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Arshid S, Ullah SE, Imran J, Syed MA, Choradia A, Gousy N, Boparai S, Shoaib M, Shah BB, Netha A. The effectiveness of hyaluronic acid in reducing adverse effects associated with inhaled hypertonic saline therapy in patients with cystic fibrosis: A systematic review and meta-analysis. CANADIAN JOURNAL OF RESPIRATORY THERAPY : CJRT = REVUE CANADIENNE DE LA THERAPIE RESPIRATOIRE : RCTR 2023; 59:214-222. [PMID: 37927455 PMCID: PMC10621800 DOI: 10.29390/001c.89093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 10/20/2023] [Indexed: 11/07/2023]
Abstract
Background Inhaled hypertonic saline (HS) is an effective mucolytic agent in patients with cystic fibrosis (CF). However, adverse events can impair the clinical utility of hypertonic saline (HS) in this patient population. In this study, we aimed to investigate the effectiveness of hyaluronic acid (HA) in reducing these adverse events. Methods A literature search was conducted across three electronic databases (Medline, Cochrane Central, and EMBASE) from inception through February 2023. Randomized controlled trials (RCTs) assessing the impact of hyaluronic acid (HA) in reducing adverse events in patients taking hypertonic saline (HS) for CF were included in the analysis. Outcomes of interest included cough, throat irritation, unpleasant taste, and FEV1. Evaluations were reported as risk ratios (RRs) and mean differences (MDs) with 95% confidence intervals (CI). The Cochrane Risk of Bias Tool (CRBT) was employed to assess the quality of RCTs. The New Castle Ottawa Scale was used to assess the quality of observational studies. Results From the 1960 articles retrieved from the initial search, five relevant studies (n=236 patients) were included in the final analysis. Compared with patients only on HS, patients with HS and HA were significantly less likely to experience cough (RR: 0.45; 95% CI, 0.28-0.72, p=0.001), throat irritation (RR: 0.43; 95% CI, 0.22-0.81, p= 0.009), and unpleasant smell (RR: 0.43; 95% CI, 0.23 - 0.80, p=0.09). In addition, patients with HS with HA had significantly less forced expiratory volume (FEV1) (MD: -2.97; 95% CI, -3.79-2.15, p=0.52) compared to patients only on HS. Discussion The addition of HA to HS was linked to a better tolerability profile. When HS was coupled with HA, there was a reduction in all side effects. This may permit tolerance of the medication in otherwise difficult patients, improve adherence to patients receiving frequent inhalations, and improve therapeutic outcomes. Conclusion The addition of HA is advantageous in CF patients who require continuous HS therapy and have previously shown poor tolerance to therapy.
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Affiliation(s)
| | | | | | | | | | - Nicole Gousy
- Department of MedicineAmerican University of Antigua
| | - Sukhman Boparai
- Department of MedicineAcharya Shri Chander College of Medical Sciences and Hospital
| | | | | | - Aadarsh Netha
- Department of MedicineMelmaruvathur Adhiparasakthi Institute of Medical Sciences and Research
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Abstract
BACKGROUND Hypertonic saline enhances mucociliary clearance and may lessen the destructive inflammatory process in the airways. This is an update of a previously published review. OBJECTIVES To investigate efficacy and tolerability of nebulised hypertonic saline treatment in people with cystic fibrosis (CF) compared to placebo or other treatments that enhance mucociliary clearance. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Cystic Fibrosis Trials Register, comprising references identified from comprehensive electronic database searches, handsearches of relevant journals and abstract books of conference proceedings. We also searched ongoing trials databases. Most recent search: 25 April 2022. SELECTION CRITERIA We included randomised and quasi-randomised controlled trials assessing hypertonic saline compared to placebo or other mucolytic therapy, for any duration or dose regimen in people with CF (any age or disease severity). DATA COLLECTION AND ANALYSIS Two authors independently reviewed all identified trials and data, and assessed trial quality. We assessed the certainty of the evidence using GRADE. For cross-over trials we stipulated a one-week washout period. We planned to use results from a paired analysis in the review, but this was only possible in one trial. For other cross-over trials, we chose to treat the trials as if they were parallel. MAIN RESULTS We included 24 trials (1318 participants, aged one month to 56 years); we excluded 29 trials, two trials are ongoing and six are awaiting classification. We judged 15 of the 24 included trials to have a high risk of bias due to participants' ability to discern the taste of the solutions. Hypertonic saline 3% to 7% versus placebo (stable disease) We are uncertain whether the regular use of nebulised hypertonic saline in stable lung disease leads to an improvement in forced expiratory volume in one second (FEV1) % predicted at four weeks, (mean difference (MD) 3.30%, 95% confidence interval (CI) 0.71 to 5.89; 4 trials, 246 participants; very low-certainty evidence). In preschool children we found no difference in lung clearance index (LCI) at four weeks, but a small improvement after 48 weeks of treatment with hypertonic saline compared to isotonic saline (MD -0.60, 95% CI -1.00 to -0.19; 2 trials, 192 participants). We are also uncertain whether hypertonic saline made a difference to mucociliary clearance, pulmonary exacerbations or adverse events compared to placebo. Hypertonic saline versus control (acute exacerbation) Two trials compared hypertonic saline to control, but only one provided data. There may be little or no difference in lung function measured by FEV1 % predicted after hypertonic saline compared to isotonic saline (MD 5.10%, 95% CI -14.67 to 24.87; 1 trial, 130 participants). Neither trial reported any deaths or measures of sputum clearance. There were no serious adverse events. Hypertonic saline versus rhDNase Three trials compared a similar dose of hypertonic saline to recombinant deoxyribonuclease (rhDNase); two trials (61 participants) provided data for inclusion in the review. We are uncertain whether there was an effect of hypertonic saline on FEV1 % predicted after three weeks (MD 1.60%, 95% CI -7.96 to 11.16; 1 trial, 14 participants; very low-certainty evidence). At three months, rhDNase may lead to a greater increase in FEV1 % predicted than hypertonic saline (5 mL twice daily) at 12 weeks in participants with moderate to severe lung disease (MD 8.00%, 95% CI 2.00 to 14.00; low-certainty evidence). We are uncertain whether adverse events differed between the two treatments. No deaths were reported. Hypertonic saline versus amiloride One trial (12 participants) compared hypertonic saline to amiloride but did not report on most of our outcomes. The trial found that there was no difference between treatments in measures of sputum clearance (very low-certainty evidence). Hypertonic saline compared with sodium-2-mercaptoethane sulphonate (Mistabron®) One trial (29 participants) compared hypertonic saline to sodium-2-mercaptoethane sulphonate. The trial did not measure our primary outcomes. There was no difference between treatments in any measures of sputum clearance, courses of antibiotics or adverse events (very low-certainty evidence). Hypertonic saline versus mannitol One trial (12 participants) compared hypertonic saline to mannitol, but did not report lung function at relevant time points for this review; there were no differences in sputum clearance, but mannitol was reported to be more 'irritating' (very low-certainty evidence). Hypertonic saline versus xylitol Two trials compared hypertonic saline to xylitol, but we are uncertain whether there is any difference in FEV1 % predicted or median time to exacerbation between groups (very low-certainty evidence). No other outcomes were reported in the review. Hypertonic saline 7% versus hypertonic saline 3% We are uncertain whether there was an improvement in FEV1 % predicted after treatment with 7% hypertonic saline compared with 3% (very low-certainty evidence). AUTHORS' CONCLUSIONS We are very uncertain if regular use of nebulised hypertonic saline by adults and children over the age of 12 years with CF results in an improvement in lung function after four weeks (three trials; very low-certainty evidence); there was no difference seen at 48 weeks (one trial; low-certainty evidence). Hypertonic saline improved LCI modestly in children under the age of six years. Evidence from one small cross-over trial in children indicates that rhDNase may lead to better lung function than hypertonic saline at three months; qualifying this, we highlight that while the study did demonstrate that the improvement in FEV1 was greater with daily rhDNase, there were no differences seen in any of the secondary outcomes. Hypertonic saline does appear to be an effective adjunct to physiotherapy during acute exacerbations of lung disease in adults. However, for the outcomes assessed, the certainty of the evidence ranged from very low to low at best, according to the GRADE criteria. The role of hypertonic saline in conjunction with cystic fibrosis transmembrane conductance regulator (CFTR) modulator therapy now needs to be considered, and future research needs to focus on this aspect.
