A controlled trial of the effect of the 5-lipoxygenase inhibitor, zileuton, on lung inflammation produced by segmental antigen challenge in human beings

Development of Adaptive Immunity and Its Role in Lung Remodeling

Asthma is characterized by airflow limitations resulting from bronchial closure, which can be either reversible or fixed due to changes in airway tissue composition and structure, also known as remodeling. Airway remodeling is defined as increased presence of mucins-producing epithelial cells, increased thickness of airway smooth muscle cells, angiogenesis, increased number and activation state of fibroblasts, and extracellular matrix (ECM) deposition. Airway inflammation is believed to be the main cause of the development of airway remodeling in asthma. In this chapter, we will review the development of the adaptive immune response and the impact of its mediators and cells on the elements defining airway remodeling in asthma.

Isoorientin ameliorates OVA-induced asthma in a murine model of asthma

Allergic asthma which is induced by ovalbumin (OVA) is a chronic airway inflammation disease. Isoorientin (Iso) is a natural C-glucosyl flavone with many biological properties. We aimed to evaluate the effectiveness of Iso on OVA-induced allergic asthma. A total of 30 C57BL/6 mice were randomly divided into five groups: control group, OVA group, Dex (dexamethasone, 10 mg/kg) group, low-dose Iso group (Iso-L, 25 mg/kg), and high-dose Iso group (Iso-H, 50 mg/kg). The serum and bronchoalveolar lavage fluid (BALF) were collected for biochemical parameters, the lung tissue was collected for hematoxylin-eosin (H&E) staining, immunohistochemistry (IHC), and western blot. The levels of IL-4, IL-5, IL-13, malondialdehyde (MDA), NO, and reactive oxygen species (ROS) in Iso-L and Iso-H groups were significantly lower than that in model group (p < 0.05). Simultaneously, the levels of superoxide dismutase (SOD) and glutathione peroxidase (GSH-Px) activity were higher than that in model group (p < 0.05). Iso significantly ameliorated airway hyperresponsiveness. Meanwhile, H&E staining revealed that mice treated with Iso resulted in the ameliorated inflammatory cell infiltration and a reduction in interstitial thickening. The nuclear factor erythroid 2-like 2 (Nrf2) and HO-1 protein expression in Iso-L and Iso-H groups were enhanced over that in model group, while p-NF-κB-p65 and p-IκB-α protein expression was decreased (p < 0.05). Our research indicated that Iso alleviated the OVA-induced allergic asthma, and this effect can be explained by the modulation of Nrf2/HO-1 and NF-κB signaling pathway; thus, the results providing a therapeutic rationale for the treatment of Iso on allergic asthma.

Apoptosis of Eosinophil Granulocytes

Simple Summary

Eosinophil granulocytes (eosinophils) belong to the family of white blood cells that play important roles in the development of asthma and various types of allergy. Eosinophils are cells with a diameter of 12–17 µm and they originate from myeloid precursors. They were discovered by Paul Ehrlich in 1879 in the process of staining fixed blood smears with aniline dyes. Apoptosis (programmed cell death) is the process by which cells lose their functionality. Therefore, it is very important to study the apoptosis of eosinophils and their survival factors to understand how to develop new drugs based on the modulation of eosinophil apoptosis for the treatment of asthma and allergic diseases.

Abstract

In the past 10 years, the number of people in the Czech Republic with allergies has doubled to over three million. Allergic pollen catarrh, constitutional dermatitis and asthma are the allergic disorders most often diagnosed. Genuine food allergies today affect 6–8% of nursing infants, 3–5% of small children, and 2–4% of adults. These disorders are connected with eosinophil granulocytes and their apoptosis. Eosinophil granulocytes are postmitotic leukocytes containing a number of histotoxic substances that contribute to the initiation and continuation of allergic inflammatory reactions. Eosinophilia results from the disruption of the standard half-life of eosinophils by the expression of mechanisms that block the apoptosis of eosinophils, leading to the development of chronic inflammation. Glucocorticoids are used as a strong acting anti-inflammatory medicine in the treatment of hypereosinophilia. The removal of eosinophils by the mechanism of apoptosis is the effect of this process. This work sums up the contemporary knowledge concerning the apoptosis of eosinophils, its role in the aforementioned disorders, and the indications for the use of glucocorticoids in their related therapies.

Proinflammatory Pathways in the Pathogenesis of Asthma

There are multiple proinflammatory pathways in the pathogenesis of asthma. These include both innate and adaptive inflammation, in addition to inflammatory and physiologic responses mediated by eicosanoids. An important component of the innate allergic immune response is ILC2 activated by interleukin (IL)-33, thymic stromal lymphopoietin, and IL-25 to produce IL-5 and IL-13. In terms of the adaptive T-lymphocyte immunity, CD4+ Th2 and IL-17-producing cells are critical in the inflammatory responses in asthma. Last, eicosanoids involved in asthma pathogenesis include prostaglandin D₂ and the cysteinyl leukotrienes that promote smooth muscle constriction and inflammation that propagate allergic responses.

The peroxisome proliferator-activated receptor agonist pioglitazone and 5-lipoxygenase inhibitor zileuton have no effect on lung inflammation in healthy volunteers by positron emission tomography in a single-blind placebo-controlled cohort study

Background

Anti-inflammatory drug development efforts for lung disease have been hampered in part by the lack of noninvasive inflammation biomarkers and the limited ability of animal models to predict efficacy in humans. We used ¹⁸F-fluorodeoxyglucose (¹⁸F-FDG) positron emission tomography (PET) in a human model of lung inflammation to assess whether pioglitazone, a peroxisome proliferator-activated receptor-γ (PPAR-γ) agonist, and zileuton, a 5-lipoxygenase inhibitor, reduce lung inflammation.

Methods

For this single center, single-blind, placebo-controlled cohort study, we enrolled healthy volunteers sequentially into the following treatment cohorts (N = 6 per cohort): pioglitazone plus placebo, zileuton plus placebo, or dual placebo prior to bronchoscopic endotoxin instillation. ¹⁸F-FDG uptake pre- and post-endotoxin was quantified as the Patlak graphical analysis-determined K_i (primary outcome measure). Secondary outcome measures included the mean standard uptake value (SUV_mean), post-endotoxin bronchoalveolar lavage (BAL) cell counts and differentials and blood adiponectin and urinary leukotriene E₄ (LTE₄) levels, determined by enzyme-linked immunosorbent assay, to verify treatment compliance. One- or two-way analysis of variance assessed for differences among cohorts in the outcome measures (expressed as mean ± standard deviation).

Results

Ten females and eight males (29±6 years of age) completed all study procedures except for one volunteer who did not complete the post-endotoxin BAL. K_i and SUV_mean increased in all cohorts after endotoxin instillation (K_i increased by 0.0021±0.0019, 0.0023±0.0017, and 0.0024±0.0020 and SUV_mean by 0.47±0.14, 0.55±0.15, and 0.54±0.38 in placebo, pioglitazone, and zileuton cohorts, respectively, p<0.001) with no differences among treatment cohorts (p = 0.933). Adiponectin levels increased as expected with pioglitazone treatment but not urinary LTE₄ levels as expected with zileuton treatment. BAL cell counts (p = 0.442) and neutrophil percentage (p = 0.773) were similar among the treatment cohorts.

Conclusions

Endotoxin-induced lung inflammation in humans is not responsive to pioglitazone or zileuton, highlighting the challenge in translating anti-inflammatory drug efficacy results from murine models to humans.

Trial registration

ClinicalTrials.gov NCT01174056.

Evaluating the role of leukotriene-modifying drugs in asthma management: Are their benefits 'losing in translation'?

