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Somayaji R, Nichols DP, Bell SC. Cystic fibrosis - Ten promising therapeutic approaches in the current era of care. Expert Opin Investig Drugs 2020; 29:1107-1124. [PMID: 32744089 DOI: 10.1080/13543784.2020.1805733] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Cystic fibrosis (CF) is a genetic disease affecting multiple organ systems. Research and innovations in novel therapeutic agents and health care delivery have resulted in dramatic improvements in quality of life and survival for people with CF. Despite this, significant disease burden persists for many and this is compounded by disparities in treatment access and care which globally necessitates further work to improve outcomes. Because of the advent of numerous therapies which include gene-targeted modulators in parallel with specialized care delivery models, innovative efforts continue. AREAS COVERED In this review, we discuss the available data on investigational agents in clinical development and currently available treatments for CF. We also evaluate approaches to care delivery, consider treatment gaps, and propose future directions for advancement. EXPERT OPINION Since the discovery of the CF gene, CFTR modulators have provided a hallmark of success, even though it was thought not previously possible. This has led to reinvigorated efforts and innovations in treatment approaches and care delivery. Numerous challenges remain because of genetic and phenotypic heterogeneity, access issues, and therapeutic costs, but the collaborative approach between stakeholders for continued innovation fuels optimism. Abbreviations: CF cystic fibrosis; CFF Cystic Fibrosis Foundation (USA); CFTR cystic fibrosis transmembrane regulator; CRISPR clustered regularly interspaced short palindromic repeats; COX cyclo oxygenase; FDA US Food and Drug Administration; FEV1% forced expiratory volume in one second % predicted; F508del deletion of phenylalanine (F) in the 508th position (most common mutation); G551D substitution of the amino acid glycine by aspartate at position 551 in the nucleotide binding domain-1 of the CFTR gene; LMIC low- and middle-income country; LTB4 leukotriene B4; MDT multi-disciplinary care team; NO nitric oxide; NSAIDs non-steroidal anti-inflammatory drugs; SLPI secretory leukocyte protease inhibitor.
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Affiliation(s)
- Ranjani Somayaji
- Departments of Medicine; Microbiology, Immunology & Infectious Disease; Community Health Sciences, University of Calgary , Calgary, AB, Canada.,Snyder Institute for Chronic Diseases , Calgary, AB, Canada.,O'Brien Institute for Public Health , Calgary, AB, Canada
| | - Dave P Nichols
- Department of Pediatrics, Seattle Children's Hospital , Seattle, WA, USA.,Department of Pediatrics, University of Washington , Seattle, WA, USA.,Seattle Children's Research Institute , Seattle, WA, USA
| | - Scott C Bell
- Department of Thoracic Medicine, The Prince Charles Hospital , Brisbane, QLD, Australia.,Children's Health Research Centre, Faculty of Medicine, The University of Queensland , Brisbane, QLD, Australia.,Translational Research Institute , Brisbane, QLD, Australia
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Clarithromycin attenuates IL-13-induced periostin production in human lung fibroblasts. Respir Res 2017; 18:37. [PMID: 28219384 PMCID: PMC5319114 DOI: 10.1186/s12931-017-0519-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Accepted: 02/06/2017] [Indexed: 01/14/2023] Open
Abstract
Background Periostin is a biomarker indicating the presence of type 2 inflammation and submucosal fibrosis; serum periostin levels have been associated with asthma severity. Macrolides have immunomodulatory effects and are considered a potential therapy for patients with severe asthma. Therefore, we investigated whether macrolides can also modulate pulmonary periostin production. Methods Using quantitative PCR and ELISA, we measured periostin production in human lung fibroblasts stimulated by interleukin-13 (IL-13) in the presence of two 14-member–ring macrolides—clarithromycin or erythromycin—or a 16-member–ring macrolide, josamycin. Phosphorylation of signal transducers and activators of transcription 6 (STAT6), downstream of IL-13 signaling, was evaluated by Western blotting. Changes in global gene expression profile induced by IL-13 and/or clarithromycin were assessed by DNA microarray analysis. Results Clarithromycin and erythromycin, but not josamycin, inhibited IL-13–stimulated periostin production. The inhibitory effects of clarithromycin were stronger than those of erythromycin. Clarithromycin significantly attenuated STAT6 phosphorylation induced by IL-13. Global gene expression analyses demonstrated that IL-13 increased mRNA expression of 454 genes more than 4-fold, while decreasing its expression in 390 of these genes (85.9%), mainly “extracellular,” “plasma membrane,” or “defense response” genes. On the other hand, clarithromycin suppressed 9.8% of the genes in the absence of IL-13. Clarithromycin primarily attenuated the gene expression of extracellular matrix protein, including periostin, especially after IL-13. Conclusions Clarithromycin suppressed IL-13–induced periostin production in human lung fibroblasts, in part by inhibiting STAT6 phosphorylation. This suggests a novel mechanism of the immunomodulatory effect of clarithromycin in asthmatic airway inflammation and fibrosis. Electronic supplementary material The online version of this article (doi:10.1186/s12931-017-0519-8) contains supplementary material, which is available to authorized users.
