with an EAR or an LAR response in childhood had NAR as an adult. The eleven subjects with a DAR during childhood also had a response to HD as an adult; five had an EAR, and six adults again had a DAR. Eleven of the 13 adults (85%) with current respiratory symptoms had a response to HD during the second survey. Although they were symptom free, 11 of the other 18 adults (61%) responded on inhalation of HD. One of the 18 subjects without (6%), and six of the 13 subjects (46%) with current respiratory symptoms, had a provocative concentration of histamine in FEV1 10% of baseline less than or equal to 16 mg/ml. We conclude that, although respiratory symptoms disappear in one half the children with asthma and although adults may believe that they have outgrown their disease, adults still have the potency to respond to inhaled allergens. Most children do outgrow their respiratory symptoms but not the susceptibility of their airways to allergens.

The inhibitory effect of terfenadine and flurbiprofen on early and late-phase bronchoconstriction following allergen challenge in atopic asthma

We have studied the effect of cyclo-oxygenase inhibition and H1-receptor antagonism on the early and late bronchoconstrictor responses to inhaled allergen in mild atopic asthmatics. In the first phase of the study histamine inhalation challenge tests were performed in seven mild, atopic asthmatics 2 h after treatment with placebo or flurbiprofen (50, 100 or 150 mg). Flurbiprofen in these single doses had no effect on histamine reactivity. Ten atopic asthmatics participated in the second phase of the study in which the time course of the bronchoconstrictor response to inhalation of allergen was observed on four separate occasions after treatment with (a) placebo, (b) flurbiprofen, 150 mg, (c) terfenadine 180 mg, and (d) the combination of flurbiprofen and terfenadine. On each occasion subjects inhaled a concentration of allergen (Dermatagaphoides pteronyssinus, grass pollen) that had previously been shown to produce a 30% fall in FEV1 (PC30 allergen). The mean maximum fall in FEV1 during the early reaction was 33.2 +/- 3.3% from the post-saline baseline value following placebo and this was reduced to 27.5 +/- 5.3% after flurbiprofen (n.s.), 20.3 +/- 3.2% after terfenadine (P less than 0.05), and 23.1 +/- 2.3 after the treatment combination (P less than 0.05). Seven subjects developed late asthmatic reactions (LAR) after placebo and in these subjects the mean maximum fall in PEFR during the LAR was reduced from 22.6 +/- 3.1% after placebo to 16.7 +/- 3.2% after flurbiprofen (P less than 0.05), 15.2 +/- 2.3% after terfenadine (P less than 0.05) and 11.5 +/- 3.1% after the treatment combination (P less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Dose-response relationship of the H1-histamine antagonist, ebastine, against histamine and methacholine-induced bronchoconstriction in patients with asthma

In a double blind, randomised, placebo controlled trial in a group of extrinsic asthmatics, we have evaluated the potency and selectivity of ebastine, a new piperidine-type H1-receptor antagonist, against histamine and methacholine-induced bronchoconstriction. The median histamine PC20FEV1 value following placebo was 3.15 mg/ml (0.24-58.84). When compared with placebo, ebastine produced significant protection at 10 mg (median PC20 = 31.36 mg/ml, p = 0.008) and 30 mg (median PC20 = 42.14 mg/ml, p = 0.001) but there appeared to be no significant dose effect. Ebastine also produced a small shift in the methacholine concentration-response curves to the right. We conclude that ebastine is an effective antagonist of histamine-induced bronchoconstriction in the asthmatic airway with evidence of minor blockade of methacholine-induced bronchoconstriction.

The effect of inhaled fenoterol, administered during the late asthmatic reaction to house dust mite (Dermatophagoides pteronyssinus)

A double-blind, placebo-controlled crossover study was set up to investigate the effect of fenoterol (400 micrograms) during the late asthmatic reaction (LAR). Twenty young subjects with asthma (mean age, 11.8 years; range, 8.3 to 20.6 years) were selected on the basis that they developed an LAR after bronchial challenge with Dermatophagoides pteronyssinus. After the LAR occurred, a placebo and fenoterol were administered blindly by a metered-dose inhaler, with an interval of 15 minutes and in alternating, random sequence. At the start of the study, that is, a documented LAR, the two groups of subjects had the same severity of LAR, as expressed by the fall of the FEV1 (mean, -34.5% versus -33.5%). The mean FEV1 of the 10 patients who received placebo first changed only -1.1% (+/- 5.0), whereas after fenoterol, The FEV1 increased by 20.7% (+/- 10.8). In the 10 patients receiving fenoterol first, the mean FEV1 rose by 18.8% (+/- 8.0), whereas the placebo inhalation resulted in a supplementary increase of 3.1% (+/- 7.0). The paired Student's t test between these differences (placebo versus fenoterol) was highly significant (p less than 0.001). Although it was demonstrated in some studies that beta-agonists did not prevent the LAR, the present study demonstrates that the administration of fenoterol can reverse the FEV1 significantly, although it was not reversed completely, during an allergen-induced LAR.

New concepts in the pathogenesis of asthma

Heightened airways reactivity is a major characteristic of asthma. Several stimuli capable of producing an inflammatory reaction within the respiratory tract can increase airways reactivity in both normal and asthmatic subjects. The association between lower airways inflammation and alterations in airways function has been studied most extensively after antigen exposure leading to an immediate and/or late asthmatic response in atopic subjects. The late asthmatic response (LAR) is of special interest because it lasts for hours, is prevented by corticosteroids and not adrenergic agents, and is associated with more severe asthma as well as increases in airways responsiveness. While late phase reactions in the lung and skin were initially thought to be Arthus reactions, more recent observations in man and animal models suggest they may be initiated when antigen-specific IgE is present, and may be blunted by antigen-specific IgG. In terms of pathology, immediate reactions are characterized primarily by edema while late phase reactions are associated with infiltration of the involved tissues with inflammatory cells. The potential importance of granulocytes to the reactions in the skin of rats and the lungs of rabbits was suggested when cytotoxic drugs that produced granulocytopenia prevented late phase responses. Several other factors also appear to be important in determining if an LAR will occur. These include the antigen load, level of airways reactivity, histamine releasing factors, lymphocyte populations within the lung, and endogenous corticosteroid levels. While various mediators of inflammation and hypersensitivity such as platelet activating factor and cyclooxygenase and lipoxygenase products of arachidonic acid metabolism produce some of the clinical features seen in asthma, one mediator is unlikely to be responsible for all the manifestations of this disorder. Rather, a series of cell-to-cell interactions mediated through the products they release are likely to produce the pathologic and physiologic features of the disease.