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Alkawadri T, Wong PY, Fong Z, Lundy FT, McGarvey LP, Hollywood MA, Thornbury KD, Sergeant GP. M2 Muscarinic Receptor-Dependent Contractions of Airway Smooth Muscle are Inhibited by Activation of β-Adrenoceptors. FUNCTION 2022; 3:zqac050. [PMID: 36325515 PMCID: PMC9617473 DOI: 10.1093/function/zqac050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 09/19/2022] [Accepted: 09/21/2022] [Indexed: 01/07/2023] Open
Abstract
Beta-adrenoceptor (β-AR) agonists inhibit cholinergic contractions of airway smooth muscle (ASM), but the underlying mechanisms are unclear. ASM cells express M3 and M2 muscarinic receptors, but the bronchoconstrictor effects of acetylcholine are believed to result from activation of M3Rs, while the role of the M2Rs is confined to offsetting β-AR-dependent relaxations. However, a profound M2R-mediated hypersensitization of M3R-dependent contractions of ASM was recently reported, indicating an important role for M2Rs in cholinergic contractions of ASM. Here, we investigated if M2R-dependent contractions of murine bronchial rings were inhibited by activation of β-ARs. M2R-dependent contractions were apparent at low frequency (2Hz) electric field stimulation (EFS) and short (10s) stimulus intervals. The β1-AR agonist, denopamine inhibited EFS-evoked contractions of ASM induced by reduction in stimulus interval from 100 to 10 s and was more effective at inhibiting contractions evoked by EFS at 2 than 20 Hz. Denopamine also abolished carbachol-evoked contractions that were resistant to the M3R antagonist 4-DAMP, similar to the effects of the M2R antagonists, methoctramine and AFDX-116. The inhibitory effects of denopamine on EFS-evoked contractions of ASM were smaller in preparations taken from M2R -/- mice, compared to wild-type (WT) controls. In contrast, inhibitory effects of the β3-AR agonist, BRL37344, on EFS-evoked contractions of detrusor strips taken from M2R -/- mice were greater than WT controls. These data suggest that M2R-dependent contractions of ASM were inhibited by activation of β1-ARs and that genetic ablation of M2Rs decreased the efficacy of β-AR agonists on cholinergic contractions.
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Affiliation(s)
- Tuleen Alkawadri
- Smooth Muscle Research Centre, Dundalk Institute of Technology, Dublin Road, Dundalk, Co. Louth A91 K584, Ireland
| | - Pei Yee Wong
- Smooth Muscle Research Centre, Dundalk Institute of Technology, Dublin Road, Dundalk, Co. Louth A91 K584, Ireland
| | - Zhihui Fong
- Smooth Muscle Research Centre, Dundalk Institute of Technology, Dublin Road, Dundalk, Co. Louth A91 K584, Ireland
| | - Fionnuala T Lundy
- The Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Belfast, BT9 7BL, Northern Ireland
| | - Lorcan P McGarvey
- The Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Belfast, BT9 7BL, Northern Ireland
| | - Mark A Hollywood
- Smooth Muscle Research Centre, Dundalk Institute of Technology, Dublin Road, Dundalk, Co. Louth A91 K584, Ireland
| | - Keith D Thornbury
- Smooth Muscle Research Centre, Dundalk Institute of Technology, Dublin Road, Dundalk, Co. Louth A91 K584, Ireland
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Optimization of Long-Acting Bronchodilator Dose Ratios Using Isolated Guinea Pig Tracheal Rings for Synergistic Combination Therapy in Asthma and COPD. Pharmaceuticals (Basel) 2022; 15:ph15080963. [PMID: 36015111 PMCID: PMC9416144 DOI: 10.3390/ph15080963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 07/28/2022] [Accepted: 07/29/2022] [Indexed: 11/16/2022] Open
Abstract
The co-administration of a long-acting β2-agonist (LABA), and a long-acting muscarinic antagonist (LAMA), has been shown to be beneficial in the management of non-communicable chronic respiratory diseases, such as asthma and chronic obstructive pulmonary disease (COPD). The resulting relaxation of the airways can be synergistically enhanced, reducing symptoms and optimizing lung function. This provides an insight into more effective treatments. In this study, the LABAs formoterol fumarate dihydrate (FOR) and indacaterol maleate (IND) were each associated with tiotropium bromide monohydrate (TIO) to assess their synergistic potential. This was done using an appropriate ex vivo model of isolated perfused guinea pig tracheal rings, and pharmacological models of drug interaction. Among the dose ratios studied for both types of combination, a higher synergistic potential was highlighted for FOR/TIO 2:1 (w/w). This was done through three steps by using multiple additions of drugs to the organ baths based on a non-constant dose ratio and then on a constant dose ratio, and by a single addition to the organ baths of specific amounts of drugs. In this way, the synergistic improvement of the relaxant effect on the airways was confirmed, providing a basis for improving therapeutic approaches in asthma and COPD. The synergy found at this dose ratio should now be confirmed on a preclinical model of asthma and COPD by assessing lung function.
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Indacaterol, glycopyrronium, and mometasone: pharmacological interaction and anti-inflammatory profile in hyperresponsive airways. Pharmacol Res 2021; 172:105801. [PMID: 34363950 DOI: 10.1016/j.phrs.2021.105801] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 08/03/2021] [Accepted: 08/03/2021] [Indexed: 12/11/2022]
Abstract
LABA/ICS and LABA/LAMA/ICS combinations elicit beneficial effects in asthma. Specific evidence concerning the impact of combining indacaterol acetate (IND), glycopyrronium bromide (GLY), and mometasone furoate (MF) on human airway hyperresponsiveness (AHR) and airway inflammation is still missing. The aim of this study was to characterize the synergy of IND/MF and IND/GLY/MF combinations, both once-daily treatments for asthma, in hyperresponsive airways. Passively sensitized human medium and small airways were stimulated by histamine and treated with IND/MF (molar ratio: 100/45, 100/90) and IND/GLY/MF (molar ratio: 100/37/45, 100/37/90). The effect on contractility and airway inflammation was tested. Drug interaction was assessed by Bliss Independence equation and Unified Theory. IND/MF 100/90 elicited middle-to-very strong synergistic relaxation in medium and small airways (+≈20-30% vs. additive effect, P<0.05), for IND/MF 100/45 the synergy was middle-to-very strong in small airways (+≈20% vs. additive effect, P<0.05), and additive in medium bronchi (P>0.05 vs. additive effect). IND/GLY/MF 100/37/45 and 100/37/90 induced very strong synergistic relaxation in medium and small airways (+≈30-50% vs. additive effect, P<0.05). Synergy was related with significant (P<0.05) reduction in IL-4, IL-5, IL-6, IL-9, IL-13, TNF-α, TSLP, NKA, SP, and non-neuronal ACh, and enhancement in cAMP. IND/MF and IND/GLY/MF combinations synergistically interact in hyperresponsive medium and small airways and modulate the levels of cytokines, neurokinins, ACh, and intracellular cAMP. The concentrations of MF in the combinations modulate the effects in the target tissue.
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Ora J, Calzetta L, Ritondo BL, Matera MG, Rogliani P. Current long-acting muscarinic antagonists for the treatment of asthma. Expert Opin Pharmacother 2021; 22:2343-2357. [PMID: 34219573 DOI: 10.1080/14656566.2021.1952182] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION The role of long-acting muscarinic antagonists (LAMAs) is well established in uncontrolled asthma, but not in milder stages. AREAS COVERED This review examines the main randomized controlled trials (RCTs) that have investigated LAMAs administered as monotherapy or in combination to asthmatic patients, according to the different phenotypes. It offers an overview of the role of LAMAs or their fixed dose combinations (FDCs) in the treatment across all the different stages of asthma. EXPERT OPINION Tiotropium is now widely recognized as treatment for moderate to severe uncontrolled asthma (step 4-5) in adults and children. The most recent new evidence is: a) in adults, three different LAMA/long-acting β2-agonist (LABA)/inhaled corticosteroid (ICS) FDCs have been recently approved, extending the treatment options for these patients; b) therapy with LAMAs does not depend on patient's Th2 status and justifies the indication regardless of patient's phenotyping; c) in the milder stages, the high variability of response to LAMAs and the lack of a good phenotyping of patients represents the main obstacle in prescribing LAMAs. A better characterization of parasympathetic tone activity could improve LAMAs prescription.
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Affiliation(s)
- Josuel Ora
- Respiratory Medicine Unit, University Hospital "Tor Vergata", Rome, Italy
| | - Luigino Calzetta
- Department of Medicine and Surgery, University of Parma, Parma, Italy
| | | | - Maria Gabriella Matera
- Department of Experimental Medicine, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Paola Rogliani
- Respiratory Medicine Unit, University Hospital "Tor Vergata", Rome, Italy.,Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
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Liang Y, Mak JCW. Inhaled Therapies for Asthma and Chronic Obstructive Pulmonary Disease. Curr Pharm Des 2021; 27:1469-1481. [PMID: 33243107 DOI: 10.2174/1389201021666201126144057] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 09/23/2020] [Accepted: 10/01/2020] [Indexed: 11/22/2022]
Abstract
Asthma and chronic obstructive pulmonary disease (COPD) are obstructive lung diseases which are characterized by chronic inflammation and an increase in mucus production, and are highly prevalent conditions. Despite recent advances and multiple available therapies, there remains a significant unmet medical need. Over the past 40 years, the introduction of new classes of safe and effective therapy is insufficient. In spite of the high burden of asthma and COPD among patients, there are fewer new approved therapies in comparison to cardiovascular, metabolic and neurological diseases due to few drug candidates and a higher failure rate in the development of respiratory medicine. Lung diseases are amongst the leading causes of death globally with asthma being one of the most prevalent respiratory diseases, which affects people of all ages but, despite effective therapies available, many patients are poorly controlled and have a low quality of life. COPD is currently ranked as the fourth cause of death worldwide and predicted to become the third leading cause of death in 2030. The development of more effective treatments is urgently needed in order to reduce the high mortality rate and the enormous suffering from asthma and COPD. Various inhalation devices with different classes of medications are the foundation as therapies in both asthma and COPD. This article gives a comprehensive review of the promising inhaled therapies in the treatment of asthma and COPD. However, the lack of disease control in asthma and COPD patients may be due to numerous reasons. The association between non-adherence to guidelines on the part of the health care provider and poor inhalation technique and/or non-adherence to the prescribed treatment plan by the patients is common. It is therefore essential to discuss the different delivery systems and the methods used in asthma and COPD patients.
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Affiliation(s)
- Yingmin Liang
- Department of Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Judith C W Mak
- Department of Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
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Rancati F, Linney ID, Rizzi A, Delcanale M, Knight CK, Schmidt W, Pastore F, Riccardi B, Mileo V, Carnini C, Cesari N, Blackaby WP, Patacchini R, Carzaniga L. Discovery of a novel class of inhaled dual pharmacology muscarinic antagonist and β 2 agonist (MABA) for the treatment of chronic obstructive pulmonary disease (COPD). Bioorg Med Chem Lett 2021; 41:127975. [PMID: 33753262 DOI: 10.1016/j.bmcl.2021.127975] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 03/08/2021] [Accepted: 03/13/2021] [Indexed: 11/28/2022]
Abstract
The targeting of both the muscarinic and β-adrenergic pathways is a well validated therapeutic approach for the treatment of chronic obstructive pulmonary disease (COPD). In this communication we report our effort to incorporate two pharmacologies into a single chemical entity, whose characteristic must be suitable for a once daily inhaled administration. Contextually, we aimed at a locally acting therapy with limited systemic absorption to minimize side effects. Our lung-tailored design of bifunctional compounds that combine the muscarinic and β-adrenergic pharmacologies by the elaboration of the muscarinic inhibitor 7, successfully led to the potent, pharmacologically balanced muscarinic antagonist and β2 agonist (MABA) 13.
