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Chapurin N, Wu J, Labby AB, Chandra RK, Chowdhury NI, Turner JH. Current Insight into Treatment of Chronic Rhinosinusitis: Phenotypes, Endotypes and Implications for Targeted Therapeutics. J Allergy Clin Immunol 2022; 150:22-32. [PMID: 35469844 DOI: 10.1016/j.jaci.2022.04.013] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 04/14/2022] [Accepted: 04/18/2022] [Indexed: 10/18/2022]
Abstract
Chronic rhinosinusitis (CRS) is characterized by persistent locoregional mucosal inflammation of the paranasal sinuses and upper airway that has substantial associated health care costs1. Personalized approaches to care that incorporate use of molecular biomarkers, phenotypes and inflammatory endotypes is a major focus of research at this time, and the concurrent rise of targeted therapeutics and biologic therapies has the potential to rapidly advance care and improve outcomes. Recent findings suggest that improved understanding of CRS phenotypic and endotypic heterogeneity, and incorporation of these characteristics into clinical care pathways, may facilitate more effective selection of surgical and/or therapeutic interventions2. Ultimately, these personalized approaches have the potential to target specific inflammatory pathways, increase efficacy, reduce costs, and limit side effects. This review summarizes recent advances in the identification and characterization of CRS phenotypes, endotypes, and biomarkers and reviews potential implications for targeted therapeutics.
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Affiliation(s)
- Nikita Chapurin
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Jeffanie Wu
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Alex B Labby
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Rakesh K Chandra
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Naweed I Chowdhury
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Justin H Turner
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, TN
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Bezerra TFP, Pezato R, de Barros PM, Coutinho LL, Costa LF, Pinna F, Voegels R. Prospective evaluation of clarithromycin in recurrent chronic rhinosinusitis with nasal polyps. Braz J Otorhinolaryngol 2019; 87:298-304. [PMID: 32144032 PMCID: PMC9422620 DOI: 10.1016/j.bjorl.2019.09.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 06/18/2019] [Accepted: 09/11/2019] [Indexed: 12/18/2022] Open
Abstract
Introduction The antiinflammatory effects of macrolides, especially clarithromycin, have been described in patients with chronic rhinosinusitis without polyps and also other chronic inflammatory airway diseases. There is no consensus in the literature regarding the effectiveness of clarithromycin in patients with chronic rhinosinusitis with sinonasal polyposis and the national literature does not report any prospective studies on the efficacy of clarithromycin in chronic rhinosinusitis in our population. Objective To evaluate the effect of clarithromycin in the adjunctive treatment of recurrent chronic rhinosinusitis with sinonasal polyposis refractory to clinical and surgical treatment. Methods Open prospective study with 52 patients with chronic rhinosinusitis and recurrent sinonasal polyposis. All subjects received nasal lavage with 20 mL 0.9% SS and fluticasone nasal spray, 200 mcg / day, 12/12 h for 12 weeks; and clarithromycin 250 mg 8/8 h for 2 weeks and, thereafter, 12/12 h for 10 weeks. The patients were assessed by SNOT 20, NOSE and Lund-Kennedy scales before, immediately after treatment and 12 weeks after treatment. The patients were also evaluated before treatment with paranasal cavity computed tomography (Lund-Mackay) and serum IgG, IgM, IgA, IgE and eosinophil levels. The outcomes evaluated were: SNOT-20, NOSE and Lund-Kennedy. Results Most patients were women, aged 47 (15) years (median / interquartile range), and 61.5% (32/52) had asthma. All patients completed the follow-up after 12 weeks and 42.3% (22/52) after 24 weeks. Treatment resulted in a quantitative decrease in the SNOT-20 [2.3 (1.6) vs. 1.4 (1.6); Δ = −0.9 (1.1); p < 0.01]; NOSE [65 (64) vs. 20 (63); Δ = −28 (38), p < 0.01] and Lund-Kennedy [11 (05) vs. 07 (05); Δ = −2 (05); p < 0.01] scores. SNOT-20 showed a qualitative improvement (>0.8) in 54% (28/52, p < 0.04) of patients, a group that showed lower IgE level [108 (147) vs. 289 (355), p < 0.01]. The group of patients who completed follow-up 12 weeks after the end of treatment (n = 22) showed no worsening of outcomes. Conclusion Long-term adjuvant use of low-dose clarithromycin for chronic rhinosinusitis patients with recurrent sinonasal polyposis refractory to clinical and surgical treatment has resulted in improved quality of life and nasal endoscopy findings, especially in patients with normal IgE levels. This improvement persisted in the patient group evaluated 12 weeks after the end of the treatment.
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Affiliation(s)
- Thiago Freire Pinto Bezerra
- Universidade Federal de Pernambuco (UFPE), Hospital das Clínicas, Departamento de Otorrinolaringologia, Recife, PE, Brazil; Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP, Brazil.
