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Koczulla AR, Vogelmeier CF, Garn H, Renz H. New concepts in asthma: clinical phenotypes and pathophysiological mechanisms. Drug Discov Today 2016; 22:388-396. [PMID: 27867084 DOI: 10.1016/j.drudis.2016.11.008] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Revised: 09/30/2016] [Accepted: 11/09/2016] [Indexed: 12/30/2022]
Abstract
Asthma is among the most common chronic inflammatory diseases worldwide. Recent evidence indicates that the pathogenesis shows a high degree of heterogeneity. Patient subsets have been identified that exhibit different cellular and molecular patterns of dysregulation. A prominent example is eosinophilic Th2-driven asthma. These unique and molecular patterns are termed endotypes. Characterization of endotypes has broad implications for therapeutic interventions. Although ∼80% of asthmatic patients respond well to standard anti-inflammatory therapies, the remaining subset particularly consisting of severe patients requires a more specialized endotype-specific approach. This interrelationship between clinical phenotypes, molecular endotypes and endotype-specific therapies is the focus of this review.
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Affiliation(s)
- Andreas R Koczulla
- Department of Medicine, Pulmonary and Critical Care Medicine, University Medical Center Giessen and Marburg, Philipps-University Marburg, Member of the German Center for Lung Research (DZL), Baldingerstrasse, 35043 Marburg, Germany
| | - Claus F Vogelmeier
- Department of Medicine, Pulmonary and Critical Care Medicine, University Medical Center Giessen and Marburg, Philipps-University Marburg, Member of the German Center for Lung Research (DZL), Baldingerstrasse, 35043 Marburg, Germany
| | - Holger Garn
- Institute of Laboratory Medicine and Pathobiochemistry, Molecular Diagnostics, Philipps University Marburg, Medical Faculty, Baldingerstrasse, 35043 Marburg, Germany
| | - Harald Renz
- Institute of Laboratory Medicine and Pathobiochemistry, Molecular Diagnostics, Philipps University Marburg, Medical Faculty, Baldingerstrasse, 35043 Marburg, Germany.
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Gil MA, Caniga M, Woodhouse JD, Eckman J, Lee HH, Salmon M, Naber J, Hamilton VT, Sevilla RS, Bettano K, Klappenbach J, Moy L, Correll CC, Gervais FG, Siliphaivanh P, Zhang W, Zhang-Hoover J, McLeod RL, Cicmil M. Anti-inflammatory actions of Chemoattractant Receptor-homologous molecule expressed on Th2 by the antagonist MK-7246 in a novel rat model of Alternaria alternata elicited pulmonary inflammation. Eur J Pharmacol 2014; 743:106-16. [PMID: 25261040 DOI: 10.1016/j.ejphar.2014.09.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Revised: 09/11/2014] [Accepted: 09/15/2014] [Indexed: 01/01/2023]
Abstract
Alternaria alternata is a fungal allergen linked to the development of severe asthma in humans. In view of the clinical relationship between A. alternata and asthma, we sought to investigate the allergic activity of this antigen after direct application to the lungs of Brown Norway rats. Here we demonstrate that a single intratracheal instillation of A. alternata induces dose and time dependent eosinophil influx, edema and Type 2 helper cell cytokine production in the lungs of BN rats. We established the temporal profile of eosinophilic infiltration and cytokine production, such as Interleukin-5 and Interleukin-13, following A. alternata challenge. These responses were comparable to Ovalbumin induced models of asthma and resulted in peak inflammatory responses 48h following a single challenge, eliminating the need for multiple sensitizations and challenges. The initial perivascular and peribronchiolar inflammation preceded alveolar inflammation, progressing to a more sub-acute inflammatory response with notable epithelial cell hypertrophy. To limit the effects of an A. alternata inflammatory response, MK-7246 was utilized as it is an antagonist for Chemoattractant Receptor-homologous molecule expressed in Th2 cells. In a dose-dependent manner, MK-7246 decreased eosinophil influx and Th2 cytokine production following the A. alternata challenge. Furthermore, therapeutic administration of corticosteroids resulted in a dose-dependent decrease in eosinophil influx and Th2 cytokine production. Reproducible asthma-related outcomes and amenability to pharmacological intervention by mechanisms relevant to asthma demonstrate that an A. alternata induced pulmonary inflammation in BN rats is a valuable preclinical pharmacodynamic in vivo model for evaluating the pharmacological inhibitors of allergic pulmonary inflammation.