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Affiliation(s)
- Fabio Rancati
- Chemistry Research and Drug Design Department, Chiesi Farmaceutici S.p.A, Nuovo Centro Ricerche, Largo Belloli 11/a, 43122 Parma, Italy
| | - Ian D Linney
- Medicinal Chemistry Department, Charles River Laboratories, Chesterford Research Park, Saffron Walden, CB10 1XL, Cambridgeshire, United Kingdom
| | - Andrea Rizzi
- Chemistry Research and Drug Design Department, Chiesi Farmaceutici S.p.A, Nuovo Centro Ricerche, Largo Belloli 11/a, 43122 Parma, Italy
| | - Maurizio Delcanale
- Chemistry Research and Drug Design Department, Chiesi Farmaceutici S.p.A, Nuovo Centro Ricerche, Largo Belloli 11/a, 43122 Parma, Italy
| | - Chris K Knight
- Medicinal Chemistry Department, Charles River Laboratories, Chesterford Research Park, Saffron Walden, CB10 1XL, Cambridgeshire, United Kingdom
| | - Wolfgang Schmidt
- Medicinal Chemistry Department, Charles River Laboratories, Chesterford Research Park, Saffron Walden, CB10 1XL, Cambridgeshire, United Kingdom
| | - Fiorella Pastore
- Pharmacology and Toxicology Department, Chiesi Farmaceutici S.p.A, Nuovo Centro Ricerche, Largo Belloli 11/a, 43122 Parma, Italy
| | - Benedetta Riccardi
- Pharmacokinetics Biochemistry and Metabolism Department, Chiesi Farmaceutici S.p.A, Nuovo Centro Ricerche, Largo Belloli 11/a, 43122 Parma, Italy
| | - Valentina Mileo
- Analytics and Early Formulation Department, Chiesi Farmaceutici S.p.A, Nuovo Centro Ricerche, Largo Belloli 11/a, 43122 Parma, Italy
| | - Chiara Carnini
- Pharmacology and Toxicology Department, Chiesi Farmaceutici S.p.A, Nuovo Centro Ricerche, Largo Belloli 11/a, 43122 Parma, Italy
| | - Nicola Cesari
- Pharmacokinetics Biochemistry and Metabolism Department, Chiesi Farmaceutici S.p.A, Nuovo Centro Ricerche, Largo Belloli 11/a, 43122 Parma, Italy
| | - Wesley P Blackaby
- Medicinal Chemistry Department, Charles River Laboratories, Chesterford Research Park, Saffron Walden, CB10 1XL, Cambridgeshire, United Kingdom
| | - Riccardo Patacchini
- Project Leader, Corporate Drug Development, Chiesi Farmaceutici S.p.A, Nuovo Centro Ricerche, Largo Belloli 11/a, 43122 Parma, Italy
| | - Laura Carzaniga
- Chemistry Research and Drug Design Department, Chiesi Farmaceutici S.p.A, Nuovo Centro Ricerche, Largo Belloli 11/a, 43122 Parma, Italy.
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Role of Airway Smooth Muscle in Inflammation Related to Asthma and COPD. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2021; 1303:139-172. [PMID: 33788192 DOI: 10.1007/978-3-030-63046-1_9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Airway smooth muscle contributes to both contractility and inflammation in the pathophysiology of asthma and COPD. Airway smooth muscle cells can change the degree of a variety of functions, including contraction, proliferation, migration, and the secretion of inflammatory mediators (phenotype plasticity). Airflow limitation, airway hyperresponsiveness, β2-adrenergic desensitization, and airway remodeling, which are fundamental characteristic features of these diseases, are caused by phenotype changes in airway smooth muscle cells. Alterations between contractile and hyper-contractile, synthetic/proliferative phenotypes result from Ca2+ dynamics and Ca2+ sensitization. Modulation of Ca2+ dynamics through the large-conductance Ca2+-activated K+ channel/L-type voltage-dependent Ca2+ channel linkage and of Ca2+ sensitization through the RhoA/Rho-kinase pathway contributes not only to alterations in the contractile phenotype involved in airflow limitation, airway hyperresponsiveness, and β2-adrenergic desensitization but also to alteration of the synthetic/proliferative phenotype involved in airway remodeling. These Ca2+ signal pathways are also associated with synergistic effects due to allosteric modulation between β2-adrenergic agonists and muscarinic antagonists. Therefore, airway smooth muscle may be a target tissue in the therapy for these diseases. Moreover, the phenotype changing in airway smooth muscle cells with focuses on Ca2+ signaling may provide novel strategies for research and development of effective remedies against both bronchoconstriction and inflammation.
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Papi A, Fabbri LM, Kerstjens HAM, Rogliani P, Watz H, Singh D. Inhaled long-acting muscarinic antagonists in asthma - A narrative review. Eur J Intern Med 2021; 85:14-22. [PMID: 33563506 DOI: 10.1016/j.ejim.2021.01.027] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 01/20/2021] [Accepted: 01/24/2021] [Indexed: 12/13/2022]
Abstract
Long-acting muscarinic antagonists (LAMAs) have a recognised role in the management of chronic obstructive pulmonary disease. In asthma, muscarinic antagonists (both short- and long-acting) were historically considered less effective than β2-agonists; only relatively recently have studies been conducted to evaluate the efficacy of LAMAs, as add-on to either inhaled corticosteroid (ICS) monotherapy or ICS/long-acting β2-agonist (LABA) combinations. These studies led to the approval of the first LAMA, tiotropium, as an add-on therapy in patients with poorly controlled asthma. Subsequently, a number of single-inhaler ICS/LABA/LAMA triple therapies have been approved or are in clinical development for the management of asthma. There is now substantial evidence of the efficacy and safety of LAMAs in asthma that is uncontrolled despite treatment with an ICS/LABA combination. This regimen is recommended by GINA as an optimisation step for patients with severe asthma before any biologic or systemic corticosteroid treatment is initiated. This narrative review summarises the potential mechanisms of action of LAMAs in asthma, together with the initial clinical evidence supporting this use. We also discuss the studies that led to the approval of tiotropium for asthma and the data evaluating the efficacy and safety of the various triple therapies, before considering other potential uses for triple therapy.
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Affiliation(s)
- Alberto Papi
- Respiratory Medicine Unit, University of Ferrara, University Hospital S.Anna, Ferrara, Italy.
| | - Leonardo M Fabbri
- Section of Respiratory Medicine, Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, Italy
| | - Huib A M Kerstjens
- University of Groningen, University Medical Center Groningen, and Groningen Research Institute for Asthma and COPD, Groningen, The Netherlands
| | - Paola Rogliani
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Henrik Watz
- Pulmonary Research Institute at Lung Clinic Grosshansdorf, Airway Research Center North (ARCN), German Center for Lung Research (DZL), Grosshansdorf, Germany
| | - Dave Singh
- Medicines Evaluation Unit, The University of Manchester, Manchester University NHS Foundation Trust, Manchester, UK
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Anzueto A, Miravitlles M. Tiotropium in chronic obstructive pulmonary disease - a review of clinical development. Respir Res 2020; 21:199. [PMID: 32727455 PMCID: PMC7389564 DOI: 10.1186/s12931-020-01407-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 05/26/2020] [Indexed: 12/13/2022] Open
Abstract
Background Bronchodilators are the mainstay of pharmacological treatment in chronic obstructive pulmonary disease (COPD), and long-acting muscarinic antagonist (LAMA) monotherapy is recommended as initial treatment for Global Initiative for Chronic Obstructive Lung Disease (GOLD) groups B, C, and D. Main body Tiotropium bromide was the first LAMA available for COPD in clinical practice and, because of its long duration of action, is administered once daily. Tiotropium was initially available as an inhalation powder delivered via a dry-powder inhaler (DPI). Later, tiotropium also became available as an inhalation spray delivered via a soft mist inhaler (SMI). The SMI was designed to overcome or minimize some of the issues associated with other inhaler types (eg, the need for strong inspiratory airflow with DPIs). Results of short- and long-term randomized, controlled clinical trials of tiotropium in patients with COPD indicated tiotropium was safe and significantly improved lung function, health-related quality of life, and exercise endurance, and reduced dyspnea, lung hyperinflation, exacerbations, and use of rescue medication compared with placebo or active comparators. These positive efficacy findings triggered the evaluation of tiotropium in fixed-dose combination with olodaterol (a long-acting β2-agonist). In this review, we provide an overview of studies of tiotropium for the treatment of COPD, with a focus on pivotal studies. Conclusion Tiotropium is safe and efficacious as a long-term, once-daily LAMA for the maintenance treatment of COPD and for reducing COPD exacerbations. The SMI generates a low-velocity, long-duration aerosol spray with a high fine-particle fraction, which results in marked lung drug deposition. In addition, high inspiratory flow rates are not required.
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Affiliation(s)
- Antonio Anzueto
- Internal Medicine, Pulmonary Disease, University of Texas Health, and South Texas Veterans Health Care System, San Antonio, TX, USA.
| | - Marc Miravitlles
- Pneumology Department, Hospital Universitary Vall d'Hebron/Vall d'Hebron Research Institute (VHIR). CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
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Matera MG, Belardo C, Rinaldi M, Rinaldi B, Cazzola M. Emerging muscarinic receptor antagonists for the treatment of asthma. Expert Opin Emerg Drugs 2020; 25:123-130. [PMID: 32312134 DOI: 10.1080/14728214.2020.1758059] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION The increased acetylcholine signaling in asthma pathophysiology offers the rationale for the use of LAMAs in the treatment of asthmatic patients. Tiotropium is still the only LAMA approved for use in asthma but there is a real interest in developing novel LAMAs for the treatment of asthma, or at least to extend this indication to other LAMAs already on the market. AREAS COVERED We examined and discussed trials and research that have studied or are evaluating the role of LAMAs already on the market in asthma and possible novel muscarinic acetylcholine receptor antagonists. EXPERT OPINION Glycopyrronium and umeclidinium will soon be included in the GINA strategy with the same current indications of tiotropium. It is likely that the choice of the LAMA will be influenced not so much by its pharmacological profile as by the type of triple therapy chosen. It is extremely difficult to identify a new LAMA that is more effective than tiotropium, but is it plausible that new technologies that will allow delivering the drug in a more targeted way and with a lower risk of adverse effects may represent the real progress in the use of LAMAs in asthma in the coming years.