Leukotrienes (LTs) initiate a cascade of reactions that cause bronchoconstriction and inflammation in asthma. LT-modifying drugs have been proved very effective to reduce inflammation and associated exacerbation however despite some illustrious clinical trials the usage of these drugs remains overlooked because the evidence to support their utility in asthma management has been mixed and varied between studies. Although, there are plenty of evidences which suggest that the leukotriene-modifying drugs provide consistent improvement even after just the first oral dose and reduce asthma exacerbations, the beneficial effect of these drugs has remained sparse and widely debated. And these beneficial effects are often overlooked because most of the clinical studies include a mixed population of asthmatics who do not respond to LT-modifiers equally. Therefore, in the present era of personalized medicine, it is important to properly stratify the patients and non-invasive measurements of biomarkers may warrant the possibility to characterize biological/pathological pathway to direct treatment to those who will benefit from it. Endotyping based on individual's leukotriene levels should probably ascertain a subgroup of patients that would clearly benefit from the treatment even though the trial fails to show overall significance. In this article, we have methodically evaluated contemporary literature describing the efficacy of LT-modifying drugs in the management of asthma and highlighted the importance of phenotyping the asthmatics for better treatment outcomes.

Patient stratification and the unmet need in asthma

Asthma is often described as an inflammatory disease of the lungs and in most patients symptomatic treatment with bronchodilators or inhaled corticosteroids is sufficient to control disease. Unfortunately there are a proportion of patients who fail to achieve control despite treatment with the best current treatment. These severe asthma patients have been considered a homogeneous group of patients that represent the unmet therapeutic need in asthma. Many novel therapies have been tested in unselected asthma patients and the effects have often been disappointing, particularly for the highly specific monoclonal antibody-based drugs such as anti-IL-13 and anti-IL-5. More recently, it has become clear that asthma is a syndrome with many different disease drivers. Clinical trials of anti-IL-13 and anti-IL-5 have focused on biomarker-defined patient groups and these trials have driven the clinical progression of these drugs. Work on asthma phenotyping indicates that there is a group of asthma patients where T helper cell type 2 (Th2) cytokines and inflammation predominate and these type 2 high (T2-high) patients can be defined by biomarkers and response to therapies targeting this type of immunity, including anti-IL-5 and anti-IL-13. However, there is still a subset of T2-low patients that do not respond to these new therapies. This T2-low group will represent the new unmet medical need now that the T2-high-targeting therapies have made it to the market. This review will examine the current thinking on patient stratification in asthma and the identification of the T2-high subset. It will also look at the T2-low patients and examine what may be the drivers of disease in these patients.

Flavones derived from nature attenuate the immediate and late-phase asthmatic responses to aerosolized-ovalbumin exposure in conscious guinea pigs

OBJECTIVE

Asthma is an inflammatory disease of the lung that is characterized by airway hyperresponsiveness and the increase of inflammatory cell infiltration into the airways. Naturally occurring flavones have potent anti-inflammatory effects, but their effects on asthmatic responses are still relatively unknown.

METHODS

We evaluated the inhibitory effects of flavone derivatives having the chromone moiety on the immediate-phase asthmatic response (IAR) and the late-phase asthmatic response (LAR) to aerosolized-ovalbumin (OA) exposure in conscious OA-sensitized guinea pigs.

RESULTS

Luteolin and apigenin (30 mg/kg, p.o.) significantly (P < 0.05) decreased not only the specific airway resistance (sRaw) in IAR and LAR, but also the recruitment of leukocytes and the release of histamine and activities of phospholipase A2 (PLA2) and eosinophil peroxide (EPO) in bronchoalveolar lavage fluid (BALF), compared to control. However, their anti-asthmatic activities were less than those of cromolyn sodium and dexamethasone.

CONCLUSIONS

These results indicate that flavones containing more hydroxyl radicals have a greater anti-asthmatic effect. The potencies of flavone anti-asthmatic activities are, in order: luteolin ≥ apigenin > baicalein > chrysin > flavone.

Anti-asthmatic effects of phenylpropanoid glycosides from Clerodendron trichotomum leaves and Rumex gmelini herbes in conscious guinea-pigs challenged with aerosolized ovalbumin

Clerodendron trichotomum leaves and Rumex aquatica herbs are used as a folk medicine for the treatment of inflammatory diseases, but their active ingredients are not known until now. We isolated caffeic acid and phenylpropanoid glycosides, 1-O-caffeoyl glycoside and acteoside [β-(3',4'-dihydroxyphenyl) ethyl-O-α-l-rhamnopyranosyl(1→3)-β-d-(4-O-caffeoyl)-glucopyranoside] from their ethylacetate fractions, respectively, and evaluated their anti-asthmatic effects on the aerosolized ovalbumin (OA) challenge in the OA-sensitized guinea-pigs measuring the specific airway resistance (sRaw) during the immediate-phase response (IAR) and late-phase response (LAR), and also measured recruitment of leukocytes and chemical mediators on the bronchoalveolar lavage fluids (BALF) in LAR, as well as histopathological survey. Acteoside and 1-O-caffeoyl glycoside (25mg/kg) significantly (P<0.05) inhibited sRaw by 32.14 and 26.79% in IAR, and by 55.88% and 52.94% in LAR, respectively, whereas caffeic acid (25mg/kg) inhibited sRaw by 30.36% in IAR and 44.12% in LAR, compared to control, but with less effective than dexamethasone, disodium cromoglycate, and salbutamol, respectively. In addition, phenylpropanoid glycosides (25mg/kg) significantly inhibited the recruitments of leukocytes, particularly neutrophils and eosinophils into lung, Furthermore, 1-O-caffeoyl glycoside, acteoside and caffeic acid significantly (P<0.05) inhibited protein content at a dose of 25mg/kg, and histamine content and PLA(2) activity at a dose of 50mg/kg, in BALF. Acteoside had more active than caffeic acid and 1-O-caffeoyl glycoside. However, their anti-asthmatic effects were less than the reference drugs. These results indicated that caffeic acid and its glycosides (25mg/kg) have anti-asthmatic effect as the same manner with dexamethasone and disodium cromoglycate.

Antiasthmatic action of dibenzylbutyrolactone lignans from fruits of Forsythia viridissima on asthmatic responses to ovalbumin challenge in conscious guinea-pigs

It was reported previously that dibenzylbutyrolactone lignans from Forsythia viridissima fruits, which are traditional medicines for the treatment of inflammatory diseases, have antiinflammatory effects. In this study, the effects on the immediate-phase response (IAR) and late-phase response (LAR) following aerosolized-ovalbumin challenge in ovalbumin-sensitized guinea-pigs were evaluated by measuring the specific airway resistance (sRaw), recruitment of leukocytes and chemical mediators in the bronchoalveolar lavage fluids (BALF) as well as a histopathological survey. Arctiin and matairesinol at 12.5 mg/kg significantly (p < 0.05) decreased sRaw by 51.83% and 43.15% in IAR and by 47.41% and 35.43% in LAR, respectively, whereas arctigenin at 25 mg/kg was significantly active, compared with the controls. Furthermore, arctiin and arctigenin dose-dependently inhibited histamine, and the activities of phospholipase A₂ (PLA₂) and eosinophil peroxidase (EPO) in BALF, respectively, whereas matairesinol inhibited EPO and PLA₂ at 12.5 mg/kg and histamine at 50 mg/kg, in addition, they moderately improved the infiltration of eosinophils, compared with controls. Dexamethasone, cromolyn and salbutamol significantly inhibited sRaw in both IAR and LAR, and the recruitment of leukocytes and chemical mediators, whereas salbutamol did not alter chemical mediators, in BALF. These results indicate the three lignans have antiasthmatic effects which were less active than those of the reference drugs.