| | - Rogério Pezato
- Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP, Brazil; Escola Paulista de Medicina (EPM/Unifesp), São Paulo, SP, Brazil
| | - Pâmella Marletti de Barros
- Universidade Federal de Pernambuco (UFPE), Hospital das Clínicas, Departamento de Otorrinolaringologia, Recife, PE, Brazil
| | - Larissa Leal Coutinho
- Universidade Federal de Pernambuco (UFPE), Hospital das Clínicas, Departamento de Otorrinolaringologia, Recife, PE, Brazil
| | - Leidianny Firmino Costa
- Instituição Materno Infantil de Pernambuco (IMIP), Departamento de Otorrinolaringologia, Recife, PE, Brazil
| | - Fabio Pinna
- Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP, Brazil
| | - Richard Voegels
- Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP, Brazil
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Liu YF, Richardson CM, Bernard SH, Church CA, Seiberling KA. Antibiotics, steroids, and combination therapy in chronic rhinosinusitis without nasal polyps in adults. EAR, NOSE & THROAT JOURNAL 2018; 97:167-172. [PMID: 30036413 DOI: 10.1177/014556131809700614] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Despite a lack of robust data regarding their efficacy, oral antibiotics and steroids remain two of the most common treatments for chronic rhinosinusitis without nasal polyps (CRSsNP). We sought to objectively compare the efficacy of antibiotics and steroids, independently and in combination, for the initial treatment of CRSsNP. To that end, we conducted a retrospective chart review of 100 patients-51 men and 49 women, age 20 to 85 years (mean: 50)-who were treated for CRSsNP from January 2010 through January 2015. Of this group, 17 patients were treated with an antibiotic only, 28 with a steroid only, and 55 with both agents. All patients underwent computed tomography (CT) before and after treatment, and we compared the three groups' pre- and post-treatment Lund-Mackay CT scores, symptom scores, and rates of surgery. The average time between the pre- and post-treatment visits was 4.4 weeks. The mean Lund-Mackay CT score for the entire study population was significantly lower after treatment than at baseline (6.3 vs. 9.1; p < 0.001); however, there were no significant differences among the three groups in either pre- or post-treatment scores. Symptom scores were significantly better in the combination therapy group than in the two monotherapy groups (p < 0.001). In all, 40 of the 100 patients underwent surgery; the difference in surgery rates among the three groups was not statistically significant (p = 0.884). Surgery was performed on 9 of the 52 (17.3%) patients who either were followed for at least 1 year or who had had surgery within the first year postoperatively; again, there were no significant differences among the three groups (p = 0.578). We conclude that although the Lund-Mackay CT scores decreased significantly in the antibiotic, steroid, and combination therapy groups, no one regimen was superior to any other for treating CRSsNP in our study.
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Affiliation(s)
- Yuan F Liu
- Department of Otolaryngology-Head and Neck Surgery, Loma Linda University Medical Center, 11234 Anderson St., Room 2586A, Loma Linda, CA 92354, USA.
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The anti-inflammatory effects of erythromycin, clarithromycin, azithromycin and roxithromycin on histamine-induced otitis media with effusion in guinea pigs. The Journal of Laryngology & Otology 2018; 132:579-583. [PMID: 29888693 DOI: 10.1017/s0022215118000610] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Otitis media with effusion is a clinical manifestation characterised by inflammation of middle-ear mucosa. This study investigated the therapeutic effect of erythromycin, clarithromycin, azithromycin and roxithromycin on a histamine-induced animal model of otitis media with effusion. METHODS The animals were divided into five groups, receiving erythromycin, clarithromycin, azithromycin, roxithromycin or saline solution. The guinea pigs in the study groups received erythromycin (40 mg/kg/day), clarithromycin (15 mg/kg/day), azithromycin (10 mg/kg/day) or roxithromycin (10 mg/kg/day) for 3 days by gastric tube. Four hours after the end of the administration, histamine solution was injected into the right middle ear. RESULTS The lowest neutrophil density value obtained using stereological techniques was in the azithromycin group (0.86 ± 0.25 × 10-5/μm3), while the highest value was observed in the control group (6.68 ± 3.12 × 10-5/μm3). The anti-inflammatory properties of clarithromycin, azithromycin and roxithromycin were similar to one another, but better than that of erythromycin. CONCLUSION The use of macrolide antibiotics is recommended, as they show antibacterial and anti-inflammatory efficacy in otitis media with effusion.
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Harvey RJ, Wallwork BD, Lund VJ. Anti-inflammatory effects of macrolides: applications in chronic rhinosinusitis. Immunol Allergy Clin North Am 2010; 29:689-703. [PMID: 19879444 DOI: 10.1016/j.iac.2009.07.006] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The anti-inflammatory effects of macrolides are significant. The clinical impact on diffuse panbronchiolitis (DPB) has improved 10-year survival from 12% to more than 90% for these patients. The immunomodulatory activity of macrolides has been a source of mechanistic research as well as clinical research in non-DPB inflammatory airway disease. Suppression of neutrophilic inflammation of the airways has been demonstrated as the most robust immunomodulatory response from 14- and 15-membered ring macrolides. The inhibition of transcription factors, mainly nuclear factor-kB and activator protein 1, from alterations in intracellular cell signaling drives this mechanism. The suppression of interleukin-8 to a range of endogenous and exogenous challenges characterizes the alterations to cytokine production. The inflammatory mechanisms of chronic rhinosinusitis (CRS) have been a major non-DPB focus. Macrolides have been trialed in more than 14 prospective trials and are the focus of numerous research projects. Evidence for a strong clinical effect in CRS is mounting, but results may be tempered by researchers' inability to characterize the disease process. Eosinophilic dominated CRS is unlikely to respond, based on current research understanding and data from clinical trials. This article discusses the current concepts of macrolides and their application in the management of CRS.
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Affiliation(s)
- Richard J Harvey
- Department of Otolaryngology, Skull Base Surgery, St. Vincent's Hospital, Sydney, NSW 2010, Australia.