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Affiliation(s)
- Maria Gabriella Matera
- Unit of Pharmacology, Department of Experimental Medicine, University of Campania "Luigi Vanvitelli" , Naples, Italy
| | - Carmela Belardo
- Unit of Pharmacology, Department of Experimental Medicine, University of Campania "Luigi Vanvitelli" , Naples, Italy
| | - Michele Rinaldi
- Multidisciplnary Department of Medical-Surgical and Dental Specialities, University of Campania "Luigi Vanvitelli" , Naples, Italy
| | - Barbara Rinaldi
- Unit of Pharmacology, Department of Experimental Medicine, University of Campania "Luigi Vanvitelli" , Naples, Italy
| | - Mario Cazzola
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome "Tor Vergata" , Rome, Italy
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Matera MG, Rinaldi B, Berardo C, Rinaldi M, Cazzola M. A review of the pharmacokinetics of M 3 muscarinic receptor antagonists used for the treatment of asthma. Expert Opin Drug Metab Toxicol 2020; 16:143-148. [PMID: 31958237 DOI: 10.1080/17425255.2020.1716730] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Introduction: There is solid evidence that in patients with poorly controlled severe asthma despite the use of ICS and LABA, the addition of LAMAs, such as tiotropium, significantly increases the time to the first severe exacerbation and provides a modest but sustained bronchodilation. However, only a very limited number of pharmacokinetic studies with these agents have been performed in asthmatic patients.Areas covered: The pharmacokinetic profile of inhaled tiotropium, umeclidinium and glycopyrronium in healthy volunteers and that of inhaled tiotropium and umeclidinium in asthmatic patients have been reviewed.Expert opinion: In asthmatic patients, LAMAs are rapidly absorbed into the systemic compartment and demonstrate bi-exponential elimination (rapidly declining plasma concentrations followed by slow apparent terminal elimination). Apparently, the severity of asthma does not change the pharmacokinetics of LAMAs. The limited information available is focused on the plasma pharmacokinetic profile of these drugs and, consequently, although suitable for establishing a systemic safety profile, it does not tell us much about possible therapeutic efficacy of LAMAs in asthmatics because quantification of systemic plasma values is neither at the airways, which are their site of action nor representative of their transport to this site.
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Affiliation(s)
- Maria Gabriella Matera
- Unit of Pharmacology, Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Barbara Rinaldi
- Unit of Pharmacology, Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Carmela Berardo
- Unit of Pharmacology, Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Michele Rinaldi
- Multidisciplnary Department of Medical-Surgical and Dental Specialities, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Mario Cazzola
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
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Cazzola M, Puxeddu E, Matera MG, Rogliani P. A potential role of triple therapy for asthma patients. Expert Rev Respir Med 2019; 13:1079-1085. [PMID: 31422716 DOI: 10.1080/17476348.2019.1657408] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Introduction: The use of LAMAs in asthma is now supported by pharmacological and clinical evidence, whereas the effectiveness of therapy with ICS/LABA/LAMA fixed dose combinations in patients with asthma still remains to be determined. Areas covered: The pharmacological rationale that explains why it is possible to use triple therapy in asthma and the results of clinical studies that have explored the effects of this therapy in asthmatics is critically examined. A systematic search was conducted on 10 August 2019, and included six electronic databases: EMBASE, MEDLINE, Scopus, The Cochrane Library, Web of Science, and Google Scholar. Expert opinion: The real role of single inhaler triple therapy in asthma will be demonstrated when the various trials that are currently ongoing or are scheduled will be completed. We believe that it is appropriate to treat with triple therapy asthmatic patients who have smoked and remain symptomatic or suffer from frequent exacerbations despite initial inhaler therapy with ICS/LABA. However, we must establish when to step up or mainly step down triple therapy especially in patients who are well controlled, and what will be the cost of these combinations in the management of asthma.
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Affiliation(s)
- Mario Cazzola
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome "Tor Vergata" , Rome , Italy
| | - Ermanno Puxeddu
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome "Tor Vergata" , Rome , Italy
| | - Maria Gabriella Matera
- Unit of Pharmacology, Department of Experimental Medicine, University of Campania "Luigi Vanvitelli" , Naples , Italy
| | - Paola Rogliani
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome "Tor Vergata" , Rome , Italy
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Kistemaker LEM, Prakash YS. Airway Innervation and Plasticity in Asthma. Physiology (Bethesda) 2019; 34:283-298. [PMID: 31165683 PMCID: PMC6863372 DOI: 10.1152/physiol.00050.2018] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 03/20/2019] [Accepted: 03/21/2019] [Indexed: 12/22/2022] Open
Abstract
Airway nerves represent a mechanistically and therapeutically important aspect that requires better highlighting in the context of diseases such as asthma. Altered structure and function (plasticity) of afferent and efferent airway innervation can contribute to airway diseases. We describe established anatomy, current understanding of how plasticity occurs, and contributions of plasticity to asthma, focusing on target-derived growth factors (neurotrophins). Perspectives toward novel treatment strategies and future research are provided.
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Affiliation(s)
- L E M Kistemaker
- Department of Molecular Pharmacology, University of Groningen , Groningen , The Netherlands
- GRIAC Research Institute, University Medical Center Groningen, University of Groningen , Groningen , The Netherlands
| | - Y S Prakash
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic , Rochester, Minnesota
- Department of Physiology and Biomedical Engineering, Mayo Clinic , Rochester, Minnesota
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14
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Buhl R, Hamelmann E. Future perspectives of anticholinergics for the treatment of asthma in adults and children. Ther Clin Risk Manag 2019; 15:473-485. [PMID: 30936709 PMCID: PMC6422409 DOI: 10.2147/tcrm.s180890] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Despite major advances in therapeutic interventions and the availability of detailed treatment guidelines, a high proportion of patients with symptomatic asthma remain uncontrolled. Asthma management is largely guided by the Global Initiative for Asthma (GINA) strategy and is based on a backbone of inhaled corticosteroid (ICS) therapy with the use of additional therapies to achieve disease control. Inhaled long-acting bronchodilators alone and in combination are the preferred add-on treatment options. Although long-acting muscarinic antagonists (LAMAs) are a relatively recent addition to disease management recommendations for asthma, tiotropium has been extensively studied in a large clinical trial program. In Europe and the United States, tiotropium is approved for patients aged ≥6 years and uncontrolled on medium- to high-dose ICS/long-acting β2-agonists at GINA Steps 4 and 5 with a history of exacerbations. Evidence supports the efficacy of tiotropium Respimat® in adults in terms of lung function and asthma control, with a safety profile comparable with that of placebo across a range of asthma severities. Similarly, clinical trials in patients aged 1-17 years have shown improvements in lung function and trends toward improved asthma control. Furthermore, its efficacy makes tiotropium relatively easy to incorporate into routine clinical practice, irrespective of allergic status and without the need for patient phenotyping. Tiotropium is a cost-effective treatment that may offer an important alternative to other, more expensive add-on therapies. This review discusses the potential future position of LAMAs in clinical practice by considering the continuously evolving evidence. Prominence is given to tiotropium, the only LAMA supported by a structured clinical trial program in asthma to date, while also considering other recommended treatment options for patients with uncontrolled asthma. The importance of effective patient/caregiver-clinician communication and shared decision-making in enhancing treatment adherence is also highlighted.
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Affiliation(s)
- Roland Buhl
- Pulmonary Department, Johannes Gutenberg University Hospital Mainz, Mainz, Germany,
| | - Eckard Hamelmann
- Children's Center Bethel, Evangelic Hospital Bethel, Department of Pediatrics, Bielefeld, Germany
- University Children's Hospital, Allergy Center Ruhr, Ruhr University Bochum, Bochum, Germany
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15
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Jenkins C. Barriers to achieving asthma control in adults: evidence for the role of tiotropium in current management strategies. Ther Clin Risk Manag 2019; 15:423-435. [PMID: 30936705 PMCID: PMC6422417 DOI: 10.2147/tcrm.s177603] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Despite the availability of a range of treatment options and management guidelines, a high proportion of adults with asthma remain uncontrolled. The challenge of managing uncontrolled asthma includes providing efficacious treatment while limiting side effects, recognizing situations when a change in asthma therapy is required, and considering patient preferences and satisfaction. In line with the Global Initiative for Asthma report, asthma management is based on a backbone of inhaled corticosteroid (ICS) therapy and use of add-on therapies to achieve disease control. This review considers whether add-on options could be better utilized in clinical practice. A number of long-acting muscarinic antagonists are in development, but tiotropium is the most widely studied for use in asthma. Evidence demonstrating the efficacy of tiotropium as an add-on therapy to at least ICS in adults with symptomatic mild, moderate, and severe asthma is presented from randomized controlled trials and real-world evidence. In addition, the benefit of tiotropium therapy in a wide range of patient phenotypes and disease severities without the need for biomarker assessment is discussed. Additional strategies that complement this approach, such as recognizing and overcoming barriers to adherence, ensuring optimal device use, and education and support to enhance patient–physician communication, are discussed. Physician education can also help raise awareness that additional management options are available for patients with moderate-to-severe asthma who remain uncontrolled on ICS/long-acting β2-agonist treatment.
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Affiliation(s)
- Christine Jenkins
- Department of Thoracic Medicine, The George Institute for Global Health and Concord Clinical School, University of Sydney, Sydney, NSW, Australia,
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Anzalone G, Albano GD, Montalbano AM, Riccobono L, Bonanno A, Gagliardo R, Bucchieri F, Marchese R, Moscato M, Profita M. IL-17A-associated IKK-α signaling induced TSLP production in epithelial cells of COPD patients. Exp Mol Med 2018; 50:1-12. [PMID: 30291224 PMCID: PMC6173689 DOI: 10.1038/s12276-018-0158-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 06/12/2018] [Accepted: 06/21/2018] [Indexed: 11/09/2022] Open
Abstract
Thymic stromal lymphopoietin (TSLP) is a cytokine expressed in the epithelium, involved in the pathogenesis of chronic disease. IL-17A regulates airway inflammation, oxidative stress, and reduction of steroid sensitivity in chronic obstructive pulmonary disease (COPD). TSLP and IL-17A were measured in induced sputum supernatants (ISs) from healthy controls (HC), healthy smokers (HS), and COPD patients by enzyme-linked immunosorbent assay. Human bronchial epithelial cell line (16HBE) and normal bronchial epithelial cells were stimulated with rhIL-17A or ISs from COPD patients to evaluate TSLP protein and mRNA expression. The effects of the depletion of IL-17A in ISs, an anticholinergic drug, and the silencing of inhibitor kappa kinase alpha (IKKα) on TSLP production were evaluated in 16HBE cells. Coimmunoprecipitation of acetyl-histone H3(Lys14)/IKKα was evaluated in 16HBE cells treated with rhIL-17A and in the presence of the drug. TSLP and IL-17A levels were higher in ISs from COPD patients and HS compared with HC. TSLP protein and mRNA increased in 16HBE cells and in normal bronchial epithelial cells stimulated with ISs from COPD patients compared with ISs from HC and untreated cells. IKKα silencing reduced TSLP production in 16HBE cells stimulated with rhIL-17A and ISs from COPD patients. RhIL-17A increased the IKKα/acetyl-histone H3 immunoprecipitation in 16HBE cells. The anticholinergic drug affects TSLP protein and mRNA levels in bronchial epithelial cells treated with rhIL-17A or with ISs from COPD patients, and IKKα mediated acetyl-histone H3(Lys14). IL-17A/IKKα signaling induced the mechanism of chromatin remodeling associated with acetyl-histone H3(Lys14) and TSLP production in bronchial epithelial cells. Anticholinergic drugs might target TSLP derived from epithelial cells during the treatment of COPD.
