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

Targeting PKCι-PAK1 signaling pathways in EGFR and KRAS mutant adenocarcinoma and lung squamous cell carcinoma

Introduction

p21-activated kinase 1 (PAK1) stimulates growth and metastasis in non-small cell lung cancer (NSCLC). Protein kinase C iota (PKCι) is an enzyme highly expressed in NSCLC, regulating PAK1 signaling. In the present study we explored whether the PKCι-PAK1 signaling pathway approach can be an efficient target in different types of NSCLC cell and mouse models.

Methods

The effect of IPA-3 (PAK1 inhibitor) plus auranofin (PKCι inhibitor) combination was evaluated by cell viability assay, colony formation and western blotting assay, using three types of NSCLC cell lines: EGFR or KRAS mutant adenocarcinoma and squamous cell carcinoma with PAK1 amplification. In addition, for clinical availability, screening for new PAK1 inhibitors was carried out and the compound OTSSP167 was evaluated in combination with auranofin in cell and mice models.

Results

The combination of IPA-3 or OTSSP167 plus auranofin showed high synergism for inhibiting cell viability and colony formation in three cell lines. Mechanistic characterization revealed that this drug combination abrogated expression and activation of membrane receptors and downstream signaling proteins crucial in lung cancer: EGFR, MET, PAK1, PKCι, ERK1/2, AKT, YAP1 and mTOR. A nude mouse xenograft assay demonstrated that this drug combination strongly suppressed tumor volume compared with single drug treatment.

Conclusions

Combination of IPA-3 or OTSSP167 and auranofin was highly synergistic in EGFR or KRAS mutant adenocarcinoma and squamous cell carcinoma cell lines and decreased tumor volume in mice models. It is of interest to further test the targeting of PKCι-PAK1 signaling pathways in EGFR mutant, KRAS mutant and squamous NSCLC patients.

Weekly low-dose methotrexate for reduction of Global Initiative for Asthma Step 5 treatment in severe refractory asthma: study protocol for a randomized controlled trial

BACKGROUND

Patients with chronic severe asthma (CSA) have a crippling disease and current available treatments are not satisfactory. Thus, management of CSA remains a major unmet need. Although the evidence from existing randomized controlled trials fails to support a definite role for immunomodulatory drugs in these patients due to major methodologic drawbacks, findings with low-dose methotrexate (MTX) are encouraging. However, larger and well-designed clinical trials are required to establish the beneficial role of MTX in CSA, and for the detection of the key characteristics of those who are going to respond to this drug.

METHODS/DESIGN

Patients will be recruited from the accessible asthmatic patients lists of tertiary referral centers. All patients will meet the stringent diagnostic criteria for CSA, including the requirement for the regular use of Global Initiative for Asthma (GINA) Global Strategy for Asthma Management and Prevention Step 5 medications (oral prednisone and/or omalizumab). The experimental design of the proposed study will take the form of a double-blind parallel-randomized placebo-controlled trial consisting of a total of eight visits, including run-in and run-out periods. Patients will be randomly allocated to receive either MTX or a matched placebo once a week as an add-on therapy to their existing medication after run-in. Physiological, laboratory and clinical assessments will be measured regularly throughout the study and compared with baseline assessments.

DISCUSSION

We expect that MTX will reduce Step 5 medications dosage in patients with CSA without compromising the overall disease control. Improvement in several indicators of asthma severity and control will be also investigated.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02124226 (assigned 25 April 2014).

Novel therapies in asthma: leukotriene antagonists, biologic agents, and beyond

Asthma is one of the most common conditions seen in clinical practice and carries both a significant disease burden in terms of patient morbidity and a high economic burden in both direct and indirect costs. Despite this, it remains a comparatively poorly understood disease, with only modest advances in treatment over the past decade. Corticosteroids remain the cornerstone of therapy. Both patient compliance with medications and physician adherence to evidence-based guidelines are often poor, and a high percentage of patients continue to have inadequately controlled disease even with optimal therapy. Following a contextual overview of the current treatment guidelines, this review focuses on novel asthma therapies, beginning with the introduction of the leukotriene receptor antagonist zafirlukast in the 1990s, continuing through advanced endoscopic therapy and into cytokine-directed biologic agents currently in development. Along with clinically relevant biochemistry and pharmacology, the evidence supporting the place of these therapies in current guidelines will be highlighted along with data comparing these agents with more conventional treatment. A brief discussion of other drugs, such as those developed for unrelated conditions and subsequently examined as potential asthma therapies, is included.