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Affiliation(s)
- Peter Wark
- Centre for Healthy Lungs, Hunter Medical Research Institute, University of Newcastle, New Lambton, Australia
| | - Vanessa M McDonald
- Centre of Excellence in Severe Asthma and Priority Research Centre for Healthy Lungs, The University of Newcastle, Newcastle, Australia
| | - Sherie Smith
- Division of Child Health, Obstetrics & Gynaecology (COG), School of Medicine, University of Nottingham, Nottingham, UK
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Barnes HW, Demirdjian S, Haddock NL, Kaber G, Martinez HA, Nagy N, Karmouty-Quintana H, Bollyky PL. Hyaluronan in the pathogenesis of acute and post-acute COVID-19 infection. Matrix Biol 2023; 116:49-66. [PMID: 36750167 PMCID: PMC9899355 DOI: 10.1016/j.matbio.2023.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 01/20/2023] [Accepted: 02/02/2023] [Indexed: 02/07/2023]
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) recently emerged as the cause of a global pandemic. Infection with SARS-CoV-2 can result in COVID-19 with both acute and chronic disease manifestations that continue to impact many patients long after the resolution of viral replication. There is therefore great interest in understanding the host factors that contribute to COVID-19 pathogenesis. In this review, we address the role of hyaluronan (HA), an extracellular matrix polymer with roles in inflammation and cellular metabolism, in COVID-19 and critically evaluate the hypothesis that HA promotes COVID-19 pathogenesis. We first provide a brief overview of COVID-19 infection. Then we briefly summarize the known roles of HA in airway inflammation and immunity. We then address what is known about HA and the pathogenesis of COVID-19 acute respiratory distress syndrome (COVID-19 ARDS). Next, we examine potential roles for HA in post-acute SARS-CoV-2 infection (PASC), also known as "long COVID" as well as in COVID-associated fibrosis. Finally, we discuss the potential therapeutics that target HA as a means to treat COVID-19, including the repurposed drug hymecromone (4-methylumbelliferone). We conclude that HA is a promising potential therapeutic target for the treatment of COVID-19.
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Affiliation(s)
- Henry W Barnes
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Beckman Center, 279 Campus Drive, Stanford, CA 94305, USA
| | - Sally Demirdjian
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Beckman Center, 279 Campus Drive, Stanford, CA 94305, USA
| | - Naomi L Haddock
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Beckman Center, 279 Campus Drive, Stanford, CA 94305, USA
| | - Gernot Kaber
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Beckman Center, 279 Campus Drive, Stanford, CA 94305, USA
| | - Hunter A Martinez
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Beckman Center, 279 Campus Drive, Stanford, CA 94305, USA
| | - Nadine Nagy
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Beckman Center, 279 Campus Drive, Stanford, CA 94305, USA
| | - Harry Karmouty-Quintana
- Department of Biochemistry and Molecular Biology, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth Houston), Houston, Texas, USA
| | - Paul L Bollyky
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Beckman Center, 279 Campus Drive, Stanford, CA 94305, USA.
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Caird R, Williamson M, Yusuf A, Gogoi D, Casey M, McElvaney NG, Reeves EP. Targeting of Glycosaminoglycans in Genetic and Inflammatory Airway Disease. Int J Mol Sci 2022; 23:ijms23126400. [PMID: 35742845 PMCID: PMC9224208 DOI: 10.3390/ijms23126400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 06/02/2022] [Accepted: 06/05/2022] [Indexed: 12/10/2022] Open
Abstract
In the lung, glycosaminoglycans (GAGs) are dispersed in the extracellular matrix (ECM) occupying the interstitial space between the capillary endothelium and the alveolar epithelium, in the sub-epithelial tissue and in airway secretions. In addition to playing key structural roles, GAGs contribute to a number of physiologic processes ranging from cell differentiation, cell adhesion and wound healing. Cytokine and chemokine–GAG interactions are also involved in presentation of inflammatory molecules to respective receptors leading to immune cell migration and airway infiltration. More recently, pathophysiological roles of GAGs have been described. This review aims to discuss the biological roles and molecular interactions of GAGs, and their impact in the pathology of chronic airway diseases, such as cystic fibrosis and chronic obstructive pulmonary disease. Moreover, the role of GAGs in respiratory disease has been heightened by the current COVID-19 pandemic. This review underlines the essential need for continued research aimed at exploring the contribution of GAGs in the development of inflammation, to provide a better understanding of their biological impact, as well as leads in the development of new therapeutic agents.
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Garantziotis S. Modulation of hyaluronan signaling as a therapeutic target in human disease. Pharmacol Ther 2021; 232:107993. [PMID: 34587477 DOI: 10.1016/j.pharmthera.2021.107993] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 09/08/2021] [Accepted: 09/09/2021] [Indexed: 12/14/2022]
Abstract
The extracellular matrix is an active participant, modulator and mediator of the cell, tissue, organ and organismal response to injury. Recent research has highlighted the role of hyaluronan, an abundant glycosaminoglycan constituent of the extracellular matrix, in many fundamental biological processes underpinning homeostasis and disease development. From this basis, emerging studies have demonstrated the therapeutic potential of strategies which target hyaluronan synthesis, biology and signaling, with significant promise as therapeutics for a variety of inflammatory and immune diseases. This review summarizes the state of the art in this field and discusses challenges and opportunities in what could emerge as a new class of therapeutic agents, that we term "matrix biologics".
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Affiliation(s)
- Stavros Garantziotis
- Division of Intramural Research, National Institute of Environmental Health Sciences, Research Triangle Park, North Carolina, USA.
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Huang Z, Kłodzińska SN, Wan F, Nielsen HM. Nanoparticle-mediated pulmonary drug delivery: state of the art towards efficient treatment of recalcitrant respiratory tract bacterial infections. Drug Deliv Transl Res 2021; 11:1634-1654. [PMID: 33694082 PMCID: PMC7945609 DOI: 10.1007/s13346-021-00954-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/01/2021] [Indexed: 12/16/2022]
Abstract
Recalcitrant respiratory tract infections caused by bacteria have emerged as one of the greatest health challenges worldwide. Aerosolized antimicrobial therapy is becoming increasingly attractive to combat such infections, as it allows targeted delivery of high drug concentrations to the infected organ while limiting systemic exposure. However, successful aerosolized antimicrobial therapy is still challenged by the diverse biological barriers in infected lungs. Nanoparticle-mediated pulmonary drug delivery is gaining increasing attention as a means to overcome the biological barriers and accomplish site-specific drug delivery by controlling release of the loaded drug(s) at the target site. With the aim to summarize emerging efforts in combating respiratory tract infections by using nanoparticle-mediated pulmonary delivery strategies, this review provides a brief introduction to the bacterial infection-related pulmonary diseases and the biological barriers for effective treatment of recalcitrant respiratory tract infections. This is followed by a summary of recent advances in design of inhalable nanoparticle-based drug delivery systems that overcome the biological barriers and increase drug bioavailability. Finally, challenges for the translation from exploratory laboratory research to clinical application are also discussed and potential solutions proposed.
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Affiliation(s)
- Zheng Huang
- Center for Biopharmaceuticals and Biobarriers in Drug Delivery, Department of Pharmacy, University of Copenhagen, Universitetsparken 2, DK-2100, Copenhagen Ø, Denmark
| | - Sylvia Natalie Kłodzińska
- Center for Biopharmaceuticals and Biobarriers in Drug Delivery, Department of Pharmacy, University of Copenhagen, Universitetsparken 2, DK-2100, Copenhagen Ø, Denmark
| | - Feng Wan
- Center for Biopharmaceuticals and Biobarriers in Drug Delivery, Department of Pharmacy, University of Copenhagen, Universitetsparken 2, DK-2100, Copenhagen Ø, Denmark.
| | - Hanne Mørck Nielsen
- Center for Biopharmaceuticals and Biobarriers in Drug Delivery, Department of Pharmacy, University of Copenhagen, Universitetsparken 2, DK-2100, Copenhagen Ø, Denmark.