Inhibitory effects of diterpene acids from root of Aralia cordata on IgE-mediated asthma in guinea pigs

This study evaluated the anti-asthmatic activities of four diterpene acids isolated from Aralia cordata root that are proposed to be the active ingredients in its traditional use as a treatment for inflammation, overheating, pain and spasm in Korea. The diterpene acids were identified as kaurenoic acid, 7-oxo-sandaracopimaric acid, 17-hydroxy-ent-kaur-15-en-19-oic acid, and hederagenin, by comparing their phytochemical and spectroscopic data with previous reports. The effects of diterpene acids on asthma were evaluated by determining the specific airway resistance (sRaw) during the immediate asthmatic response (IAR) and the late-phase asthmatic response (LAR) in guinea pigs with IgE-mediated asthma. Recruitment of leukocytes and the presence of chemical mediators in bronchoalveolar lavage fluid (BALF) were determined, and histopathological surveys performed. The four diterpene acids dosed at 25 approximately 100 mg/kg had dose-dependently anti-asthmatic effects: 7-oxo-sandaracopimaric acid > 17-hydroxy-ent-kaur-15-en-19-oic acid > kaurenoic acid > hederagenin. 7-oxo-sandaracopimaric acid (25 mg/kg) significantly (p < 0.05) inhibited sRaw by 59.5% in IAR and LAR, and also dose-dependently inhibited recruitment of eosinophils and neutrophils into lung and release of chemical mediators, histamine, and the activity of phospholipase A(2) and eosinophil peroxidase in BALF. 7-Oxo-sandaracopimaric acid had the highest activity among the diterpene acids. But its effect was lower than cromolyn sodium, salbutamol, or dexamethasone in both the IAR and the LAR. These results suggested that C(7)-oxo radical of 7-oxo-sandaracopimaric acid was more active than the C(7)-hydroxy and hydrogen of the other compounds, and showed diterpene acids have anti-asthmatic effects, supporting the traditional application of this herb in treating IgE-mediated asthma.

[Therapy of asthma: anti-inflammatory effects of antileukotrienes]

The antileukotrienes (anti-LT), consisting of synthesis inhibitors and leukotriene receptor antagonists, represent a new direction in targeted drug therapy for asthma. In the present article, the anti-inflammatory properties of anti-LT are briefly summarized. Orally administered anti-LT inhibit the allergen-induced early and late asthmatic reactions and may attenuate the allergen-associated hyperresponsiveness. They also have a remarkable inhaled steroid-sparing effect. In chronic asthma, anti-LT may exert significant therapeutic benefit. In addition to their properties as relievers, anti-LT may have properties as controllers of asthma.

Efficacy of leukotriene receptor antagonists and synthesis inhibitors in asthma

Cysteinyl leukotrienes are important mediators of asthmatic responses. They are the most potent bronchoconstrictors known; their release is triggered by exposure to inhaled allergens after exercise and after aspirin ingestion by subjects with aspirin-sensitive asthma. The cysteinyl leukotrienes promote inflammatory cell migration into the airways, as well as bone marrow eosinophilopoiesis after allergen inhalation. Leukotriene inhibitors are effective at attenuating asthmatic responses to all of these stimuli and are also effective at treating persistent asthma. These drugs are a viable alternative to low-dose inhaled corticosteroid (ICS) treatment but should be reserved for patients who cannot or will not use ICSs, often because of concerns about potential side effects of ICS treatment, which limits their use, particularly in children. Leukotriene receptor antagonists are also alternatives to long-acting inhaled beta(2)-agonists as add-on therapy to ICSs, but their efficacy together with ICSs is less than that of ICS/long-acting inhaled beta(2)-agonist combinations. Leukotriene receptor antagonists have an excellent safety profile.

Biology of the eosinophil

In this review, we aim to put in perspective the biology of a multifunctional leukocyte, the eosinophil, by placing it in the context of innate and adaptive immune responses. Eosinophils have a unique contribution in initiating inflammatory and adaptive responses, due to their bidirectional interactions with dendritic cells and T cells, as well as their large panel of secreted cytokines and soluble mediators. The mechanisms and consequences of eosinophil responses in experimental inflammatory models and human diseases are discussed.

Expanding roles for leukotrienes in airway inflammation

Leukotrienes (LTs) are lipid mediators derived from the 5-lipoxygenase pathway of arachidonic acid metabolism. Cysteinyl (cys) LTs C(4), D(4), and E(4) are long known to contribute to airway contractile responses via ligation of the cysLT1 receptor, and cysLT1 antagonists are beneficial in some patients with asthma. Research advances over the past several years suggest that cysLT1 also mediates the ability of cysLTs to modulate inflammation, immune responses, and airway remodeling. Although less is known about an additional receptor, cysLT2, emerging evidence indicates that it likely also contributes to cysLT actions promoting inflammation, vascular permeability, and perhaps fibrosis. LTB(4), best known as a neutrophil chemoattractant, is now recognized to exert other important effects contributing to inflammatory and immune responses. These recent data highlight a growing appreciation for LTs as pleiotropic effectors, which are integral components in the network of molecules that mediate the expression of asthma.

Eosinophils: biological properties and role in health and disease

Eosinophils are pleiotropic multifunctional leukocytes involved in initiation and propagation of diverse inflammatory responses, as well as modulators of innate and adaptive immunity. In this review, the biology of eosinophils is summarized, focusing on transcriptional regulation of eosinophil differentiation, characterization of the growing properties of eosinophil granule proteins, surface proteins and pleiotropic mediators, and molecular mechanisms of eosinophil degranulation. New views on the role of eosinophils in homeostatic function are examined, including developmental biology and innate and adaptive immunity (as well as their interaction with mast cells and T cells) and their proposed role in disease processes including infections, asthma, and gastrointestinal disorders. Finally, strategies for targeted therapeutic intervention in eosinophil-mediated mucosal diseases are conceptualized.

Anti-asthmatic action of quercetin and rutin in conscious guinea-pigs challenged with aerosolized ovalbumin

The effects of quercetin and rutin on the asthmatic responses were studied in ovalbumin (OA)-sensitized conscious guinea pigs challenged with aerosolized-OA. We measured the specific airway resistance (sRaw) in the double-chambered plethysmograph during the immediate-phase response (IAR) and late-phase response (LAR) at 3 approximately 10 min and 24 hr after OA challenge, respectively. We counted leukocytes in bronchoalveolar lavage fluid (BALF) using Wright's stain, as well as in lung tissue fixed with 10% formalin and stained with H & E stain. Quercetin and rutin (7.5 mg/kg, p.o.) significantly and dose-dependently inhibited both sRaw on IAR (31.60 and 26.44%) and LAR (29.87 and 28.69%) but with less efficacy than dexamethasone (3 mg/kg) and salbutamol (0.3 mg/kg), which inhibited IAR by 36.71 and 69.45%, and LAR by 67.23 and 0%, respectively, Quercetin and rutin (15 mg/kg) also inhibited production of histamine, PLA2, and EPO, and recruitment of leukocytes, particularly neutrophils and eosinophils, during LAR. respectively. Dexamethasone (3 mg/kg) also significantly reduced the recruitment of neutrophils, eosinophils, and lymphocytes in BALF, and salbutamol (0.3 mg/kg) reduced neutrophils and eosinophils with lower activity than dexamethasone. These results indicate that quercetin and rutin may be useful in the treatment of IAR and LAR in asthma via inhibition of histamine release, PLA2, and EPO, and reduced recruitment of neutrophils and eosinophils into the lung.