Therapeutic options for severe asthma

As the overall prevalence of asthma has escalated in the past decades, so has the population of patients with severe asthma. This condition is often difficult to manage due to the relative limitation of effective therapeutic options for the physician and the social and economic burden of the disease on the patient. Management should include an evaluation and elimination of modifiable risk factors such as smoking, allergen exposure, obesity and non-adherence, as well as therapy for co-morbidities like gastro-esophageal reflux disease and obstructive sleep apnea. Current treatment options include conventional agents such as inhalational corticosteroids, long acting β(2) agonists, leukotriene antagonists, and oral corticosteroids. Less conventional treatment options include immunotherapy with methotrexate, cyclosporine and tacrolimus, biological drugs like monoclonal antibodies, tumor necrosis factor-α blockers and oligonucleotides, phosphodiesterase inhibitors, antimicrobials and bronchial thermoplasty.

Rationale for the use of immunomodulatory therapies in the Global Initiative for Asthma (GINA) step V asthma other than oral glucocorticosteroids

Asthma is a major problem worldwide, which is estimated to affect 300 million individuals. The global prevalence ranges from 1% to 18% of the population. The incidence, morbidity and mortality of the condition have increased over the last 50 years despite the development of new anti-asthmatic drugs. Fewer than 1% of the asthmatic population are steroid-dependent, but these patients consume most of the resources and time at asthma units. The consensus documents published by professional societies all support a stepwise therapeutic approach for asthma. However, patients who require frequent or continuous oral corticosteroid administration have received little attention. Due to the severe side-effects of oral corticosteroids when administered over long periods or at high doses, many drugs have been assessed in the search for a possible corticosteroid-sparing agent. Recently, the update of the Global Initiative for Asthma (GINA) introduced a new drug--omalizumab--as an alternative to oral corticosteroids in patients included in step V. Other alternatives include immunosuppressive drugs, among which methotrexate has been found to offer the best benefit/risk ratio. This paper will review, comment and criticize the evidence of the effectiveness of immunomodulatory drugs, as an alternative to oral glucocorticosteroid treatment in GINA step V asthma patients. The experience of the authors combined with the information of the literature will lead to the conclusion that methotrexate and omalizumab are the only advisable drugs and will clarify when and how these drugs should be used.

Current treatment of severe asthma

Severe asthma is considered a heterogeneous disease in which a variety of clinical, physiological and inflammatory markers determine disease severity. Pivotal studies in the last 5 years have led to substantial progress in many areas, ranging from a more accurate definition of truly severe, refractory asthma, to classification of the disease into distinct clinical phenotypes, and introduction of new therapies. This review focuses on three common clinical phenotypes of severe asthma in adults (early onset severe allergic asthma, late onset non-atopic eosinophilic asthma, late onset non-eosinophilic asthma with obesity), and provides an overview of recent developments regarding treatment options that are best suited for each of these phenotypes.

Phenotypes of refractory/severe asthma

The acid test of phenotyping is that it leads either to a clinically useful or mechanistically important insight. Phenotypes may change over time, but the exact definition of a phenotype shift is unclear. Methods of phenotyping are either investigator driven, in which a priori prejudices are applied to the data, or (semi) objective, in which mathematical techniques or systems biology approaches are applied to the dataset. However, the composition of the dataset is driven by investigator prejudice. Phenotyping is likely most useful in severe asthma, because mild and moderate asthma responds to simple treatments, and no great subtlety is required. Our non-evidence based approach is to define the subpopulation of genuine severe, therapy-resistant asthmatics from the generality of problematic severe asthma. We then investigate them invasively with bronchoscopy and a steroid trial using intramuscular triamcinolone to determine the nature of any inflammatory process; whether inflammation and symptoms are concordant or discordant; whether the inflammatory process is steroid resistant or sensitive; and whether the child has persistent airflow limitation. Other possibly relevant phenotypes include the child with severe exacerbations; brittle asthma; and severe asthma with fungal sensitization. Severe, therapy resistant asthma is a disparate disease, and only international uniform approaches, carefully characterising the children as a prelude to focussed clinical trials will allow progress to be made, and vindicate (or otherwise) our suggested approach.