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Affiliation(s)
- Malgorzata A Gil
- Pharmacology, Merck Research Laboratories, Boston, MA 02115, USA
| | - Michael Caniga
- Pharmacology, Merck Research Laboratories, Boston, MA 02115, USA
| | | | - Joseph Eckman
- Pharmacology, Merck Research Laboratories, Boston, MA 02115, USA
| | - Hyun-Hee Lee
- Biology Discovery, Merck Research Laboratories, Boston, MA 02115, USA
| | - Michael Salmon
- Biology Discovery, Merck Research Laboratories, Boston, MA 02115, USA
| | - John Naber
- Discovery Pharmaceutical Sciences, Merck Research Laboratories, Boston, MA 02115 , USA
| | - Valerie T Hamilton
- Safety Assessment and Laboratory Animal Sciences, Merck Research Laboratories, West Point, PA 19486, USA
| | | | - Kimberly Bettano
- Target & Pathway Biology, Merck Research Laboratories, Boston, MA 02115, USA
| | - Joel Klappenbach
- Target & Pathway Biology, Merck Research Laboratories, Boston, MA 02115, USA
| | - Lily Moy
- Pharmacology, Merck Research Laboratories, Boston, MA 02115, USA
| | - Craig C Correll
- Biology Discovery, Merck Research Laboratories, Boston, MA 02115, USA
| | - Francois G Gervais
- Target & Pathway Biology, Merck Research Laboratories, Boston, MA 02115, USA
| | | | - Weisheng Zhang
- Imaging, Merck Research Laboratories, Boston, MA 02115, USA
| | - Jie Zhang-Hoover
- Pharmacology, Merck Research Laboratories, Boston, MA 02115, USA
| | - Robbie L McLeod
- Pharmacology, Merck Research Laboratories, Boston, MA 02115, USA
| | - Milenko Cicmil
- Pharmacology, Merck Research Laboratories, Boston, MA 02115, USA.
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Holgate ST. Stratified approaches to the treatment of asthma. Br J Clin Pharmacol 2013; 76:277-91. [PMID: 23163316 DOI: 10.1111/bcp.12036] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2012] [Accepted: 10/28/2012] [Indexed: 01/01/2023] Open
Abstract
While asthma is a chronic inflammatory disorder that is managed with inhaled controller and reliever drugs, there remains a large unmet need at the severe end of the disease spectrum. Here, a novel stratified approach to its treatment is reviewed, based upon identification of causal pathways, with a focus on biologics. A systematic search of the literature was made using Medline, and publications were selected on the basis of their relevance to the topic. Despite strong preclinical data for many of the more recently identified asthma targets, especially those relating to the T-helper 2 allergic pathway, clinical trials with specific biologics in moderate to severe asthma as a group have been disappointing. However, subgroup analyses based upon pathway-specific biomarkers suggest specific endotypes that are responsive. Application of hypothesis-free analytical approaches (the 'omics') to well-defined phenotypes is leading to the stratification of asthma along causal pathways. Refinement of this approach is likely to be the future for diagnosing and treating this group of diseases, as well as helping to define new causal pathways. The identification of responders and nonresponders to targeted asthma treatments provides a new way of looking at asthma diagnosis and management, especially with biologics that are costly. The identification of novel biomarkers linked to well-phenotyped patients provides a stratified approach to disease management beyond simple disease severity and involving causal pathways. In order to achieve this effectively, a closer interaction will be required between industry (therapeutic and diagnostic), academia and health workers.