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Affiliation(s)
- Giulia Anzalone
- Institute of Biomedicine and Molecular Immunology "A. Monroy" (IBIM), National Research Council of Italy (CNR), Palermo, Italy
| | - Giusy Daniela Albano
- Institute of Biomedicine and Molecular Immunology "A. Monroy" (IBIM), National Research Council of Italy (CNR), Palermo, Italy
| | - Angela Marina Montalbano
- Institute of Biomedicine and Molecular Immunology "A. Monroy" (IBIM), National Research Council of Italy (CNR), Palermo, Italy
| | - Loredana Riccobono
- Institute of Biomedicine and Molecular Immunology "A. Monroy" (IBIM), National Research Council of Italy (CNR), Palermo, Italy
| | - Anna Bonanno
- Institute of Biomedicine and Molecular Immunology "A. Monroy" (IBIM), National Research Council of Italy (CNR), Palermo, Italy
| | - Rosalia Gagliardo
- Institute of Biomedicine and Molecular Immunology "A. Monroy" (IBIM), National Research Council of Italy (CNR), Palermo, Italy
| | - Fabio Bucchieri
- Dipartimento di Biomedicina sperimentale e Neuroscienze Cliniche (BioNec), University of Palermo, Palermo, Italy
| | - Roberto Marchese
- Interventional Pulmonology Unit, La Maddalena Cancer Center, Palermo, Italy
| | - Monica Moscato
- Institute of Biomedicine and Molecular Immunology "A. Monroy" (IBIM), National Research Council of Italy (CNR), Palermo, Italy
| | - Mirella Profita
- Institute of Biomedicine and Molecular Immunology "A. Monroy" (IBIM), National Research Council of Italy (CNR), Palermo, Italy.
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Huo Y, Xu J, Guan L, Wu W, Guo B, Yang Y, Lin L, Ou Y, Jiang F, Zhou L, Chen R. Methacholine induces extracellular matrix production by human airway smooth muscle cells through β-catenin signaling. Respir Physiol Neurobiol 2018; 254:55-63. [PMID: 29715518 DOI: 10.1016/j.resp.2018.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2017] [Revised: 04/21/2018] [Accepted: 04/28/2018] [Indexed: 11/28/2022]
Abstract
Altered extracellular matrix (ECM) production by airway smooth muscle cells (ASMCs) is an important feature of airway remodeling. Muscarinic receptor agonists contribute to ECM production in vivo, but the mechanisms involved remain unclear. This study attempted to investigate the role of methacholine in promoting ECM production by human ASMCs (HASMCs) and the underlying mechanism. We found that methacholine induced the expression of collagen I protein and multiple ECM genes. β-catenin signaling was activated in this process upon GSK3β phosphorylation, leading to upregulation of total and active β-catenin. Silencing β-catenin by specific small interfering RNA (siRNA) or with the β-catenin inhibitor, PKF115-584, decreased collagen I expression. Conversely, overexpression of active β-catenin by adenoviruses carrying the S33Y-β-catenin mutant increased the methacholine-induced collagen I expression. Furthermore, methacholine induced TGF-β expression in HASMCs, while pan-TGF-β-neutralizing antibody only partially decreased collagen I expression. These findings suggest that methacholine induced ECM production through β-catenin signaling and partially through TGF-β.
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Affiliation(s)
- Yating Huo
- State Key Laboratory of Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, 151 Yan Jiang Rd., Guangzhou 510120, China.
| | - Jiawen Xu
- State Key Laboratory of Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, 151 Yan Jiang Rd., Guangzhou 510120, China.
| | - Lili Guan
- State Key Laboratory of Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, 151 Yan Jiang Rd., Guangzhou 510120, China.
| | - Weiliang Wu
- State Key Laboratory of Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, 151 Yan Jiang Rd., Guangzhou 510120, China.
| | - Bingpeng Guo
- State Key Laboratory of Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, 151 Yan Jiang Rd., Guangzhou 510120, China.
| | - Yuqiong Yang
- State Key Laboratory of Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, 151 Yan Jiang Rd., Guangzhou 510120, China.
| | - Lin Lin
- State Key Laboratory of Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, 151 Yan Jiang Rd., Guangzhou 510120, China.
| | - Yonger Ou
- State Key Laboratory of Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, 151 Yan Jiang Rd., Guangzhou 510120, China.
| | - Fangfang Jiang
- State Key Laboratory of Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, 151 Yan Jiang Rd., Guangzhou 510120, China.
| | - Luqian Zhou
- State Key Laboratory of Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, 151 Yan Jiang Rd., Guangzhou 510120, China.
| | - Rongchang Chen
- State Key Laboratory of Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, 151 Yan Jiang Rd., Guangzhou 510120, China.
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Abstract
PURPOSE OF REVIEW Current guidelines recommend a stepwise approach for pharmacological therapy aimed to achieve and maintain asthma control. Despite these recommendations, at least 50% of patients continue to be uncontrolled with risk of asthma exacerbations that can often be serious and are associated with deterioration of quality of life. In recent years, the interest in anticholinergic bronchodilators, which have been primarily used in the treatment of chronic obstructive pulmonary disease, has increased patients with uncontrolled asthma. This review analyzes the mechanisms for the proposed clinical use of anticholinergic bronchodilators as an adjunctive therapy in asthma. RECENT FINDINGS Based on existing and recent evidence, the use of anticholinergic bronchodilators, particularly long-acting muscarinic antagonists (LAMAs), plays an important role as add-on therapy in patients uncontrolled on existing therapies. In particular, the use of anticholinergics in asthma may have a role in patients intolerant to long-acting β2 agonist, in patients with certain pharmacogenetic profiles and in those patients with asthma symptoms mostly at night. SUMMARY Data from clinical trials and from real-life confirm the safety and efficacy of LAMAs, especially tiotropium, in patients who remain uncontrolled despite the use of inhaled corticosteroid therapy.
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Abstract
Asthma is one of the most common chronic diseases in children, with a high proportion of patients demonstrating poor control despite the availability of disease management guidelines. Global Initiative for Asthma guidelines include tiotropium as an add-on therapy option at Steps 4 and 5 in patients aged ≥ 12 years with a history of exacerbations, and tiotropium delivered via the Respimat® Soft Mist™ Inhaler has recently been approved for use as once-daily maintenance therapy for children with asthma over the age of 6 years in the USA. A large clinical trial program has been conducted in children, adolescents, and adults across the spectrum of asthma severity. Findings from these clinical studies and pooled analyses in children and adolescents with symptomatic moderate or severe asthma have demonstrated that tiotropium Respimat® as add-on to inhaled corticosteroids, with or without other maintenance therapies, is a well-tolerated and efficacious bronchodilator, showing improved lung function and trends towards improved asthma control, mirroring findings in adult studies. This review discusses the evidence to date for tiotropium Respimat® for the management of asthma in adolescents and children with symptomatic moderate and severe asthma, and considers the challenges of asthma management in these patients. Factors affecting this population group, such as poor adherence, underreporting of symptoms, and social and psychological issues, are highlighted, along with the need for active review and management of treatment to help achieve optimal control.
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Affiliation(s)
- Eckard Hamelmann
- Children's Center Bethel, Evangelisches Klinikum Bethel GmbH, Grenzweg 10, 33617, Bielefeld, Germany.
| | - Stanley J Szefler
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, USA
- Breathing Institute, Children's Hospital Colorado, Aurora, USA
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Chen XX, Zhang JH, Pan BH, Ren HL, Feng XL, Wang JL, Xiao JH. Role of canonical transient receptor potential channel-3 in acetylcholine-induced mouse airway smooth muscle cell proliferation. Life Sci 2017; 187:64-73. [PMID: 28802903 DOI: 10.1016/j.lfs.2017.08.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Revised: 07/22/2017] [Accepted: 08/08/2017] [Indexed: 12/17/2022]
Abstract
AIMS Canonical transient receptor potential channel-3 (TRPC3)-encoded Ca2+-permeable nonselective cation channel (NSCC) has been proven to be an important native constitutively active channel in airway smooth muscle cell (ASMC), which plays significant roles in physiological and pathological conditions by controlling Ca2+ homeostasis in ASMC. Acetylcholine (ACh) is generally accepted as a contractile parasympathetic neurotransmitter in the airway. Recently studies have revealed the pathological role of ACh in airway remodeling, however, the mechanisms remain unclear. Here, we investigated the role of TRPC3 in ACh-induced ASMC proliferation. MATERIALS AND METHODS Primary mouse ASMCs were cultured with or without ACh treatment, then cell viability, TRPC3 expression, NSCC currents and [Ca2+]i changes were examined by MTT assay, cell counting, Western blotting, standard whole-cell patch clamp recording and calcium imaging, respectively. Small interfering RNA (siRNA) technology was used to confirm the contribution of TRPC3 to ACh-induced ASMC proliferation. KEY FINDINGS TRPC3 blocker Gd3+, antibody or siRNA largely inhibited ACh-induced up-regulation of TRPC3 protein, enhancement of NSCC currents, resting [Ca2+]i and KCl-induced changes in [Ca2+]i, eventually inhibiting ACh-induced ASMC proliferation. SIGNIFICANCE Our data suggested ACh could induce ASMC proliferation, and TRPC3 may be involved in ACh-induced ASMC proliferation that occurs with airway remodeling.
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Affiliation(s)
- Xiao-Xu Chen
- Department of Pharmacology, School of Basic Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Jia-Hua Zhang
- Center for Stem Cell Research and Application, Union Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Bin-Hua Pan
- Department of Pharmacology, School of Basic Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Hui-Li Ren
- Department of Pharmacology, School of Basic Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Xiu-Ling Feng
- Department of Pharmacology, School of Basic Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Jia-Ling Wang
- Department of Pharmacology, School of Basic Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Jun-Hua Xiao
- Department of Pharmacology, School of Basic Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; The Key Laboratory for Drug Target Researches and Pharmacodynamic Evaluation of Hubei Province, Wuhan 430030, China.
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21
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Page C, Cazzola M. Bifunctional Drugs for the Treatment of Respiratory Diseases. Handb Exp Pharmacol 2017; 237:197-212. [PMID: 27787715 DOI: 10.1007/164_2016_69] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Over the last decade, there has been a steady increase in the use of fixed dose combinations for the treatment of a range of diseases, including cancer, AIDS, tuberculosis and other infectious diseases. It is now evident that patients with asthma or chronic obstructive pulmonary disease (COPD) can also benefit from the use of fixed dose combinations, including combinations of a long-acting β2-agonist (LABA) and an inhaled corticosteroid (ICS), and combinations of LABAs and long-acting muscarinic receptor antagonists (LAMAs). There are now also "triple inhaler" fixed dose combinations (containing a LABA, LAMA and ICS) under development and already being made available in clinical practice, with the first such triple combination having been approved in India. The use of combinations containing drugs with complementary pharmacological actions in the treatment of patients with asthma or COPD has led to the discovery and development of drugs having two different primary pharmacological actions in the same molecule that we have called "bifunctional drugs". In this review we have discussed the state of the art of bifunctional drugs that can be categorized as bifunctional bronchodilators, bifunctional bronchodilator/anti-inflammatory drugs, bifunctional anti-inflammatory drugs and bifunctional mucolytic and anti-inflammatory drugs.