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Galdi F, Pedone C, McGee CA, George M, Rice AB, Hussain SS, Vijaykumar K, Boitet ER, Tearney GJ, McGrath JA, Brown AR, Rowe SM, Incalzi RA, Garantziotis S. Inhaled high molecular weight hyaluronan ameliorates respiratory failure in acute COPD exacerbation: a pilot study. Respir Res 2021; 22:30. [PMID: 33517896 PMCID: PMC7847749 DOI: 10.1186/s12931-020-01610-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 12/27/2020] [Indexed: 12/31/2022] Open
Abstract
Background Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) carry significant morbidity and mortality. AECOPD treatment remains limited. High molecular weight hyaluronan (HMW-HA) is a glycosaminoglycan sugar, which is a physiological constituent of the lung extracellular matrix and has notable anti-inflammatory and hydrating properties. Research question We hypothesized that inhaled HMW-HA will improve outcomes in AECOPD. Methods We conducted a single center, randomized, placebo-controlled, double-blind study to investigate the effect of inhaled HMW-HA in patients with severe AECOPD necessitating non-invasive positive-pressure ventilation (NIPPV). Primary endpoint was time until liberation from NIPPV. Results Out of 44 screened patients, 41 were included in the study (21 for placebo and 20 for HMW-HA). Patients treated with HMW-HA had significantly shorter duration of NIPPV. HMW-HA treated patients also had lower measured peak airway pressures on the ventilator and lower systemic inflammation markers after liberation from NIPPV. In vitro testing showed that HMW-HA significantly improved mucociliary transport in air–liquid interface cultures of primary bronchial cells from COPD patients and healthy primary cells exposed to cigarette smoke extract. Interpretation Inhaled HMW-HA shortens the duration of respiratory failure and need for non-invasive ventilation in patients with AECOPD. Beneficial effects of HMW-HA on mucociliary clearance and inflammation may account for some of the effects (NCT02674880, www.clinicaltrials.gov).
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Affiliation(s)
- Flavia Galdi
- Division of Geriatrics, Department of Medicine, Campus Bio-Medico University and Teaching Hospital, Rome, Italy
| | - Claudio Pedone
- Division of Geriatrics, Department of Medicine, Campus Bio-Medico University and Teaching Hospital, Rome, Italy
| | - Christopher A McGee
- Division of Intramural Research, National Institute of Environmental Health Sciences, 111 TW Alexander Dr, Research Triangle Park, NC, 27709, USA
| | - Margaret George
- Division of Intramural Research, National Institute of Environmental Health Sciences, 111 TW Alexander Dr, Research Triangle Park, NC, 27709, USA
| | - Annette B Rice
- Division of Intramural Research, National Institute of Environmental Health Sciences, 111 TW Alexander Dr, Research Triangle Park, NC, 27709, USA
| | - Shah S Hussain
- Department of Medicine and the Gregory Fleming James Cystic Fibrosis Research Center, University of Alabama in Birmingham Medical Center, Birmingham, USA
| | - Kadambari Vijaykumar
- Department of Medicine and the Gregory Fleming James Cystic Fibrosis Research Center, University of Alabama in Birmingham Medical Center, Birmingham, USA
| | - Evan R Boitet
- Department of Medicine and the Gregory Fleming James Cystic Fibrosis Research Center, University of Alabama in Birmingham Medical Center, Birmingham, USA
| | - Guillermo J Tearney
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, USA.,Department of Dermatology, Massachusetts General Hospital, Boston, USA.,Harvard Medical School, Boston, USA.,Harvard-MIT Division of Health Sciences and Technology, Cambridge, USA.,Department of Pathology, Massachusetts General Hospital, Boston, USA
| | | | | | - Steven M Rowe
- Department of Medicine and the Gregory Fleming James Cystic Fibrosis Research Center, University of Alabama in Birmingham Medical Center, Birmingham, USA.,Department of Pediatrics, UAB, Birmingham, USA.,Department of Cell development & Integrative Biology, UAB, Birmingham, USA
| | - Raffaele A Incalzi
- Division of Geriatrics, Department of Medicine, Campus Bio-Medico University and Teaching Hospital, Rome, Italy
| | - Stavros Garantziotis
- Division of Intramural Research, National Institute of Environmental Health Sciences, 111 TW Alexander Dr, Research Triangle Park, NC, 27709, USA.
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Use of Hyaluronic Acid (HA) in Chronic Airway Diseases. Cells 2020; 9:cells9102210. [PMID: 33003557 PMCID: PMC7601363 DOI: 10.3390/cells9102210] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 09/20/2020] [Accepted: 09/29/2020] [Indexed: 12/16/2022] Open
Abstract
Hyaluronic acid (HA) is a key component of the extracellular matrix of the lungs. A unique attribute of HA is its water-retaining properties, so HA has a major role in the regulation of fluid balance in the lung interstitium. Hyaluronic acid has been widely used in the treatment of eyes, ears, joints and skin disorders, but in the last years, it has been also proposed in the treatment of certain lung diseases, including airway diseases, due to its anti-inflammatory and water-binding capacities. Hyaluronic acid aerosol decreases the severity of elastase-induced emphysema in murine models, prevents bronchoconstriction in asthmatics and improves some functional parameters in chronic obstructive pulmonary disease (COPD) patients. Due to the protection of HA against bronchoconstriction and its hydration properties, inhaled HA would increase the volume of airway surface liquid, resulting in mucus hydration, increased mucous transport and less mucous plugging of the airways. In addition, it has been seen in human studies that the treatment with nebulised HA improves the tolerability of nebulised hypertonic saline (even at 6% or 7% of concentration), which has been demonstrated to be an effective treatment in bronchial secretion management in patients with cystic fibrosis and bronchiectasis. Our objective is to review the role of HA treatment in the management of chronic airway diseases.
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Di Cicco M, Peroni D, Sepich M, Tozzi MG, Comberiati P, Cutrera R. Hyaluronic acid for the treatment of airway diseases in children: Little evidence for few indications. Pediatr Pulmonol 2020; 55:2156-2169. [PMID: 32530559 DOI: 10.1002/ppul.24901] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 06/10/2020] [Indexed: 11/06/2022]
Abstract
BACKGROUND Hyaluronic acid (HA) is major physiological component of the extracellular matrix, which, in its high molecular weight form (HMW-HA) has anti-inflammatory properties. The diffusion of many different medical devices for inhalation therapy containing HA has led to an increase in their prescription, also in children. Here, we systematically review the published evidence on the efficacy and safety of HA for the treatment of upper and lower airway diseases in childhood. METHODS Relevant published studies (randomized controlled trials) for the efficacy of HA inhalation in children with upper airways diseases, asthma, cystic fibrosis (CF), and non-CF bronchiectasis were searched in Pubmed, Scopus, and Web of Knowledge databases by combining the adequate Medical Subject Headings terms and keywords, with no limit for the year of publication. RESULTS We identified seven relevant publications for upper airways diseases, one for asthma, and five for CF, while we found no clinical trial including children with non-CF bronchiectasis. Meta-analysis was not conducted due to the heterogeneity of the included studies. CONCLUSIONS The evidence of HA efficacy in the treatment of the upper and lower airways is still limited in children. Available data suggest that inhaled HMW-HA could be useful in the treatment of recurrent upper respiratory infections and chronic or recurrent inflammation of the middle ear and adenoids as well as of the lower airways in cystic fibrosis in association with hypertonic saline solution. Studies on larger populations and on the different formulations and nebulization methods, especially in pediatric age, are urgently needed.
