An open study of auranofin in the treatment of steroid-dependent asthma

Auranofin: Past to Present, and repurposing

Auranofin (AF), a gold compound, has been used to treat rheumatoid arthritis (RA) for more than 40 years; however, its mechanism of action remains unknown. We revealed that AF inhibited the induction of proinflammatory proteins and their mRNAs by the inflammatory stimulants, cyclooxygenase-2 and inducible nitric oxide synthase, and their upstream regulator, NF-κB. AF also activated the proteins peroxyredoxin-1, Kelch-like ECH-associated protein 1, and NF-E2-related factor 2, and inhibited thioredoxin reductase, all of which are involved in oxidative or electrophilic stress under physiological conditions. Although the cell membrane was previously considered to be permeable to AF because of its hydrophobicity, the mechanisms responsible for transporting AF into and out of cells as well as its effects on the uptake and excretion of other drugs have not yet been elucidated. Antibodies for cytokines have recently been employed in the treatment of RA, which has had an impact on the use of AF. Trials to repurpose AF as a risk-controlled agent to treat cancers or infectious diseases, including severe acute respiratory syndrome coronavirus 2/coronavirus disease 2019, are ongoing. Novel gold compounds are also under development as anti-cancer and anti-infection agents.

Seleno-auranofin (Et3PAuSe-tagl): synthesis, spectroscopic (EXAFS, 197Au Mössbauer, 31P, 1H, 13C, and 77Se NMR, ESI-MS) characterization, biological activity, and rapid serum albumin-induced triethylphosphine oxide generation

Seleno-auranofin (SeAF), an analogue of auranofin (AF), the orally active antiarthritic gold drug in clinical use, was synthesized and has been characterized by an array of physical techniques and biological assays. The Mössbauer and extended X-ray absorption fine structure (EXAFS) parameters of the solid compound demonstrate a linear P-Au-Se coordination environment at a gold(I) center, analogous to the structure of auranofin. The (31)P, (13)C, and (1)H NMR spectra of SeAF in chloroform solution closely resemble those of auranofin. The (77)Se spectrum consists of a singlet at 481 ppm, consistent with a metal-bound selenolate ligand. The absence of (2)J(PSe) coupling in the (31)P and (77)Se spectra may arise from dynamic processes occurring in solution or because the (2)J(PSe) coupling constants are smaller than the observed bandwidths. Electrospray ionization mass spectrometry (ESI-MS) spectra of SeAF in 50:50 methanol-water exhibited strong signals for [(Et(3)P)(2)Au](+), [(Et(3)PAu)(2)-mu-Se-tagl](+), and [Au(Se-tagl)(2)](-), which arise from ligand scrambling reactions. Three assays of the anti-inflammatory activity of SeAF allowed comparison to AF. SeAF exhibited comparable activity in the topically administered murine arachadonic acid-induced and phorbol ester-induced anti-inflammatory assays but was inactive in the orally administered carrageenan-induced assay in rats. However, in vivo serum gold levels were comparable in the rat, suggesting that differences between the in vivo metabolism of the two compounds, leading to differences in transport to the inflamed site, may account for the differential activity in the carrageenan-induced assay. Reactions of serum albumin, the principal transport protein of gold in the serum, demonstrated formation of AlbSAuPEt(3) at cysteine 34 and provided evidence for facile reduction of disulfide bonds at cysteine 34 and very rapid formation of Et(3)P=O, a known metabolite of auranofin.

Immunomodulatory and biologic therapies for severe refractory asthma

Despite undoubted efficacy of the combination of inhaled corticosteroids and beta(2)-agonists for most asthmatic patients with moderate-to-severe disease, there remains approximately 10% of the asthmatic population with serious unremitting symptoms, resulting in considerable impact on quality of life, disproportionate use of health care resources, and adverse effects from regular systemic steroid use. In an ideal world, optimal treatment of severe refractory asthma should achieve the best possible asthma control and quality of life with the least dose of systemic corticosteroids. The choice and formulation of therapeutic agent are dictated by the severity of disease and may include immunological modifiers and biologic therapies. Unfortunately, current asthma guidelines offer little contribution to the management of the challenging patient with severe refractory asthma and none of them have addressed therapeutic alternatives to oral corticosteroids. This article reviews the current evidence for immunomodulating and biologic approaches in severe refractory asthma.

Oral corticosteroid-dependent asthma: a 30-year review

OBJECTIVE

To identify novel aspects of the pathogenesis, therapeutic options, and prophylaxis measures of corticosteroid-dependent asthma.