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Nichols DP, Konstan MW, Chmiel JF. Anti-inflammatory therapies for cystic fibrosis-related lung disease. Clin Rev Allergy Immunol 2009; 35:135-53. [PMID: 18546078 DOI: 10.1007/s12016-008-8081-2] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Cystic fibrosis (CF) is an autosomal recessive disease affecting many organ systems. In the lung, the underlying ion transport defect in CF establishes a perpetuating cycle of impaired airway clearance, chronic endobronchial infection, and exuberant inflammation. The interrelated nature of these components of CF lung disease makes it likely that the most effective therapeutic strategies will include treatments of each of these. This chapter reviews the preclinical and clinical data focused on ways to better understand and particularly to limit inflammation in the CF airway. Anti-inflammatories are an attractive therapeutic target in CF with a proven ability to decrease the rate of decline in lung function. However, the inherent complexity of the inflammatory response combined with the obvious dependency on this response to contain infection and the side effect profiles of common anti-inflammatories have made identifying the most suitable agents challenging. Research continues to discover impairments in signaling events in CF that may contribute to the excessive inflammation seen clinically. Concurrent with these findings, promising new therapies are being evaluated to determine which agents will be most effective and well tolerated. Available data from studies commenced over the last two decades, which have generated both encouraging and disappointing results, are reviewed below.
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Affiliation(s)
- David P Nichols
- Department of Pediatrics, Case Western Reserve University School of Medicine, Rainbow Babies and Children's Hospital, Cleveland, OH, USA.
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7
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Abstract
OBJECTIVE To review antibiotic use and selection for disorders commonly seen in allergy practice. DATA SOURCES MEDLINE searches were performed cross-referencing the keywords antibiotic, antimicrobial, management, and treatment with multiple disorders commonly seen in allergy practice. References of the chosen articles were also examined. STUDY SELECTION Articles were selected based on their relevance to the subject matter. RESULTS A large body of research is available that is relevant to both conventional and novel uses of antibiotics. The use of antibiotics is in question for some disorders, whereas novel approaches to therapy with macrolide antibiotics are areas of active investigation. Meanwhile, patterns of microbial resistance continue to evolve. CONCLUSION For decades, antibiotics have been traditional first-line treatments for many disorders. Recently, this paradigm appears to be shifting as periods of observation come into favor and nonbacterial causes of inflammation are under greater scrutiny. Nonetheless, appropriate antibiotic selection often remains a key element in the treatment of these disorders. Knowledge of the relevant microbiology is an inherent requirement in selecting antibiotic therapies and necessitates awareness of current trends in bacterial resistance.
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Cervin A, Wallwork B, Mackay-Sim A, Coman WB, Greiff L. Effects of long-term clarithromycin treatment on lavage-fluid markers of inflammation in chronic rhinosinusitis. Clin Physiol Funct Imaging 2008; 29:136-42. [PMID: 19076731 DOI: 10.1111/j.1475-097x.2008.00848.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Macrolides can be clinically effective in chronic rhinosinusitis (CRS). However, little is known about how these drugs affect pathophysiological features of CRS in vivo. In the present study, patients with CRS were subjected to long-term treatment with clarithromycin. Nasal lavages with and without histamine (40 and 400 microg ml(-1)) were carried out prior to and late into the treatment period. Histamine was included as a tool to produce plasma exudation, a process known to move free cellular products from the mucosal tissue into the airway lumen thereby enriching nasal surface liquids with such products. Interleukin-8 (IL-8), myeloperoxidase (MPO), eosinophil cationic protein (ECP), alpha(2)-macroglobulin and fucose were monitored as indices of pro-inflammatory cytokine production, neutrophil and eosinophil granulocyte activities, plasma exudation and mucinous secretion, respectively. Clarithromycin reduced the lavage fluid levels of IL-8 at the low-dose histamine observation (P<0.001). There was a trend towards reduced MPO by the treatment, whereas ECP was significantly reduced at the low-dose histamine observation (P<0.05). alpha(2)-Macroglobulin was reduced by clarithromycin (saline lavages) (P = 0.05), whereas fucose was unaffected. The exudative responsiveness to high-dose histamine was significantly reduced by the treatment (P<0.05). Furthermore, significantly lower levels of fucose were observed at the low-dose histamine observation (P<0.01). We conclude that long-term clarithromycin treatment likely exerts an anti-inflammatory effect in CRS.
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Affiliation(s)
- Anders Cervin
- National Centre for Adult Stem Cell Research, Griffith University, Brisbane, Australia.
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Hatipoğlu U, Rubinstein I. Anti-inflammatory treatment of chronic rhinosinusitis: a shifting paradigm. Curr Allergy Asthma Rep 2008; 8:154-61. [PMID: 18417058 DOI: 10.1007/s11882-008-0026-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Treatment of chronic rhinosinusitis still represents an unmet medical need. Presently, the US Food and Drug Administration has not approved any drugs for the treatment of this common condition. Various inflammatory processes are involved in the pathogenesis of chronic rhinosinusitis. Treatment of infection and surgical intervention to correct anatomic abnormalities often are inadequate in management when singly employed. Anti-inflammatory therapy such as topical cortico-steroids and more recently long-term, low-dose macrolide therapy has been integrated into the treatment algorithm for chronic rhinosinusitis. Better classification and point-of-care identification of inflammatory features may improve choice of anti-inflammatory therapy and thus outcome.