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The design of novel classes of macrolides for neutrophil-dominated inflammatory diseases. Future Med Chem 2015; 6:657-74. [PMID: 24895894 DOI: 10.4155/fmc.14.14] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Neutrophil-dominated inflammatory diseases, like chronic obstructive pulmonary disease, cystic fibrosis, bronchiectasis, bronchiolitis obliteras syndrome and non-eosinophilic asthma, present a significant medical problem lacking adequate therapy. Macrolide antibiotics have been reported to be effective in the treatment of the aforementioned diseases, for reasons unrelated to their antibacterial action. This has resulted in research activities aimed at gaining a better understanding of the immunomodulatory actions of macrolides and the synthesis of various novel anti-inflammatory macrolides without antimicrobial activity. Despite the difficult chemistry and lack of an extensive knowledge for their mechanism of action, several interesting molecules from this class, including potential clinical candidates, are on the horizon.
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Li YJ, Shimizu T, Hirata Y, Inagaki H, Takizawa H, Azuma A, Kawada T, Sugawara I, Kudoh S, Sunazuka T, Omura S. EM, EM703 inhibit NF-kB activation induced by oxidative stress from diesel exhaust particle in human bronchial epithelial cells: Importance in IL-8 transcription. Pulm Pharmacol Ther 2013; 26:318-24. [DOI: 10.1016/j.pupt.2012.12.010] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2011] [Revised: 12/13/2012] [Accepted: 12/24/2012] [Indexed: 01/17/2023]
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Serisier DJ. Risks of population antimicrobial resistance associated with chronic macrolide use for inflammatory airway diseases. THE LANCET RESPIRATORY MEDICINE 2013; 1:262-74. [PMID: 24429132 DOI: 10.1016/s2213-2600(13)70038-9] [Citation(s) in RCA: 117] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Macrolide antibiotics have established efficacy in the management of cystic fibrosis and diffuse panbronchiolitis-uncommon lung diseases with substantial morbidity and the potential for rapid progression to death. Emerging evidence suggests benefits of maintenance macrolide treatment in more indolent respiratory diseases including chronic obstructive pulmonary disease and non-cystic fibrosis bronchiectasis. In view of the greater patient population affected by these disorders (and potential for macrolide use to spread to disorders such as chronic cough), widespread use of macrolides, particularly azithromycin, has the potential to substantially influence antimicrobial resistance rates of a range of respiratory microbes. In this Personal View, I explore theories around population (rather than patient) macrolide resistance, appraise evidence linking macrolide use with development of resistance, and highlight the risks posed by injudicious broadening of their use, particularly of azithromycin. These risks are weighed against the potential benefits of macrolides in less aggressive inflammatory airway disorders. A far-sighted approach to maintenance macrolide use in non-cystic fibrosis inflammatory airway diseases is needed, which minimises risks of adversely affecting community macrolide resistance: combining preferential use of erythromycin and restriction of macrolide use to those patients at greatest risk represents an appropriately cautious management approach.