DATA SOURCES

PubMed searches were undertaken of studies published between 1966 and 2006 on the pathogenesis of and corticosteroid-sparing therapies for corticosteroid-dependent asthma. Identified review articles were surveyed for additional and earlier citations. Recent American Academy of Asthma, Allergy, and Immunology meeting abstracts were also searched to identify other recently published and unpublished studies.

STUDY SELECTION

Inclusion of studies in the review was decided by simple agreement of both reviewers, who independently read the "Methods" and "Discussion" sections of articles identified using the search strategy. Quality assessment was performed by the 2 reviewers.

RESULTS

High-dose inhaled corticosteroids are the first-line option for corticosteroid-dependent asthmatic patients with clear efficacy. Omalizumab is effective in reducing oral corticosteroid requirements in allergic asthma. Methotrexate, gold, and cyclosporine have corticosteroid-sparing effects clinically that must be weighed against a serious adverse effect profile. Nebulized diuretics and lidocaine, with a low adverse effect profile, offer promising results but require further study. Clarithromycin and telithromycin seem to have an independent mechanism of inflammatory modulation, but their effect on corticosteroid-dependent asthma remains to be seen. Etanercept offers only early clinical evidence of a role in corticosteroid-dependent asthma.

CONCLUSIONS

With no clear consensus on corticosteroid-sparing treatment in corticosteroid-dependent asthmatic patients, systemic glucocorticoids remain the foremost therapy, with adverse effects that require monitoring and prophylaxis.

Corticosteroid therapy in asthma: predictors of responsiveness

Variable responses to corticosteroids are seen in a multitude of disease states including asthma, a disease in which these anti-inflammatory medications play a central role in both acute and chronic management. Clinical factors associated with steroid insensitivity, strategies for managing patients with steroid insensitivity, and underlying molecular mechanisms responsible for variable responses to corticosteroids are described.

Histamine release test and measurement of antigen-specific IgE antibody in the diagnosis of allergic conjunctival diseases

Although systemic allergic laboratory tests for the quantification of allergen-specific serum IgE antibody have been widely used, in these tests a high titer of serum specific IgE does not necessarily indicate evidence of allergy. We evaluated the diagnostic value of the glass microfiber-based histamine release test (HRT) using small amounts of whole blood, in 36 cases of allergic conjunctival diseases: 17 cases of allergic conjunctivitis and 19 of atopic keratoconjunctivitis. The patients were evaluated by HRT, capsulated hydrolic carrier polymer (CAP)-RAST, and conjunctival provocation test (CPT) against ten allergens. The positive rates for all allergens were higher in CAP-RAST than in HRT. The mean concordance of HRT with CAP-RAST results was 0.789. The mean concordance of HRT with CPT was 0.892 and that of CAP-RAST with CPT was 0.693. A significantly higher concordance was observed in HRT than CAP-RAST for Japanese cedar and mite antigen. The mean sensitivity, specificity, and efficiency of HRT were higher than those of CAP-RAST. These results indicate that CAP-RAST is good for the screening of allergens and that HRT has an advantage in the confirmation of clinical allergens in allergic conjunctival diseases because of its high sensitivity, specificity, efficiency, and higher concordance with CPT.

Gold as an oral corticosteroid sparing agent in stable asthma

BACKGROUND

Patients with chronic severe asthma are often dependent on the long term prescription of oral corticosteroids. The use of steroids is associated with serious side effects. Physicians treating such patients continue to search for alternative therapies that reduce the need for chronic dosing with oral steroids. Gold compounds are immunosuppressive agents and have benefits in the treatment of a number of inflammatory disorders. They have therefore been identified as an potentially useful agents in the treatment of chronic severe asthma both in terms of possible efficacy and as steroid sparing agents.

OBJECTIVES

The objective of this review was to assess the effects of adding gold to oral steroids in the treatment of chronic steroid dependent asthmatics.

SEARCH STRATEGY

The Cochrane Airways Group trials register and reference lists of identified articles were searched.

SELECTION CRITERIA

Randomised trials looking at the addition of gold compared to placebo in adult steroid dependent asthmatics.

DATA COLLECTION AND ANALYSIS

Trial quality was assessed and data extraction was carried out by two reviewers independently. Study authors were contacted for missing information.

MAIN RESULTS

Three trials fulfilled the criteria for inclusion in the review and a total of 376 patients were recruited into these studies. Data from 311 patients could be analysed. There was a small but significant treatment effect for gold in terms of steroid dose reduction (Peto Odds Ratio 0.51, 95% confidence intervals 0.31,0.83). No meta-analysis could be done for measures of lung function although overall there were few changes suggesting a positive benefit for gold. There were trends suggestive of adverse effects but no significant changes for gold treated patients with respect to proteinuria (Peto Odds Ratio 1.4, 95% confidence intervals 0.6, 3.3) dermatitis/eczema Peto Odds Ratio 2.1, 95% confidence intervals 0.9, 4.7).