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Affiliation(s)
- Umur Hatipoğlu
- Department of Medicine (M/C 719), University of Chicago, Chicago, IL 60612-4325, USA
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Chmiel JF, Konstan MW. Inflammation and anti-inflammatory therapies for cystic fibrosis. Clin Chest Med 2007; 28:331-46. [PMID: 17467552 DOI: 10.1016/j.ccm.2007.02.002] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Cystic fibrosis lung disease is characterized by a self-propagating cycle of obstruction, infection, and inflammation. The inflammatory response, which accounts for the majority of the morbidity and mortality of the disease, begins early in life, becomes persistent, and is excessive relative to the bacterial burden. Therapies aimed at decreasing the inflammatory response represent a relatively new strategy for treatment. This article reviews the current state of the art of anti-inflammatory therapy in cystic fibrosis and introduces clinical trials that are underway.
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Affiliation(s)
- James F Chmiel
- Division of Pediatric Pulmonology, Department of Pediatrics, Case Western Reserve University School of Medicine, 11100 Euclid Avenue, Cleveland, OH 44106, USA
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11
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Abstract
Cystic fibrosis (CF) results in chronic pulmonary disease in the majority of patients resulting from the production of viscous secretions and impairment of mucociliary clearance due to alterations in airway surface liquid. Chronic infection results, and the combination of tissue damage by pathogenic organisms and a robust host inflammatory response leads to the development of bronchiectasis and progressive lung disease. Macrolide antibiotics have demonstrated efficacy in diffuse panbronchiolitis, a disease that shares many similarities to CF, and this has generated interest in the use of these agents in patients who have CF. The authors review the data that demonstrate clinical benefits of long-term azithromycin administration in patients who have CF and discuss potential host- and pathogen-related explanations for the positive therapeutic effect.
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Affiliation(s)
- John R McArdle
- Adult Cystic Fibrosis Program, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06520, USA.
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Hatipo U, Rubinstein I. Anti-inflammatory treatment of chronic rhinosinusitis: A shifting paradigm. Curr Infect Dis Rep 2007; 9:193-200. [PMID: 17430700 DOI: 10.1007/s11908-007-0031-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Treatment of chronic rhinosinusitis still represents an unmet medical need. Presently, the US Food and Drug Administration has not approved any drugs for the treatment of this common condition. Various inflammatory processes are involved in the pathogenesis of chronic rhinosinusitis. Treatment of infection and surgical intervention for correction of anatomical abnormalities often are inadequate in management when singly employed. Anti-inflammatory therapy such as topical cortico-steroids and more recently long-term, low-dose macrolide therapy have been integrated into the treatment algorithm for chronic rhinosinusitis. Better classification and point-of-care identification of inflammatory features may improve choice of anti-inflammatory therapy and thus outcome.
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Affiliation(s)
- Umur Hatipo
- Department of Medicine (M/C 719), University of Chicago, CSB 920, Room 913-N, Chicago, IL 60612-4325, USA
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Oyama T, Matsushita K, Sakuta T, Tokuda M, Tatsuyama S, Nagaoka S, Torii M. Roxithromycin inhibits tumor necrosis factor-alpha-induced matrix metalloproteinase-1 expression through regulating mitogen-activated protein kinase phosphorylation and Ets-1 expression. J Periodontal Res 2007; 42:53-61. [PMID: 17214640 DOI: 10.1111/j.1600-0765.2006.00914.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND OBJECTIVE In periodontitis, matrix metalloproteinases (MMPs) are upregulated in response to locally released inflammatory cytokines, resulting in pathologic processes. Roxithromycin is a 14-membered ring macrolide antibiotic with broad-spectrum antibacterial effects against oral pathogens and immunomodulatory effects. Recently, we reported that roxithromycin inhibits tumor necrosis factor (TNF)-alpha-induced vascular endothelial growth factor expression in human periodontal ligament (HPDL) cell cultures. In the present study, we examined the effect of roxithromycin on TNF-alpha-induced MMP-1 production by HPDL cells. MATERIAL AND METHODS Cultured cells were incubated with 1% fetal bovine serum for 24 h, followed by treatment with 10 ng/ml TNF-alpha, 10 microM roxithromycin, and mitogen-activated protein kinase inhibitor at various concentrations. Culture supernatants and sediments were collected at different time-points and used for enzyme-linked immunosorbent assays, and northern and western blot analyses. RESULTS In HPDL cell cultures, roxithromycin strongly inhibited TNF-alpha-induced MMP-1 mRNA expression and production. The inhibition of MMP-1 gene expression by roxithromycin was dependent on de novo protein synthesis and was regulated at the transcriptional level. Roxithromycin significantly inhibited TNF-alpha-induced c-Jun N-terminal kinase activation (JNP) and marginally inhibited extracellular signal-regulated kinase (ERK) 1/2 activation, but not p38 mitogen-activated protein kinase activation. Furthermore, roxithromycin reduced the induction of Ets-1, one of the critical factors in MMP-1 transcription. CONCLUSION Roxithromycin inhibits TNF-alpha-mediated MMP-1 induction through the downregulation of ERK1/2 and JNK activation and the subsequent reduction of Ets-1, suggesting that roxithromycin may have therapeutic use in periodontitis and other chronic inflammatory conditions involving MMP-1 induction.
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Affiliation(s)
- T Oyama
- Department of Restorative Dentistry and Endodontology, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan.