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Affiliation(s)
- Maria Di Cicco
- Pediatrics Unit, Allergology Section, Pisa University Hospital, Pisa, Italy.,Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Diego Peroni
- Pediatrics Unit, Allergology Section, Pisa University Hospital, Pisa, Italy.,Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Margherita Sepich
- Pediatrics Unit, Allergology Section, Pisa University Hospital, Pisa, Italy.,Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Maria Giulia Tozzi
- Pediatrics Unit, Allergology Section, Pisa University Hospital, Pisa, Italy.,Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Pasquale Comberiati
- Pediatrics Unit, Allergology Section, Pisa University Hospital, Pisa, Italy.,Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Renato Cutrera
- Department of Academic Pediatric, Respiratory unit, Pediatric Hospital "Bambino Gesù", Rome, Italy
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San Miguel-Pagola M, Reychler G, Cebrià i Iranzo MA, Gómez-Romero M, Díaz-Gutiérrez F, Herrero-Cortina B. Impact of hypertonic saline nebulisation combined with oscillatory positive expiratory pressure on sputum expectoration and related symptoms in cystic fibrosis: a randomised crossover trial. Physiotherapy 2020; 107:243-251. [DOI: 10.1016/j.physio.2019.11.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 09/01/2019] [Accepted: 11/05/2019] [Indexed: 01/11/2023]
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Sepe A, Villella VR, Cimbalo C, Castaldo A, Nunziata F, Corcione A, Bona G, Maiuri L, Raia V. Inhaled medications in cystic fibrosis beyond antibiotics. Minerva Pediatr 2019; 71:371-375. [PMID: 30761821 DOI: 10.23736/s0026-4946.19.05509-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Structural lung disease begins very early in children with cystic fibrosis (CF), often in the first three months of life. Inhaled medications represent an attractive therapeutic approach in CF that are routinely used as early intervention strategies. Two aerosolized solutions, hypertonic saline and dornase alfa, have significant potential benefits by improving mucociliary clearance, with minimal associated side-effects. In particular, they favor rehydration of airway surface liquid and cleavage of extracellular DNA in the airways, respectively, consequently reducing rate of pulmonary disease exacerbations. Indirect anti-inflammatory effects have been documented for both drugs, addressing each of the three interrelated elements in the vicious cycle of lung disease in CF: airway obstruction, inflammation and infection. This short review aimed to summarize the main papers that support potential clinical impact of inhaled solutions on pulmonary disease in CF.
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Affiliation(s)
- Angela Sepe
- Department of Translational Medical Sciences, University Federico II, Naples, Italy.,Department of Pediatrics, University Federico II, Naples, Italy
| | - Valeria R Villella
- European Institute for Research in Cystic Fibrosis, San Raffaele Scientific Institute, Milan, Italy
| | - Chiara Cimbalo
- Department of Translational Medical Sciences, University Federico II, Naples, Italy.,Department of Pediatrics, University Federico II, Naples, Italy
| | - Alice Castaldo
- Department of Translational Medical Sciences, University Federico II, Naples, Italy.,Department of Public Health, University Federico II, Naples, Italy
| | - Francesco Nunziata
- Department of Translational Medical Sciences, University Federico II, Naples, Italy.,Department of Pediatrics, University Federico II, Naples, Italy
| | - Adele Corcione
- Department of Translational Medical Sciences, University Federico II, Naples, Italy.,Department of Pediatrics, University Federico II, Naples, Italy
| | - Gianni Bona
- Department of Health Sciences, University of Eastern Piedmont, Novara, Italy
| | - Luigi Maiuri
- European Institute for Research in Cystic Fibrosis, San Raffaele Scientific Institute, Milan, Italy.,Department of Health Sciences, University of Eastern Piedmont, Novara, Italy
| | - Valeria Raia
- Department of Translational Medical Sciences, University Federico II, Naples, Italy - .,Department of Pediatrics, University Federico II, Naples, Italy
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Johnson CG, Stober VP, Cyphert-Daly JM, Trempus CS, Flake GP, Cali V, Ahmad I, Midura RJ, Aronica MA, Matalon S, Garantziotis S. High molecular weight hyaluronan ameliorates allergic inflammation and airway hyperresponsiveness in the mouse. Am J Physiol Lung Cell Mol Physiol 2018; 315:L787-L798. [PMID: 30188746 PMCID: PMC6425518 DOI: 10.1152/ajplung.00009.2018] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Revised: 08/27/2018] [Accepted: 08/27/2018] [Indexed: 12/22/2022] Open
Abstract
Allergic asthma is a major cause of morbidity in both pediatric and adult patients. Recent research has highlighted the role of hyaluronan (HA), an extracellular matrix glycosaminoglycan, in asthma pathogenesis. Experimental allergic airway inflammation and clinical asthma are associated with an increase of shorter fragments of HA (sHA), which complex with inter-α-inhibitor heavy chains (HCs) and induce inflammation and airway hyperresponsiveness (AHR). Importantly, the effects of sHA can be antagonized by the physiological counterpart high molecular weight HA (HMWHA). We used a mouse model of house dust mite-induced allergic airway inflammation and demonstrated that instilled HMWHA ameliorated allergic airway inflammation and AHR, even when given after the establishment of allergic sensitization and after challenge exposures. Furthermore, instilled HMWHA reduced the development of HA-HC complexes and the activation of Rho-associated, coiled-coil containing protein kinase 2. We conclude that airway application of HMWHA is a potential treatment for allergic airway inflammation.
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Affiliation(s)
- Collin G Johnson
- Division of Intramural Research, National Institute of Environmental Health Sciences , Research Triangle Park, North Carolina
| | - Vandy P Stober
- Division of Intramural Research, National Institute of Environmental Health Sciences , Research Triangle Park, North Carolina
| | - Jaime M Cyphert-Daly
- Division of Intramural Research, National Institute of Environmental Health Sciences , Research Triangle Park, North Carolina
| | - Carol S Trempus
- Division of Intramural Research, National Institute of Environmental Health Sciences , Research Triangle Park, North Carolina
| | - Gordon P Flake
- Division of Intramural Research, National Institute of Environmental Health Sciences , Research Triangle Park, North Carolina
| | - Valbona Cali
- Department of Pathobiology, Cleveland Clinic Foundation , Cleveland, Ohio
| | - Israr Ahmad
- Division of Molecular and Translational Biomedicine, Department of Anesthesiology and Perioperative Medicine, and Pulmonary Injury and Repair Center, School of Medicine, The University of Alabama at Birmingham , Birmingham, Alabama
| | - Ronald J Midura
- Department of Pathobiology, Cleveland Clinic Foundation , Cleveland, Ohio
| | - Mark A Aronica
- Department of Pathobiology, Cleveland Clinic Foundation , Cleveland, Ohio
| | - Sadis Matalon
- Division of Molecular and Translational Biomedicine, Department of Anesthesiology and Perioperative Medicine, and Pulmonary Injury and Repair Center, School of Medicine, The University of Alabama at Birmingham , Birmingham, Alabama
| | - Stavros Garantziotis
- Division of Intramural Research, National Institute of Environmental Health Sciences , Research Triangle Park, North Carolina
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Abstract