REVIEWER'S CONCLUSIONS

The changes seen in these trials are small and probably of limited clinical significance. Given the side effects of gold and necessity for monitoring the use of gold as a steroid sparing agent in asthma cannot be recommended.

Theophylline pharmacokinetics with concomitant steroid and gold therapy

BACKGROUND

Theophylline has been used for several decades in the treatment of asthma. In recent years, however, with the appreciation of the importance of inflammation in the pathogenesis of asthma, new therapeutic approaches have arisen, including beta2-agonists, steroid and nonsteroidal anti-inflammatory drugs, such as gold salts.

OBJECTIVE

In the present work we studied the kinetic behaviour of theophylline administered concomitantly with methylprednisolone (steroid compound) and auranofin (oral gold) in six adult female patients.

METHOD

Drug concentration data for patients under routine care were collected. The kinetic analysis (Bayesian Approach) was done using two different commercial software packages, PKS (Abbott Diagnostics) and CAPCIL (SIMKIN Inc., courtesy of Dade-Behring). A one-compartment open model with first-order absorption (ka for PKS=0. 5/h; ka for CAPCIL=0.3/h ) and first- order elimination. Default CL, t1/2 and Vd values were used for each program was assumed. The measured and predicted theophylline concentrations were used to calculate percentage prediction errors defined as %PE=[(predicted conc. - measured conc.)/measured conc.] x 100. A linear regression analysis was also carried out for the observed concentrations and those predicted by each method (PKS vs. CAPCIL).

RESULTS

The predicted concentrations indicating persistently over-predicted the observed theophylline serum levels (results expressed as median and interquartile range; %PE for PKS=58.1 [37.1-126.0]; %PE for CAPCIL=34.0 [12.5-93.8]). The regression analysis confirmed the same tendency, showing an intercept significantly different from zero using both PKS and CAPCIL.

CONCLUSION

The results suggest a possible interaction between theophylline and auranofin. Both PKS and CAPCIL failed to predict theophylline serum levels based exclusively on population pharmacokinetic parameters. The lower observed concentrations than expected have obvious implications in practice. Periodic theophylline serum determinations are advisable until further studies provide the necessary clarification about the kinetic profile of theophylline in patients taking concomitant steroids and gold salts.

Treatment of late-onset asthma with fluconazole

BACKGROUND

Although the etiology of intrinsic or late-onset asthma is generally not known, some cases are associated with overt dermatophyte infection and immediate hypersensitivity to proteins derived from fungi of the genus Trichophyton.

OBJECTIVE

We sought to test the efficacy of oral antifungal treatment for Trichophyton-induced asthma by using fluconazole in a placebo-controlled trial.

METHODS

Eleven patients with severe or moderately severe asthma were randomized to treatment with fluconazole 100 mg daily or placebo for 5 months (phase 1); during the following 5 months, all patients received active drug (phase 2). Subjects were evaluated by skin tests, bronchial provocation tests, and measurement of serum antibodies to Trichophyton species antigens. Clinical response was monitored by changes in peak flow values measured during a 2-week period at the end of each phase and by changes in bronchial sensitivity, symptoms, and steroid requirements.

RESULTS

At the end of the first 5 months of active treatment, there was a highly significant decrease in bronchial sensitivity to Trichophyton (P =.012) and in oral steroid requirement (P =.01). At the end of phase 2, mean peak expiratory flow rates increased in 9 of 11 patients. An improvement in symptoms, peak flow, and steroid use was maintained up to 36 months after starting fluconazole in patients who continued to receive treatment.

CONCLUSION

The results show that fluconazole can be useful in the treatment of patients with severe or moderately severe asthma who have dermatophytosis. These findings are consistent with the argument that proteins derived from fungi on the skin and nails can contribute to allergic disease.