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Crowley S, Egan JJ. Macrolide antibiotics and bronchiolitis obliterans following lung transplantation. Expert Rev Anti Infect Ther 2006; 3:923-30. [PMID: 16307505 DOI: 10.1586/14787210.3.6.923] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The anti-inflammatory effects of macrolide antibiotics are of emerging importance. Over the past 20 years, chronic inflammatory respiratory conditions, including diffuse panbronchiolitis, cystic fibrosis and asthma have benefited from long-term low-dose macrolide therapy. Obliterative bronchiolitis, a form of chronic allograft dysfunction in lung transplant recipients, has been reported to be a condition in which macrolide therapy may be indicated. A number of recent cohort studies have been encouraging. Disease progression was delayed with macrolide antibiotic therapy as patients showed a sustained improvement in pulmonary function tests. Up to now, obliterative bronchiolitis has been resistant to most forms of proposed treatment. This review aims to highlight the etiology of obliterative bronchiolitis, the mechanisms of immunomodulation associated with macrolide therapy and how macrolide therapy may be effective by way of these possible mechanisms.
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Affiliation(s)
- Seamus Crowley
- Mater Misericordiae University Hospital, University College Dublin, Dublin 7, Ireland
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15
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Cervin A, Wallwork B. Anti-inflammatory effects of macrolide antibiotics in the treatment of chronic rhinosinusitis. Otolaryngol Clin North Am 2006; 38:1339-50. [PMID: 16326189 DOI: 10.1016/j.otc.2005.08.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Apart from their obvious antibiotic effects, the macrolides have some potentially useful immunomodulatory properties. Which pathway dominates the clinical effect is debatable. Favoring the anti-inflammatory effects are the substantial in vitro data and serum concentrations well below minimal inhibitory concentrations for several pathogens. Furthermore, tissue reparative effects are seen in diffuse panbronchiolitis regardless of the presence of P. aeruginosa, a pathogen not sensitive to macrolide antibiotics. Clinical studies support the view that prolonged treatment is likely to be beneficial in most patients who have CRS. The evidence concerning CRS is still weak because placebo-controlled trials are missing. One should remember, however, the general lack of placebo-controlled trials even in the "more established" medical management of CRS. The concern for an increasing incidence of macrolide-resistant bacterial strains must be taken seriously. Therefore the authors advocate repeated nasal cultures during macrolide therapy. It is hoped that the future will bring larger, prospective, randomized, controlled trials that will investigate the efficacy and safety of macrolides in CRS.
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Affiliation(s)
- Anders Cervin
- Department of Oto-Rhino-Laryngology, Head and Neck Surgery, Lund University Hospital, SE 221 85, Sweden.
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16
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Hatipoglu U, Rubinstein I. Treatment of chronic rhinosinusitis with low-dose, long-term macrolide antibiotics: an evolving paradigm. Curr Allergy Asthma Rep 2006; 5:491-4. [PMID: 16216175 DOI: 10.1007/s11882-005-0031-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The 14-membered and 15-membered ring macrolide antibiotics express immunomodulatory effects in chronic respiratory disorders in humans that are distinct from their antimicrobial properties. These drugs downregulate the excessive immune and inflammatory responses observed in these conditions while promoting tissue repair. To this end, chronic rhinosinusitis is characterized by mucosal inflammation of nasal and sinus mucosa for more than 3 months and accounts for significant health care resource allocation due to difficulties in treatment. Clinical efficacy of macrolide antibiotics as biologic response modifiers in patients with chronic rhinosinusitis is suggested by compelling basic research and small, uncontrolled clinical studies. Hence, long-term, prospective double-blind placebo-controlled clinical studies are indicated to establish the utility of these drugs in the treatment of patients with chronic rhinosinusitis.
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Affiliation(s)
- Umur Hatipoglu
- Department of Medicine (M/C 719), University of Illinois at Chicago, 840 South Wood Street, Room 913, Chicago, IL 60616-7323, USA
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Abstract
Lung transplantation has become an accepted therapy for selected patients with advanced lung disease. One of the main limitations to successful lung transplantation is rejection of the transplanted organ. This article discusses the clinical presentation, treatment, and prevention of hyperacute, acute, and chronic rejection in the lung transplant recipient.
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Affiliation(s)
- Timothy P M Whelan
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Minnesota, Minneapolis, MN 55455, USA.
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Shitrit D, Bendayan D, Gidon S, Saute M, Bakal I, Kramer MR. Long-Term Azithromycin Use for Treatment of Bronchiolitis Obliterans Syndrome in Lung Transplant Recipients. J Heart Lung Transplant 2005; 24:1440-3. [PMID: 16143268 DOI: 10.1016/j.healun.2004.08.006] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2004] [Revised: 07/22/2004] [Accepted: 08/15/2004] [Indexed: 11/24/2022] Open
Abstract
Short-term improvement in lung function was observed in 5 of 6 lung transplant recipients with bronchiolitis obliterans syndrome (BOS) who were treated with oral azithromycin. We assessed the long-term effect (mean duration 10 months) of treatment with oral azithromycin in 11 lung transplant recipients with BOS. Mean forced expiratory volume in 1 second (FEV1) was 40 +/- 9% at initiation of azithromycin treatment, 39 +/- 10% after 1 month, 39 +/- 12% after 4 months, 38 +/- 10% after 7 months and 38 +/- 10% after 10 months, respectively (statistically non-significant for all data). We conclude that long-term administration with oral azithromycin does not reverse BOS in lung transplant recipients, but may slow progression of the disease.