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

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

Management of severe asthma in children

Children who are referred to specialist care with asthma that does not respond to treatment (problematic severe asthma) are a heterogeneous group, with substantial morbidity. The evidence base for management is sparse, and is mostly based on data from studies in children with mild and moderate asthma and on extrapolation of data from studies in adults with severe asthma. In many children with severe asthma, the diagnosis is wrong or adherence to treatment is poor. The first step is a detailed diagnostic assessment to exclude an alternative diagnosis ("not asthma at all"), followed by a multidisciplinary approach to exclude comorbidities ("asthma plus") and to assess whether the child has difficult asthma (improves when the basic management needs, such as adherence and inhaler technique, are corrected) or true, therapy-resistant asthma (still symptomatic even when the basic management needs are resolved). In particular, environmental causes of secondary steroid resistance should be identified. An individualised treatment plan should be devised depending on the clinical and pathophysiological characterisation. Licensed therapeutic approaches include high-dose inhaled steroids, the Symbicort maintenance and reliever (SMART) regimen (with budesonide and formoterol fumarate), and anti-IgE therapy. Unlicensed treatments include methotrexate, azathioprine, ciclosporin, and subcutaneous terbutaline infusions. Paediatric data are needed on cytokine-specific monoclonal antibody therapies and bronchial thermoplasty. However, despite the interest in innovative approaches, getting the basics right in children with apparently severe asthma will remain the foundation of management for the foreseeable future.

Therapeutic targets for persistent airway inflammation in refractory asthma

The management of refractory asthma remains a compelling clinical problem that contributes significantly to the morbidity of patients as well as posing a financial burden to the health system. Treatment failure in this group of patients is associated with continued airway inflammation and dampening of the inflammatory cascade is the focus of much research in this area. Continued airway inflammation has been associated with higher patient morbidity and is being increasingly measured using markers of systemic and local inflammation in order to target therapy more effectively. This review focuses on the published evidence for both established and novel treatments in refractory asthma that act to control this pathological inflammatory process. No clear treatment yet exists to control this process and further research into inhibiting newly elucidated inflammatory pathways or new drugs more effectively or accurate targeting existing pathways are discussed along with the clinical evidence and the relative merits of each treatment.

Managing patients with chronic severe asthma: rise to the challenge

Most asthmatic patients with moderate to severe disease can be satisfactorily managed with a combination of inhaled corticosteroids and beta(2)-agonists. However, there are perhaps 10% of the asthmatic population with persistent symptoms, impaired quality of life and excessive health-care utilization, despite this management regime. These patients often require frequent and even occasionally regular oral corticosteroid use. Chronic, severe asthma is a heterogeneous disease with distinct sub-phenotypes. A systematic diagnostic work-up may help to identify these distinct sub-phenotypes and this may help guide treatment and may even provide information about prognosis. Optimal treatment of chronic severe asthma should achieve the best possible asthma control and quality of life with the least dose of systemic corticosteroids. The choice and formulation of therapeutic agent is dictated by the severity of disease and includes conventional, immunosuppressive/immunomodulating and biologic therapies. Unfortunately, current asthma management guidelines offer little contribution to the care of the challenging patient with chronic severe asthma. This review article aims at summarizing the evidence regarding various therapeutic modalities for chronic severe asthma and also aims to provide a practical approach to diagnosis and management for the benefit of those who have a specific interest in this problematic condition.

Immunomodulatory and biologic therapies for severe refractory asthma

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

Oral corticosteroid-dependent asthma: a 30-year review

OBJECTIVE

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

DATA SOURCES

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

STUDY SELECTION

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

RESULTS

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

CONCLUSIONS

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

An overview of chronic severe asthma

Most asthmatic patients with moderate to severe disease can be satisfactorily managed with a combination of inhaled corticosteroids and beta(2)-agonists. However, there are a few with persistent symptoms, impaired quality of life and excessive health-care utilization, despite this management regimen. These patients often require frequent and even occasionally regular oral corticosteroid use. Chronic, severe asthma is a heterogeneous disease and a systematic diagnostic work-up may help to guide treatment and may even provide information about prognosis. Optimal treatment of chronic severe asthma (CSA) should achieve the best possible asthma control and quality of life with the least dose of systemic corticosteroids. The choice and formulation of therapeutic agent is dictated by the severity of disease and includes conventional, immunosuppressive/immunomodulating and biologic therapies. Unfortunately, current asthma management guidelines offer little contribution to the care of the challenging patient with CSA. In this review, a diagnostic and therapeutic overview of CSA is provided for the benefit of those who have a specific interest in this problematic condition.

[Targeted immunologic therapies for severe asthma]

Better understanding of the cellular and molecular mechanisms of asthma have made it possible to envision a large number of new treatment targets. Clinical trials assessing some of these targets were recently published. The results of these trials were often disappointing. For example, parenteral administration of anti-interleukin-5 antibodies diminished bronchial eosinophilic inflammation but without improving either asthma symptoms or bronchial hyperreactivity. Other treatments are promising but have not yet been proved effective in patients with asthma: open studies with anti-TNF alpha antibodies are interesting but the efficacy of this treatment strategy remains uncertain and must be validated against placebo. The first targeted treatment approved for severe difficult-to-control allergic asthma is an anti-IgE monoclonal antibody (omalizumab).