A multicenter, randomized, double-blind, placebo-controlled trial of high-dose intravenous immunoglobulin for oral corticosteroid-dependent asthma

To determine the efficacy of high doses of intravenous gammaglobulin (IVIG) for the treatment of severe, steroid-dependent asthma in patients between 6 and 68 years of age, a randomized, double-blind, placebo-controlled multicenter clinical trial was conducted in private and university hospitals in the United States. Patients were randomized to one of three treatment arms: 2 g IVIG/kg/month (16 patients); 1 g IVIG/kg/month (9 patients); or 2 g iv albumin (placebo)/kg/month (15 patients). The treatment consisted of seven monthly infusions followed by a posttreatment observation period. The primary outcome measurement was mean daily prednisone-equivalent dose requirements, determined during the observation month preceding initiation of treatment and compared to the month preceding the seventh infusion. Secondary clinical endpoints measured were pulmonary function, frequency of emergency room visits or hospitalizations, and number of days absent from school or work. When adjusted for body weight, the mean dose requirements fell by 33, 39, and 33% in the placebo, IVIG (1 g/kg), and IVIG (2 g/kg) treatment arms, respectively. The differences between therapies were not statistically different (P = 0.9728). The mean percentage-of-predicted FEV1 fell in all three treatment groups during the treatment period but there was no significant difference between treatment groups (P = 0.8291). There was also no significant difference in the percentage of subjects requiring emergency room visits or hospitalizations or missing days of work/school, among the three treatment groups. The trial was terminated prematurely after interim analysis determined the adverse experience rate was different between the three groups. Three patients, all randomized to the 2-g/kg IVIG dose group, were hospitalized with symptoms consistent with aseptic meningitis. In summary, in this randomized, double-blind, placebo-controlled multicenter study, high doses of IVIG did not demonstrate a clinically or statistically significant advantage over placebo (albumin) infusions for the treatment of corticosteroid-dependent asthma. Subgroup analysis failed to identify markers predicting responsiveness. High-dose IVIG can also be associated with a significant incidence of serious adverse events.

Diagnosis and management of steroid-resistant asthma

The term "steroid-resistant (SR) asthma" has been used to describe a group of asthmatics who demonstrate persistent airway obstruction and inflammation despite treatment with high doses of systemic glucocorticoids. There are at least two forms of SR asthma, that is, primary and acquired types. Type I SR asthma is acquired and is associated with abnormally reduced glucocorticoid receptor (GR) ligand and DNA binding affinity. Type II SR asthma is due to a primary GR binding abnormality. An important distinction between these two types of SR asthma is that the GR defect in Type I, but not Type II, SR asthma is reversible in culture and is sustained by incubation with combination IL-2 and IL-4. The treatment of these patients requires a systematic approach to rule out confounding factors, including triggers of immune activation, optimizing steroid therapy, and use of alternative strategies to inhibit airway inflammation.

Steroid-resistant asthma: evaluation and management

LEARNING OBJECTIVES

Reading this article will reinforce the reader's knowledge of the definition, pathophysiology, differential diagnosis, and treatment of the steroid-resistant asthmatic patient.

DATA SOURCES

Prospective and retrospective data from the authors' experience were evaluated. In addition, a Medline database was searched from 1981, using the key words "asthma," "glucocorticoids," and "glucocorticoid resistance" with the restrictions of English language and human subjects. Relevant articles referenced in retrieved sources and current texts on severe asthma were also utilized.

STUDY SELECTION

Data source abstracts, pertinent articles, and book chapters meeting the objectives were critically reviewed.

RESULTS

Although rare, individuals with steroid-resistant asthma are often the most difficult-to-manage asthmatic patients in that they have severe disease yet fail to respond to glucocorticoids. To make the diagnosis of steroid-resistant asthma, the patient must fail to respond to a 7 to 14-day course of daily prednisone as measured by less than a 15% improvement in morning prebronchodilator FEV1 following the glucocorticoid course. Ongoing inflammation is thought to play a major role in the pathogenesis of steroid-resistant asthma, and recent studies have demonstrated diminished glucocorticoid receptor to glucocorticoid, or diminished glucocorticoid receptor to DNA binding as possible mechanisms for diminished glucocorticoid responsiveness. Alternative asthma therapies such as methotrexate, cyclosporine, and intravenous gammaglobulin are often used in this group of asthmatic patients.

CONCLUSIONS

The patient with steroid-resistant asthma presents several challenges. These individuals often display many of the sequelae of long-term systemic glucocorticoid use while achieving little therapeutic benefit. Prior to making the diagnosis of steroid-resistant asthma, diseases that can contribute to poor control of asthma must be ruled out, and noncompliance issues addressed. Alternative asthma therapies are often used; however, they also carry the potential for adverse effects, and have not been thoroughly studied in this population of asthmatic patients.

A placebo-controlled multicenter study of auranofin in the treatment of patients with corticosteroid-dependent asthma. Auranofin Multicenter Drug Trial

BACKGROUND

Previous clinical studies have demonstrated that injectable gold salts and the oral gold compound, auranofin, possess significant steroid-sparing effects in the treatment of asthma.

OBJECTIVES

The objectives of this investigation were to determine whether auranofin could reduce oral corticosteroid requirements and to evaluate the safety of auranofin in the treatment of chronic corticosteroid-dependent asthma.