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Affiliation(s)
- David Shitrit
- Pulmonary Institute, Rabin Medical Center, Beilinson Campus, Petach Tikva, Israel
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Affiliation(s)
- Bruce K Rubin
- Department of Pediatrics, Wake Forest University School of Medicine, Winston-Salem, North Carolina 27157-1081, USA
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20
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Wallwork B, Coman W. Chronic rhinosinusitis and eosinophils: do macrolides have an effect? Curr Opin Otolaryngol Head Neck Surg 2004; 12:14-7. [PMID: 14712113 DOI: 10.1097/00020840-200402000-00005] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Long-term, low-dose macrolide therapy is effective in the treatment of chronic airway inflammation. It is believed that macrolide antibiotics produce this benefit through an antiinflammatory effect that is separate from their antibiotic effect. Eosinophils are key mediators in the inflammation seen in chronic rhinosinusitis. This review discusses the effect of macrolides on eosinophilic inflammation. RECENT FINDINGS In vitro studies recently have suggested that macrolides increase eosinophil apoptosis and reduce production of eosinophil chemotactic cytokines and adhesion molecules. In vivo studies have shown a reduction in eosinophil count and activity in asthma and chronic rhinosinusitis. Clinical response to macrolide treatment is thought to be less likely in patients with atopy. SUMMARY In contrast to the evidence supporting the effect of macrolides on neutrophilic inflammation, there are limited data to suggest an influence on eosinophilic inflammation. For this reason, patients with prominent eosinophilic inflammation may in the future be identified as being less likely to respond to treatment. Further in vitro and clinical studies are required to investigate this subject.
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Affiliation(s)
- Ben Wallwork
- School of Biomolecular and Biomedical Science, Griffith University, Brisbane, Australia.
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21
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Abstract
The patient referred to the otolaryngologist for the treatment of CRS has received many therapies for the condition. Newer therapies available focus on the anti-inflammatory therapies and local application of antimicrobial and antifungal agents to the sinus cavities. Much clinical work remains to be done to prove the efficacy of currently available treatments. The recent advances in the understanding of allergic and immune mechanisms may allow eventual intervention at the level of cytokines and other immunomodulators of inflammation. The complex cascade of interleukins and proinflammatory agents in CRS patients may some day allow "silver bullet" therapies in the properly selected patient. Until then, a systematic approach to the evaluation of these patients and management with the currently available treatment modalities may help relieve the symptoms in patients with CRS.
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Affiliation(s)
- Mark A Zacharek
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, 3181 Southwest Sam Jackson Park Road, Portland, OR 97239, USA
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22
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Gerhardt SG, McDyer JF, Girgis RE, Conte JV, Yang SC, Orens JB. Maintenance azithromycin therapy for bronchiolitis obliterans syndrome: results of a pilot study. Am J Respir Crit Care Med 2003; 168:121-5. [PMID: 12672648 DOI: 10.1164/rccm.200212-1424bc] [Citation(s) in RCA: 236] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Bronchiolitis obliterans syndrome remains the leading cause of morbidity and mortality in the pulmonary transplant population. Previous studies show that macrolide antibiotics may be efficacious in the treatment of panbronchiolitis and cystic fibrosis. In the latter, azithromycin decreases the number of respiratory exacerbations, improves FEV1, and improves quality of life. We hypothesized that oral azithromycin therapy may improve lung function in patients with bronchiolitis obliterans syndrome. To test this hypothesis, we conducted an open-label pilot trial using maintenance azithromycin therapy in six lung transplant recipients (250 mg orally three times per week for a mean of 13.7 weeks). In this study, five of these six individuals demonstrated significant improvement in pulmonary function, as assessed by FEV1, as compared with their baseline values at the start of azithromycin therapy. The mean increase in the percentage of predicted FEV1 values in these individuals was 17.1% (p </= 0.05). In addition, the absolute FEV1 increased by 0.50 L (range -0.18 to 1.36 L). These data suggest a potential role for maintenance macrolide therapy in the treatment of bronchiolitis obliterans syndrome in lung transplant recipients.
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Affiliation(s)
- Susan G Gerhardt
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland 21287, USA
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23
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Klossek J, Dufour X, Rodier M, Kauffman-Lacroix C. Est-ce que l’allergie rhinosinusienne fongique existe ? ACTA ACUST UNITED AC 2003. [DOI: 10.1016/s0335-7457(03)00105-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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24
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Garey KW, Alwani A, Danziger LH, Rubinstein I. Tissue reparative effects of macrolide antibiotics in chronic inflammatory sinopulmonary diseases. Chest 2003; 123:261-5. [PMID: 12527628 DOI: 10.1378/chest.123.1.261] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
It is well established that macrolide antibiotics are efficacious in treating sinopulmonary infections in humans. However, a growing body of experimental and clinical evidence indicates that they also express distinct salutary effects that promote and sustain the reparative process in the chronically inflamed upper and lower respiratory tract. Unlike the anti-infective properties, these distinct effects are manifested at lower doses, usually after a relatively prolonged period (weeks) of treatment, and in the absence of an identifiable, viable pathogen. Long-term, low-dose administration of macrolide antibiotics has been used most commonly for sinusitis, diffuse panbronchiolitis, asthma, bronchiectasis, and cystic fibrosis. It is associated with down-regulation of nonspecific host inflammatory response to injury and promotion of tissue repair. Although large-scale trials are lacking, the prolonged use of these drugs has not been associated with emergence of clinically significant bacterial resistance or immunosuppression. Long-term, low-dose administration of 14- and 15-membered ring macrolide antibiotics may represent an important adjunct in the treatment of chronic inflammatory sinopulmonary diseases in humans.