Enhanced cellular delivery and transfection efficiency of plasmid DNA using positively charged biocompatible colloidal gold nanoparticles

Efficient and safe nonviral gene delivery systems are a prerequisite for the clinical application of therapeutic genes. In this study, we report an enhancement of the transfection efficiency of plasmid DNA, via the use of positively charged colloidal gold nanoparticles (PGN). Plasmid DNA encoding for murine interleukin-2 (pVAXmIL-2) was complexed with PGN at a variety of ratios. The delivery of pVAXmIL-2 into C2C12 cells was dependent on the complexation ratios between PGN and the plasmid DNA, presented the highest delivery at a ratio of 2400:1. After complexation with DNA, PGN showed significantly higher cellular delivery and transfection efficiency than did the polyethylenimines (PEI) of different molecular weights, such as PEI25K (m.w. 25 kd) and PEI2K (m.w. 2 kd). PGN resulted in a cellular delivery of pVAXmIL-2 6.3-fold higher than was seen with PEI25K. The PGN/DNA complex resulted in 3.2- and 2.1-fold higher murine IL-2 protein expression than was seen in association with the PEI25K/DNA and PEI2K/DNA complexes, respectively. Following intramuscular administration, PGN/DNA complexes showed more than 4 orders of magnitude higher expression levels as compared to naked DNA. Moreover, the PGN/DNA complexes showed higher cell viability than other cationic nonviral vectors. Collectively, the results of this study suggest that the PGN/DNA complexes may harbor the potential for development into efficient and safe gene delivery vehicles.

Interferon-alphacon-1 treatment of three patients with severe glucocorticoid-dependent asthma. Effect on disease control and systemic glucocorticosteroid dose

We report herein the therapeutic effect of interferon (IFN)-alphacon in three patients with severe persistent asthma and long-term oral glucocorticoid treatment. IFN-alphacon (9 microg) administered subcutaneously thrice a week over a period of more than 24 months led to a substantial clinical improvement with regard to the number of daily asthma attacks, nighttime disturbance, emergency visits and hospitalizations. In addition, lung function and exercise capacity improved. At the same time, treatment with IFN allowed discontinuation of the daily glucocorticoid dose in all patients for the first time in more than 8 years. Our findings suggest that IFN-alphacon leads to a significant clinical improvement while at the same time allowing reduction and discontinuation of the glucocorticoid treatment in severe persistent glucocorticoid-dependent asthma.

Methotrexate therapy of oral corticosteroid-dependent asthmatics reduces serum immunoglobulins: correlation with clinical response to therapy

BACKGROUND

Concomitant methotrexate (MTX) therapy of oral corticosteroid (CS)-dependent asthmatics has been shown to spare CS therapy, but the mechanism is unknown. In a previous report, we showed that MTX increases T cell inhibition by CS. In this report we focus on effects of MTX on immunoglobulin concentrations and their possible clinical relevance.

OBJECTIVE

To monitor changes in circulating leucocytes and Ig in a group of these patients during MTX therapy, and to relate these changes to clinical 'response' as defined by oral CS reduction.

METHODS

Sixteen severe asthmatics dependent on oral prednisolone 15 (7.5-25) mg/day in addition to high dose inhaled CS were treated with MTX 15 mg intramuscularly, weekly for 28 weeks. Prednisolone dosages were maintained constant for 12 weeks then reduced systematically over the next 16 weeks provided that asthma control did not deteriorate. Patients were classified a priori as 'responders' or 'non-responders' to MTX (reduction of initial oral prednisolone requirement by >or=50% or <50%, respectively). Patients were followed-up for a further 12 weeks after MTX withdrawal. Serum Ig and differential blood leucocyte counts were measured at baseline, 12, 28 and 40 weeks.

RESULTS

MTX therapy allowed significant, but individually variable, reductions in oral prednisolone dosages (P<0.00001) without alteration of lung function or symptoms. This was associated with significant reductions in mean serum concentrations of Ig of all classes, which reversed following MTX withdrawal. Reductions in IgE and IgG were significantly greater in the MTX 'responders' as compared with 'non-responders', and changes in IgE, IgG and IgM correlated with changes in prednisolone requirements. Differential blood leucocyte counts showed no significant variation.

CONCLUSION

MTX therapy reduced oral CS requirements in these severe asthmatics to a degree which correlated with reduced circulating Ig but not lymphopaenia, suggesting a possible cause and effect relationship. These reductions might also contribute to the documented incidence of opportunistic infection in these circumstances.

