The effect of 443C81, a mu opioid receptor agonist, on the response to inhaled capsaicin in healthy volunteers

The Effect of Ramosetron on Remifentanil in Preventing Emergence Cough from Sevoflurane Anesthesia in Female Patients

BACKGROUND

Remifentanil reduces cough during extubation. Ramosetron, a 5-HT3 receptor antagonist, is a potent antiemetic. Regarding the antitussive property of 5-HT receptor agonists, ramosetron can mediate the cough reflex, as increasing the remifentanil requirement. The aim of this study was to evaluate the effect of ramosetron on the optimal effect-site concentration (Ce) of remifentanil for preventing emergence cough from sevoflurane anesthesia in female patients.

METHODS

Forty-seven female patients undergoing laparoscopic cholecystectomy randomly received either ramosetron 0.3 mg (n = 23) or the same volume of normal saline (n = 24) intravenously at the end of surgery. The remifentanil Ce using target controlled infusion in 50% of patients (EC50) and 95% of patients (EC95) were assessed using Dixon's up-and-down or isotonic regression method with a boot¬strapping approach.

RESULTS

Using Dixon's up-and-down method, the EC50 of remifentanil in the control group (1.33 ± 0.38 ng/mL) was comparable to that of ramosetron group (1.50 ± 0.69 ng/mL) (P = 0.615). Using isotonic regression analysis, the EC50 (83% confidence interval) did not differ between the two groups (1.17 [0.86-1.43] ng/mL and 1.13 [0.68-1.56] ng/mL in control and ramosetron groups). However, the EC95 (95% confidence interval) was significantly lower in the control group than in the ramosetron group (1.90 [1.45-1.96] ng/mL and 2.92 [2.35-2.97] ng/mL).

CONCLUSION

Remifentanil Ce for preventing emergence cough was higher in the ramosetron group than the control group. It may indicate the lowering effect of ramosetron on antitussive activity of remifentanil.

Regulating cough through modulation of sensory nerve function in the airways

Whilst local anaesthetics when applied directly to laryngeal nerves or topically to the lung can suppress cough, their chronic use is constrained because of dose limiting side effects. However, the effectiveness of local anaesthetics suggests that selectivity targeting nerves in the airway may provide novel approaches for the treatment of cough in the future. There is a considerable wealth of evidence showing that there are different afferent nerve subtypes in the airways. Traditionally C-fibres have been the focus of much research in the cough field since the stimulation of these afferents by capsaicin is able to elicit cough in guinea-pigs and in man, and drugs targeting various proteins expressed in these nerves (e.g. mu-opioid, NOP1, TRPV1, sodium channels) have been shown to be anti-tussive in preclinical models of cough. However, interest in Aδ fibres has increased recently in light of the discovery of a specific cough receptor in the guinea-pig that is provoked by citric acid and punctate stimulation, but not capsaicin and which has been anatomically linked to Aδ fibres. There is also some evidence that as a result of inflammation in the airways, Aδ fibres can begin to express neuropeptides and TRPV1 receptors so that they can become responsive to endogenous activators of this ion channel and to irritants like capsaicin. Consequently, there is considerable interest in targeting either one or both afferent nerve types for the treatment of chronic cough. However, to date the translation of preclinical studies into man has largely been disappointing and certainly there is a need for better preclinical models in this field. There also remain many challenges to overcome at a clinical level, such as what patient group(s) should be used to assess anti-tussive drugs and whether the use of irritants that induce cough in healthy volunteers (such as citric acid or capsaicin) is of any value in the assessment of novel anti-tussive drugs. The development of several continuous monitoring methodologies for measuring cough will hopefully allow better evaluation of treatments in patients with chronic cough. Nonetheless, cough remains a major unmet clinical need in respiratory medicine where new drugs are urgently required.