The impact of a medical food containing gammalinolenic and eicosapentaenoic acids on asthma management and the quality of life of adult asthma patients

BACKGROUND

Leukotriene synthesis inhibitors and receptor antagonists are efficacious for the treatment of asthma. Diets containing the fatty acids gammalinolenic acid (GLA) and eicosapentaenoic acid (EPA) decrease leukotriene synthesis; however, their impact on asthma management and quality of life (QOL) has not been evaluated in asthmatic subjects.

OBJECTIVE

To evaluate asthma management and the QOL of asthmatic adult subjects consuming a medical food emulsion containing GLA and EPA.

RESEARCH DESIGN AND METHODS

Trial 1 was a randomized, prospective, double-blind, placebo-controlled, parallel group trial in atopic subjects with mild-to-moderate asthma (n = 35 evaluable) consuming a low dose (0.75 g GLA + 0.5 g EPA), high dose (1.13 g GLA + 0.75 g EPA) or placebo emulsion daily. Subjects were questioned about their asthma management using a non-validated questionnaire after 2 and 4 weeks. Blood leukotrienes were measured at baseline and after 4 weeks. Trial 2 was an open-label study (n = 65 evaluable) where subjects consumed the low-dose medical food emulsion, EFF1009, daily. QOL and asthma management were measured using the validated Mini Asthma Quality of Life (MiniAQLQ) and the Asthma Control (ACQ) questionnaires, respectively, administered at baseline and after 4 weeks.

RESULTS

In Trial 1, leukotriene biosynthesis decreased (p < 0.05). Self-reported asthma status and bronchodilator use improved in subjects consuming low- and high-dose emulsion between week 2 and week 4 (p < 0.01), but not compared to placebo (p > 0.1). In Trial 2, mean +/- standard error total MiniAQLQ and ACQ scores improved by 1.5 +/- 0.2 and 1.0 +/- 0.1, respectively (p < 0.001). Subdomain scores from MiniAQLQ improved and rescue bronchodilator use decreased (p < 0.001).

CONCLUSION

The inclusion of the medical food EFF1009 in asthma management regimens can improve patient quality of life and decrease reliance on rescue medication.

Cysteinyl-leukotrienes and their receptors in asthma and other inflammatory diseases: critical update and emerging trends

Cysteinyl-leukotrienes (cysteinyl-LTs), that is, LTC4, LTD4, and LTE4, trigger contractile and inflammatory responses through the specific interaction with G protein-coupled receptors (GPCRs) belonging to the purine receptor cluster of the rhodopsin family, and identified as CysLT receptors (CysLTRs). Cysteinyl-LTs have a clear role in pathophysiological conditions such as asthma and allergic rhinitis (AR), and have been implicated in other inflammatory conditions including cardiovascular diseases, cancer, atopic dermatitis, and urticaria. Molecular cloning of human CysLT1R and CysLT2R subtypes has confirmed most of the previous pharmacological characterization and identified distinct expression patterns only partially overlapping. Interestingly, recent data provide evidence for the immunomodulation of CysLTR expression, the existence of additional receptor subtypes, and of an intracellular pool of CysLTRs that may have roles different from those of plasma membrane receptors. Furthermore, genetic variants have been identified for the CysLTRs that may interact to confer risk for atopy. Finally, a crosstalk between the cysteinyl-LT and the purine systems is being delineated. This review will summarize and attempt to integrate recent data derived from studies on the molecular pharmacology and pharmacogenetics of CysLTRs, and will consider the therapeutic opportunities arising from the new roles suggested for cysteinyl-LTs and their receptors.

The eosinophil

Eosinophils have been considered end-stage cells involved in host protection against parasites. However, numerous lines of evidence have now changed this perspective by showing that eosinophils are pleiotropic multifunctional leukocytes involved in initiation and propagation of diverse inflammatory responses, as well as modulators of innate and adaptive immunity. In this review, we summarize the biology of eosinophils, focusing on the growing properties of eosinophil-derived products, including the constituents of their granules as well as the mechanisms by which they release their pleiotropic mediators. We examine new views on the role of eosinophils in homeostatic function, including developmental biology and innate and adaptive immunity (as well as interaction with mast cells and T cells). The molecular steps involved in eosinophil development and trafficking are described, with special attention to the important role of the transcription factor GATA-1, the eosinophil-selective cytokine IL-5, and the eotaxin subfamily of chemokines. We also review the role of eosinophils in disease processes, including infections, asthma, and gastrointestinal disorders, and new data concerning genetically engineered eosinophil-deficient mice. Finally, strategies for targeted therapeutic intervention in eosinophil-mediated mucosal diseases are conceptualized.

Treatment of asthma with antileukotrienes: first line or last resort therapy?

Twenty five years after the structure elucidation of slow reacting substance of anaphylaxis, antileukotrienes are established as a new therapeutic modality in asthma. The chapter reviews the biochemistry and pharmacology of leukotrienes and antileukotrienes with particular focus on the different usage of antileukotrienes for treatment of asthma and rhinitis in Europe and the US. Further research needs and new areas for leukotriene involvement in respiratory diseases are also discussed.

Role of cysteinyl leukotrienes in airway inflammation and responsiveness following RSV infection in BALB/c mice

Cysteinyl leukotrienes (CysLTs) contribute to the development of airway obstruction and inflammation in asthma; however little information is available on the role of these molecules in the pathophysiology of respiratory syncytial virus (RSV) bronchiolitis. This study was designed to evaluate the effects of RSV infection on CysLTs production in a well-established mouse infection model. Furthermore, we assessed the effect of anti-inflammatory agents (a leukotriene receptor antagonist, MK-571, and dexamethasone) on the functional and immune changes induced by RSV infection. Six to 8-wk-old BALB/c mice were infected with human RSV (strain A2). Measurements of airway function were performed using whole body plethysmography. Lung inflammation was assessed by cell counts, measurement of cytokines and CysLTs in bronchoalveolar lavage fluid (BALF) in the absence and presence of treatment with MK-571 or dexamethasone. RSV infection produced a marked increase in CysLTs in the BALF and lung tissue, recruitment of neutrophils and lymphocytes into the airways, increased IFN-gamma levels and airway hyperresponsiveness (AHR). Treatment with MK-571 decreased RSV-induced AHR without affecting the cellular and inflammatory responses to RSV. Dexamethasone decreased AHR and markedly reduced the recruitment of inflammatory cells and production of IFN-gamma. Our findings suggest CysLTs play an important role in the pathogenesis of RSV-induced airway dysfunction. Treatment with MK-571 decreases RSV-induced AHR but does not appear to alter the lung inflammatory responses to RSV. In contrast, dexamethasone decreases RSV-induced AHR but interferes with recruitment of inflammatory cells, resulting in decreased Th1 cytokines (a potentially Th2-prone environment) in this model. These studies support recent reports on the beneficial effects of CysLT receptor antagonist in human trials and provide a model for investigating the role of CysLTs in RSV bronchiolitis.

Eicosanoids: mediators and therapeutic targets in fibrotic lung disease

Fibrosis is a common end-stage sequella of a number of acute and chronic lung diseases. Current concepts of pathogenesis implicate dysregulated interactions between epithelial cells and mesenchymal cells. Although investigative efforts have documented important roles for cytokines and growth factors in the pathogenesis of fibrotic lung diseases, these observations have not as yet been translated into efficacious therapies, and there is a pressing need for new pathogenetic insights and therapeutic approaches for these devastating disorders. Eicosanoids are lipid mediators derived from arachidonic acid, the most studied of which are the prostaglandins and leukotrienes. Although they are primarily known for their roles in asthma, pain, fever and vascular responses, present evidence indicates that eicosanoids exert relevant effects on immune/inflammatory, as well as structural, cells pertinent to fibrogenesis. In general, leukotrienes promote, whereas prostaglandin E(2) opposes, fibrogenic responses. An imbalance of eicosanoids also exists in pulmonary fibrosis, which favours the production of leukotrienes over prostaglandin E(2). This review highlights the role of this imbalance in the evolution of fibrotic lung disease, discusses the mechanisms by which it may arise and considers approaches for therapeutic targeting of eicosanoids in these conditions.