Asthma refractory to glucocorticoids: the role of newer immunosuppressants

Asthma is orchestrated by cytokine products of activated T cells. Glucocorticoids are thought to ameliorate asthma at least partly through T cell inhibition. Consequently, other T cell immunomodulatory agents have been assessed for asthma therapy. Since these agents may have serious unwanted effects, attention has been focused on patients with severe asthma refractory to maximal topical, and additional systemic glucocorticoid therapy. Although gold salts show a modest but significant glucocorticoid-sparing effect in severe asthma, lung function is not improved and not all patients respond. The minimum duration of a valid trial of therapy is probably 6 months. Unwanted effects include dermatitis, hepatic dysfunction, proteinuria and interstitial pneumonitis. Meta-analysis of trials of methotrexate in oral glucocorticoid-dependent asthma have confirmed that concomitant weekly methotrexate for a minimum of 3 to 6 months enables significant (approximately 20%) overall reduction in oral glucocorticoid requirements, although only approximately 60% of patients show a significant response. There is little effect on lung function. Blood count and liver function must be monitored. Opportunistic infection is rare but potentially fatal. Cyclosporine, administered for at least 3 months, is effective in only a proportion of patients with oral glucocorticoid-dependent asthma, where it may improve disease severity and/or enable oral glucocorticoid dosage reductions. Regular monitoring of renal function, blood pressure and blood concentrations of cyclosporine is required. The evidence that intravenous immunoglobulin (Ig) is of any benefit in patients with glucocorticoid-dependent asthma is at present equivocal. The therapy is expensive and associated with a high incidence of unwanted effects (fever, aseptic meningitis, urticaria). The macrolides tacrolimus (FK506) and sirolimus (rapamycin) have end effects similar to those of cyclosporine. Brequinar sodium, mycophenolate mofetil and leflunomide are inhibitors of de novo synthesis of pyrimidines and purines, to which T cells are particularly sensitive. Such drugs may in theory be beneficial for therapy of patients with oral glucocorticoid-dependent asthma. Humanized anti-CD4, anti-IgE and anti-interleukin (IL)-5 monoclonal antibodies, and other cytokine inhibitors such as soluble IL-4 receptor have entered early trials. The worth of current immunomodulatory drugs is limited since: (i) not all patients respond, and response cannot be predicted a priori; (ii) the high incidence of unwanted effects makes it difficult to assess overall benefit/risk ratios; (iii) there is increased risk of opportunistic infection and (theoretically) neoplasia; (iv) there are many relative and absolute contraindications to therapy; and (v) there is lack of knowledge about the long-term effects, beneficial or otherwise, of therapy.

Severe asthma

Severe asthma is a term that is commonly used to describe patients with refractory, brittle, near fatal, and difficult-to-control asthma. Patients with severe asthma typically experience persistent symptoms despite medical therapy, report decreased quality of life and suffer an accelerated loss of lung function. The role of genetics, environmental exposure, and infection in the development of more severe asthma is the focus of ongoing research. While pathologic changes in these patients are now believed to involve lung parenchyma, in addition to large and small airways, the independent contribution of each of these compartments to the severe asthma phenotype is not well defined. The clinical evaluation of severe asthma patients should include investigating conditions commonly associated with severe asthma, such as gastroesophageal reflux disease, vocal cord dysfunction, and rhinosinusitis. In addition, advanced imaging techniques, measurement of exhaled gas or sputum indices, and airway biopsy are tools that may aid in evaluating severe asthma patients in the near future. Management of patients with severe asthma requires a comprehensive approach that includes non-pharmacological and pharmacological measures. Combination antiinflammatory and long-acting bronchodilator therapy remains the mainstay of management.

Management of asthma in adults: current therapy and future directions

Asthma is increasing in prevalence worldwide and results in significant use of healthcare resources. Although most patients with asthma can be adequately treated with inhaled corticosteroids, an important number of patients require additional therapy and an increasing number of options are available. A further minority of patients develop severe persistent asthma which remains difficult to manage despite current pharmacological therapies. This review discusses the various treatment options currently available for each stage of asthma severity, highlights some of the limitations of current management, and outlines directions which may improve the management of asthma in the future.

Improvement in health care utilization and pulmonary function with fluticasone propionate in patients with steroid-dependent asthma at a National Asthma Referral Center

The impact of switching from other inhaled corticosteroids to fluticasone propionate was studied in patients with severe oral-steroid-dependent asthma over a 1-year period. In this open-label prospective study, patients on maintenance doses of oral and inhaled steroids were referred to a national asthma treatment center and were switchedfrom their previous inhaled corticosteroid to fluticasone propionate 880 microg BID. Compared with data collected from the year prior to enrollment, treatment with fluticasone propionate resulted in significant improvements in pulmonary function, oral steroid requirements, and health resource utilization. In addition, five patients were completely weaned off oral steroids.