Review: Effect of drugs on human cough reflex sensitivity to inhaled capsaicin

Capsaicin, the pungent extract of red peppers, has been used in clinical research for almost three decades. Capsaicin has gained favor as the provocative agent of choice to measure cough reflex sensitivity, as it induces cough in a safe, reproducible, and dose-dependent manner. One of the major uses of capsaicin cough challenge testing has been to evaluate the effect of a pharmacological intervention on the human cough reflex. The current review summarizes the published experience with capsaicin inhalation challenge in the evaluation of drug effects on cough reflex sensitivity. A notable contrast evident between studies demonstrating a drug effect (inhibition of cough reflex sensitivity) and those that do not, is the predominance of healthy volunteers as subjects in the latter. This observation suggests that subjects with pathological cough, rather than normal volunteers, comprise the optimal group in which to evaluate the effect of potential antitussive agents on human cough reflex sensitivity.

Clinical cough VI: the need for new therapies for cough: disease-specific and symptom-related antitussives

Cough is a common symptom that can be self-limiting or persistent. Ideally, treatment of the underlying cause(s) of cough with specific treatments should eliminate cough. This approach may not be successful if no cause can be established or if the treatment of the cause fails. Suppression of cough may be disease-specific or symptom-related. There has been a long tradition in acute cough usually due to upper respiratory tract infections to use symptom-related antitussives. In chronic cough, suppression of cough may be achieved by disease-specific therapies, but in many patients it may be necessary to use symptomatic antitussives. The efficacy of some over-the-counter symptomatic antitussives is often no better than that of a placebo. Currently available cough suppressants include the centrally acting opioids such as morphine, codeine, pholcodeine, and dextromethorphan. Early studies reported success in reducing cough in patients with chronic bronchitis or chronic obstructive pulmonary disease (COPD); however, a carefully conducted blinded controlled study showed no effect of codeine on cough of COPD. Success with these cough suppressants may be achieved at high doses that are associated with side effects. A slow-release preparation of morphine has been shown to have some degree of efficacy, but this should be reserved for the most severe chronic cough patient, and for patients with terminal cancer who may also benefit from its analgesic effects. There are case reports of the success of centrally acting drugs such as amitriptyline, paroxetine, gabapentin, and carbamezepine in chronic cough. New agents derived from basic research such as new opioids such as nociceptin or antagonists of transient receptor potential vanniloid-1 may turn out to have antitussive effects. Efficacy of symptomatic cough suppressants must be tested in double-blind randomized trials using validated measures of cough in patients with chronic cough not responding to specific treatments. Patients with chronic cough need effective antitussives that could be used either on demand or on a long-term basis.

Management of chronic cough

Cough that remains unexplained after basic clinical assessment is a common reason for referral to secondary care. Much of the evidence about management of isolated chronic cough is derived from case series; this evidence suggests that isolated chronic cough is usually due to asthma, gastro-oesophageal reflux disease, and upper airway conditions, and that it can be cured in most people by treatment of these conditions. However, there is increasing recognition that satisfactory control of chronic cough is not achieved in a substantial number of patients seen in secondary care. Moreover, there is a concern that perpetuation of the belief that chronic cough is solely due to the effects of comorbid conditions is inhibiting research into the pathophysiology of an abnormally heightened cough reflex, and jeopardising development of improved treatments. We advocate a change in emphasis, which makes a clear distinction between cough due to corticosteroid-responsive eosinophilic airway diseases and corticosteroid-resistant non-eosinophilic cough. We recommend that some factors with weak evidence of an association with cough are best viewed as potential aggravating factors of an intrinsic abnormality of the cough reflex, rather than the cause. We call for more research into the basic mechanisms and pharmacological control of an abnormally heightened cough reflex, and recommend ways to assess the effects of potentially antitussive treatments.

The problem of cough and development of novel antitussives

Cough is a very common clinical symptom and current therapies are largely ineffective, indicating a major unmet medial need. There is a pressing need to develop novel and safe antitussive therapies. This is likely to arise from better understanding of the sensory nerves involved in cough and the signalling pathways that are activated. A major therapeutic target should be sensitization of the cough reflex which is a feature of patients with both acute (virally induced) cough and chronic cough, including chronic idiopathic cough. Studies on human cough mechanisms are limited. There are several novel therapeutic approaches that are currently being explored. Perhaps the most promising drugs are transient receptor potential vanilloid-1 (TRPV(1)) antagonists, selective cannabinoid agonists (CB2 agonists), maxi-K channel openers and P2X3 antagonists. New cough therapies may target airway nerve sensitization and may best be delivered as inhalers to minimize any systemic effects. Understanding the intercellular signalling pathways involved in nociception may lead to novel drugs, such as p38 mitogen-activated protein (MAP) kinase inhibitors, being used in the treatment of cough in the future. It is also likely that several novel treatments that are developed as analgesics will also prove to be beneficial in the treatment of cough.