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Caruso M, Crisafulli E, Demma S, Holgate S, Polosa R. Disabling inflammatory pathways with biologics and resulting clinical outcomes in severe asthma. Expert Opin Biol Ther 2013; 13:393-402. [PMID: 23289846 DOI: 10.1517/14712598.2013.743989] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
INTRODUCTION Patients with severe asthma have a significant unmet need with persistent symptoms and/or frequent exacerbations despite high intensity treatment. These severe unrelenting symptoms have a huge impact on heathcare resources due to frequent hospital admissions and requirement for intensive and expensive medications. There is a compelling need for more effective and safer therapies to help severe asthma sufferers to achieve adequate control of their disease. AREAS COVERED Expanding knowledge of innate and adaptive immune responses has led to development of new biologic approaches for severe asthma. Here, the authors will review the existing efficacy and safety data from clinical trials of some of the new biologic therapies that are in development for severe asthma. Their specific role in distinctively targeted subpopulations of severe asthmatics will be also discussed. EXPERT OPINION Defining and phenotyping severe asthma patients will become increasingly important as some patients who were previously classified as having severe asthma may become well-controlled with a targeted phenotype-specific treatment. However, pharmacoeconomic concerns should also be taken into account given the elevated acquisition costs of recombinant human monoclonals and of the diagnostic screening procedures for the identification of potential responders.
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Affiliation(s)
- Massimo Caruso
- University of Catania-AOU Policlinico-V. Emanuele, Department of Clinical and Molecular Bio-Medicine-Institute of Internal Medicine and Clinical Immunology, Catania, 95124, Italy
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Jang AS, Kwon HS, Cho YS, Bae YJ, Kim TB, Park JS, Park SW, Uh ST, Choi JS, Kim YH, Hwang HK, Moon HB, Park CS. Identification of subtypes of refractory asthma in Korean patients by cluster analysis. Lung 2012; 191:87-93. [PMID: 23143671 DOI: 10.1007/s00408-012-9430-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2012] [Accepted: 10/10/2012] [Indexed: 11/25/2022]
Abstract
BACKGROUND Refractory asthma, a subtype of asthma with uncontrolled symptoms despite antiasthma medications, is a heterogeneous syndrome with variable clinical features, presumably different etiologies, and pathophysiological mechanisms. The heterogeneity of refractory asthma, however, is poorly understood. We aimed to characterize refractory asthma and to improve our understanding of the heterogeneity of refractory asthma patients. METHODS We identified refractory asthma patients (n = 96) as defined by the American Thoracic Society's criteria from a cohort of Korean asthma patients (n = 2,187). Then, cluster analysis was conducted to classify subtypes of refractory asthma. RESULTS Among the study group, 4.4 % (n = 96) of all asthma patients had refractory asthma. Cluster analysis identified four distinct groups of refractory asthma. Age at onset was younger in clusters 1 and 2 than in clusters 3 and 4. Patients in cluster 1 had the most well-preserved pulmonary function; patients in cluster 2 had a female predominance and the most severe airway obstruction; patients in cluster 3 were mostly female and had the most enhanced bronchial hyperresponsiveness; and patients in cluster 4 were most male and tended to be cigarette smokers. CONCLUSIONS The current results suggest that refractory asthma is a heterogeneous syndrome and could be classified into four subtypes. Underlying pathogenesis and therapeutic approaches may differ for the different subtypes and further research is needed.
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Affiliation(s)
- An Soo Jang
- Division of Allergy and Respiratory Medicine, Genome Research Center for Allergy and Respiratory Diseases, Soonchunhyang University Bucheon Hospital, Gyeonggi-do, 420-767, Republic of Korea
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Polosa R, Casale T. Monoclonal antibodies for chronic refractory asthma and pipeline developments. Drug Discov Today 2012; 17:591-9. [PMID: 22306350 DOI: 10.1016/j.drudis.2012.01.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2011] [Revised: 12/22/2011] [Accepted: 01/18/2012] [Indexed: 01/21/2023]
Abstract
Patients with severe asthma suffer persistent symptoms and/or frequent exacerbations despite high-intensity treatment. Their severe unrelenting symptoms have a huge impact on healthcare resources owing to frequent hospital admissions and requirement for intensive treatments. Consequently, there is an undeniable need for more-effective and safer medications. Expanding knowledge of innate and adaptive immune responses is leading to the development of novel therapies for severe asthma. Herein, we review efficacy and safety data from human clinical trials of monoclonal antibodies that are approved or under investigation for use in asthma. Future drug candidates directed at key targets and the specific role of monoclonal antibodies in distinctively targeted sub-populations of severe asthmatics will be also discussed.