METHODS

Patients with asthma were eligible if they required at least 10 mg of prednisone per day for control and prevention of asthma exacerbations. Two hundred seventy-nine patients with chronic corticosteroid-dependent asthma (requiring > or = 10 mg/day) were randomized to receive auranofin, 3 mg twice daily, or placebo during an 8-month clinical trial, which was divided into three phases including: a 4-week baseline period (phase I), a 6-month double-blind treatment and steroid reduction period (phase II), and a 4-week posttreatment observation period during which steroid and auranofin doses or placebo doses were maintained at levels achieved by the end of phase II (phase III). The primary efficacy variable was "therapeutic success" or reduction of daily corticosteroid use by 50% or more.

RESULTS

The proportion of patients in the auranofin group achieving therapeutic success (41%) was significantly higher than that in the placebo group (27%) (p = 0.01). This effect was greatest in patients requiring 10 to 19 mg of oral prednisone per day at baseline (p < 0.001). In all treated patients, including those who did and did not complete the trial, significant reduction (> or = 50% of baseline) in oral corticosteroid dosage was achieved in the auranofin group (60%) compared with the placebo group (32%) (p < 0.001). There were no significant differences between treatment groups in symptoms, concomitant medication use, or lung function. Mean serum total IgE levels decreased significantly from baseline in the auranofin group (-44.63 IU/ml) compared with the placebo group (p = 0.001). Gastrointestinal and cutaneous adverse events were greater in the auranofin group.

CONCLUSIONS

Auranofin demonstrated a steroid-sparing effect without concomitant worsening of symptoms or lung function and appeared to be more effective in patients dependent on 10 to 19 mg of prednisone per day. Therefore this study has demonstrated that auranofin is useful as a steroid-sparing agent in the treatment of chronic corticosteroid-dependent asthma.

Asthma in the pregnant adolescent: a review

Adolescent pregnancy has increased in the past decade (1-5), often in association with poverty, poor education, and inadequate prenatal care. While it has been suggested that adverse pregnancy outcomes are more common among adolescents in the inner city, recent data show that in a white, middle-class population teenaged mothers are more likely to have adverse pregnancy outcomes (5). Asthma is also becoming more common, with an incidence of at least 6.6% in 15-16 year old girls (6,7). Poverty and living in the inner city are associated with increased morbidity and mortality from asthma (8-11). Adolescents with asthma who become pregnant provide an added challenge to the physician who must consider the impact of the pregnancy on the asthma and vice versa. The physician must understand the effects of both the asthma medication and/or poorly controlled disease on the fetus. The physician must also be able to convey this information to the adolescent in a developmentally appropriate manner to enable the patient to make informed health care decisions (12).

A mechanism for masking receptors with particular application to asthma

This study ensconces the concept currently popular in neurophysiology that nerve terminals can be sensitized by 'unmasking' more receptors, but goes on to propose that the unknown substance masking the remainder is surface-active phospholipid. These molecules are considered to bind reversibly by adsorption to receptor surfaces just as they are known to do at a variety of tissue surfaces at which they impart 'barrier' properties very similar to those much exploited in the physical sciences. This model of nonspecific adsorption is further extended to a wide variety of receptors in lung airways including those on smooth muscle, to explain the normal control of sensitivity of reflex bronchoconstriction indicated by many physiological features. In the corollary hypothesis, asthma is attributed to a basic deficiency in surfactant causing undue unmasking of receptors exposed to the next noxious stimulus to enter the lungs. This model is shown to be compatible with the actions of a very wide variety of sensitizing agents which are physical, chemical and biological in nature; while the inflammation arising from the more biological routes can be correlated according to whether they release surfactant or disrupt it. Special attention is focused upon the diverse actions of nonsteroidal anti-inflammatory drugs versus steroids widely prescribed for asthma which promote the secretion of surfactant, as do the popular beta-agonists.

Investigating severe and fatal asthma

BACKGROUND

Severe asthma continues to present a major therapeutic problem despite advances in our understanding of the disease. Innovative ideas for investigating the underlying causes and treatment of severe asthma are few, and many patients still become dependent on oral steroids. We describe two separate studies: first, a prospective investigation measuring the responses of persons with severe asthma to an allergen-free environment; second, a retrospective analysis of factors associated with eight fatalities and one near fatality caused by asthma exacerbations.

METHODS

In the prospective study 17 persons with severe asthma were admitted to a hospital clinical research unit containing an allergen-free room for steroid dose reduction. Peak flow measurements, treatment requirements, and evidence of infection were followed up. In the retrospective study, the cases of nine patients who had been evaluated for asthma and who subsequently died during an asthma attack were reviewed; where possible allergen levels in their house dust and specific IgE antibodies to common indoor allergens were measured.