Children with difficult asthma: a practical approach

Many open studies investigating the effects of innovative treatments for steroid-dependent asthma demonstrate some benefit. This is also true of the majority of placebo arms in placebo-controlled trials. This suggests that children with difficult asthma benefit from the high level of input that is typically provided in clinical trials, with or without additional medication. Such intensive management of patients, with the emphasis on establishing the diagnosis, improving adherence, and identifying provoking factors, is the key to optimizing asthma control for these children. For patients with genuinely severe asthma, despite high doses of conventional treatment, a greater understanding of the pathological basis of persistent symptoms is needed. Identification of different pathological subtypes of severe asthma should allow for more rational prescribing of asthma therapy, as well as the design of further trials of potential steroid-sparing treatments.

Difficult asthma: defining the problems

A retrospective survey was undertaken of children with difficult asthma, attending a respiratory clinic. The clinical and laboratory profiles of asthmatic children who were poorly controlled on > or = 800 microg of inhaled corticosteroids (ICS) were studied and compared to children well-controlled on > or = 800 microg ICS. Assessments were made of atopy, growth, lung function, treatment adherence, home environment, and responsiveness to corticosteroids (CS). Fiftyseven "difficult" and 23 well-controlled children were studied. Significant differences in the home environment were identified. Smoking was significantly more common in the difficult-to-control group. Nine children had alternative diagnoses. Poor CS responsiveness was present in 10 children. Adverse home environments, poor treatment supervision, alternative diagnoses, and unresponsiveness to CS were the most important factors in difficult asthma. A full assessment, including bronchoscopy, is indicated to avoid unnecessary increases in CS to doses that could cause side-effects.

Gold as an oral corticosteroid sparing agent in stable asthma

BACKGROUND

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

OBJECTIVES

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

SEARCH STRATEGY

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

REVIEWER'S CONCLUSIONS

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

Pathophysiology of severe asthma

Although asthma affects nearly 8% of the adult population, most of these patients have mild-to-moderate disease that can be controlled with appropriate treatment. It is estimated, however, that 5% to 10% of patients with asthma have severe disease that is unresponsive to typical therapeutics, including corticosteroids. Because patients with severe asthma are disproportionately affected by their disease, in terms of both impaired lifestyle and health care costs, the National Heart, Lung, and Blood Institute sponsored a workshop on the pathogenesis of severe asthma. The goals of this workshop were to begin to define the characteristics of severe asthma. In these discussions, it was clear that many characteristics need to be considered in defining this phenotype of asthma, including symptoms, intensity of therapy (including administration of systemic corticosteroids), and impairment of lung function. Also discussed were potential mechanisms of severe asthma including the role of allergic diseases, which may play less of a role in severe asthma than in mild-to-moderate disease, and infections. A major limitation to control of severe asthma is the recalcitrant response of these patients to usual therapy including systemic corticosteroids; the potential of other therapies was reviewed. From these discussions, recommendations were made for future research needs to gain insights into a difficult therapeutic and possibly novel mechanistic area of asthma.

Theophylline pharmacokinetics with concomitant steroid and gold therapy

BACKGROUND

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSION

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

Evidence that severe asthma can be divided pathologically into two inflammatory subtypes with distinct physiologic and clinical characteristics

The mechanisms associated with the development of severe, corticosteroid (CS)-dependent asthma are poorly understood, but likely heterogenous. It was hypothesized that severe asthma could be divided pathologically into two inflammatory groups based on the presence or absence of eosinophils, and that the inflammatory subtype would be associated with distinct structural, physiologic, and clinical characteristics. Thirty-four severe, refractory CS-dependent asthmatics were evaluated with endobronchial biopsy, pulmonary function, allergy testing, and clinical history. Milder asthmatic and normal control subjects were also evaluated. Tissue cell types and subbasement membrane (SBM) thickness were evaluated immunohistochemically. Fourteen severe asthmatics [eosinophil (-)] had nearly absent eosinophils (< 2 SD from the normal mean). The remaining 20 severe asthmatics were categorized as eosinophil (+). Eosinophil (+) severe asthmatics had associated increases (p < 0.05) in lymphocytes (CD3+, CD4+, CD8+), mast cells, and macrophages. Neutrophils were increased in severe asthmatics and not different between the groups. The SBM was significantly thicker in eosinophil (+) severe asthmatics than eosinophil (-) severe asthmatics and correlated with eosinophil numbers (r = 0.50). Despite the absence of eosinophils and the thinner SBM, the FEV(1) was marginally lower in eosinophil (-) asthmatics (p = 0.05) with no difference in bronchodilator response. The eosinophil (+) group (with a thicker SBM) had more intubations than the eosinophil (-) group (p = 0.0004). Interestingly, this group also had a decreased FVC/slow vital capacity (SVC). These results suggest that two distinct pathologic, physiologic, and clinical subtypes of severe asthma exist, with implications for further research and treatment.