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Affiliation(s)
- Riccardo Polosa
- Institute of Internal Medicine, G. Rodolico, Azienda Ospedaliero-Universitaria "Policlinico-Vittorio Emanuele", Università di Catania, Italy.
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Abstract
BACKGROUND Asthma is a disorder of the conducting airways that contract too easily and too much to cause variable airflow obstruction with symptoms of wheeze, cough, chest tightness and shortness of breath. Based on this knowledge, initial treatments were directed to dilating the contracted airways with anticholinergic and adrenergic drugs. The recognition that allergic-type inflammation underlay the hyperresponsive airways in asthma led to the introduction of anti-inflammatory drugs such as sodium cromoglicate and corticosteroids. Over the 2 decades that followed, these drugs have been progressively improved by increasing their therapeutic index and duration of action. METHODS A review of the recent literature indicates that since the 1980s, the explosive increase in knowledge of the cell and mediator mechanisms of asthma has only led to modest improvements in therapy including the introduction of leukotriene modifiers and a blocking monoclonal antibody against IgE. Indeed, biologics targeting allergic cytokines and effector cells have on the whole proven disappointing despite initial promise being shown in animal models. RESULTS Part of the difficulty lies in the oversimplified concept that asthma is only driven by allergic processes when in reality there are many environmental causes and triggers and the view that it is a homogeneous disorder only varying in severity. CONCLUSIONS The more recent views that asthma is a complex disorder made up of different subtypes with differing causes, treatment responses and natural histories creates a new opportunity for stratified medicine in which therapies acting upstream selectively target specific disease subtypes identified by specific diagnostic biomarkers.
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Clienti S, Morjaria JB, Basile E, Polosa R. Monoclonal antibodies for the treatment of severe asthma. Curr Allergy Asthma Rep 2011; 11:253-60. [PMID: 21360131 DOI: 10.1007/s11882-011-0184-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Patients with severe asthma have a significant unmet need with persistent symptoms and/or frequent exacerbations despite treatment with high-dose steroid and other currently available therapies. These patients are also at risk of developing steroid-related side effects, and their severe, unrelenting symptoms have a huge impact on health care resources due to frequent hospital admissions and requirement for intensive medication use. Consequently, a compelling need exists for more effective and safer pharmacotherapies to help them achieve adequate disease control. Recent novel therapies for severe asthma are now emerging, some of the most promising of which are monoclonal antibodies. Monoclonal antibodies represent a form of immunotherapy used in a wide variety of therapeutic roles. The spectrum of disease states in which monoclonal antibodies have been approved for therapeutic use now includes respiratory and allergic diseases. At present, only one drug is licensed for allergic asthmatics with severe disease, omalizumab. We review some of the currently available biologics that are approved or under investigation for use in severe asthma. Some have shown to be useful in specifically targeted subpopulations of patients with severe asthma, whereas other have proven to be unsafe and/or unsuccessful. Despite these developments, more effort should be devoted to identifying new molecular targets, testing innovative approaches, and establishing the best use of what is available. Regarding this latter point, identifying individual characteristics that predict successful responses to these treatments is highly desirable.
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Affiliation(s)
- Salvatore Clienti
- Institute of Internal Medicine, S. Marta Hospital, Azienda Ospedaliero-Universitaria "Policlinico-Vittorio Emanuele", Università di Catania, Catania, Italy
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Abstract
Asthma usually presents with symptoms of wheeze, dyspnoea and cough. However, clinicians should be aware of atypical presentation of this disorder when cough is the main or only symptom in conditions such as cough-variant asthma, nonasthmatic eosinophilic bronchitis and atopic cough. Early diagnosis and treatment of these conditions with inhaled corticosteroids improves symptoms in the majority of patients. Up to 10% of patients with asthma remain poorly controlled in spite of optimal standard therapy. These patients have been encompassed under the term 'treatment-refractory asthma' (TRA), have the greatest morbidity and are responsible for more than 50% of healthcare costs. In this review we discuss investigations, management and pathophysiology of the various phenotypes of atypical presentations of asthma as well as novel biological agents licensed and those that have been reported in clinical trials in terms of their efficacy and safety in TRA.