BACKGROUND Impaired mucociliary clearance characterises lung disease in cystic fibrosis (CF). Hypertonic saline enhances mucociliary clearance and may lessen the destructive inflammatory process in the airways. This is an update of a previously published review. OBJECTIVES To investigate efficacy and tolerability of treatment with nebulised hypertonic saline on people with CF compared to placebo and or other treatments that enhance mucociliary clearance. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Cystic Fibrosis Trials Register, comprising references identified from comprehensive electronic database searches, handsearches of relevant journals and abstract books of conference proceedings. We also searched ongoing trials databases.Date of most recent searches: 08 August 2018. SELECTION CRITERIA Randomised and quasi-randomised controlled trials assessing hypertonic saline compared to placebo or other mucolytic therapy, for any duration or dose regimen in people with CF (any age or disease severity). DATA COLLECTION AND ANALYSIS Two authors independently reviewed all identified trials and data, and assessed trial quality. The quality of the evidence was assessed using GRADE. MAIN RESULTS A total of 17 trials (966 participants, aged 4 months to 63 years) were included; 19 trials were excluded, three trials are ongoing and 16 are awaiting classification. We judged 14 of the 17 included trials to have a high risk of bias due to participants ability to discern the taste of the solutions.Hypertonic saline 3% to 7% versus placeboAt four weeks, we found very low-quality evidence from three placebo-controlled trials (n = 225) that hypertonic saline (3% to 7%, 10 mL twice-daily) increased the mean change from baseline of the forced expiratory volume at one second (FEV1) (% predicted) by 3.44% (95% confidence interval (CI) 0.67 to 6.21), but there was no difference between groups in lung clearance index in one small trial (n = 10). By 48 weeks the effect was slightly smaller in one trial (n = 134), 2.31% (95% CI -2.72 to 7.34) (low-quality evidence). No deaths occurred in the trials. Two trials reporting data on exacerbations were not combined as the age difference between the participants in the trials was too great. One trial (162 adults) found 0.5 fewer exacerbations requiring antibiotics per person in the hypertonic saline group; the second trial (243 children, average age of two years) found no difference between groups (low-quality evidence). There was insufficient evidence reported across the trials to determine the rate of different adverse events such as cough, chest tightness, tonsillitis and vomiting (very low-quality evidence). Four trials (n = 80) found very low-quality evidence that sputum clearance was better with hypertonic saline.A further trial was performed in adults with an acute exacerbation of lung disease (n = 132). The effects of hypertonic saline on short-term lung function, 5.10% higher (14.67% lower to 24.87% higher) and the time to the subsequent exacerbation post-discharge, hazard ratio 0.86 (95% CI 0.57 to 1.30) are uncertain (low-quality evidence). No deaths were reported. Cough and wheeze were reported but no serious adverse events (very low-quality evidence).Hypertonic saline versus mucus mobilising treatments Three trials compared a similar dose of hypertonic saline to recombinant deoxyribonuclease (rhDNase); two (61 participants) provided data for inclusion in the review. There was insufficient evidence from one three-week trial (14 participants) to determine the effects of hypertonic saline on FEV1 % predicted, mean difference (MD) 1.60% (95% CI -7.96 to 11.16) (very low-quality evidence). In the second trial, rhDNase led to a greater increase in FEV1 % predicted than hypertonic saline (5 mL twice daily) at 12 weeks in participants with moderate to severe lung disease, MD 8.00% (95% CI 2.00 to 14.00) (low-quality evidence). One cross-over trial (47 participants) reported 15 exacerbations during treatment with hypertonic saline and 18 exacerbations in the rhDNase group (low-quality evidence). Increased cough was reported in 13 participants using hypertonic saline and 17 on daily rhDNase in one cross-over trial of 47 people (low-quality evidence). There was insufficient evidence to assess rates of other adverse events reported. No deaths were reported.One trial (12 participants) compared hypertonic saline to amiloride and one (29 participants) to sodium-2-mercaptoethane sulphonate. Neither trial found a difference between treatments in any measures of sputum clearance; additionally the comparison of hypertonic saline and sodium-2-mercaptoethane sulphonate reported no differences in courses of antibiotics or adverse events (very low-quality evidence).One trial (12 participants) compared hypertonic saline to mannitol but did not report lung function at relevant time points for this review; there were no differences in sputum clearance, but mannitol was reported to be more 'irritating' (very low-quality evidence). AUTHORS' CONCLUSIONS Regular use of nebulised hypertonic saline by adults and children over the age of 12 years with CF results in an improvement in lung function after four weeks (very low-quality evidence from three trials), but this was not sustained at 48 weeks (low-quality evidence from one trial). The review did show that nebulised hypertonic saline reduced the frequency of pulmonary exacerbations (although we found insufficient evidence for this outcome in children under six years of age) and may have a small effect on improvement in quality of life in adults.Evidence from one small cross-over trial in children indicates that rhDNase may lead to better lung function at three months; qualifying this we highlight that while the study did demonstrate that the improvement in FEV1 was greater with daily rHDNase, there were no differences seen in any of the secondary outcomes.Hypertonic saline does appear to be an effective adjunct to physiotherapy during acute exacerbations of lung disease in adults. However, for the outcomes assessed, the quality of the evidence ranged from very low to at best moderate, according to the GRADE criteria.
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Affiliation(s)
- Peter Wark
- Hunter Medical Research Institute, University of NewcastleCentre for Healthy Lungs1 Kookaburra CloseNew LambtonNew South WalesAustralia2305
| | - Vanessa M McDonald
- The University of NewcastleSchool of Nursing and Midwifery, Priority Reseach Centre for Asthma and Respiratory DiseaseLocked Bag 1000New LambtionNewcastleNSWAustralia2305
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Herrero-Cortina B, Alcaraz V, Vilaró J, Torres A, Polverino E. Impact of Hypertonic Saline Solutions on Sputum Expectoration and Their Safety Profile in Patients with Bronchiectasis: A Randomized Crossover Trial. J Aerosol Med Pulm Drug Deliv 2018; 31:281-289. [PMID: 29878856 DOI: 10.1089/jamp.2017.1443] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The role of hyaluronic acid plus hypertonic saline (HA+HS) as a mucoactive treatment in patients with bronchiectasis is still unknown. This study evaluated whether HA+HS solution enhances similar sputum quantity with better safety profile than HS alone in patients with bronchiectasis. METHODS In this double-blind randomized crossover trial, three solutions (7% HS; 0.1% HA +7%HS; and 0.9% isotonic saline, IS) were compared in outpatients with bronchiectasis and chronic sputum expectoration. Participants inhaled each solution across four consecutive sessions. All sessions, except on session 3, also included 30 minutes of airway clearance technique. A 7-day washout period was applied. Sputum weight was collected during the sessions (primary outcome) as well as during a 24-hour follow-up. The Leicester Cough Questionnaire (LCQ) and lung function were measured before/after each treatment arm. Safety was assessed by the monitoring of adverse events (AEs). RESULTS Twenty-eight patients with bronchiectasis (mean age of 64.0 (17.9) and FEV1% 60.9 (24.6) of predicted) were recruited. HS and HA+HS promoted similar expectoration during sessions, both being greater than IS [median difference HS vs. IS 3.7 g (95% CI 0.5-6.9); HA+HS vs. IS 3.2 g (95%CI 0.5-5.9)]. Sputum expectorated exclusively during the ACT period was similar across all treatment arms [HS vs. IS -0.3 g (95% CI -1.7 to 0.9); HA+HS vs. IS 0.0 g (95% CI -1.3 to 1.4); HS vs. HA+HS 0.0 g (95% CI -1.2 to 0.4)]. Sputum collected over the 24-hour follow-up tended to be lower for HS and HA+HS compared with IS [HS vs. IS -1.7 g (95% CI -4.2 to 0.0); HA+HS vs. IS -1.1 g (95%CI -3.6 to 0.7)]. No differences in LCQ or lung function were observed. Most severe AEs were reported using HS. CONCLUSION HS and HA+HS were more effective on sputum expectoration than IS in patients with bronchiectasis, reporting HA+HS better safety profile than HS.