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Affiliation(s)
- Clive Page
- Sackler Institute of Pulmonary Pharmacology, Institute of Pharmaceutical Science, King's College London, 150 Stamford Street, London, SE1 9NH, UK.
| | - Mario Cazzola
- Division of Respiratory Medicine and Research Unit of Respiratory Clinical Pharmacology, Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy
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Abstract
Parasympathetic activity is increased in patients with chronic obstructive pulmonary disease (COPD) and asthma and appears to be the major reversible component of airway obstruction. Therefore, treatment with muscarinic receptor antagonists is an effective bronchodilator therapy in COPD and also in asthmatic patients. In recent years, the accumulating evidence that the cholinergic system controls not only contraction by airway smooth muscle but also the functions of inflammatory cells and airway epithelial cells has suggested that muscarinic receptor antagonists could exert other effects that may be of clinical relevance when we must treat a patient suffering from COPD or asthma. There are currently six muscarinic receptor antagonists licenced for use in the treatment of COPD, the short-acting muscarinic receptor antagonists (SAMAs) ipratropium bromide and oxitropium bromide and the long-acting muscarinic receptor antagonists (LAMAs) aclidinium bromide, tiotropium bromide, glycopyrronium bromide and umeclidinium bromide. Concerns have been raised about possible associations of muscarinic receptor antagonists with cardiovascular safety, but the most advanced compounds seem to have an improved safety profile. Further beneficial effects of SAMAs and LAMAs are seen when added to existing treatments, including LABAs, inhaled corticosteroids and phosphodiesterase 4 inhibitors. The importance of tiotropium bromide in the maintenance treatment of COPD, and likely in asthma, has spurred further research to identify new LAMAs. There are a number of molecules that are being identified, but only few have reached the clinical development.
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Del Bello F, Bonifazi A, Giorgioni G, Petrelli R, Quaglia W, Altomare A, Falcicchio A, Matucci R, Vistoli G, Piergentili A. Novel muscarinic acetylcholine receptor hybrid ligands embedding quinuclidine and 1,4-dioxane fragments. Eur J Med Chem 2017; 137:327-337. [DOI: 10.1016/j.ejmech.2017.06.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Revised: 05/24/2017] [Accepted: 06/02/2017] [Indexed: 12/18/2022]
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Prakash YS, Halayko AJ, Gosens R, Panettieri RA, Camoretti-Mercado B, Penn RB. An Official American Thoracic Society Research Statement: Current Challenges Facing Research and Therapeutic Advances in Airway Remodeling. Am J Respir Crit Care Med 2017; 195:e4-e19. [PMID: 28084822 DOI: 10.1164/rccm.201611-2248st] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Airway remodeling (AR) is a prominent feature of asthma and other obstructive lung diseases that is minimally affected by current treatments. The goals of this Official American Thoracic Society (ATS) Research Statement are to discuss the scientific, technological, economic, and regulatory issues that deter progress of AR research and development of therapeutics targeting AR and to propose approaches and solutions to these specific problems. This Statement is not intended to provide clinical practice recommendations on any disease in which AR is observed and/or plays a role. METHODS An international multidisciplinary group from within academia, industry, and the National Institutes of Health, with expertise in multimodal approaches to the study of airway structure and function, pulmonary research and clinical practice in obstructive lung disease, and drug discovery platforms was invited to participate in one internet-based and one face-to-face meeting to address the above-stated goals. Although the majority of the analysis related to AR was in asthma, AR in other diseases was also discussed and considered in the recommendations. A literature search of PubMed was performed to support conclusions. The search was not a systematic review of the evidence. RESULTS Multiple conceptual, logistical, economic, and regulatory deterrents were identified that limit the performance of AR research and impede accelerated, intensive development of AR-focused therapeutics. Complementary solutions that leverage expertise of academia and industry were proposed to address them. CONCLUSIONS To date, numerous factors related to the intrinsic difficulty in performing AR research, and economic forces that are disincentives for the pursuit of AR treatments, have thwarted the ability to understand AR pathology and mechanisms and to address it clinically. This ATS Research Statement identifies potential solutions for each of these factors and emphasizes the importance of educating the global research community as to the extent of the problem as a critical first step in developing effective strategies for: (1) increasing the extent and impact of AR research and (2) developing, testing, and ultimately improving drugs targeting AR.
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Long-Acting Muscarinic Antagonists for Difficult-to-Treat Asthma: Emerging Evidence and Future Directions. Drugs 2017; 76:999-1013. [PMID: 27289376 DOI: 10.1007/s40265-016-0599-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Asthma is a complex disease where many patients remain symptomatic despite guideline-directed therapy. This suggests an unmet need for alternative treatment approaches. Understanding the physiological role of muscarinic receptors and the parasympathetic nervous system in the respiratory tract will provide a foundation of alternative therapeutics in asthma. Currently, several long-acting muscarinic antagonists (LAMAs) are on the market for the treatment of respiratory diseases. Many studies have shown the effectiveness of tiotropium, a LAMA, as add-on therapy in uncontrolled asthma. These studies led to FDA approval for tiotropium use in asthma. In this review, we discuss how the neurotransmitter acetylcholine itself contributes to inflammation, bronchoconstriction, and remodeling in asthma. We further describe the current clinical studies evaluating LAMAs in adult and adolescent patients with asthma, providing a comprehensive review of the current known physiological benefits of LAMAs in respiratory disease.
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Cazzola M, Ora J, Rogliani P, Matera MG. Role of muscarinic antagonists in asthma therapy. Expert Rev Respir Med 2017; 11:239-253. [PMID: 28140686 DOI: 10.1080/17476348.2017.1289844] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
INTRODUCTION Higher parasympathetic tone has been reported in asthmatics. In general, cholinergic contractile tone is increased by airway inflammation associated with asthma. Nevertheless, the role of muscarinic antagonists for the treatment of asthma has not yet been clearly defined. Areas covered: The use of SAMAs and LAMAs in asthma has been examined and discussed according with the published evidence. Particular attention has been given to the large Phase III clinical trial program designed to evaluate the efficacy and safety of tiotropium respimat added to standard treatment in adults, adolescents and children with persistent asthma across the spectrum of asthma severity. Expert commentary: The current evidence is that in patients with poorly controlled severe asthma despite the use of ICS and LABA, the addition of tiotropium significantly increases the time to the first severe exacerbation and provides a modest but sustained bronchodilation. Identical results should be produced using other LAMAs. In any case, the documentation that, at least in animal or in vitro models, LAMAs show significant anti-inflammatory and anti-proliferative capacities and are able to inhibit airway remodeling induced by allergens makes a strong presumption that the use of LAMAs in asthma may go beyond the simple bronchodilator effect.
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Affiliation(s)
- Mario Cazzola
- a Chair of Respiratory Medicine, Department of Systems Medicine , University of Rome Tor Vergata , Rome , Italy
| | - Josuel Ora
- b Division of Respiratory Medicine, Department of Internal Medicine , University Hospital Tor Vergata , Rome , Italy
| | - Paola Rogliani
- a Chair of Respiratory Medicine, Department of Systems Medicine , University of Rome Tor Vergata , Rome , Italy.,b Division of Respiratory Medicine, Department of Internal Medicine , University Hospital Tor Vergata , Rome , Italy
| | - Maria Gabriella Matera
- c Chair of Pharmacology, Department of Experimental Medicine , Second University of Naples , Naples , Italy
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Blasi F, Canonica GW, Miravitlles M. Is aclidinium alone or combined with a LABA a rational choice for symptomatic COPD patients? Respir Res 2017; 18:19. [PMID: 28100244 PMCID: PMC5242048 DOI: 10.1186/s12931-017-0506-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2016] [Accepted: 01/13/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND As emphasized by international recommendations and largely confirmed by clinical experience, long-acting bronchodilators play a central role in the maintenance treatment of chronic obstructive pulmonary disease (COPD) due to their proven efficacy in reducing airflow obstruction and improving symptoms. MAIN BODY There are some important aspects to define with regard to inhalation therapy for COPD, particularly those concerning the selection criteria and the optimal use of long-acting bronchodilators. First of all, it needs to be determined in which patients and clinical situations monotherapy with one bronchodilator, such as a long-acting muscarinic antagonist (LAMA), should be considered adequate, and in which cases the use of combination therapies, such as the "double bronchodilation" with a LAMA and a long-acting β2-agonist (LABA), should be preferred. Another critical issue concerns the effect of the frequency of daily administration of inhaled agents on the control of symptoms during the 24 h. COPD symptoms are known to exhibit considerable circadian variability with worsening in the early morning, and a significant proportion of patients have disease-related sleep disorders which can adversely affect their quality of life. The worsening of symptoms in the early morning may be due, at least in part, to a reduction in airway caliber caused by an increased "cholinergic tone" at night. As such, the coverage of nighttime and early morning symptoms is a reasonable therapeutic goal, which can be achieved by many patients using LAMAs such as aclidinium bromide twice daily (BID). Therapeutic adherence is known to be a multifactorial phenomenon that is frequently affected by other aspects than dosing frequency, including the technical features and ease of use of the inhalers. To this end, it should be mentioned that certain new-generation inhalers such as Genuair® have been associated in clinical trials with higher patient preference. CONCLUSION In this work, in addition to presenting an overview of the main evidence on the efficacy of COPD treatment with the LAMA aclidinium bromide BID, we suggest some selection criteria for the monotherapy with one long-acting bronchodilator or the combination therapy with LAMA and LABA in COPD patients, with particular reference to specific clinical scenarios.
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Affiliation(s)
- F Blasi
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Cardio-thoracic unit and Cystic Fibrosis Adult Center Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico Milano, Milan, Italy.
| | - G W Canonica
- Department of Biomedical Science, Personalized Medicine Clinic: Asthma & Allergy - Humanitas Clinical and Research Center, Humanitas University -Rozzano (Milano), Milan, Italy
| | - M Miravitlles
- Pneumology Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
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Albertson TE, Chenoweth JA, Adams JY, Sutter ME. Muscarinic antagonists in early stage clinical development for the treatment of asthma. Expert Opin Investig Drugs 2016; 26:35-49. [PMID: 27927039 DOI: 10.1080/13543784.2017.1264388] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Parasympathetic neurons utilize the neurotransmitter acetylcholine to modulate and constrict airway smooth muscles at the muscarinic acetylcholine receptor. Inhaled agents that antagonize the muscarinic (M) acetylcholine receptor, particularly airway M3 receptors, have increasing data supporting use in persistent asthma. Areas covered: Use of inhaled long-acting muscarinic antagonists (LAMA) in asthma is explored. The LAMA tiotropium is approved for maintenance in symptomatic asthma patients despite the use of inhaled corticosteroids (ICS), leukotriene receptor antagonists (LTRA) and/or long-acting beta2 agonists (LABA). LAMA agents currently approved for chronic obstructive pulmonary disease (COPD) include tiotropium, glycopyrrolate/glycopyrronium, umeclidinium and aclidinium. These agents are reviewed for their pharmacological differences and clinical trials in asthma. Expert opinion: Current guidelines place inhaled LAMAs as adjunctive maintenance therapy in symptomatic asthma not controlled by an ICS and/or a LTRA. LAMA agents will play an increasing role in moderate to severe symptomatic asthma patients. Additional LAMA agents are likely to seek a maintenance indication perhaps as a combined inhaler with an ICS or with an ICS and a LABA. These fixed-dose combination inhalers are being tested in COPD and asthma patients. Once-a-day dosing of inhaled LAMA agents in severe asthma patients will likely become the future standard.