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Affiliation(s)
- David J Serisier
- Department of Respiratory Medicine, Mater Adult Hospital, South Brisbane, QLD, Australia; University of Queensland and Mater Medical Research Institute, Mater Health Services, South Brisbane, QLD, Australia.
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Cameron EJ, McSharry C, Chaudhuri R, Farrow S, Thomson NC. Long-term macrolide treatment of chronic inflammatory airway diseases: risks, benefits and future developments. Clin Exp Allergy 2013; 42:1302-12. [PMID: 22925316 DOI: 10.1111/j.1365-2222.2012.03979.x] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Macrolide antibiotics were discovered over 50 years ago and following their use as antimicrobials it became apparent that this group of antibiotics also possessed anti-inflammatory properties. Subsequent clinical trials showed benefits of macrolides as long-term adjuncts in the treatment of a spectrum of chronic inflammatory respiratory diseases, particularly diffuse panbronchiolitis, cystic fibrosis, post-transplant bronchiolitis obliterans and more recently chronic obstructive pulmonary disease (COPD). The evidence for efficacy of macrolides in the long-term treatment of chronic asthma and bronchiectasis is less well established. The mechanism(s) of action of macrolides in the treatment of these diseases remains unexplained, but may be due to their antibacterial and/or anti-inflammatory actions, which include reductions in interleukin-8 production, neutrophil migration and/or function. Macrolides have additional potentially beneficial properties including anti-viral actions and an ability to restore corticosteroid sensitivity. The increased prescribing of macrolides for long-term treatment could result in the development of microbial resistance and adverse drug effects. New macrolides have been developed which do not possess any antimicrobial activity and hence lack the ability to produce microbial resistance, but which still retain immunomodulatory effects. Potentially novel macrolides may overcome a significant barrier to the use of this type of drug for the long-term treatment of chronic inflammatory airway diseases.
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Affiliation(s)
- E J Cameron
- Respiratory Medicine, Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK.
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Banerjee B, Musk M, Sutanto EN, Yerkovich ST, Hopkins P, Knight DA, Lindsey-Temple S, Stick SM, Kicic A, Chambers DC. Regional differences in susceptibiity of bronchial epithelium to mesenchymal transition and inhibition by the macrolide antibiotic azithromycin. PLoS One 2012; 7:e52309. [PMID: 23284981 PMCID: PMC3528745 DOI: 10.1371/journal.pone.0052309] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2012] [Accepted: 11/16/2012] [Indexed: 12/11/2022] Open
Abstract
Objective Dysregulated repair following epithelial injury is a key forerunner of disease in many organs, and the acquisition of a mesenchymal phenotype by the injured epithelial cells (epithelial to mesenchymal transition, EMT) may serve as a source of fibrosis. The macrolide antibiotic azithromycin and the DNA synthesis inhibitor mycophenolate are in clinical use but their mechanism of action remains unknown in post-transplant bronchiolitis obliterans syndrome (BOS). Here we determined if regional variation in the EMT response to TGFβ1 underlies the bronchiolocentric fibrosis leading to BOS and whether EMT could be inhibited by azithromycin or mycophenolate. Methods/Results We found that small and large airway epithelial cells from stable lung transplant patients underwent EMT when stimulated with TGFβ1, however mesenchymal protein expression was higher and loss of epithelial protein expression more complete in small airway epithelial cells. This regional difference was not mediated by changes in expression of the TGFβRII or Smad3 activation. Azithromycin potentially inhibited EMT in both small and large airway epithelial cells by inhibiting Smad3 expression, but not activation. Conclusion Collectively, these observations provide a biologic basis for a previously unexplained but widely observed clinical phenomena, and a platform for the development of new approaches to fibrotic diseases.