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Affiliation(s)
| | - Victoria Alcaraz
- 2 Fundaciò Clínic, Hospital Clínic de Barcelona, Universitat de Barcelona , IDIBAPS, CIBERES, Barcelona, España
| | - Jordi Vilaró
- 3 Facultat de Ciències de la Salut Blanquerna, Universitat Ramon Llull , Grup de Recerca en Salut, Activitat Física i Esport (SAFE), Barcelona, Spain
| | - Antoni Torres
- 4 Servei de Pneumologia, Hospital Clínic de Barcelona, Universitat de Barcelona , IDIBAPS, CIBERES, Barcelona, España
| | - Eva Polverino
- 4 Servei de Pneumologia, Hospital Clínic de Barcelona, Universitat de Barcelona , IDIBAPS, CIBERES, Barcelona, España.,5 Servei de Pneumologia, Hospital UniversitariValld'Hebron (HUVH), Institut de Recerca Valld'Hebron (VHIR) , Barcelona, España
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15
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Xu C, Shi Q, Zhang L, Zhao H. High molecular weight hyaluronan attenuates fine particulate matter-induced acute lung injury through inhibition of ROS-ASK1-p38/JNK-mediated epithelial apoptosis. ENVIRONMENTAL TOXICOLOGY AND PHARMACOLOGY 2018; 59:190-198. [PMID: 29625389 DOI: 10.1016/j.etap.2018.03.020] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/03/2018] [Revised: 03/27/2018] [Accepted: 03/28/2018] [Indexed: 06/08/2023]
Abstract
Inhalation of fine particulate matter (PM2.5) is asscoiated with lung injury. High molecular weight hyaluronan (HMW-HA) is an essential constituent of extracellular matrix (ECM), exhibiting anti-oxidative and anti-inflammatory properties when administered by injection, inhalation, nebulization or gene delivery of HA synthases. The aim of the present study is to determine whether HMW-HA alleviates PM2.5-induced acute lung injury (ALI) and investigate the underlying mechanisms. We observed that HMW-HA suppressed pathological injury, inflammation, oxidative stress, edema and epithelial damage caused by PM2.5 in the lungs of the rats. The protective mechanism of HMW-HA was further explored in vitro. The results elucidated that reactive oxygen species (ROS) was involved in PM2.5-induced cell apoptosis, and HMW-HA mitigated the oxidative potential of PM2.5, subsequently inhibiting phosphorylation of ASK1 at Thr845, downstream phosphorylation of p38 and JNK, and eventual apoptosis. Our study indicates that HMW-HA is a promising strategy in the prevention of PM2.5-induced pulmonary damage.
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Affiliation(s)
- Chenming Xu
- Collaborative Innovation Center of Yangtze River Delta Region Green Pharmaceuticals, Zhejiang University of Technology, PR China
| | - Qiwen Shi
- Collaborative Innovation Center of Yangtze River Delta Region Green Pharmaceuticals, Zhejiang University of Technology, PR China.
| | - Leifang Zhang
- Collaborative Innovation Center of Yangtze River Delta Region Green Pharmaceuticals, Zhejiang University of Technology, PR China
| | - Hang Zhao
- Collaborative Innovation Center of Yangtze River Delta Region Green Pharmaceuticals, Zhejiang University of Technology, PR China
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16
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Nenna R, Midulla F, Lambiase C, De Castro G, Zicari AM, Indinnimeo L, Cimino G, Troiani P, Quattrucci S, Tancredi G. Effects of inhaled hypertonic (7%) saline on lung function test in preschool children with cystic fibrosis: results of a crossover, randomized clinical trial. Ital J Pediatr 2017; 43:60. [PMID: 28709466 PMCID: PMC5512793 DOI: 10.1186/s13052-017-0376-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 07/07/2017] [Indexed: 12/28/2022] Open
Abstract
Background This crossover, randomized, double-blind study (conducted over a 32-week period) was performed to determine, in clinically stable Cystic fibrosis (CF) preschool children: the effects of 7% inhaled hypertonic saline on spirometry and interrupter resistance technique (Rint), and the possible side effects. Methods Twelve CF children (6M, mean age ± SD: 5.7 ± 0.8 yrs) were enrolled and randomly assigned to receive hypertonic saline (HS-4 ml 7% sodium chloride), or normal saline (NS-0.9% sodium chloride) twice a day. After a 16 weeks period, therapy was exchanged to allow all the patients enrolled in the study to carry out both treatments. Monitoring visits, spirometry (COSMED Quark PFT4 ergo) and Rint were scheduled at 0,4,16,20,32 weeks. At T0, spirometric measurements and Rint were performed immediately before and 30 min after the inhalation therapy. Salbutamol (400 mcg) was administered before the drug at each visit. Results After a 16-weeks treatment with HS an improvement of FVC (p = 0.02) and a favorable trend of FEV1 were registered. A worsening of FEV1 (p < 0.0001) and of FEF25-75 (p = 0.019) were found in NS group. No differences were found in expiratory and inspiratory Rint in both groups. No serious adverse events occurred. Conclusions Seven percent hypertonic saline therapy proved to be a useful and safe treatment in young CF children with clinically stable conditions. Trial registration ISRCTN12345678.
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Affiliation(s)
- Raffaella Nenna
- Department of Pediatrics and Infantile Neuropsychiatry, "Sapienza" University of Rome, Rome, Italy.
| | - Fabio Midulla
- Department of Pediatrics and Infantile Neuropsychiatry, "Sapienza" University of Rome, Rome, Italy
| | - Caterina Lambiase
- Department of Pediatrics and Infantile Neuropsychiatry, "Sapienza" University of Rome, Rome, Italy
| | - Giovanna De Castro
- Department of Pediatrics and Infantile Neuropsychiatry, "Sapienza" University of Rome, Rome, Italy
| | - Anna Maria Zicari
- Department of Pediatrics and Infantile Neuropsychiatry, "Sapienza" University of Rome, Rome, Italy
| | - Luciana Indinnimeo
- Department of Pediatrics and Infantile Neuropsychiatry, "Sapienza" University of Rome, Rome, Italy
| | - Giuseppe Cimino
- Cystic Fibrosis Centre-Department of Pediatrics and Infantile Neuropsychiatry, "Sapienza" University of Rome, Rome, Italy
| | - Patrizia Troiani
- Cystic Fibrosis Centre-Department of Pediatrics and Infantile Neuropsychiatry, "Sapienza" University of Rome, Rome, Italy
| | - Serena Quattrucci
- Cystic Fibrosis Centre-Department of Pediatrics and Infantile Neuropsychiatry, "Sapienza" University of Rome, Rome, Italy
| | - Giancarlo Tancredi
- Department of Pediatrics and Infantile Neuropsychiatry, "Sapienza" University of Rome, Rome, Italy
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17
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Köwitsch A, Zhou G, Groth T. Medical application of glycosaminoglycans: a review. J Tissue Eng Regen Med 2017; 12:e23-e41. [DOI: 10.1002/term.2398] [Citation(s) in RCA: 123] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Revised: 10/08/2016] [Accepted: 01/09/2017] [Indexed: 12/19/2022]
Affiliation(s)
- Alexander Köwitsch
- Biomedical Materials Group, Institute of Pharmacy; Martin Luther University Halle-Wittenberg; Halle Germany
| | - Guoying Zhou
- Biomedical Materials Group, Institute of Pharmacy; Martin Luther University Halle-Wittenberg; Halle Germany
| | - Thomas Groth
- Biomedical Materials Group, Institute of Pharmacy; Martin Luther University Halle-Wittenberg; Halle Germany
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18
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The Advantages of Adding Hyaluronic Acid or Mannitol to Hypertonic Saline Inhalation Treatment in Cystic Fibrosis. J Aerosol Med Pulm Drug Deliv 2017; 30:141-142. [DOI: 10.1089/jamp.2016.1318] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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19
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Brivio A, Conese M, Gambazza S, Biffi A, Tirelli AS, Russo M, Foà M, Colombo C. Pilot Randomized Controlled Trial Evaluating the Effect of Hypertonic Saline With and Without Hyaluronic Acid in Reducing Inflammation in Cystic Fibrosis. J Aerosol Med Pulm Drug Deliv 2016; 29:482-489. [DOI: 10.1089/jamp.2015.1256] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Affiliation(s)
- Anna Brivio
- Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Cystic Fibrosis Centre, Milan, Italy
| | - Massimo Conese
- Department of Medical and Surgical Sciences, Centro di Ricerche Biomediche “E. Altomare”, Laboratory of Experimental and Regenerative Medicine, University of Foggia, Foggia, Italy
| | - Simone Gambazza
- Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Cystic Fibrosis Centre, Milan, Italy
| | - Arianna Biffi
- Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Cystic Fibrosis Centre, Milan, Italy
| | - Amedea Silvia Tirelli
- Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Laboratory of Clinical Pathology and CF Microbiology, Milan, Italy
| | - Maria Russo
- Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Cystic Fibrosis Centre, Milan, Italy
| | - Michaela Foà
- Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Cystic Fibrosis Centre, Milan, Italy
| | - Carla Colombo
- Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Cystic Fibrosis Centre, Milan, Italy
- University of Milan, Italy
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20
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Lamas A, Marshburn J, Stober VP, Donaldson SH, Garantziotis S. Effects of inhaled high-molecular weight hyaluronan in inflammatory airway disease. Respir Res 2016; 17:123. [PMID: 27716205 PMCID: PMC5048477 DOI: 10.1186/s12931-016-0442-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Accepted: 09/27/2016] [Indexed: 01/08/2023] Open
Abstract
Cystic fibrosis (CF) is a chronic inflammatory disease that is affecting thousands of patients worldwide. Adjuvant anti-inflammatory treatment is an important component of cystic fibrosis treatment, and has shown promise in preserving lung function and prolonging life expectancy. Inhaled high molecular weight hyaluronan (HMW-HA) is reported to improve tolerability of hypertonic saline and thus increase compliance, and has been approved in some European countries for use as an adjunct to hypertonic saline treatment in cystic fibrosis. However, there are theoretical concerns that HMW-HA breakdown products may be pro-inflammatory. In this clinical pilot study we show that sputum cytokines in CF patients receiving HMW-HA are not increased, and therefore HMW-HA does not appear to adversely affect inflammatory status in CF airways.