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Affiliation(s)
- Timothy E Albertson
- a Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine , School of Medicine, U.C. Davis , Sacramento , CA , USA.,b Department of Emergency Medicine , School of Medicine U. C. Davis , Sacramento , CA , USA.,c Department of Medicine , Veterans Administration Northern California Health Care System , Mather , CA , USA
| | - James A Chenoweth
- b Department of Emergency Medicine , School of Medicine U. C. Davis , Sacramento , CA , USA.,c Department of Medicine , Veterans Administration Northern California Health Care System , Mather , CA , USA
| | - Jason Y Adams
- a Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine , School of Medicine, U.C. Davis , Sacramento , CA , USA
| | - Mark E Sutter
- b Department of Emergency Medicine , School of Medicine U. C. Davis , Sacramento , CA , USA.,c Department of Medicine , Veterans Administration Northern California Health Care System , Mather , CA , USA
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Anzalone G, Gagliardo R, Bucchieri F, Albano GD, Siena L, Montalbano AM, Bonanno A, Riccobono L, Pieper MP, Gjomarkaj M, Profita M. IL-17A induces chromatin remodeling promoting IL-8 release in bronchial epithelial cells: Effect of Tiotropium. Life Sci 2016; 152:107-16. [DOI: 10.1016/j.lfs.2016.03.031] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Revised: 03/04/2016] [Accepted: 03/17/2016] [Indexed: 01/26/2023]
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Abstract
PURPOSE OF REVIEW Although the use of inhaled anticholinergics in obstructive airway disease has been established for several years, the clinical experience using these medications in treating patients with asthma is limited. Only few studies so far have included pediatric patients with asthma, but these studies demonstrate relevant therapeutic effects. This review will explore the pharmacological effects of inhaled anticholinergics, provide an overview about current adult and pediatric asthma studies using tiotropium, and describe future research needs. RECENT FINDINGS In a phase II study with tiotropium as add-on to maintenance treatment to inhaled corticosteroids (ICSs) in moderate persistent adolescent with asthma, significant improvement of peak and trough forced expiratory volume in 1 s (FEV1) with a good safety profile could be demonstrated. A pediatric phase II study in symptomatic patients with asthma aged 6-11with comparable study design also demonstrated significant improvement of peak FEV1 with no serious adverse events. However, both studies could not document a significant clinical improvement analyzed by standardized scores. SUMMARY Tiotropium might become an add-on treatment option in symptomatic pediatric and adolescent patients with asthma despite adequate therapy with ICS and long-acting β2-agonist (LABA) or as an alternative to LABA in patients with safety concerns related to LABA. For a better assessment of the clinical effect, long-term studies are needed.
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Bidan CM, Veldsink AC, Meurs H, Gosens R. Airway and Extracellular Matrix Mechanics in COPD. Front Physiol 2015; 6:346. [PMID: 26696894 PMCID: PMC4667091 DOI: 10.3389/fphys.2015.00346] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Accepted: 11/06/2015] [Indexed: 12/28/2022] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is one of the most common lung diseases worldwide, and is characterized by airflow obstruction that is not fully reversible with treatment. Even though airflow obstruction is caused by airway smooth muscle contraction, the extent of airway narrowing depends on a range of other structural and functional determinants that impact on active and passive tissue mechanics. Cells and extracellular matrix in the airway and parenchymal compartments respond both passively and actively to the mechanical stimulation induced by smooth muscle contraction. In this review, we summarize the factors that regulate airway narrowing and provide insight into the relative contributions of different constituents of the extracellular matrix and their biomechanical impact on airway obstruction. We then review the changes in extracellular matrix composition in the airway and parenchymal compartments at different stages of COPD, and finally discuss how these changes impact airway narrowing and the development of airway hyperresponsiveness. Finally, we position these data in the context of therapeutic research focused on defective tissue repair. As a conclusion, we propose that future works should primarily target mild or early COPD, prior to the widespread structural changes in the alveolar compartment that are more characteristic of severe COPD.
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Affiliation(s)
- Cécile M Bidan
- Department of Molecular Pharmacology, University of Groningen Groningen, Netherlands ; Groningen Research Institute for Asthma and COPD, University of Groningen Netherlands ; Laboratoire Interdisciplinaire de Physique (LIPhy), Université Grenoble Alpes Grenoble, France ; Centre National de la Recherche Scientifique, LIPhy Grenoble, France
| | - Annemiek C Veldsink
- Department of Molecular Pharmacology, University of Groningen Groningen, Netherlands ; Groningen Research Institute for Asthma and COPD, University of Groningen Netherlands
| | - Herman Meurs
- Department of Molecular Pharmacology, University of Groningen Groningen, Netherlands ; Groningen Research Institute for Asthma and COPD, University of Groningen Netherlands
| | - Reinoud Gosens
- Department of Molecular Pharmacology, University of Groningen Groningen, Netherlands ; Groningen Research Institute for Asthma and COPD, University of Groningen Netherlands
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Dittrich NP, Kummer W, Clauss WG, Fronius M. Luminal acetylcholine does not affect the activity of the CFTR in tracheal epithelia of pigs. Int Immunopharmacol 2015; 29:166-72. [DOI: 10.1016/j.intimp.2015.08.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2015] [Revised: 08/05/2015] [Accepted: 08/06/2015] [Indexed: 11/29/2022]
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Kume H, Fukunaga K, Oguma T. Research and development of bronchodilators for asthma and COPD with a focus on G protein/KCa channel linkage and β2-adrenergic intrinsic efficacy. Pharmacol Ther 2015; 156:75-89. [PMID: 26432616 DOI: 10.1016/j.pharmthera.2015.09.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Bronchodilators are used to improve symptoms and lung function in asthma and COPD. Airway smooth muscle tone is regulated by both muscarinic and β2-adrenergic receptor activity. Large-conductance Ca(2+)-activated K(+) (KCa) channels are activated by β2-adrenergic receptor agonists, via Gs, and suppressed by muscarinic receptor antagonists via Gi. This functional antagonism converges on the G protein/KCa channel linkages. Membrane potential regulated by KCa channels contributes to airway smooth muscle tension via Ca(2+) influx passing through voltage-dependent Ca(2+) (VDC) channels. The Gs/KCa/VDC channel linkage is a key process in not only physiological effects, but also in dysfunction of β2-adrenergic receptors and airway remodeling. Moreover, this pathway is involved in the synergistic effects between β2-adrenergic receptor agonists and muscarinic receptor antagonists. Intrinsic efficacy is also an important characteristic for both maintenance and loss of β2-adrenergic action. Allosteric modulators of G protein-coupled receptors contribute not only to this synergistic effect between β2-adrenergic and muscarinic M2 receptors, but also to intrinsic efficacy. The effects of weak partial agonists are suppressed by lowering receptor number, disordering receptor function, and enhancing functional antagonism; in contrast, those of full or strong partial agonists are not suppressed. Excessive exposure to full agonists causes β2-adrenergic desensitization; in contrast, exposure to partial agonists does not cause desensitization. Intrinsic efficacy may provide the rationale for the clinical use of β2-adrenergic receptor agonists in asthma and COPD. In conclusion, the G protein/KCa linkage and intrinsic efficacy (allosteric effects) may be therapeutic targets for research and development of novel agents against both airway obstruction and airway remodeling.
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Affiliation(s)
- Hiroaki Kume
- Department of Respiratory Medicine and Allergology, Kinki University Faculty of Medicine, Japan.
| | - Kentaro Fukunaga
- Division of Respiratory Medicine, Department of Internal Medicine, Shiga University of Medical Science, Japan
| | - Tetsuya Oguma
- Division of Respiratory Medicine, Department of Internal Medicine, Shiga University of Medical Science, Japan
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Roth M. Airway and lung remodelling in chronic pulmonary obstructive disease: a role for muscarinic receptor antagonists? Drugs 2015; 75:1-8. [PMID: 25414120 DOI: 10.1007/s40265-014-0319-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Lung tissue remodelling in chronic inflammatory lung diseases has long been regarded as a follow-up event to inflammation. Recent studies have indicated that, although airway and lung tissue remodelling is often independent of inflammation, it precedes or causes inflammation. None of the available therapies has a significant effect on airway and lung tissue remodelling in asthma, bronchiectasis, fibrosis and chronic obstructive pulmonary disease (COPD). The goal of stopping or reversing lung tissue remodelling is difficult, as the term summarizes the net effect of independent events, including (1) cell proliferation, (2) cell volume increase, (3) cell migration, (4) modified deposition and metabolism of specific extracellular matrix components, and (5) local action of infiltrated inflammatory cells. The extracellular matrix of the lung has a very high turnover, and thus small changes may accumulate to significant structural pathologies, which seem to be irreversible. The most important question is 'why are pathological changes of the lung structure irreversible and resistant to drugs?' Many drugs have the potential to reduce remodelling mechanisms in vitro but fail in clinical trials. New evidence suggests that muscarinic receptor inhibitors have the potential to improve lung function through modifying tissue remodelling. However, the role of muscarinic receptors in lung remodelling, especially their supportive role for other remodelling driving factors, needs to be further investigated. The focus of this review is the role of muscarinic receptors in lung tissue remodelling as it has been reported in the human lung.
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Affiliation(s)
- Michael Roth
- Pulmonary Cell Research and Pneumology, Department Biomedicine and Internal Medicine, University Hospital Basel, 4031, Basel, Switzerland,
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Abstract
The most widely used maintenance therapies in chronic obstructive pulmonary disease (COPD) are long-acting muscarinic antagonists (LAMAs), and a number of these drugs are now available in combination with long-acting β2-agonists (LABAs). LAMAs inhibit the parasympathetic muscarinic pathway, while LABAs, as sympathomimetics, reduce airway smooth muscle (ASM) tone. As well as directly controlling the constriction and relaxation of ASM, muscarinic and adrenergic receptors are found on inflammatory cells, and drugs that target these receptors may also reduce inflammation in COPD. Evidence suggests that the muscarinic and adrenergic pathways cross-talk at the level of neuronal input to the ASM via second-messenger pathways within ASM cells. Although the cross-talk is not completely understood, pharmacologically targeting both pathways in COPD can maximize bronchodilation. Combining LAMAs and LABAs demonstrated improved efficacy compared with the individual therapies and so, for greater convenience, several fixed-dose combinations for once-daily use have been developed. These fixed-dose combinations demonstrate improvements in both lung-function and patient-reported outcomes compared with well-established monotherapies, with similar tolerability profiles to the individual agents.