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Affiliation(s)
- Balarka Banerjee
- School of Paediatrics and Child Health, the University of Western Australia, Nedlands, Western Australia, Australia
- School of Medicine and Pharmacology, the University of Western Australia, Nedlands, Western Australia, Australia
- Western Australia Lung Transplant Program, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Michael Musk
- Western Australia Lung Transplant Program, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Erika N. Sutanto
- Telethon Institute for Child Health Research, Centre for Child Health Research, the University of Western Australia, Subiaco, Western Australia, Australia
| | | | - Peter Hopkins
- School of Medicine, The University of Queensland, Herston, Queensland, Australia
| | - Darryl A. Knight
- University of British Columbia, James Hogg Research Centre for Cardiovascular and Pulmonary Research, Vancouver, British Columbia, Canada
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Suzanna Lindsey-Temple
- Centre for Asthma and Allergy Research Institute (CAARR) The Lung Institute of Western Australia, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Stephen M. Stick
- School of Paediatrics and Child Health, the University of Western Australia, Nedlands, Western Australia, Australia
- Department of Respiratory Medicine, Princess Margaret Hospital for Children, Perth, Western Australia, Australia
- Telethon Institute for Child Health Research, Centre for Child Health Research, the University of Western Australia, Subiaco, Western Australia, Australia
| | - Anthony Kicic
- School of Paediatrics and Child Health, the University of Western Australia, Nedlands, Western Australia, Australia
- Department of Respiratory Medicine, Princess Margaret Hospital for Children, Perth, Western Australia, Australia
- Telethon Institute for Child Health Research, Centre for Child Health Research, the University of Western Australia, Subiaco, Western Australia, Australia
| | - Daniel C. Chambers
- School of Medicine, The University of Queensland, Herston, Queensland, Australia
- Queensland Lung Transplant Service, The Prince Charles Hospital, Brisbane, Queensland, Australia
- * E-mail:
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Wu M, Aung H, Hirsch CS, Toossi Z. Inhibition of Mycobacterium tuberculosis-induced signalling by transforming growth factor-β in human mononuclear phagocytes. Scand J Immunol 2012; 75:301-4. [PMID: 22150316 DOI: 10.1111/j.1365-3083.2011.02668.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Tuberculosis (TB) is associated with excessive production and bioactivation of transforming growth factor bets (TGF-β) in situ. Here, modification of expression of components of plasminogen/plasmin pathway in human monocytes (MN) by inhibitors of TGF-β signalling was examined. Smad3 siRNA effectively inhibited TGF-β-induced urokinase plasminogen activator receptor (uPAR). Agents known to interfere with TGF-β signalling, including the Smad inhibitors SIS3 and erythromycin derivatives, and ALK5 receptor inhibitor (SB 431542) in inhibition of uPAR expression in response to Mycobacterium tuberculosis (MTB) were examined. Inhibition by SIS3 only inhibited uPAR mRNA significantly. SIS3 may prove to be an effective adjunct to TB therapy.
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Affiliation(s)
- M Wu
- Case Western Reserve University Veterans Affairs Medical Center, Cleveland, OH, USA
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Zarogoulidis P, Papanas N, Kioumis I, Chatzaki E, Maltezos E, Zarogoulidis K. Macrolides: from in vitro anti-inflammatory and immunomodulatory properties to clinical practice in respiratory diseases. Eur J Clin Pharmacol 2011; 68:479-503. [PMID: 22105373 DOI: 10.1007/s00228-011-1161-x] [Citation(s) in RCA: 187] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2011] [Accepted: 10/25/2011] [Indexed: 12/12/2022]
Abstract
BACKGROUND Macrolides have long been recognised to exert immunomodulary and anti-inflammatory actions. They are able to suppress the "cytokine storm" of inflammation and to confer an additional clinical benefit through their immunomodulatory properties. METHODS A search of electronic journal articles was performed using combinations of the following keywords: macrolides, COPD, asthma, bronchitis, bronchiolitis obliterans, cystic fibrosis, immunomodulation, anti-inflammatory effect, diabetes, side effects and systemic diseases. RESULTS Macrolide effects are time- and dose-dependent, and the mechanisms underlying these effects remain incompletely understood. Both in vitro and in vivo studies have provided ample evidence of their immunomodulary and anti-inflammatory actions. Importantly, this class of antibiotics is efficacious with respect to controlling exacerbations of underlying respiratory problems, such as cystic fibrosis, asthma, bronchiectasis, panbrochiolitis and cryptogenic organising pneumonia. Macrolides have also been reported to reduce airway hyper-responsiveness and improve pulmonary function. CONCLUSION This review provides an overview on the properties of macrolides (erythromycin, clarithromycin, roxithromycin, azithromycin), their efficacy in various respiratory diseases and their adverse effects.