An update of the leukotriene modulators for the treatment of asthma

Bronchial asthma is a chronic inflammatory airway disease involving many cells and mediators. Chronic inflammation constitutes an important predisposing condition for airway remodelling with secondary irreversible airflow obstruction. Current approaches for asthma treatment involve many classes of drugs, adequate patient education for their correct use, environmental exposure control and daily monitoring of pulmonary function. Unfortunately, the use of multiple therapies complicates treatment regimens, thus leading to a reduced compliance to therapy. Available evidence from randomised clinical trials and real-word experience derived from managing patients with asthma justifies a broader role for leukotriene receptor antagonist drugs in asthma management than that recommended in the National Asthma Education and Prevention Programme and National Health Lung and Blood Institute Treatment Guidelines. While a low dose of inhaled corticosteroids remains the reference drug as a controller in mild-to-moderate persistent asthma, oral therapy with an leukotriene-receptor antagonist drug represents a good option providing the clinical efficacy requested in common clinical practice. For this reason the recent Global Initiative for Asthma Guidelines allocate this drug to the second and third steps of asthma treatment.

Impact of inhaled corticosteroids and leukotriene receptor antagonists on airway remodeling

Asthma is a chronic inflammatory disease of the airways that is characterized by the presence of inflammatory cells and remodeling, a term used to define complex morphological changes involving all the structures of the bronchial wall (e.g., goblet cell hyperplasia of the epithelium, thickening of reticular basement membrane, increases of airway smooth muscle[ASM], and blood vessels). An important factor in the pathophysiology of asthma is the recognition that airway inflammation and airway remodeling are linked, as they are in other chronic inflammatory diseases. First-line therapy of persistent asthma involves the use of inhaled corticosteroids to control the underlying inflammation of the airways. Because remodeling of the airway wall is thought to be a result of chronic inflammation within the bronchial wall, it follows that because steroids reduce or reverse inflammation, they may also prevent or modulate remodeling. It has been revealed that steroids improve the subepithelial fibrosis and also significantly reduce airway vascularity. The cysteinyl leukotrienes receptor antagonists may also be helpful regarding the targeting of the inflammation and remodeling in asthma. However,long-term studies were needed to appreciate the prevention and treatment of remodeling by drug therapies.

5-Oxo-6,8,11,14-eicosatetraenoic Acid Stimulates the Release of the Eosinophil Survival Factor Granulocyte/Macrophage Colony-stimulating Factor from Monocytes

Allergic diseases such as asthma are characterized by tissue eosinophilia induced by the combined effects of chemoattractants and cytokines. Lipid mediators are a major class of endogenous chemoattractants, among which 5-oxo-6,8,11,14-eicosatetraenoic acid (5-oxo-ETE) is the most potent for human eosinophils. In this study, we investigated the effects of 5-oxo-ETE on eosinophil survival by flow cytometry. We found that this compound could promote eosinophil survival in the presence of small numbers of contaminating monocytes, but not in their absence. The conditioned medium from monocytes treated for 24 h with 5-oxo-ETE also strongly promoted eosinophil survival, whereas the medium from vehicle-treated monocytes had no effect. An antibody against the granulocyte/macrophage colony-stimulating factor (GM-CSF) completely blocked the response of eosinophils to the conditioned medium from 5-oxo-ETE-treated monocytes, whereas an antibody against interleukin-5 had no effect. Furthermore, 5-oxo-ETE stimulated the release of GM-CSF from cultured monocytes in amounts compatible with eosinophil survival activity, with a maximal effect being observed after 24 h. This effect was concentration-dependent and could be observed at concentrations in the picomolar range. 5-Oxo-ETE and leukotriene B(4) had similar effects on GM-CSF release at low concentrations, but 5-oxo-ETE induced a much stronger response at concentrations of 10 nm or higher. This is the first report that 5-oxo-ETE can induce the release of any cytokine, suggesting that it could be an important mediator in allergic and other inflammatory diseases due both to its chemoattractant properties and to its potent effects on the synthesis of the survival factor GM-CSF.

A review of montelukast in the treatment of asthma and allergic rhinitis

Montelukast sodium (Singulair, Merck) is a selective and orally-active leukotriene-receptor antagonist (LTRA) that inhibits the cysteinyl leukotriene 1 (CysLT1) receptor. Montelukast is an effective and well-tolerated preventative treatment for asthma and allergic rhinitis in adults and children. The upper and lower airway show similar inflammatory responses to allergen challenge. Leukotrienes are inflammatory mediators that are known as the slow-reacting substance of anaphylaxis produced by a number of cell types including mast cells, eosinophils, basophils, macrophages and monocytes. Synthesis of these mediators results from the cleavage of arachidonic acid in cell membranes and they exert their biological effects by binding and activating specific receptors. This occurs in a series of events that lead to contraction of the human airway smooth muscle, chemotaxis and increased vascular permeability. These effects have led to their important role in the diseases of asthma and allergic rhinitis. As these agents lead to the production of symptoms in patients that are asthmatic or allergic, the use of LTRAs, particularly montelukast, may seem appropriate. Clinical trials have shown that montelukast is effective and safe in the treatment of patients with asthma, allergic rhinitis or both diseases.

Pharmacology of airway inflammation in asthma and COPD

The current asthma therapies are not cures and symptoms return soon after treatment is stopped even after long term treatment. Although inhaled glucocorticoids are highly effective in controlling airway inflammation in asthma, they are ineffective in the small group of patients with glucocorticoid-dependent and -resistant asthma. With very few exceptions, COPD is caused by tobacco smoking, and smoking cessation is the only truly effective treatment of COPD available. Current pharmacological treatment of COPD is unsatisfactory, as it does not significantly influence the severity of the disease or its natural course. Glucocorticoids are scarcely effective in COPD patients without concomitant asthma. Bronchodilators improves symptoms and quality of life, in COPD patients, but, with the exception of tiotropium, they do not significantly influence the natural course of the disease. Theophylline is the only drug which has been demonstrated to have a significant effect on airway inflammation in patients with COPD. Here we review the pharmacology of currently used antiinflammatory therapies for asthma and COPD and their proposed mechanisms of action. Recent understanding of disease mechanisms in severe steroid-dependent and -resistant asthma and in COPD, has lead to the development of novel compounds, which are in various stages of clinical development. We review the current status of some of these new potential drugs.

Transfection efficiency and toxicity following delivery of naked plasmid DNA and cationic lipid–DNA complexes to ovine lung segments

We defined, using a novel large animal model system, the acute pathologic response to localized pulmonary administration of either naked plasmid DNA (pDNA) or cationic lipid-pDNA complexes (pDNA:GL67) and related such responses to concomitant indicators of transfection efficiency, namely levels of chloramphenicol acetyl transferase (CAT) protein and mRNA in specific lung tissue compartments. We instilled doses of 0.2, 1, and 5 mg pDNA to spatially distinct lung segments in six anesthetized sheep and doses of 0.2, 1, and 5 mg pDNA:GL67 to a further six sheep. Twenty-four hours after gene delivery the sheep were euthanized and necropsy examination with sampling of relevant tissues was carried out. Levels of plasmid-derived CAT-specific mRNA and CAT protein in samples derived from segments treated with either pDNA or pDNA:GL67 increased in relation to the administered dose. Levels of mRNA and protein expression were greater for pDNA:GL67 than for pDNA alone. A significant correlation was observed between mRNA and protein expression in samples derived from airways treated with pDNA:GL67. Histopathological changes following administration of both pDNA and pDNA:GL67 were characterized by a neutrophilic inflammation predominantly oriented on airways. The severity of the inflammatory response appeared to correlate with the administered dose of DNA and was generally more severe for pDNA:GL67.