Fluticasone propionate powder: oral corticosteroid-sparing effect and improved lung function and quality of life in patients with severe chronic asthma

BACKGROUND

Many patients with severe asthma are dependent on oral corticosteroids for maintenance control of their disease. Treatments that allow patients to be weaned off oral corticosteroids may help to minimize the risk of side effects associated with their chronic use.

OBJECTIVE

This study evaluated whether inhaled fluticasone propionate powder could maintain pulmonary function while reducing the dose of oral prednisone in patients with chronic, severe asthma.

METHODS

Oral prednisone-dependent (5 to 40 mg/day) adolescents and adults with asthma (n = 111; mean FEV1 = 61% of predicted value) were randomized to placebo or twice daily fluticasone propionate 500 or 1000 microg administered by means of a multidose powder inhaler for 16 weeks in a double-blind, parallel-group study. Patients underwent controlled prednisone reduction on the basis of predetermined asthma stability criteria.

RESULTS

Oral prednisone was eliminated by 75% and 89% of patients in the twice daily 500 and 1000 microg fluticasone propionate groups, respectively, versus 9% of the placebo group (P <.001). FEV1, morning and evening peak expiratory flow, asthma symptoms, albuterol use, and nighttime awakenings improved with fluticasone propionate treatment, achieving statistical significance (P </=.009) primarily in the 1000 microg twice daily group. Hypothalamic-pituitary-adrenal axis suppression observed at baseline improved when patients were weaned off oral prednisone to fluticasone propionate. Adverse events ascribed to drug treatment were primarily topical effects of inhaled corticosteroids or those associated with prednisone withdrawal. Patient quality of life assessed by means of the Asthma Quality of Life Questionnaire was clinically and significantly improved after fluticasone propionate treatment (P </=.003).

CONCLUSION

Fluticasone propionate powder (500 or 1000 microg twice daily) effectively improved lung function, adrenal function, and asthma-specific quality of life in patients with severe chronic asthma previously treated with oral prednisone while allowing most patients to be weaned off oral corticosteroid therapy.

Randomised, dose-ranging, placebo-controlled study of chimeric antibody to CD4 (keliximab) in chronic severe asthma

BACKGROUND

There is substantial circumstantial evidence that CD4 lymphocytes have a role in the pathogenesis of chronic asthma. We investigated the efficacy and safety in severe corticosteroid-dependent asthma of a single intravenous infusion of keliximab (IDEC CE9.1), a chimeric monoclonal antibody to CD4.

METHODS

22 patients were recruited from two asthma clinics. In an ascending-dose design, the first eight patients were assigned 0.5 mg/kg keliximab (six) or placebo (two); the next seven were assigned 1.5 mg/kg (five) or placebo (two); and the last seven were assigned 3.0 mg/kg (five) or placebo (two). Masked data on safety for each dose group were assessed before progression to the next dose. Patients kept a daily symptom diary and measured morning and evening peak expiratory flow (PEF) at home. PEF and forced expiratory volume in 1 s (FEV1) were measured at follow-up clinic visits.

FINDINGS

Patients given 0.5 mg/kg or 1.5 mg/kg keliximab and placebo recipients did not differ in change from baseline of PEF, FEV1, or symptom score. Those given 3.0 mg/kg keliximab differed significantly from placebo recipients in change in morning PEF (median area under curve [AUC] 445 vs -82.5, p=0.005) and evening PEF (median AUC 548 vs -85, p=0.014). Symptom score showed the same pattern (though differences did not achieve significance), but there was no difference in clinic FEV1. There were no serious adverse effects related to treatment. Two patients had mild exacerbations of eczema and one developed a transient maculopapular rash. All doses of keliximab were associated with a reduction from baseline in CD4 count.

INTERPRETATION

Our findings raise the possibility that T-cell-directed treatment may be an alternative approach to the treatment of severe asthma.

Hydroxychloroquine improves airflow and lowers circulating IgE levels in subjects with moderate symptomatic asthma

BACKGROUND

Although antiinflammatory therapy is accepted as the cornerstone of asthma treatment, available systemic immunosuppressive agents are not widely used because of justified concerns over potential toxicity. Hydroxychloroquine (HCQ) is a well-tolerated, safe immunomodulating drug, with proven efficacy in rheumatic diseases and known actions that suggest potential utility in the treatment of asthma.

OBJECTIVE

We sought to assess the effectiveness of HCQ in subjects with moderate symptomatic asthma.