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Affiliation(s)
- Kevin W Garey
- Department of Clinical Sciences and Administration, University of Houston College of Pharmacy, Houston, TX, USA
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25
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Wallwork B, Coman W, Feron F, Mackay-Sim A, Cervin A. Clarithromycin and prednisolone inhibit cytokine production in chronic rhinosinusitis. Laryngoscope 2002; 112:1827-30. [PMID: 12368623 DOI: 10.1097/00005537-200210000-00022] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Long-term, low-dose macrolide therapy is effective in the treatment of chronic rhinosinusitis. The mechanism of its anti-inflammatory effect and how this differs from corticosteroids remains unclear. The effect of clarithromycin and prednisolone on interleukin-5, interleukin-8, and granulocyte-macrophage colony-stimulating factor production by cultured chronic sinusitis nasal mucosa was examined in the study. STUDY DESIGN AND METHODS Nasal mucosa was obtained from 11 patients with chronic sinusitis. This tissue was cultured for 24 hours in the presence of clarithromycin or prednisolone at a variety of concentrations. Cytokine levels were determined by enzyme-linked immunoassay. RESULTS Clarithromycin and prednisolone each produced significant reductions in interleukin-5, interleukin-8, and granulocyte-macrophage colony-stimulating factor production. There was no significant difference between the effects of clarithromycin and prednisolone. CONCLUSION Macrolide antibiotics are capable of inhibiting pro-inflammatory cytokine production in vitro and are as potent as prednisolone. This mechanism is likely to be at least partly responsible for the clinical efficacy of macrolide antibiotics in chronic rhinosinusitis.
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Affiliation(s)
- Ben Wallwork
- School of Biomolecular and Biomedical Science, Griffith University, Brisbane, Australia.
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Abstract
Macrolides are widely used as antibacterial drugs. Clinical and experimental data, however, indicate that they also modulate inflammatory responses, both contributing to the treatment of infective diseases and opening new opportunities for the therapy of other inflammatory conditions. Considerable evidence, mainly from in vitro studies, suggests that leukocytes and neutrophils in particular, are important targets for modulatory effects of macrolides on host defense responses. This underlies the use of the 14-membered macrolide erythromycin for the therapy of diffuse panbronchiolitis. A variety of other inflammatory mediators and processes are also modulated by macrolides, suggesting that the therapeutic indications for these drugs may be extended significantly in future.
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Affiliation(s)
- O Culić
- PLIVA d.d. Research Institute, Prilaz baruna Filipovića 25, HR-10000 Zagreb, Croatia
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Mori S, Lee K, Fujieda S, Kojima A, Saito H. Antrolithiasis in the frontal sinus. ORL J Otorhinolaryngol Relat Spec 2000; 62:335-7. [PMID: 11054018 DOI: 10.1159/000027765] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
A very rare case of sinusitis with antrolithiasis in the left frontal sinus of a 63-year-old male patient is reported. Various conservative treatments had no effect on the decrease of his left frontal pain and of postnasal drip. Neither bacteria nor fungus were detected in the discharge. Computed tomographic scanning revealed several high-dense spots in an isodense shadow in the left frontal sinus. At first, endoscopic sinus surgery (ESS) was employed and a stony mass was detected in the nasofrontal duct and sinus. Patency of the nasofrontal duct was insured and a sticky paste and small masses were removed as well as possible. However, the flow of discharge from the frontal duct continued after surgery. We performed a second operation with extranasal approach and additional stones in the sinus were successfully removed. Most cases of antrolithiasis are caused by a foreign body or caseous sinusitis with fungus. The maxillary sinus is the most common site of disease in antrolithiasis. It is unknown why the present case of antrolithiasis was in the frontal sinus. In such cases of antrolithiasis or cases having pastelike contents in the frontal sinuses, we conclude that ESS may be an unsuccessful treatment and a classical surgical approach may be required.
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Affiliation(s)
- S Mori
- Department of Otorhinolaryngology, Fukui Medical University, Matsuoka, Fukui, Japan.
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Oyama T, Sakuta T, Matsushita K, Maruyama I, Nagaoka S, Torii M. Effects of roxithromycin on tumor necrosis factor-alpha-induced vascular endothelial growth factor expression in human periodontal ligament cells in culture. J Periodontol 2000; 71:1546-53. [PMID: 11063386 DOI: 10.1902/jop.2000.71.10.1546] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Aberrant angiogenesis is associated with lesion formation in chronic periodontitis. However, little is known about the mediators that contribute to angiogenesis or about therapeutic agents that control the production of the mediators. Roxithromycin (RXM), which is a new 14-member macrolide antibiotic, has a wide antibacterial spectrum against oral pathogens and an immunomodulatory effect. In the present study, we examined the effects of RXM on tumor necrosis factor (TNF)-alpha-induced vascular endothelial growth factor (VEGF) in human periodontal ligament (HPDL) cells. In addition, the effect of RXM on VEGF expression in HPDL cells was examined. METHODS HPDL cells were plated at 5 x 10(5) cells/ml in 150 cm2 cell culture dishes. The confluent-stage cells were pretreated with or without 10 microg/ml of RXM or other antibiotics in 1% FBS-containing alpha-MEM for 24 hours, followed by simultaneous treatment with 10 ng/ml of TNF-alpha and 10 microg/ml of these antibiotics. After incubation for various periods, the culture supernatants and sediments were collected and analyzed by ELISA, Northern blot, and gel shift assays. RESULTS VEGF mRNA and its protein were constitutively expressed in HPDL cells, and the level of expression was markedly enhanced by stimulation with TNF-alpha. RXM strongly inhibited the expression of VEGF mRNA and the production of VEGF. Furthermore, RXM suppressed activation of transcription factors AP-1 and SP-1, which were critical factors in VEGF transcription, in TNF-alpha-stimulated HPDL cells. CONCLUSION These results indicate that TNF-alpha, one of the proinflammatory cytokines implicated in the pathogenesis of periodontitis, induces excess induction of VEGF in HPDL, which may account for increased angiogenesis in periodontitis lesions. Interestingly, the antibiotic roxithromycin inhibits TNF-mediated VEGF induction, suggesting its possible therapeutic utility in periodontitis and other chronic inflammatory conditions involving VEGF induction.