Safety of capsaicin cough challenge testing

BACKGROUND

Capsaicin, the pungent extract of red peppers, has achieved widespread use in clinical research because it induces cough in a dose-dependent and reproducible manner. Although > 2 decades of experience has led investigators to consider capsaicin cough challenge testing a safe diagnostic modality, this issue has not been specifically addressed in the literature.

STUDY OBJECTIVES

To review the published experience with capsaicin inhalation challenge testing in terms of safety.

DESIGN

Literature review and personal communication with study authors.

SETTING

Academic medical center.

RESULTS

One hundred twenty-two published studies since 1984 described 4,833 subjects (4,374 adults, 459 children) undergoing capsaicin cough challenge, with no serious adverse events reported. Subjects included healthy volunteers as well as patients with asthma, COPD, pathologic cough, and other respiratory conditions. Minor complaints described in a small fraction of studies consisted mainly of transient throat irritation. Personal communication with the authors of > 90% of the studies confirmed an absence of any serious adverse events. Furthermore, these investigators have performed thousands of additional capsaicin challenge studies not reported in the literature, also without any associated serious adverse events.

CONCLUSIONS

A review of the 20-year clinical experience has failed to uncover a single serious adverse event associated with capsaicin cough challenge testing in humans. Given the need for better antitussive therapies, capsaicin represents a vital component of future scientific inquiry in the field of cough.

Cough: potential pharmacological developments

Cough is an important defensive reflex of the upper airway and is also a very common symptom of respiratory disease. Cough following an upper respiratory viral infection is transient, and persistent cough is associated with a whole range of conditions, such as asthma, rhino-sinusitis and gastro-oesophageal reflux. Treatment directed at these conditions may improve the associated cough. There is often a need, however, to control cough itself whatever the cause. The most effective drugs in this class are the opioids, such as morphine, codeine or pholcodeine, but at effective doses they have side effects including drowsiness, nausea, constipation and physical dependence. Investigations into the cough reflex and into the potential mechanisms of sensitised cough reflex have uncovered several potential targets for novel drugs. New opioids apart from mu-agonists such as kappa- and delta -receptor agonists, have been developed, in addition to non-opioids such as nociceptin. Neurokinin receptor antagonists, bradykinin receptor antagonists, vanniloid receptor VR-1 antagonists may be beneficial by blocking effects of tachykinins and sensory nerve activation. Local anaesthetics, blockers of sodium-dependent channels and maxi-K Ca2+-dependent channel activators of afferent nerves are inhibitors of the cough reflex. Some of these novel agents may act centrally or peripherally or at both sites as antitussives. Large scale trials of these novel compounds have not been carried out in cough in man but there is a serious need for more effective antitussives devoid of side effects.

The effect of 15-HPETE on airway responsiveness and pulmonary cell recruitment in rabbits

1. In the present study we have investigated the effect of 15-hydroperoxyeicosatetraenoic acid (15-HPETE) and 15-hydroxyeicosatetraenoic acid (15-HETE) on airway responsiveness to inhaled histamine in rabbits in vivo. 2. 15-HPETE increased airway responsiveness to histamine 24 h after tracheal instillation and this was associated with a cellular infiltration consisting mainly of neutrophils, as measured by bronchoalveolar lavage. The airway hyperresponsiveness induced by 15-HPETE was still present 72 h after tracheal instillation of 15-HPETE, but had returned to baseline values one week post challenge. The number of neutrophils in bronchoalveolar lavage remained significantly elevated compared to pre-challenge levels. In contrast to 15-HPETE, the major metabolite 15-HETE, failed to alter airway hyperresponsiveness to histamine despite the recruitment of neutrophils into the lung, suggesting that the effect of 15-HPETE was not secondary to the generation of this metabolite nor dependent on the influx of neutrophils. 3. Both capsaicin and atropine but not the peripherally acting mu-opioid receptor agonist, BW443C (H-Tyr-D-Arg-Gly-Phe(4-NO2)-Pro-NH4), attenuated 15-HPETE-induced hyperresponsiveness. The increased cellular infiltration induced by 15-HPETE was only attenuated by capsaicin. 4. The results of the present study suggest that the release of 15-HPETE into the airways could contribute to sensitization of afferent nerve endings analogous to the hyperalgesia induced by this mediator in skin.