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Affiliation(s)
- Jaymin B. Morjaria
- Division of Respiratory Medicine, Hull and East Yorkshire NHS Trust, University of Hull, Hull York Medical School, Castle Hill Hospital, Castle Road, Cottingham HU16 5JQ, UK
| | - Jack A. Kastelik
- Division of Respiratory Medicine, Hull and East Yorkshire NHS Trust, University of Hull, Hull York Medical School, Castle Hill Hospital, Castle Road, Cottingham HU16 5JQ, UK
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Morjaria JB, Polosa R. Recommendation for optimal management of severe refractory asthma. J Asthma Allergy 2010; 3:43-56. [PMID: 21437039 PMCID: PMC3047913 DOI: 10.2147/jaa.s6710] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2010] [Indexed: 11/23/2022] Open
Abstract
Patients whose asthma is not adequately controlled despite treatment with a combination of high dose inhaled corticosteroids and long-acting bronchodilators pose a major clinical challenge and an important health care problem. Patients with severe refractory disease often require regular oral corticosteroid use with an increased risk of steroid-related adverse events. Alternatively, immunomodulatory and biologic therapies may be considered, but they show wide variation in efficacy across studies thus limiting their generalizability. Managing asthma that is refractory to standard treatment requires a systematic approach to evaluate adherence, ensure a correct diagnosis, and identify coexisting disorders and trigger factors. In future, phenotyping of patients with severe refractory asthma will also become an important element of this systematic approach, because it could be of help in guiding and tailoring treatments. Here, we propose a pragmatic management approach in diagnosing and treating this challenging subset of asthmatic patients.
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Chian CF, Tsai CL, Wu CP, Chiang CH, Su WL, Chen CW, Perng WC. Five-day course of budesonide inhalation suspension is as effective as oral prednisolone in the treatment of mild to severe acute asthma exacerbations in adults. Pulm Pharmacol Ther 2010; 24:256-60. [PMID: 20659578 DOI: 10.1016/j.pupt.2010.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2010] [Revised: 06/23/2010] [Accepted: 07/16/2010] [Indexed: 10/19/2022]
Abstract
BACKGROUND Limited evidence is available on the use of budesonide inhalation suspension (BIS) for the treatment of mild to severe acute asthma exacerbations (AAE) in adults in an inpatient setting. This study was conducted to evaluate the efficacy of a five-day course of BIS compared with oral prednisolone (OP) in the management of adults with AAE. METHODS A retrospective study examined the response of 28 patients hospitalized with mild to severe acute asthma exacerbation from January 2003 to December 2003. These patients, who were steroid free ≥ 1 yr, were administered a five-day course of BIS (2 × 2 mg bid) or OP (2 × 15 mg bid). PEF, FEV(1) and asthma symptom scores were recorded daily. RESULTS The BIS (n = 13) and OP (n = 15) treatment groups were comparable at baseline for demographic characteristics and prebronchodilator (fenoterol) FEV(1) of 52.4% predicted normal value and 54.6% predicted normal value, respectively. Mean change of morning PEF was 152 L/min during BIS treatment and 130 L/min for OP treatment; the mean changes of morning forced expiratory volumes in 1 s (FEV(1)) were 1.0 and 0.7 L, respectively. The mean change in daytime symptom scores were -1.6 and -1.3 in the BIS and the OP groups, respectively. Improvements in PEF, FEV(1) and daytime symptom scores were significantly different between baseline and after treatment in each treatment group (p < 0.05). However, improvements in both BIS and OP groups were similar. CONCLUSION Budesonide inhalation suspension may be an alternative treatment of acute asthma exacerbation in adults who are at risk for systemic corticosteroids.
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Affiliation(s)
- Chih-Feng Chian
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
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