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Affiliation(s)
- T Oyama
- Department of Operative Dentistry and Endodontology, Kagoshima University Dental School, Japan.
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Suzuki H, Ikeda K, Honma R, Gotoh S, Oshima T, Furukawa M, Takasaka T. Prognostic factors of chronic rhinosinusitis under long-term low-dose macrolide therapy. ORL J Otorhinolaryngol Relat Spec 2000; 62:121-7. [PMID: 10810255 DOI: 10.1159/000027731] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
We studied the immunological and histopathological factors that affect the prognosis of chronic rhinosinusitis under long-term low-dose macrolide therapy. Sixteen patients with chronic rhinosinusitis were given 200 mg clarithromycin or 150 mg roxithromycin orally once a day without other concurrent treatments for 2-3 months. Measurement of the serum IgE level, blood cell count and differential leukocyte count of the peripheral blood, cytological assessment of the nasal smear and computed tomographic (CT) scans of the paranasal sinuses were performed before treatment. The opacity of the sinuses was estimated and scored by the CT images. After treatment, anterior ethmoidal mucosa samples were collected, an infiltrated inflammatory cells, interferon (IFN)-gamma-positive cells and interleukin (IL)-4-positive cells were examined histologically and immunohistochemically. The severity of nasal symptoms was scored before and after treatment, and the improvement rate of the score (symptomatic improvement rate) was calculated. Patients with normal levels of serum IgE (</=250 U/ml) showed a significantly higher symptomatic improvement rate than those with high levels of serum IgE (42.1 +/- 11.2 vs. 4.9 +/- 3.1%, p = 0.046). The symptomatic improvement rate was inversely correlated with the eosinophil counts in the peripheral blood (r = -0.51, p = 0.04), in the nasal smear (r = -0.54, p = 0.045) and in the sinus mucosa (r = -0.54, p = 0.02). Meanwhile, the CT score, the number of IFN-gamma-positive cells and IL-4-positive cells in the sinus mucosa and neutrophil counts in the nasal smear and in the sinus mucosa failed to correlate with the symptomatic improvement rate. These results suggest that macrolide therapy is indicated for patients without atopy or smear/tissue/peripheral blood eosinophilia. On the contrary, the severity of the disease, Th1/Th2 dominance in the sinus mucosa and neutrophilia are unlikely to be prognostic factors of chronic rhinosinusitis under long-term low-dose marolide therapy.
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Affiliation(s)
- H Suzuki
- Department of Otolaryngology, Sendai National Hospital, Sendai, Japan.
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Yamada T, Fujieda S, Mori S, Yamamoto H, Saito H. Macrolide treatment decreased the size of nasal polyps and IL-8 levels in nasal lavage. AMERICAN JOURNAL OF RHINOLOGY 2000; 14:143-8. [PMID: 10887619 DOI: 10.2500/105065800782102717] [Citation(s) in RCA: 118] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Recently, epidemiologic and experimental studies have been reported that long-term macrolides are effective for the treatment of chronic airway inflammatory diseases including diffuse panbronchiolitis, chronic rhinosinusitis, and cystic fibrosis (Jaffe A, Francis J, Rosenthal M, et al. Long-term azithromycin may improve lung function in children with cystic fibrosis. Lancet 351:420, 1998), and that macrolides can directly reduce the production of IL-8 by nasal epithelial cells (Suzuki H, Shimomura A, Ikeda K, et al. Inhibitory effect of macrolides on interleukin-8 secretion from cultured human nasal epithelial cells. Laryngoscope 107:1661-1666, 1997). In this study we administered macrolides with 14-membered rings to patients with nasal polyps due to chronic rhinosinusitis for at least 3 months and measured the IL-8 level in nasal lavage from those patients. The IL-8 levels in nasal lavage from patients with nasal polyps were reduced during macrolide treatment. There was significant correlation between decreased IL-8 levels in nasal lavage and the clinical effect of macrolides on the size of the nasal polyps. In the group whose polyps were reduced in size, the IL-8 levels dramatically decreased from 231.2 pg/mL to 44.0 pg/mL (p < 0.05), and were significantly higher before macrolide treatment than those in the group whose polyps showed no change (p < 0.005). This reduction in IL-8 may be an important aspect of the effect of macrolide treatment on nasal polyps in chronic rhinosinusitis.
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Affiliation(s)
- T Yamada
- Department of Otorhinolaryngology, Fukui Medical University, Japan
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31
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Maximal medical management of chronic rhinosinusitis. Curr Opin Otolaryngol Head Neck Surg 2000. [DOI: 10.1097/00020840-200002000-00003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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