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Affiliation(s)
- P Zarogoulidis
- Pulmonary Department, G. Papanikolaou Hospital, Aristotle University of Thessaloniki, Thessaloniki 57010, Greece.
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Lee YC, Hung MH, Liu LY, Chang KT, Chou TY, Wang YC, Wu YC, Lai CL, Tsai CC, Su KC, Perng DW. The roles of transforming growth factor-β₁ and vascular endothelial growth factor in the tracheal granulation formation. Pulm Pharmacol Ther 2010; 24:23-31. [PMID: 21056681 DOI: 10.1016/j.pupt.2010.10.016] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2010] [Revised: 10/27/2010] [Accepted: 10/29/2010] [Indexed: 11/26/2022]
Abstract
BACKGROUND Acquired tracheal stenosis is common in patients with a long-term tracheostomy and granulation is one of the most commonly observed lesions in benign airway stenosis. The aim of this study was to investigate the mechanisms of tracheal granulation formation and find the potential therapeutic targets to prevent the granulation formation. RESULTS In granulation tissue obtained from patients during interventional bronchoscopy for the relief of airway obstruction, increased expression of transforming growth factor (TGF)-β₁ and vascular endothelial growth factor (VEGF), as well as increased numbers of fibroblasts, was found by immunohistochemical staining. TGF-β₁ expression was detected in both the epithelial and submucosal layers. The highest levels of VEGF and vimentin expression occurred in the submucosal layers. In comparison with the control, significantly increased numbers of small vessels were observed in the submucosal layers of the granulation tissue. In vitro, TGF-β₁ stimulated production of VEGF by cultured fibroblasts at both the mRNA and protein level. VEGF siRNA treatment resulted in a significant decrease of TGF-β₁-induced VEGF production. SIS3, a selective Smad3 inhibitor, and UO126 both inhibited p44/42 MAP kinase phosphorylation and attenuated subsequent VEGF production by fibroblasts. A low concentration of erythromycin (1 μg/ml), but not dexamethasone (100 μM), inhibited TGF-β₁-induced VEGF production. CONCLUSION This study provides important information that facilitates an understanding, at least in part, of the mechanisms of granulation formation. Targeting these mediators and cells may help to prevent the formation of granulation tissue in long-term tracheostomy or prolonged endotracheal intubation patients.
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Affiliation(s)
- Yu-Chin Lee
- Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan
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Mechanisms of action and clinical application of macrolides as immunomodulatory medications. Clin Microbiol Rev 2010; 23:590-615. [PMID: 20610825 DOI: 10.1128/cmr.00078-09] [Citation(s) in RCA: 442] [Impact Index Per Article: 31.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Macrolides have diverse biological activities and an ability to modulate inflammation and immunity in eukaryotes without affecting homeostatic immunity. These properties have led to their long-term use in treating neutrophil-dominated inflammation in diffuse panbronchiolitis, bronchiectasis, rhinosinusitis, and cystic fibrosis. These immunomodulatory activities appear to be polymodal, but evidence suggests that many of these effects are due to inhibition of extracellular signal-regulated kinase 1/2 (ERK1/2) phosphorylation and nuclear factor kappa B (NF-kappaB) activation. Macrolides accumulate within cells, suggesting that they may associate with receptors or carriers responsible for the regulation of cell cycle and immunity. A concern is that long-term use of macrolides increases the emergence of antimicrobial resistance. Nonantimicrobial macrolides are now in development as potential immunomodulatory therapies.
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