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Affiliation(s)
- Reynold A Panettieri
- a University of Pennsylvania, Perelman School of Medicine , Philadelphia, PA, USA
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36
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Rossi A, Zanardi E, Poletti V, Cazzola M. Clinical role of dual bronchodilation with an indacaterol-glycopyrronium combination in the management of COPD: its impact on patient-related outcomes and quality of life. Int J Chron Obstruct Pulmon Dis 2015; 10:1383-92. [PMID: 26229457 PMCID: PMC4516211 DOI: 10.2147/copd.s55488] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is the result of persistent and progressive pathologic abnormalities in the small airways, most often associated with alveolar loss. Smoking cessation is the most effective intervention to slow down the progression of COPD. Long-acting inhaled bronchodilators are prescribed for the symptomatic relief at any stage of disease severity. For patients whose COPD cannot be not sufficiently controlled with long-acting bronchodilator monotherapy, international guidelines suggest the possibility of associating a long-acting beta2 agonist (LABA) with a long-acting muscarinic antagonist (LAMA), ie, dual bronchodilation. This is not a new concept as the combination of short-acting agents has been popular in the past. In recent years, several fixed-dose combinations containing a LAMA and a LABA in a single inhaler have been approved by regulatory authorities in several countries. Among the new LAMA/LABA combinations, the fixed-dose combination of indacaterol 110 µg/glycopyrronium 50 µg (QVA149) has been shown in a series of clinical trials to be as safe as the single components and placebo, and more effective than placebo and the single components with regard to lung function, symptoms, and patient-oriented outcomes. Furthermore, QVA149 achieved better bronchodilation than salmeterol 50 µg/fluticasone 500 µg twice daily. Compared with tiotropium, a well-recognized treatment for COPD, the percentage of patients that exceed the minimal clinical important difference for dyspnea and health-related quality of life measurements was superior with QVA149. Other patient-oriented outcomes, such as daily symptoms, night-time awakening, and use of rescue medication consistently favored QVA149. Finally, QVA149 was significantly superior to LAMAs for reducing all types of exacerbation. In conclusion, several years after introduction of dual bronchodilation, the fixed-dose combination of indacaterol 110 µg/glycopyrronium 50 µg in a single inhaler for once-daily administration via the Breezhaler® device (QVA149) has been demonstrated to be a safe and effective treatment for COPD patients.
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Affiliation(s)
- Andrea Rossi
- Pulmonary Unit, University of Verona, Verona, Italy
| | - Erika Zanardi
- Department of Respiratory and General Rehabilitation, ULSS 20, Verona, Italy
| | | | - Mario Cazzola
- Pulmonary Unit, University of Rome, Tor Vergata, Italy
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Role of anticholinergics in asthma management: recent evidence and future needs. Curr Opin Pulm Med 2015; 21:103-8. [PMID: 25415409 DOI: 10.1097/mcp.0000000000000126] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
PURPOSE OF REVIEW Anticholinergic antimuscarinic bronchodilators play a major role in the treatment of chronic obstructive pulmonary disease, but their role in asthma has long been limited to acute management. More recently, the role of long-acting antimuscarinic bronchodilators (LAMAs) in chronic asthma management has been explored. This review will examine the pharmacological rationale for use of inhaled anticholinergics in the treatment of asthma, and provide an overview of the current literature supporting this use, as well as describe future research needs in this area. RECENT FINDINGS Short-acting anticholinergic bronchodilators have a role as add-on agents in the treatment of acute asthma. Preliminary clinical studies suggest that inhaled LAMAs may be comparable to long-acting beta2-agonists (LABAs) as an add-on therapy in patients not controlled by inhaled corticosteroids (ICS) alone, and may also have added benefit in patients not controlled on combined ICS-LABA. Mechanistic studies suggest that apart from their bronchodilator activity, LAMAs may have anti-inflammatory and antiremodeling influences on the airways. Further research is needed to clarify the clinical relevance of these experimental observations. SUMMARY Accumulating evidence supports the use of inhaled LAMAs as an add-on therapy in patients with asthma, who remain symptomatic despite guideline-based therapy with ICS with or without LABAs. Further studies are warranted to help define mechanisms of action of LAMAs, apart from their role as bronchodilators, and determine how these other actions impact asthma outcomes over time. Furthermore, future studies need to examine the long-term efficacy and safety of LAMAs in asthma and identify a subgroup of patients who would benefit from such therapies to facilitate early, personalized therapy.
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Matera MG, Rogliani P, Cazzola M. QVA149 (indacaterol/glycopyrronium) for the treatment of chronic obstructive pulmonary disease. Expert Opin Pharmacother 2015; 16:1079-90. [DOI: 10.1517/14656566.2015.1032247] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Poppinga WJ, Heijink IH, Holtzer LJ, Skroblin P, Klussmann E, Halayko AJ, Timens W, Maarsingh H, Schmidt M. A-kinase-anchoring proteins coordinate inflammatory responses to cigarette smoke in airway smooth muscle. Am J Physiol Lung Cell Mol Physiol 2015; 308:L766-75. [PMID: 25637608 DOI: 10.1152/ajplung.00301.2014] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Accepted: 01/29/2015] [Indexed: 01/13/2023] Open
Abstract
β2-Agonist inhibitors can relieve chronic obstructive pulmonary disease (COPD) symptoms by stimulating cyclic AMP (cAMP) signaling. A-kinase-anchoring proteins (AKAPs) compartmentalize cAMP signaling by establishing protein complexes. We previously reported that the β2-agonist fenoterol, direct activation of protein kinase A (PKA), and exchange factor directly activated by cAMP decrease cigarette smoke extract (CSE)-induced release of neutrophil attractant interleukin-8 (IL-8) from human airway smooth muscle (ASM) cells. In the present study, we tested the role of AKAPs in CSE-induced IL-8 release from ASM cells and assessed the effect of CSE on the expression levels of different AKAPs. We also studied mRNA and protein expression of AKAPs in lung tissue from patients with COPD. Our data show that CSE exposure of ASM cells decreases AKAP5 and AKAP12, both capable of interacting with β2-adrenoceptors. In lung tissue of patients with COPD, mRNA levels of AKAP5 and AKAP12 were decreased compared with lung tissue from controls. Using immunohistochemistry, we detected less AKAP5 protein in ASM of patients with COPD Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage II compared with control subjects. St-Ht31, which disrupts AKAP-PKA interactions, augmented CSE-induced IL-8 release from ASM cells and diminished its suppression by fenoterol, an effect mediated by disturbed ERK signaling. The modulatory role of AKAP-PKA interactions in the anti-inflammatory effects of fenoterol in ASM cells and the decrease in expression of AKAP5 and AKAP12 in response to cigarette smoke and in lungs of patients with COPD suggest that cigarette smoke-induced changes in AKAP5 and AKAP12 in patients with COPD may affect efficacy of pharmacotherapy.
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Affiliation(s)
- Wilfred J Poppinga
- University of Groningen, Department of Molecular Pharmacology, Groningen, The Netherlands; University of Groningen, University Medical Center Groningen, Groningen Research Institute for Asthma and COPD, GRIAC, Groningen, The Netherlands; Max-Delbrück-Centrum für Molekulare Medizin, Berlin, Germany;
| | - Irene H Heijink
- University of Groningen, University Medical Center Groningen, Groningen Research Institute for Asthma and COPD, GRIAC, Groningen, The Netherlands; University of Groningen, University Medical Center Groningen, Department of Pathology and Medical Biology, Groningen, The Netherlands
| | - Laura J Holtzer
- University of Groningen, Department of Molecular Pharmacology, Groningen, The Netherlands; Max-Delbrück-Centrum für Molekulare Medizin, Berlin, Germany
| | | | - Enno Klussmann
- Max-Delbrück-Centrum für Molekulare Medizin, Berlin, Germany
| | - Andrew J Halayko
- University of Manitoba, Departments of Physiology and Pathophysiology, and Internal Medicine, Winnipeg, Manitoba, Canada
| | - Wim Timens
- University of Groningen, University Medical Center Groningen, Groningen Research Institute for Asthma and COPD, GRIAC, Groningen, The Netherlands; University of Groningen, University Medical Center Groningen, Department of Pathology and Medical Biology, Groningen, The Netherlands
| | - Harm Maarsingh
- University of Groningen, Department of Molecular Pharmacology, Groningen, The Netherlands; University of Groningen, University Medical Center Groningen, Groningen Research Institute for Asthma and COPD, GRIAC, Groningen, The Netherlands; Palm Beach Atlantic University, Lloyd L. Gregory School of Pharmacy, Department of Pharmaceutical Sciences, West Palm Beach, Florida
| | - Martina Schmidt
- University of Groningen, Department of Molecular Pharmacology, Groningen, The Netherlands; University of Groningen, University Medical Center Groningen, Groningen Research Institute for Asthma and COPD, GRIAC, Groningen, The Netherlands
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Soler X, Ramsdell J. Anticholinergics/antimuscarinic drugs in asthma. Curr Allergy Asthma Rep 2014; 14:484. [PMID: 25283149 DOI: 10.1007/s11882-014-0484-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Anticholinergic alkaloids have been used for thousands of years for the relief of bronchoconstriction and other respiratory symptoms, and their use in the treatment of chronic obstructive pulmonary disease is well established. Acetylcholine, acting through muscarinic receptor (M) receptor, modulates multiple physiologic functions pertinent to asthma including airway muscle tone, mucus gland secretion, and various parameters of inflammation and remodeling. In addition, activation of M receptors may inhibit beta2 adrenoreceptor. These observations offer the rationale for the use of M receptors antagonists in the treatment of asthma. Short-acting antimuscarinic agents may be effective alone or in combination with short-acting beta agonists for the relief of acute symptoms. Long-acting antimuscarinic agents have emerged as potentially useful in the long-term treatment of difficult-to-control asthma. This review will analyze the mechanisms of action and therapeutic role of antimuscarinic agents on asthma including current guidelines regarding antimuscarinic drugs, recent studies in asthma, special populations to consider, and possible predictors of response.
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Affiliation(s)
- Xavier Soler
- Department of Medicine, University of California, 200 West Arbor Dr., San Diego, CA, 92103, USA
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Poppinga WJ, Muñoz-Llancao P, González-Billault C, Schmidt M. A-kinase anchoring proteins: cAMP compartmentalization in neurodegenerative and obstructive pulmonary diseases. Br J Pharmacol 2014; 171:5603-23. [PMID: 25132049 PMCID: PMC4290705 DOI: 10.1111/bph.12882] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Revised: 07/14/2014] [Accepted: 08/10/2014] [Indexed: 12/25/2022] Open
Abstract
The universal second messenger cAMP is generated upon stimulation of Gs protein-coupled receptors, such as the β2 -adreneoceptor, and leads to the activation of PKA, the major cAMP effector protein. PKA oscillates between an on and off state and thereby regulates a plethora of distinct biological responses. The broad activation pattern of PKA and its contribution to several distinct cellular functions lead to the introduction of the concept of compartmentalization of cAMP. A-kinase anchoring proteins (AKAPs) are of central importance due to their unique ability to directly and/or indirectly interact with proteins that either determine the cellular content of cAMP, such as β2 -adrenoceptors, ACs and PDEs, or are regulated by cAMP such as the exchange protein directly activated by cAMP. We report on lessons learned from neurons indicating that maintenance of cAMP compartmentalization by AKAP5 is linked to neurotransmission, learning and memory. Disturbance of cAMP compartments seem to be linked to neurodegenerative disease including Alzheimer's disease. We translate this knowledge to compartmentalized cAMP signalling in the lung. Next to AKAP5, we focus here on AKAP12 and Ezrin (AKAP78). These topics will be highlighted in the context of the development of novel pharmacological interventions to tackle AKAP-dependent compartmentalization.