RESULTS

Analysis of the patients in the prospective study revealed two categories of responses to steroid dose reduction: (1) asthmatic persons who either maintained or improved peak flow values on steroid reduction; these patients were predominantly allergic to indoor allergens; (2) asthmatic persons whose condition deteriorated; these patients were unable to tolerate reduction in steroid dose. The second group included persons with sensitization to fungal antigens who had asthmatic exacerbations in association with culture-documented fungal colonization. The retrospective study revealed that in five of the eight fatalities caused by asthma, exposure to a relevant allergen had occurred at home before death.

CONCLUSION

Some steroid-dependent persons with severe asthma are allergic to inhalant allergens and may benefit from avoiding allergens. In some cases there is no evidence that antigen exposure from diet, inhalants, fungal infections, or sinusitis is relevant to their disease. However, persons with severe asthma include individuals infected with and sensitized to fungal antigens. The results suggest that cases of severe asthma should be investigated to identify treatable causes.

Effect of an oral gold compound, auranofin, on non-specific bronchial hyperresponsiveness in mild asthma

BACKGROUND

A recent double blind clinical trial in Japan has shown that auranofin (6 mg/day) is a useful treatment for patients with moderate to severe asthma. To investigate the mechanism of action of auranofin the bronchial responsiveness to inhaled methacholine has been studied in well controlled asthmatic subjects.

METHODS

Nineteen adult asymptomatic asthmatic subjects received auranofin (3 mg orally twice a day) or inactive placebo in random order for 12 weeks in a double blind fashion. Bronchial responsiveness to inhaled methacholine and pulmonary function tests were measured at the same time on different days before, and six and 12 weeks after, each treatment.

RESULTS

Non-specific bronchial hyperresponsiveness 12 weeks after treatment with auranofin was decreased compared with that before treatment with auranofin and 12 weeks after treatment with inactive placebo, although the treatment did not improve pulmonary function tests.

CONCLUSIONS

Non-specific bronchial hyperresponsiveness 12 weeks after treatment with auranofin is decreased in a group of mild asymptomatic asthmatic patients with normal lung function.

Difficult-to-control asthma. Contributing factors and outcome of a systematic management protocol

To our knowledge, there are no published results of protocols for managing difficult to control asthma (DTCA) or of the spectrum and frequencies of reasons why asthma can be difficult to control (DTC). To assess the usefulness of a systematic management protocol and determine the reason(s) why asthmatics are DTC, we developed a protocol that systematically considered multiple factors that may make asthma worse and prospectively evaluated the outcomes of therapeutic interventions for these factors and of inhaled corticosteroids (ICS) and azathioprine. We studied 42 consecutive and unselected DTCAs (19 men and 23 women) whose age was 48 +/- 15.9 years. They had a diagnosis of asthma for 15.1 +/- 15.8 years, were DTC for 4.8 +/- 7.8 years, and were followed up by us in the study for a total of 3.5 +/- 1.9 years. Initially, the dose of prednisone was 30.2 +/- 22 mg/d. Following utilization of the protocol, 74 percent were no longer DTC. It took 1.8 +/- 1.7 years for them to no longer be DTC; they remained so for 1.8 +/- 1.5 years. In these patients, 2.7 +/- 1.2 factors appeared to be responsible for the DTC state; 80 percent had > or = 2. Improvement was more likely if gastroesophageal reflux (GER) was a factor (p = 0.014); it correlated with the addition of ICS (p = 0.04) and treatment for GER (p = 0.02). Failure to reverse DTCA correlated with the suspicion (p = 0.004) and admission of nonadherence (p = 0.04). In 14 patients given azathioprine, prednisone dose decreased from 45 +/- 25.3 to 13.3 +/- 21.6 mg/d (p = 0.003); 6 of 14 achieved no longer DTC status; and substantial morbidity occurred. The reason(s) for DTCA could be determined in most instances by utilizing a systematic protocol; multiple factors were responsible in the majority of cases; treatment for GER and ICS were the two most helpful interventions; nonadherence was the most likely reason suspected for maintaining DTCA; and azathioprine acted as a corticosteroid-sparing agent that should not be prescribed routinely.