Benefit-risk assessment of antileukotrienes in the management of asthma

Antileukotrienes are a relatively new class of anti-asthma drugs that either block leukotriene synthesis (5-lipoxygenase inhibitors) like zileuton, or antagonise the most relevant of their receptors (the cysteinyl leukotriene 1 receptor [CysLT1]) like montelukast, zafirlukast or pranlukast. Hence, their major effect is an anti-inflammatory one. With the exception of pranlukast, the other antileukotrienes have been studied and marketed in the US and Europe for long enough to establish that they are useful drugs in the management of asthma. Their effects, significantly better than placebo, seem more pronounced in subjective measurements (i.e. symptoms scores or quality-of-life tests) than in objective parameters (i.e. forced expiratory volume in 1 second or peak expiratory flow rate). Also, there is some evidence that these drugs work better in some subsets of patients with certain genetic polymorphisms - probably related to their leukotriene metabolism - or patients with certain asthma characteristics. There are a small number of comparative studies only, and with regard to long-term asthma control differences between the agents have not been evaluated. Nevertheless, their overall effect appears comparable with sodium cromoglycate (cromolyn sodium) or theophylline, but significantly less than low-dose inhaled corticosteroids. Antileukotrienes have been shown to have a degree of corticosteroid-sparing effect, but salmeterol appears to perform better as an add-on drug. Montelukast is probably the most useful antileukotriene for continuous treatment of exercise-induced asthma, performing as well as salmeterol without inducing any tolerance. All antileukotrienes are taken orally; their frequency of administration is quite different ranging from four times daily (zileuton) to once daily (montelukast). Antileukotrienes are well tolerated drugs, even though zileuton intake has been related to transitional liver enzyme elevations in some cases. Also Churg-Strauss syndrome (a systemic vasculitis), has been described in small numbers of patients taking CysLT1 antagonists. It is quite probable that this disease appears as a consequence of an 'unmasking' effect when corticosteroid dosages are reduced in patients with severe asthma once CysLT1 antagonists are introduced, but more data are needed to definitely establish the mechanism behind this effect. Overall, however, the benefits of antileukotrienes in the treatment of asthma greatly outweigh their risks.

Inhibition of leukotriene biosynthesis by a novel dietary fatty acid formulation in patients with atopic asthma: a randomized, placebo-controlled, parallel-group, prospective trial

BACKGROUND

Leukotriene inhibitors and leukotriene-receptor antagonists are effective in the treatment of inflammatory diseases such as asthma. A search of the entirety of MEDLINE using the terms diet plus leukotrienes identified numerous studies that have explored dietary-management strategies to reduce leukotriene levels through supplementation with polyunsaturated fatty acids such as gamma-linolenic acid (GLA) and eicosapentaenoic acid (EPA). However, the search found no studies on the use of combinations of these fatty acids in patients with asthma.

OBJECTIVE

The goal of this study was to determine the effect of daily intake of an emulsion (PLT 3514) containing dietary GLA and EPA on ex vivo stimulated whole blood leukotriene biosynthesis in patients with atopic asthma.

METHODS

This was a randomized, double-blind, placebo-controlled, parallel-group, prospective trial in patients with mild to moderate atopic asthma. Patients consumed 10 g PLT 3514 emulsion (containing 0.75 g GLA + 0.5 g EPA), 15 g PLT 3514 emulsion (containing 1.13 g GLA + 0.75 g EPA), or placebo (olive oil) emulsion daily for 4 weeks. Plasma fatty acids were measured by gas chromatography, and stimulated whole blood leukotrienes were measured by reverse-phase high-performance liquid chromatography with ultraviolet detection using a diode array detector.

RESULTS

Forty-three patients (33 women, 10 men) participated in the study. Leukotriene biosynthesis was significantly decreased in patients consuming 10 or 15 g PLT 3514 compared with placebo (P < 0.05, analysis of covariance). No clinically significant changes in vital signs were observed throughout the study, and there were no significant between-group differences in treatment-emergent adverse events or mean clinical laboratory values.

CONCLUSION

Daily consumption of dietary GLA and EPA in a novel emulsion formulation inhibited leukotriene biosynthesis in this population of patients with atopic asthma and was well tolerated.

Inhibition of leukotriene synthesis, pharmacokinetics, and tolerability of a novel dietary fatty acid formulation in healthy adult subjects

BACKGROUND

Numerous studies have explored dietary-management strategies for decreasing leukotriene synthesis by inflammatory cells through supplementation with polyunsaturated fatty acids such as gamma-linolenic acid (GLA) and eicosapentaenoic acid (EPA).

OBJECTIVES

This study sought to determine the optimal daily intake, ratios, and formulation of dietary GLA and EPA required to safely reduce leukotriene biosynthesis in healthy individuals, and to evaluate the pharmacokinetics and safety profile of such a formulation.

METHODS

Two preliminary trials were conducted to determine the minimum effective levels of GLA and EPA intake needed to reduce leukotriene biosynthesis and prevent increases in plasma arachidonic acid (AA) concentrations. These preliminary trials were followed by a single-center, randomized, double-blind, placebo-controlled, parallel-group, escalating-intake inpatient trial of a dietary GLA/EPA emulsion (PLT 3514) in healthy adult subjects. Subjects consumed either 10, 20, or 100 g of the PLT 3514 emulsion (respectively containing 0.75 g GLA + 0.5 g EPA, 1.5 g GLA + 1 g EPA, and 7.5 g GLA + 5 g EPA), or a placebo emulsion containing olive oil daily for 14 days. Plasma fatty acids were measured by gas chromatography Stimulated whole blood leukotrienes were measured by high-performance liquid chromatography with ultraviolet detection.

RESULTS

Thirty subjects were included in the preliminary trials; 47 subjects were enrolled in the escalating-intake trial, of whom 42 completed the study. In the preliminary trials, intake of GLA 1.5 g/d in gelatin capsules decreased the capacity to synthesize leukotrienes but increased plasma levels of AA (both, P < 0.05). Inclusion of 0.25 or 1 g of dietary EPA prevented the increase in plasma AA concentrations. Dietary GLA and EPA showed significantly enhanced bioavailability when consumed in 20 g PLT 3514 emulsion compared with consumption in gelatin capsules (P < 0.05), resulting in a reduction in the amount of intake required to block leukotriene biosynthesis. Pharmacokinetic analyses indicated that fasting plasma GLA and EPA levels plateaued within 7 days' daily consumption at all levels of intake, whereas the time to maximum plasma concentration (Tmax) was shorter for GLA than for EPA. The Tmax was similar on days 1 and 14 for both GLA and EPA. There were no clinically significant between-group differences in changes in vital signs, mean clinical laboratory values, or abbreviated hematology laboratory tests, or significant differences in the occurrence of treatment-emergent adverse events between the group consuming up to 20 g/d of the GLA/EPA emulsion and the group consuming placebo.

CONCLUSION

Consumption of specific proportions and intake levels of dietary GLA and EPA in a novel emulsion formulation inhibited leukotriene biosynthesis and appeared to be well tolerated in this population of healthy adult subjects.