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Affiliation(s)
- W J Poppinga
- Department of Molecular Pharmacology, University of GroningenGroningen, The Netherlands
- Groningen Research Institute for Asthma and COPD (GRIAC), University Medical Center Groningen, University of GroningenGroningen, The Netherlands
| | - P Muñoz-Llancao
- Department of Molecular Pharmacology, University of GroningenGroningen, The Netherlands
- Laboratory of Cell and Neuronal Dynamics (Cenedyn), Department of Biology, Faculty of Sciences, Universidad de ChileSantiago, Chile
- Department of Neuroscience, Section Medical Physiology, University Medical Center Groningen, University of GroningenGroningen, The Netherlands
| | - C González-Billault
- Laboratory of Cell and Neuronal Dynamics (Cenedyn), Department of Biology, Faculty of Sciences, Universidad de ChileSantiago, Chile
| | - M Schmidt
- Department of Molecular Pharmacology, University of GroningenGroningen, The Netherlands
- Groningen Research Institute for Asthma and COPD (GRIAC), University Medical Center Groningen, University of GroningenGroningen, The Netherlands
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Matera MG, Rogliani P, Rinaldi B, Cazzola M. Umeclidinium bromide + vilanterol for the treatment of chronic obstructive pulmonary disease. Expert Rev Clin Pharmacol 2014; 8:35-41. [DOI: 10.1586/17512433.2015.977256] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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43
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Sarai M, Sin D, FitzGerald JM, Aaron S. Long-acting beta 2-agonists and long-acting muscarinic antagonists in a combined inhaler versus either agent alone or placebo for chronic obstructive pulmonary disease. Hippokratia 2014. [DOI: 10.1002/14651858.cd011282] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Michael Sarai
- Kansas City University of Medicine & Biosciences; College of Medicine; 1750 E Independence Ave Kansas City Missouri USA
| | - Don Sin
- University of British Columbia; Department of Medicine (Respiratory Division); Vancouver BC Canada
| | - J. Mark FitzGerald
- University of British Columbia; Department of Medicine (Respiratory Division); Vancouver BC Canada
| | - Shawn Aaron
- The Ottawa Hospital; University of Ottawa Division of Respiratory Medicine; 501 Smyth Road Ottawa ON Canada K1H 8L6
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McGovern AE, Mazzone SB. Neural regulation of inflammation in the airways and lungs. Auton Neurosci 2014; 182:95-101. [DOI: 10.1016/j.autneu.2013.12.008] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2013] [Accepted: 12/12/2013] [Indexed: 10/25/2022]
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Pera T, Penn RB. Crosstalk between beta-2-adrenoceptor and muscarinic acetylcholine receptors in the airway. Curr Opin Pharmacol 2014; 16:72-81. [PMID: 24747364 DOI: 10.1016/j.coph.2014.03.005] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2014] [Revised: 03/17/2014] [Accepted: 03/21/2014] [Indexed: 01/12/2023]
Abstract
The M3 and M2 muscarinic acetylcholine receptors (mAChRs) and beta-2-adrenoceptors (β2ARs) are important regulators of airway cell function, and drugs targeting these receptors are among the first line drugs in the treatment of the obstructive lung diseases asthma and chronic obstructive lung disease (COPD). Cross-regulation or crosstalk between mAChRs and β2ARs in airway smooth muscle (ASM) helps determine the contractile state of the muscle, thus airway diameter and resistance to airflow. In this review we will detail mAChR and β2AR-signaling and crosstalk, focusing on events in the ASM cell but also addressing the function of these receptors in other cell types that impact airway physiology. We conclude by discussing how recent advances in GPCR pharmacology offer a unique opportunity to fine tune mAChR and β2AR signaling and their crosstalk, and thereby produce superior therapeutics for obstructive lung and other diseases.
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Affiliation(s)
- Tonio Pera
- Center for Translational Medicine, Jefferson-Jane and Leonard Korman Lung Center, Department of Medicine, Division of Pulmonary and Critical Care Medicine, Thomas Jefferson University, Philadelphia, PA 19107, USA
| | - Raymond B Penn
- Center for Translational Medicine, Jefferson-Jane and Leonard Korman Lung Center, Department of Medicine, Division of Pulmonary and Critical Care Medicine, Thomas Jefferson University, Philadelphia, PA 19107, USA.
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Santos LMO, Cervilha DADB, Cabral LDM, Garcia ÉKI, Teixeira VP, Brito JM, Moriya HT, Soncini R. Bronchial responsiveness in an elastase-induced mouse model of emphysema. Respir Physiol Neurobiol 2014; 194:9-14. [DOI: 10.1016/j.resp.2014.01.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Revised: 01/08/2014] [Accepted: 01/08/2014] [Indexed: 12/21/2022]
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Sánchez-Recillas A, Navarrete-Vázquez G, Hidalgo-Figueroa S, Rios MY, Ibarra-Barajas M, Estrada-Soto S. Semisynthesis, ex vivo evaluation, and SAR studies of coumarin derivatives as potential antiasthmatic drugs. Eur J Med Chem 2014; 77:400-8. [PMID: 24681028 DOI: 10.1016/j.ejmech.2014.03.029] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Revised: 03/08/2014] [Accepted: 03/11/2014] [Indexed: 01/03/2023]
Abstract
Asthma is a chronic inflammatory disorder that causes contraction in the smooth muscle of the airway and blocking of airflow. Reversal the contractile process is a strategy for the search of new drugs that could be used for the treatment of asthma. This work reports the semisynthesis, ex vivo relaxing evaluation and SAR studies of a series of 18 coumarins. The results pointed that the ether derivatives 1-3, 7-9 and 13-15 showed the best activity (Emax = 100%), where compound 2 (42 μM) was the most potent, being 4-times more active than theophylline (positive control). The ether homologation (methyl, ethyl and propyl) in position 7 or positions 6 and 7 of coumarins lead to relaxing effect, meanwhile formation of esters generated less active compounds than ethers. The SAR analysis showed that it is necessary the presence of two small ether groups and the methyl group at position 4 (site 3) encourage biological activity through soft hydrophobic changes in the molecule, without drastically affecting the cLogP.
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Affiliation(s)
- Amanda Sánchez-Recillas
- Laboratorio de Farmacognosia y Química de Productos Naturales, Facultad de Farmacia, Universidad Autónoma del Estado de Morelos, Avenida Universidad 1001, Col. Chamilpa, 62209 Cuernavaca, Morelos, Mexico
| | - Gabriel Navarrete-Vázquez
- Laboratorio de Química Farmacéutica, Facultad de Farmacia, Universidad Autónoma del Estado de Morelos, Avenida Universidad 1001, Col. Chamilpa, 62209 Cuernavaca, Morelos, Mexico.
| | - Sergio Hidalgo-Figueroa
- Laboratorio de Química Farmacéutica, Facultad de Farmacia, Universidad Autónoma del Estado de Morelos, Avenida Universidad 1001, Col. Chamilpa, 62209 Cuernavaca, Morelos, Mexico
| | - María Yolanda Rios
- Centro de Investigaciones Químicas, Universidad Autónoma del Estado de Morelos, Avenida Universidad 1001, Col. Chamilpa, 62209 Cuernavaca, Morelos, Mexico
| | - Maximiliano Ibarra-Barajas
- Unidad de Biomedicina, Facultad de Estudios Superiores Iztacala, Universidad Nacional Autónoma de México, 54090 Tlalnepantla, Estado de México, Mexico
| | - Samuel Estrada-Soto
- Laboratorio de Farmacognosia y Química de Productos Naturales, Facultad de Farmacia, Universidad Autónoma del Estado de Morelos, Avenida Universidad 1001, Col. Chamilpa, 62209 Cuernavaca, Morelos, Mexico.
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Cazzola M, Segreti A, Matera MG. New developments in the combination treatment of COPD: focus on umeclidinium/vilanterol. Drug Des Devel Ther 2013; 7:1201-8. [PMID: 24143077 PMCID: PMC3797618 DOI: 10.2147/dddt.s39449] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
An increasing body of evidence suggests that the long-acting muscarinic antagonist (LAMA)/long-acting β2-agonist (LABA) combination appears to play an important role in maximizing bronchodilation, with studies to date indicating that combining different classes of bronchodilators may result in significantly greater improvements in lung function compared to the use of a single drug, and that these combinations are well tolerated in patients with moderate-to-severe chronic obstructive pulmonary disease (COPD). An inhaled, fixed-dose combination of two 24-hour bronchodilators, the LAMA umeclidinium and the LABA vilanterol, is under development as a once-daily treatment for COPD. The efficacy of both mono-components has already been demonstrated. The information currently available suggests that umeclidinium/vilanterol is an effective once-daily dual bronchodilator fixed-dose combination in the treatment of COPD. However, it remains to be seen if it compares favorably with current therapies. Moreover, the question remains whether umeclidinium/vilanterol fixed-dose combination, which significantly improves FEV1, is also associated with improvements in other outcome measures that are important to COPD patients.
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Affiliation(s)
- Mario Cazzola
- Department of System Medicine, University of Rome ‘Tor Vergata’, Rome, Italy
| | - Andrea Segreti
- Department of System Medicine, University of Rome ‘Tor Vergata’, Rome, Italy
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García-Martín E, Canto G, Agúndez JAG. Metabolic considerations of drugs in the treatment of allergic diseases. Expert Opin Drug Metab Toxicol 2013; 9:1437-52. [PMID: 23902458 DOI: 10.1517/17425255.2013.823400] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION The clinical management of allergic diseases involves a number of drugs, most of which are extensively metabolized. This review aims to analyze the metabolism and the clinical implications of altered metabolism for these drugs. AREAS COVERED The authors present an overview of current knowledge of the metabolism of: antihistamine drugs, glucocorticoids, inhaled β-2 bronchodilators, anticholinergics and other drugs used in allergic diseases, such as cromoglycate, omalizumab, montelukast and epinephrine. Polymorphic drug metabolism is relevant for chlorpheniramine, loratadine and montelukast. Inhibition of drug metabolism is relevant for loratadine, methylprednisolone, fluticasone, mometasone, triamcinolone or prednisolone. Polymorphic pre-systemic metabolism may be relevant to budesonide, fluticasone, beclomethasone, mometasone or salmeterol. The authors also discuss the current information on gene variations according to the 1,000 genomes catalog and other databases. Finally, the authors review the clinical implications of these variations with a particular regard to drugs used in the management of allergic diseases. EXPERT OPINION Most drugs used in allergic diseases are extensively metabolized. Drug interaction or adverse reactions related to altered metabolism are relevant issues that should be considered in the management of allergic diseases. However, much additional research is required before defining pharmacogenomic biomarkers for the management of drugs used in allergic diseases.
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Affiliation(s)
- Elena García-Martín
- University of Extremadura, Department of Biochemistry & Molecular Biology , Avda. de la Universidad s/n, E-10071, Cáceres , Spain +34927257000 ext 89676 ;
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