Antirheumatic drug reactions in the lung

Drug-induced lung disease during treatment with antirheumatic drugs should be considered in all patients receiving these agents who develop new pulmonary symptoms. When a potential drug-related reaction is identified, the possible offending agents should be discontinued, appropriate respiratory support initiated, and a thorough investigation for other causes of respiratory disease launched to exclude infection or other pulmonary processes. Lung biopsy may be needed to define the disorder completely. In patients with acute pneumonitis, the use of corticosteroids should be considered. Although significant morbidity and even mortality may occur with drug-induced pulmonary events, proper and prompt evaluation and treatment of these disorders can often result in complete resolution of the pulmonary disease.

Asthma

There is an active inflammatory process in the airways of patients with asthma, even when the patients are asymptomatic. Some of the types of cells involved in this process possess the necessary biologic activities to produce many of the pathophysiologic features of asthma, but the underlying mechanisms have not yet been elucidated. Reducing the severity of the inflammatory process appears to be a reasonable goal of therapy, with potential long-range implications for the morbidity of asthma. Whether this theoretical benefit will be realized awaits further observation.

Management of chronic asthma

The treatment of asthma is changing to reflect the importance of inflammation in the disease pathogenesis. Medicines that alter the inflammatory response are the cornerstone of therapy for patients with persistent symptoms. Bronchodilators are important in acute care, but in chronic illness they are adjuvant therapy. Patient education is essential for successful outcome.

Is asthma curable?

The information reviewed here supports the concept that asthma is potentially curable. Reports of complete, durable remission of asthma can no longer be regarded as fortuitous occurrences, unrepresentative of asthma in general. Systematic studies of anti-inflammatory drug therapy designed to explore possible induction or remission of asthma clearly are warranted. Studies of aggressive anti-inflammatory drug therapy of asthma at the onset, to avoid establishment of chronic asthma, also are desirable. The current goals of therapy of asthma have been revised to include reduction of airway hyperreactivity with topical anti-inflammatory drugs, in addition to relief of current symptoms. This approach may provide valuable resistance to exacerbations in response to antigen exposures, infections, exercise, or irritants. Pathophysiologic mechanisms apparently essential to the establishment and perpetuation of chronic asthma have been identified. These processes may be vulnerable to eradication by combination therapy with existing pharmacologic agents such as cyclosporin A or FK-506 (to suppress cytokine production), gold, methotrexate, and other anti-inflammatory drugs, alone or in combination. Equally important, the vigorous anti-inflammatory therapy may be necessary only long enough to achieve a resolution of the chronic pulmonary inflammation. Systematic studies of the use of these agents to induce partial, or complete, stable remissions of asthma should be performed. In the past, remissions of asthma in children with neoplasia and the other patients presented herein were complete, durable, and welcome, but they were largely unexpected and unpredictable. For the future, there is increasing reason to believe that predictable pharmacologically induced remission of asthma will be feasible.

Pharmacotherapy of childhood asthma. An inflammatory disease

The recognition that asthma constitutes 2 kinds of physiopathological reactions, namely bronchospasms (immediate reactions) and inflammatory responses (late reactions), suggests that the treatment should be focused against these events. Furthermore, the allergen provocation model, showing the existence of immediate and late asthmatic reactions, can be used to study the effects of different antiasthmatic drugs. Recently, the importance of inflammation in the pathogenesis of asthma in adults has led to the development of therapeutic regimens in which anti-inflammatory treatments are used frequently as a first-line step in the management of asthma. Although at the moment the hard data showing inflammation in childhood asthma are scarce, it is assumed that childhood asthma constitutes the same kind of chronic inflammatory processes as in adult asthma and that its treatment should also include anti-inflammatory drugs.

Anti-inflammatory drugs in the treatment of allergic disease

The treatment of asthma is undergoing significant change with an emphasis on anti-inflammatory therapy. While glucocorticoids are the most potent anti-inflammatory agent, certain patients fail to respond. These patients may be candidates for alternative anti-inflammatory therapy, such as troleandomycin, methotrexate, gold, hydroxychloroquine, or dapsone. In addition, the application of immunomodulator therapy, such as intravenous gamma globulin or cyclosporine, may be useful.

Auranofin in the treatment of steroid dependent asthma: a double blind study

BACKGROUND

Long term administration of oral corticosteroids in patients with asthma may be associated with serious side effects. Non-steroidal anti-inflammatory drugs, including gold salts, have been shown to reduce the need for systemic corticosteroid treatment in uncontrolled studies. The effect of oral gold (auranofin) on asthma symptoms, lung function, and the need for oral prednisone treatment was investigated.

METHODS

A 26 week randomised, double blind, placebo controlled, parallel group trial of auranofin was performed in 32 patients with moderately severe chronic asthma who required an oral corticosteroid dose of at least 5 mg prednisone a day (or equivalent) or 2.5 mg/day prednisone plus more than 800 micrograms/day inhaled corticosteroids. Auranofin was given orally in a dose of 3 mg twice daily. Asthma symptoms, lung function, and adverse effects were assessed at regular intervals. After 12 weeks of treatment prednisone dosage was tapered down by 2.5 mg every two weeks if the patient was clinically stable. Asthma exacerbations were treated with short courses of high doses of oral steroids.