METHODS

Symptomatic asthmatic subjects receiving stable doses of at least 6 puffs of inhaled corticosteroid per day with daily need for beta2-adrenergic agonists were studied. After baseline run-in, these subjects were randomized to 30 weeks of HCQ (n = 8) or placebo (n = 9). Objective measures included change from baseline mean FEV1, morning and evening peak flows, beta2-agonist use, IgE level, and need for rescue corticosteroids. Subjective symptom scores from bidaily diaries were also obtained.

RESULTS

In the treatment group, mean FEV1 at the last 2 visits on therapy increased by 10.8% (P < .05), morning peak flows rose 16.2% (P < .03), evening peak flows rose 14.2% (P < .04), and beta2-agonist use fell 18.6% (P < .03). Mean IgE level declined 48% from 240 to 125 IU/mL. (P < .05). In the placebo group no significant change in these parameters occurred. Comparison of changes in these objective measures between the treatment and placebo groups failed to reach significance in the small population studied. Corticosteroid rescue interventions were required in 4 patients receiving placebo and 2 receiving HCQ. HCQ was well tolerated without notable side effects.

CONCLUSIONS

Although the size of our sample population precludes definitive conclusions, these findings extend previous open-label observations. The late improvement in the HCQ group is consistent with its known slow onset of action. Further studies are warranted to confirm the antiasthmatic and antiallergic effects of HCQ and to investigate its potential as a disease-modifying agent.

Oral glucocorticosteroid-sparing effect of budesonide administered by Turbuhaler: a double-blind, placebo-controlled study in adults with moderate-to-severe chronic asthma. Pulmicort Turbuhaler Study Group

OBJECTIVE

To determine the ability of budesonide via an inhaler (Pulmicort Turbuhaler; Astra Draco AB) to replace oral glucocorticosteroids (GCSs) in adult subjects with moderate-to-severe asthma.

DESIGN

Double-blind, randomized, and placebo-controlled study, with parallel groups.

SETTING

Multicenter study in outpatient setting.

PARTICIPANTS

Eighty men and 79 women, aged 20 to 69 years, with moderate-to-severe asthma and a mean FEV1 of 58.3% predicted normal. All subjects were receiving oral GCS treatment and 79% of subjects were also receiving inhaled beclomethasone dipropionate (BDP). The mean daily doses of prednisone at baseline, including converted dose of BDP, for the placebo, budesonide 400 microg, and budesonide 800 microg, respectively, were 19.7 mg, 19.5 mg, and 18.7 mg.

MEASUREMENTS AND INTERVENTIONS

After a 2-week baseline period, subjects entered a 20-week treatment period, during which the oral dose of prednisone was reduced by forced down-titration at 2-weekly intervals.

RESULTS

Subjects receiving 400 microg or 800 microg bid of budesonide achieved a significantly greater reduction (82.9% and 79.0% respectively) in oral GCS dose compared with placebo-treated subjects (27%; p<0.001). Two thirds of the subjects receiving budesonide were able to achieve sustained oral corticosteroid cessation, compared with 8% in the placebo group. Additionally, both doses of budesonide resulted in significant improvement in results of pulmonary function tests and asthma symptoms scores, and a significant decrease in the use of bronchodilator therapy. The mean plasma cortisol levels before and after adrenocorticotropic hormone stimulation increased most toward the normal range in the budesonide-treated groups compared with placebo-treated subjects.

CONCLUSION

Budesonide administered via Turbuhaler has a significant oral GCS-sparing capacity with maintained or improved asthma control in adult subjects with moderate-to-severe asthma.

New approaches to anti-inflammatory therapy for asthma

Currently, corticosteroids are the therapy of choice for the inflammatory component of asthma. This class of drug provides powerful anti-inflammatory effects in most patients; however, these effects are not specific and in some cases may result in serious side effects. Also, many patients have difficulty adhering to therapy with inhaled forms of these drugs, which are administered by metered-dose inhalers up to several times per day. There are several other therapies that provide potential anti-inflammatory effects, but they are of low efficacy, with little definitive anti-inflammatory effect. While efforts are currently under way to improve corticosteroid therapy, other directions include the development of targeted anti-inflammatory agents. For example, the leukotrienes, a family of inflammatory mediators that have been shown to enhance bronchoconstriction and airway mucus secretion, have been the focus of numerous investigations. Specific leukotriene receptor antagonists and synthesis inhibitors have been developed and are currently showing promise in clinical trials; one leukotriene receptor antagonist (zafirlukast) and one 5-lipoxygenase inhibitor (zileuton) were recently approved by the United States Food and Drug Administration for the treatment of asthma.