Inflammatory cells in asthma: mechanisms and implications for therapy

Recent clinical studies have brought asthma's complex inflammatory processes into clearer focus, and understanding them can help to delineate therapeutic implications. Asthma is a chronic airway inflammatory disease characterized by the infiltration of airway T cells, CD(+) (T helper) cells, mast cells, basophils, macrophages, and eosinophils. The cysteinyl leukotrienes also are important mediators in asthma and modulators of cytokine function, and they have been implicated in the pathophysiology of asthma through multiple mechanisms. Although the role of eosinophils in asthma and their contribution to bronchial hyperresponsiveness are still debated, it is widely accepted that their numbers and activation status are increased. Eosinophils may be targets for various pharmacologic activities of leukotriene receptor antagonists through their ability to downregulate a number of events that may be key to the effector function of these cells.

Effects of montelukast and budesonide on airway responses and airway inflammation in asthma

Inhaled corticosteroids are effective antiinflammatory therapy for asthma; however, they do not completely abolish allergen-induced airway inflammation. Leukotriene modifiers attenuate both early and late allergen responses and have antiinflammatory properties. We reasoned that treatment with budesonide and montelukast in combination might provide greater antiinflammatory effects than either drug alone, and the purpose of this study was to compare the effects of treatment with budesonide and montelukast, alone or in combination, on outcome variables after allergen inhalation. Ten subjects with asthma with dual responses after allergen inhalation were included in this randomized, double-blind, crossover study. Outcomes included early and late asthmatic responses, and changes in airway responsiveness and sputum eosinophilia, measured before and after challenge. Treatment with montelukast attenuated the maximal early asthmatic response compared with placebo (p < 0.001) and budesonide (p = 0.002). Both budesonide and montelukast, alone and in combination, attenuated the maximal late asthmatic response compared with placebo (p < 0.01). Budesonide and montelukast, alone and in combination, afforded protection against allergen-induced airway hyperresponsiveness (p < 0.05), although the treatment effect of budesonide was greater than that of montelukast (p < 0.05). Treatment with budesonide and montelukast, alone and in combination, also attenuated allergen-induced sputum eosinophilia. Thus, montelukast and budesonide attenuated allergen-induced asthmatic responses, airway hyperresponsiveness, and sputum eosinophilia, although combination treatment did not provide greater antiinflammatory effects than either drug alone.

Comparison of a nasal glucocorticoid, antileukotriene, and a combination of antileukotriene and antihistamine in the treatment of seasonal allergic rhinitis

BACKGROUND

Allergic rhinitis requires active intervention for symptom relief. A combination of antileukotriene and antihistamine drugs has been suggested to provide additive treatment benefits for patients with allergic rhinitis.

OBJECTIVE

We evaluated how such a combination treatment would affect symptoms and local mucosal eosinophilia in comparison with a nasal glucocorticoid.

METHODS

In a double-blind, randomized study 62 patients with grass pollen-induced allergic rhinitis received a nasal glucocorticoid (fluticasone propionate aqueous nasal spray [FPANS], 200 microg/d), an antileukotriene (montelukast, 10 mg/d), a combination of montelukast with an antihistamine (loratadine, 10 mg/d), or placebo throughout the season. Cromoglycate eyedrops and a limited amount of loratadine were allowed as rescue medication for severe symptoms. Patients recorded their symptoms for nasal blockage, itching, rhinorrhea, and sneezing. Before and during the season, nasal biopsy specimens were obtained from patients for evaluation of local eosinophilic inflammation.

RESULTS

During the peak season, both FPANS and combined montelukast-loratadine were significantly more effective than placebo and montelukast alone for daytime symptom prevention. For nighttime symptoms, FPANS was significantly more effective compared with all other treatments, whereas combined montelukast-loratadine and montelukast alone did not provide significant symptom prevention compared with placebo. The pollen-induced increase in the numbers of epithelial eosinophils was significantly lower for FPANS-treated patients compared with that seen in all other treatment groups.

CONCLUSION

In patients with seasonal allergic rhinitis, intranasal glucocorticoids are more effective than an antileukotriene drug or combined antileukotriene-antihistamine for the reduction of pollen-induced nasal eosinophilic inflammation and for control of nasal symptoms.

Pathophysiological role of leukotrienes in dermatological diseases: potential therapeutic implications

In vitro and in vivo data have demonstrated that leukotrienes play a key role not only in allergic airway diseases but also in inflammatory reactions of the skin. Antileukotriene drugs, i.e. leukotriene receptor antagonists and synthesis inhibitors, are a new class of anti-inflammatory drugs that have shown clinical efficacy in the management of asthma, allergic rhinitis and inflammatory bowel disease. To address the question of the validity and applicability of published evidence of the use of antileukotriene drugs in dermatological diseases, we reviewed data concerning the pathophysiological effect of leukotrienes in the skin and in skin diseases, and the experience with antileukotriene treatment that has been published. In vivo and in vitro data suggest that antileukotriene treatment may have efficacy in atopic dermatitis, different types of urticaria or psoriasis and other skin diseases such as bullous skin diseases, collagenoses, Sjogren-Larsson syndrome or Kawasaki disease. Nevertheless, published evidence is very limited and before any conclusions can be drawn, additional basic research needs to be performed with regard to the role of different leukotrienes and leukotriene receptors in skin diseases. On the basis of these data, randomised and placebo-controlled clinical trials with leukotriene antagonists and synthesis inhibitors should be performed. Moreover, future studies investigating the additive benefit of antileukotriene drugs are warranted, e.g. in combination with antihistamines, corticosteroids or other anti-inflammatory drugs.

Local lung responses following local lung challenge with recombinant lungworm antigen in systemically sensitized sheep

BACKGROUND

Chronic mast cell-mediated inflammation may contribute significantly towards the extensive tissue remodelling that is a feature of lungworm infection in ruminants. Understanding the factors that control tissue remodelling is a necessary step toward effective management and treatment of conditions that feature such pathology.

OBJECTIVE

We sought to define in a novel ovine model system, the cellular, immune and mast cell phenotypic events that occur following local lung challenge with a recombinant protein antigen, DvA-1, derived from the ruminant lungworm nematode, Dictyocaulus viviparus.

METHODS

Two spatially disparate lung segments in systemically sensitized sheep were challenged on three occasions with DvA-1 (3xDVA) and two further segments were challenged with saline (3xSAL). Two months after the third challenge, one of the two segments previously repeatedly challenged with DvA-1 was challenged again with DvA-1 (3xDVA:DVA) whilst the other was challenged with saline (3xDVA:SAL). A similar protocol was followed with the saline challenged segments (3xSAL:SAL and 3xSAL:DVA). Bronchoalveolar lavage fluid (BALF) (n = 16) and tissue (n = 3) were collected after the last challenge.

RESULTS

Cellular changes 24 h after the fourth challenge were characterized by an increase in the absolute numbers of neutrophils and eosinophils in BALF from 3xDVA:DVA and 3xSAL:DVA segments. Local antibody production was implied through increased levels of antibody in both 3xDVA:DVA and 3xDVA:SAL segments, with the latter being unaffected by inflammation. Levels of active transforming growth factor beta-1 (TGF-beta(1)) were significantly increased in 3xDVA:SAL segments and a trend towards an increase was apparent in 3xDVA:DVA segments. Total TGF-beta1 levels were significantly correlated with eosinophil counts in all except the 3xDVA:SAL segments. Such changes in the bronchoalveolar space were complemented by increased ratios of sheep mast cell proteinase-1 expressing cells and tryptase expressing cells, to toluidine blue positive cells in airways from 3xDVA:DVA segments.

CONCLUSION

Mast cell phenotypic events occurring as a consequence of antigen challenge were limited to segments in which changes in BALF were characterized by neutrophil influx and increased local antibody production.