RESULTS

Twenty eight of the 32 patients, 13 in the placebo group and 15 in the auranofin group, completed the study. The total corticosteroid reduction achieved after 26 weeks of treatment was significantly greater (4 mg) in the auranofin group than in the placebo group (0.3 mg). The number of exacerbations requiring an increase of steroids was greater in the placebo group (2.1) than in the active group (0.9). A significant increase in FEV1 of 6.4% predicted occurred in the auranofin group during the study and there was a reduction of asthma symptoms such as wheezing and cough. There was no difference between the groups in peak flow measurements or in the number of asthma attacks. The incidence of side effects of auranofin was low, but exacerbations of constitutional eczema were noticeable.

CONCLUSION

Auranofin provides an effective adjunct to treatment for steroid dependent asthma, leading to a reduction of oral steroid dose.

Alternative treatments for asthma: assessing the need

Alternative treatments such as troleandomycin methotrexate, gold, and intravenous gamma globulin are sometimes considered for severe asthmatics to minimize the need for systemic corticosteroids and reduce adverse effects. These alternative therapies may also be associated with significant toxicity and expense. The ability to reduce corticosteroid use and the need for alternative treatment interventions in 125 pediatric patients at our institution were reviewed. Because corticosteroid requirements were reduced significantly, only 23 of 125 children evaluated were considered for treatment alternatives with only 10 receiving such therapy. This study emphasizes the importance of a thorough and comprehensive review of corticosteroid requirements and usage prior to initiating alternative approaches to treatment in moderate to severe asthmatics as well as in patients thought to be "steroid-dependent."

Glucocorticoid resistance in chronic asthma. Peripheral blood T lymphocyte activation and comparison of the T lymphocyte inhibitory effects of glucocorticoids and cyclosporin A

A total of 37 chronic severe asthmatic patients with documented reversible airways obstruction were classified as glucocorticoid sensitive or resistant according to changes in the FEV1 following a course of oral prednisolone. The phenotype and expression of activation molecules on peripheral blood T lymphocytes from these patients just before the course of prednisolone were studied using flow cytometry. The resistant patients had significantly elevated percentages of T lymphocytes expressing the activation molecules IL-2R and HLA-DR compared to the sensitive patients. There were no differences between the patient groups in the percentages of peripheral blood T lymphocytes expressing the phenotypic markers CD4 and CD8. Peripheral blood mononuclear cells (PBMC) from 29 patients were cultured in vitro with the T lymphocyte mitogen PHA in the presence or absence of dexamethasone or cyclosporin A. Dexamethasone (10(-7) mol/L) significantly inhibited the proliferation of T lymphocytes from the sensitive but not the resistant asthmatic subjects. In contrast, cyclosporin A (500 ng/ml) inhibited proliferation of T lymphocytes from both the sensitive and the resistant asthmatic subjects, although the effect was less marked in the latter group. Inhibition of elaboration of interleukin-2 and interferon-gamma by mitogen-stimulated T lymphocytes from sensitive and resistant asthmatic patients was also studied. Dexamethasone (10(-7) mol/L) significantly inhibited the production of interleukin-2 and interferon-gamma by proliferating T lymphocytes isolated from the glucocorticoid-sensitive but not the resistant chronic asthmatic patients. Cyclosporin A (500 ng/ml) inhibited the elaboration of both lymphokines by T lymphocytes derived from both patient groups.(ABSTRACT TRUNCATED AT 250 WORDS)

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.

Cyclosporin for steroid-dependent asthma

We used cyclosporin to treat 12 adult patients with severe bronchial asthma who had been on systemic steroids for an average of 16 years. During the baseline period, lasting 4-6 months, therapy with high doses of inhaled beclamethasone, aminophylline and salbutamol was standardized and a minimum necessary dose of systemic steroids was established. After 9 months' treatment with low-dose cyclosporin (average whole-blood trough levels of 105 ng/ml), in six patients the daily dose of oral prednisone could be reduced from mean 30 mg to mean 11 mg, while daily symptom scores and peak expiratory flows improved significantly. This was accompanied by a reduction in exacerbations of asthma. However, in six other patients attempts to taper the steroid doses were unsuccessful, and cyclosporin was stopped after 4 to 7 months. These preliminary results suggest that cyclosporin might be of benefit in some patients with steroid-dependent asthma.