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Affiliation(s)
- Adelaida Lamas
- Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
| | - Jamie Marshburn
- Division of Intramural Research, National Institute of Environmental Health Sciences, Research Triangle Park, Durham, NC, USA
| | - Vandy P Stober
- Division of Intramural Research, National Institute of Environmental Health Sciences, Research Triangle Park, Durham, NC, USA
| | | | - Stavros Garantziotis
- Division of Intramural Research, National Institute of Environmental Health Sciences, Research Triangle Park, Durham, NC, USA. .,National Institute of Environmental Health Sciences, 111 TW Alexander Dr, Research Triangle Park, Durham, NC, 27709, USA.
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21
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Matuska B, Comhair S, Farver C, Chmiel J, Midura RJ, Bonfield T, Lauer ME. Pathological Hyaluronan Matrices in Cystic Fibrosis Airways and Secretions. Am J Respir Cell Mol Biol 2016; 55:576-585. [PMID: 27243106 DOI: 10.1165/rcmb.2015-0358oc] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Hyaluronan (HA) has been used in treatment of cystic fibrosis (CF) via a nebulizer and has demonstrated success in clinical outcomes. HA is an important glycosaminoglycan that is cross-linked by heavy chains (HCs) from inter-α-inhibitor during inflammation. HC cross-linked HA (HC-HA) becomes significantly more adhesive for leukocytes than non-cross-linked HA, which can enhance inflammation. Our studies tested the hypothesis that HC-HA is present in CF airways and that altered ratios of HC-HA to its degradation into relatively lower molecular weight HA contribute to the pathophysiology of chronic inflammation in CF. We evaluated the distribution, levels, and size of HC-HA within CF, healthy, and diseased control lung, bronchus, and sputum tissues by histological and biochemical approaches. HC-HA was significantly elevated in CF, with deposits around the pulmonary vasculature, airway submucosa, and in the stroma of the submucosal glands. The increased infiltration of leukocyte populations correlated with the distribution of HC-HA matrices in the airways. Elevated lung tissue HC-HA correlated with decreased HA levels in CF mucus and sputum compared with controls, suggesting that aberrant degradation and cross-linking of HA in lung tissue is a unique feature of CF. The accumulation and degradation of proinflammatory HC-HA in CF lung tissue suggests that aberrant HA catabolism and cross-linking may contribute to chronic inflammation in airway tissues and affect mucus viscosity in CF airways.
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Affiliation(s)
| | | | | | - James Chmiel
- 4 Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio; and.,5 Pediatric Pulmonology and Allergy/Immunology, Rainbow Babies and Children's Hospital, Cleveland, Ohio
| | | | - Tracey Bonfield
- 4 Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio; and
| | - Mark E Lauer
- Departments of 1 Biomedical Engineering.,6 Pediatric Institute, Cleveland Clinic, Cleveland, Ohio
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Costabile G, d'Angelo I, d'Emmanuele di Villa Bianca R, Mitidieri E, Pompili B, Del Porto P, Leoni L, Visca P, Miro A, Quaglia F, Imperi F, Sorrentino R, Ungaro F. Development of inhalable hyaluronan/mannitol composite dry powders for flucytosine repositioning in local therapy of lung infections. J Control Release 2016; 238:80-91. [DOI: 10.1016/j.jconrel.2016.07.029] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2016] [Revised: 07/12/2016] [Accepted: 07/17/2016] [Indexed: 11/28/2022]
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Edmondson C, Davies JC. Current and future treatment options for cystic fibrosis lung disease: latest evidence and clinical implications. Ther Adv Chronic Dis 2016; 7:170-83. [PMID: 27347364 PMCID: PMC4907071 DOI: 10.1177/2040622316641352] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Treatment for cystic fibrosis (CF) has conventionally targeted downstream consequences of the defect such as mucus plugging and infection. More recently, significant advances have been made in treating the root cause of the disease, namely a defective CF transmembrane conductance regulator (CFTR) gene. This review summarizes current pulmonary treatment options and highlights advances in research and development of new therapies.
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Affiliation(s)
- Claire Edmondson
- Royal Brompton & Harefield NHS Foundation Trust, Paediatric Respiratory Medicine, London, UK
| | - Jane C. Davies
- Imperial College London, Paediatric Respirology and Experimental Medicine, London SW7 2AZ, UK
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Liang J, Jiang D, Noble PW. Hyaluronan as a therapeutic target in human diseases. Adv Drug Deliv Rev 2016; 97:186-203. [PMID: 26541745 PMCID: PMC4753080 DOI: 10.1016/j.addr.2015.10.017] [Citation(s) in RCA: 150] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2015] [Revised: 10/19/2015] [Accepted: 10/20/2015] [Indexed: 02/07/2023]
Abstract
Accumulation and turnover of extracellular matrix is a hallmark of tissue injury, repair and remodeling in human diseases. Hyaluronan is a major component of the extracellular matrix and plays an important role in regulating tissue injury and repair, and controlling disease outcomes. The function of hyaluronan depends on its size, location, and interactions with binding partners. While fragmented hyaluronan stimulates the expression of an array of genes by a variety of cell types regulating inflammatory responses and tissue repair, cell surface hyaluronan provides protection against tissue damage from the environment and promotes regeneration and repair. The interactions of hyaluronan and its binding proteins participate in the pathogenesis of many human diseases. Thus, targeting hyaluronan and its interactions with cells and proteins may provide new approaches to developing therapeutics for inflammatory and fibrosing diseases. This review focuses on the role of hyaluronan in biological and pathological processes, and as a potential therapeutic target in human diseases.
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Affiliation(s)
- Jiurong Liang
- Department of Medicine and Women's Guild Lung Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Dianhua Jiang
- Department of Medicine and Women's Guild Lung Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Paul W Noble
- Department of Medicine and Women's Guild Lung Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA.
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Tewes F, Gobbo OL, Ehrhardt C, Healy AM. Amorphous Calcium Carbonate Based-Microparticles for Peptide Pulmonary Delivery. ACS APPLIED MATERIALS & INTERFACES 2016; 8:1164-1175. [PMID: 26692360 DOI: 10.1021/acsami.5b09023] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Amorphous calcium carbonate (ACC) is known to interact with proteins, for example, in biogenic ACC, to form stable amorphous phases. The control of amorphous/crystalline and inorganic/organic ratios in inhalable calcium carbonate microparticles may enable particle properties to be adapted to suit the requirements of dry powders for pulmonary delivery by oral inhalation. For example, an amorphous phase can immobilize and stabilize polypeptides in their native structure and amorphous and crystalline phases have different mechanical properties. Therefore, inhalable composite microparticles made of inorganic (i.e., calcium carbonate and calcium formate) and organic (i.e., hyaluronan (HA)) amorphous and crystalline phases were investigated for peptide and protein pulmonary aerosol delivery. The crystalline/amorphous ratio and polymorphic form of the inorganic component was altered by changing the microparticle drying rate and by changing the ammonium carbonate and HA initial concentration. The bioactivity of the model peptide, salmon calcitonin (sCT), coprocessed with alpha-1-antitrypsin (AAT), a model protein with peptidase inhibitor activity, was maintained during processing and the microparticles had excellent aerodynamic properties, making them suitable for pulmonary aerosol delivery. The bioavailability of sCT after aerosol delivery as sCT and AAT-loaded composite microparticles to rats was 4-times higher than that of sCT solution.