Leukotrienes in respiratory disease

Arachidonic acid metabolism via 5-lipoxygenase gives rise to a group of biologically active lipids known as leukotrienes: leukotriene B(4), which is a potent activator of leukocyte chemotaxis, and cysteinyl leukotrienes (leukotriene C(4), D(4)and E(4)) which account for the spasmogenic activity previously described as slow-reacting substance of anaphylaxis. The biological actions of leukotrienes and the observations that leukotrienes are synthesised in the lung following antigen provocation and are elevated in asthma, stimulated considerable activity in the pharmaceutical industry to find drugs that modulate the synthesis or actions of leukotrienes. Three cysteinyl leukotriene antagonists (zafirlukast [Accolate], montelukast [Singulair] and pranlukast) and one 5-lipoxygenase inhibitor (zileuton) have received regulatory approval for the treatment of asthma. The clinical data obtained from using these drugs are generally consistent and complimentary. As a class the leukotriene modulators produce a rapid improvement in lung function after the first oral dose. Lung function improvements are maintained on chronic administration and are associated with reductions in a variety of asthma symptom scores. All of the available data are consistent with the hypothesis that all the leukotriene modulators exert their clinical benefit primarily through interference with cysteinyl leukotrienes. There are no compelling clinical data for an additional contribution by leukotriene B(4)in human asthma. In other respiratory conditions such as COPD, which are characterised by pronounced neutrophil infiltration, it may be that the chemotactic properties of leukotriene B(4)are more important and therefore evaluation of 5-lipoxygenase inhibitors in this condition is warranted. The introduction of the leukotriene modulators into clinical practice is the culmination of over 60 years of research since the initial discovery of the slow-reacting substances. The leukotriene modulators, and in particular the cysteinyl leukotriene antagonists, provide respiratory physicians with an oral therapeutic option and have set an efficacy standard which new oral anti-inflammatory approaches will have to beat.

Efficacy of antileukotriene agents in asthma management

OBJECTIVE

This article reviews information on the role of three antileukotrienes (anti-LTs), montelukast, zafirlukast, and zileuton, in the management of asthma. After reading this article, readers should have an understanding of the efficacy of anti-LTs in specific patient populations.

DATA SOURCES

Relevant and appropriately controlled clinical studies on the efficacy of anti-LTs were used. Only literature in the English language was reviewed.

STUDY SELECTION

Material was taken from peer-reviewed journals and published abstracts.

RESULTS

The efficacy of anti-LTs has been established in numerous randomized, controlled, multicenter trials involving patients with mild-to-moderate disease. These agents reduce asthma symptoms, beta2-agonist use, and asthma exacerbations, in addition to improving pulmonary function. The anti-LTs are also effective when added to low-dose or high-dose corticosteroid regimens in symptomatic asthma patients. They have proven efficacy in patients with aspirin-sensitive asthma, and they appear able to reduce nasal congestion in asthma patients with concomitant upper airway symptoms. Some anti-LTs have been shown to be effective in pediatric asthma patients.

CONCLUSIONS

In reviewing available clinical results as well as real-world experience in managing asthma patients, the Antileukotriene Working Group concludes that anti-LTs may be used in patients with mild persistent asthma as well as in combination with other asthma medications at all levels of disease severity for long-term maintenance of asthma control.

The role of antileukotrienes in the treatment of asthma

OBJECTIVE

This article reviews the literature on the role of antileukotrienes (anti-LTs), specifically montelukast, zafirlukast, and zileuton, in the treatment of asthma.

DATA SOURCES

Relevant and appropriate controlled clinical studies were used. Only literature in the English language was reviewed.

STUDY SELECTION

Material was taken from academic/scholarly journals, appropriate reviews, and published abstracts.

RESULTS

In guidelines established by the National Asthma Education and Prevention Program and the National Heart, Lung, and Blood Institute, a stepwise approach to asthma management is recommended, with recommendations varying depending on degree of disease severity. The anti-LTs, the newest class of drugs for the treatment of asthma, play a circumscribed role in the guidelines as they were only recently available when the latest guidelines were published. Subsequently, however, extensive clinical experience with the anti-LTs has been amassed. Multiple clinical studies have demonstrated that the anti-LTs improve pulmonary function and quality of life, and reduce asthma symptoms, asthma exacerbations, and use of beta2-agonists and oral steroids. The anti-LTs may be particularly useful in asthma patients with aspirin sensitivity or concomitant allergic rhinitis, as well as in pediatric patients. These agents have additive effects with inhaled corticosteroids and may permit a reduction in inhaled corticosteroid dosages.

CONCLUSIONS

The anti-LTs have several features that are likey to promote adherence to treatment and are generally well tolerated. The available clinical data suggest that anti-LTs should be considered as a therapeutic option or as additive therapy in patients with mild to severe asthma.

Update on the role of leukotrienes in the pathogenesis of atopy: a comparative review

The pathogenesis of atopic disease (AD) is controversial in humans and dogs. In humans, leukotrienes (LT) are thought to play an important role in this disease and LT inhibitors are commonly used as treatment for AD. Leukotrienes are a heterogeneous group of biologically active compounds that mediate many aspects of inflammatory and allergic reactions. This paper will review the role of LT in atopic disease in a comparative manner. Leukotriene inhibitors and their therapeutic use in the management of atopic disease in humans and dogs are discussed.

Leukotrienes as mediators of asthma

This review describes the aspects of leukotriene (LT) pharmacology and biology that are relevant to their important role in asthma. The biosynthesis and metabolism, including transcellular metabolism, of LTB4 and the cysteinyl-LTs (i.e. LTC4, LTD4 and LTE4) are described, and their transport is briefly outlined. The existence, distribution and pharmacological characterization of the receptors (BLT, CysLT1, CysLT2), as well as the transduction mechanisms triggered, are discussed in detail. We also describe their effects on airway smooth muscle tone, hyperresponsiveness and proliferation, on vascular tone and permeability, on mucus secretion, on neural fibers and inflammatory cell functions. Finally, the evidence supporting their role as asthma mediators is reviewed, including the effects of anti LT drugs (both biosynthesis inhibitors and receptor antagonists) in experimental and clinical asthma.

Antileukotrienes in asthma: present situation

Leukotrienes are key mediators in asthma. Over the last 5 years, several antileukotrienes, including three receptor antagonists (montelukast, pranlukast and zafirlukast) and one 5-lipoxygenase inhibitor (zileuton), have been marketed and, to date, this class of drugs is being used widely. Still, their definite place in the asthma treatment algorithm is not yet established. These novel drugs have not yet all been evaluated in the same depth, but they have all been shown to possess anti-inflammatory properties and to be effective in chronic asthma treatment. Zafirlukast and montelukast are particularly efficacious in exercise-induced asthma and zileuton appears valuable for treating aspirin-intolerant asthmatics. Clinical comparisons to other anti-asthma drugs are still sparse. The corticosteroid-sparing effect of antileukotrienes is fairly well established except for zileuton, even though this drug has been evaluated most thoroughly in terms of its anti-inflammatory effects. Montelukast is the antileukotriene most extensively evaluated in children and zafirlukast has recently been approved for use in children in the USA, although not yet in Europe. Therapeutic regimes are quite variable depending on the drug, but all of the antileukotrienes marketed to date are taken orally; hence, compliance is usually greater than that with inhaled medication. Response to antileukotrienes appears to depend on the individual patients' characteristics, in particular on genetic polymorphisms related to leukotriene metabolism. All drugs of this class are well tolerated and only in the case of zileuton is there potential for hepatic adverse effects. The diagnosis of Churg-Strauss syndrome made among patients taking antileukotrienes seems to be more related to the withdrawal of corticosteroids than to the antileukotrienes themselves.