Effect of 443c81, an inhaled mu-opioid receptor agonist in asthma

Stimulation of exposed C-fibre afferent nerve endings by inflammatory mediators may contribute to airway inflammation and bronchoconstriction in asthma through the release of neuropeptides from collateral nerve endings. The polar opioid peptide 443c81 is a mu-opioid receptor agonist which inhibits C-fibre activation and non-cholinergic neurally mediated bronchoconstriction in animal models. We have compared the effect of 443c81 (5 ml of a 4 mg/ml solution nebulized) four times daily for 7 days with placebo on asthma control in a double-blind parallel group study of 40 subjects with mild asthma. Twenty subjects (12 male, mean FEV1 83% predicted) received placebo and 20 (15 male, mean FEV1 91% predicted) 443c81 after a 1 week run-in. Efficacy was assessed by comparing changes from baseline values in FEV1, provocative dose of histamine causing a 20% fall in FEV1 (PD20), symptom scores, bronchodilator use and home peak flow readings. 443c81 had no acute effect on FEV1 and the mean changes in FEV1 after 1 week of treatment were not significantly different (placebo -0.9%; 443c81-3.8%). One hour after the first dose of 443c81 PD20 increased from a geometric mean of 0.88 to 1.48 mumol (mean change 0.76 doubling doses; 95% CI 0.23, 1.29) but this did not differ significantly from the change with placebo (mean difference between 443c81 and placebo 0.63 doubling doses; 95% CI -0.2, 1.5; P = 0.095). After 1 week's treatment, PD20 was similar to baseline values with 443c81 (0.78 mumol) and placebo (baseline 0.71, post-treatment 0.93 mumol).(ABSTRACT TRUNCATED AT 250 WORDS)

Neuronal control of airways smooth muscle

Sensory afferent nerves relay impulses from the airways to the central nervous system so that appropriate changes in bronchomotor tone and breathing patterns may occur. The dominant efferent control of airways smooth muscle is exerted via bronchoconstrictor parasympathetic cholinergic nerves. In some species this is opposed by bronchodilator sympathetic noradrenergic nerves. In addition, there exist both excitatory bronchoconstrictor and inhibitory bronchodilator non-adrenergic, non-cholinergic pathways. This review examines the role of the different branches of the autonomic nervous system in the control of airways smooth muscle tone with particular reference to modulation of these branches and the interactions which may exist between them.

Effects of inhaled alpha 2-adrenoceptor and GABAB receptor agonists on citric acid-induced cough and tidal volume changes in guinea pigs

The effects of alpha 2-adrenoceptor and GABA receptor agonists on citric acid-induced cough and increased tidal volume were investigated in conscious guinea pigs. Inhalation of low doses of B-HT 920 (5-allyl-2-amino 5,6,7,8-tetrahydro-4H-thiazolo[4,5-d]azepine dihydrochloride), and xylazine significantly inhibited citric acid-induced cough and tidal volume increases. Intraperitoneal administration of higher doses of B-HT 920 than those given by aerosol were ineffective. The inhibitory effects of B-HT 920 were antagonised by prior intraperitoneal administration of yohimbine, but not atropine. Inhalation of GABA or baclofen inhibited tidal volume increases, but had no effect on cough. Inhaled alpha 2-adrenoceptor or GABA agonists had no effect on the reduced respiratory rate after citric acid inhalation. It is concluded that alpha 2-adrenoceptor agonists inhibit cough via a mechanism which may not be related to their ability to reduce citric acid-induced tidal volume increases, since GABA and baclofen inhibited tidal volume increases but not cough. We suggest that alpha 2-adrenoceptor agonists may have therapeutic potential in the treatment of cough.