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Affiliation(s)
- Frederic Tewes
- School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin , Dublin 2, Ireland
- INSERM U 1070, Pôle Biologie-Santé, Université de Poitiers , Faculté de Médecine & Pharmacie, 1 Rue Georges Bonnet, 86022 Poitiers Cedex, France
| | - Oliviero L Gobbo
- School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin , Dublin 2, Ireland
| | - Carsten Ehrhardt
- School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin , Dublin 2, Ireland
| | - Anne Marie Healy
- School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin , Dublin 2, Ireland
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Garantziotis S, Brezina M, Castelnuovo P, Drago L. The role of hyaluronan in the pathobiology and treatment of respiratory disease. Am J Physiol Lung Cell Mol Physiol 2016; 310:L785-95. [PMID: 26747781 DOI: 10.1152/ajplung.00168.2015] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Accepted: 01/05/2016] [Indexed: 12/11/2022] Open
Abstract
Hyaluronan, a ubiquitous naturally occurring glycosaminoglycan, is a major component of the extracellular matrix, where it participates in biological processes that include water homeostasis, cell-matrix signaling, tissue healing, inflammation, angiogenesis, and cell proliferation and migration. There are emerging data that hyaluronan and its degradation products have an important role in the pathobiology of the respiratory tract. We review the role of hyaluronan in respiratory diseases and present evidence from published literature and from clinical practice supporting hyaluronan as a novel treatment for respiratory diseases. Preliminary data show that aerosolized exogenous hyaluronan has beneficial activity against airway inflammation, protects against bronchial hyperreactivity and remodeling, and disrupts the biofilm associated with chronic infection. This suggests a role in airway diseases with a predominant inflammatory component such as rhinosinusitis, asthma, chronic obstructive pulmonary disease, cystic fibrosis, and primary ciliary dyskinesia. The potential for hyaluronan to complement conventional therapy will become clearer when data are available from controlled trials in larger patient populations.
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Affiliation(s)
- Stavros Garantziotis
- Clinical Research Program, National Institute of Environmental Health Sciences, National Institutes of Health, Research Triangle Park, North Carolina;
| | - Martin Brezina
- Clinic of Pediatric Pneumology and Phthisiology, University Hospital Bratislava, Bratislava, Slovakia
| | - Paolo Castelnuovo
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Insubria, Ospedale di Circolo, Fondazione Macchi, Varese, Italy; and
| | - Lorenzo Drago
- Laboratory of Clinical Chemistry and Microbiology, IRCCS Galeazzi Orthopaedic Institute, Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
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Tewes F, Brillault J, Lamy B, O'Connell P, Olivier JC, Couet W, Healy AM. Ciprofloxacin-Loaded Inorganic-Organic Composite Microparticles To Treat Bacterial Lung Infection. Mol Pharm 2015; 13:100-12. [PMID: 26641021 DOI: 10.1021/acs.molpharmaceut.5b00543] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Ciprofloxacin (CIP) is an antibiotic that has been clinically trialed for the treatment of lung infections by aerosolization. However, CIP is rapidly systemically absorbed after lung administration, increasing the risk for subtherapeutic pulmonary concentrations and resistant bacteria selection. In the presence of calcium, CIP forms complexes that reduce its oral absorption. Such complexation may slow down CIP absorption from the lung thereby maintaining high concentration in this tissue. Thus, we developed inhalable calcium-based inorganic-organic composite microparticles to sustain CIP within the lung. The aerodynamics and micromeritic properties of the microparticles were characterized. FTIR and XRD analysis suggest that the inorganic component of the particles comprised amorphous calcium carbonate and amorphous calcium formate, and that CIP and calcium interact in a 1:1 stoichiometry in the particles. CIP was completely released from the microparticles within 7 h, with profiles showing a slight dependence on pH (5 and 7.4) compared to the dissolution of pure CIP. Transport studies of CIP across Calu-3 cell monolayers, in the presence of various calcium concentrations, showed a decrease of up to 84% in CIP apparent permeability. The apparent minimum inhibitory concentration of CIP against Pseudomonas aeruginosa and Staphylococcus aureus was not changed in the presence of the same calcium concentration. These results indicate that the designed particles should provide sustained levels of CIP with therapeutic effect in the lung. With these microparticles, it should be possible to control CIP pharmacokinetics within the lung, based on controlled CIP release from the particles and reduced apparent permeability across the epithelial barrier due to the cation-CIP interaction.
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Affiliation(s)
- Frederic Tewes
- INSERM U 1070, Pôle Biologie-Santé, Faculté de Médecine & Pharmacie, Université de Poitiers , CHU de Poitiers, 86022 Poitiers Cedex, France.,School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, University of Dublin , Dublin 2, Ireland
| | - Julien Brillault
- INSERM U 1070, Pôle Biologie-Santé, Faculté de Médecine & Pharmacie, Université de Poitiers , CHU de Poitiers, 86022 Poitiers Cedex, France
| | - Barbara Lamy
- INSERM U 1070, Pôle Biologie-Santé, Faculté de Médecine & Pharmacie, Université de Poitiers , CHU de Poitiers, 86022 Poitiers Cedex, France
| | - Peter O'Connell
- School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, University of Dublin , Dublin 2, Ireland
| | - Jean-Christophe Olivier
- INSERM U 1070, Pôle Biologie-Santé, Faculté de Médecine & Pharmacie, Université de Poitiers , CHU de Poitiers, 86022 Poitiers Cedex, France
| | - William Couet
- INSERM U 1070, Pôle Biologie-Santé, Faculté de Médecine & Pharmacie, Université de Poitiers , CHU de Poitiers, 86022 Poitiers Cedex, France
| | - Anne Marie Healy
- School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, University of Dublin , Dublin 2, Ireland
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The Rise and Fall of Hyaluronan in Respiratory Diseases. Int J Cell Biol 2015; 2015:712507. [PMID: 26448757 PMCID: PMC4581576 DOI: 10.1155/2015/712507] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Revised: 02/11/2015] [Accepted: 05/03/2015] [Indexed: 12/24/2022] Open
Abstract
In normal airways, hyaluronan (HA) matrices are primarily located within the airway submucosa, pulmonary vasculature walls, and, to a lesser extent, the alveoli. Following pulmonary injury, elevated levels of HA matrices accumulate in these regions, and in respiratory secretions, correlating with the extent of injury. Animal models have provided important insight into the role of HA in the onset of pulmonary injury and repair, generally indicating that the induction of HA synthesis is an early event typically preceding fibrosis. The HA that accumulates in inflamed airways is of a high molecular weight (>1600 kDa) but can be broken down into smaller fragments (<150 kDa) by inflammatory and disease-related mechanisms that have profound effects on HA pathobiology. During inflammation in the airways, HA is often covalently modified with heavy chains from inter-alpha-inhibitor via the enzyme tumor-necrosis-factor-stimulated-gene-6 (TSG-6) and this modification promotes the interaction of leukocytes with HA matrices at sites of inflammation. The clearance of HA and its return to normal levels is essential for the proper resolution of inflammation. These data portray HA matrices as an important component of normal airway physiology and illustrate its integral roles during tissue injury and repair among a variety of respiratory diseases.
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Size Matters: Molecular Weight Specificity of Hyaluronan Effects in Cell Biology. Int J Cell Biol 2015; 2015:563818. [PMID: 26448754 PMCID: PMC4581549 DOI: 10.1155/2015/563818] [Citation(s) in RCA: 264] [Impact Index Per Article: 29.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Accepted: 01/05/2015] [Indexed: 01/22/2023] Open
Abstract
Hyaluronan signaling properties are unique among other biologically active molecules, that they are apparently not influenced by postsynthetic molecular modification, but by hyaluronan fragment size. This review summarizes the current knowledge about the generation of hyaluronan fragments of different size and size-dependent differences in hyaluronan signaling as well as their downstream biological effects.
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