Fluticasone propionate in Crohn's disease

Drug Repurposing in Crohn's Disease Using Danish Real-World Data

Aim

Drug repurposing, utilizing electronic healthcare records (EHRs), offers a promising alternative by repurposing existing drugs for new therapeutic indications, especially for patients lacking effective therapies. Intestinal fibrosis, a severe complication of Crohn's disease (CD), poses significant challenges, increasing morbidity and mortality without available pharmacological treatments. This article focuses on identifying medications associated with an elevated or reduced risk of fibrosis in CD patients through a population-wide real-world data and artificial intelligence (AI) approach.

Methods

Patients aged 65 or older with a diagnosis of CD from 1996 to 2019 in the Danish EHRs were followed for up to 24 years. The primary outcome was the need of specific surgical procedures, namely proctocolectomy with ileostomy and ileocecal resection as proxies of intestinal fibrosis. The study explored drugs linked to an increased or reduced risk of the study outcome through machine-learning driven survival analysis.

Results

Among the 9179 CD patients, 1029 (11.2%) underwent surgery, primarily men (58.5%), with a mean age of 76 years, 10 drugs were linked to an elevated risk of surgery for proctocolectomy with ileostomy and ileocecal resection. In contrast, 10 drugs were associated with a reduced risk of undergoing surgery for these conditions.

Conclusion

This study focuses on repurposing existing drugs to prevent surgery related to intestinal fibrosis in CD patients, using Danish EHRs and advanced statistical methods. The findings offer valuable insights into potential treatments for this condition, addressing a critical unmet medical need. Further research and clinical trials are warranted to validate the effectiveness of these repurposed drugs in preventing surgery related to intestinal fibrosis in CD patients.

Experimental and molecular modeling approach to optimize suitable polymers for fabrication of stable fluticasone nanoparticles with enhanced dissolution and antimicrobial activity

BACKGROUND AND AIM

The challenges with current antimicrobial drug therapy and resistance remain a significant global health threat. Nanodrug delivery systems are playing a crucial role in overcoming these challenges and open new avenues for effective antimicrobial therapy. While fluticasone (FLU), a poorly water-soluble corticosteroid, has been reported to have potential antimicrobial activity, approaches to optimize its dissolution profile and antimicrobial activity are lacking in the literature. This study aimed to combine an experimental study with molecular modeling to design stable FLU nanopolymeric particles with enhanced dissolution rates and antimicrobial activity.

METHODS

Six different polymers were used to prepare FLU nanopolymeric particles: hydroxyl propyl methylcellulose (HPMC), poly (vinylpyrrolidone) (PVP), poly (vinyl alcohol) (PVA), ethyl cellulose (EC), Eudragit (EUD), and Pluronics®. A low-energy method, nanoprecipitation, was used to prepare the polymeric nanoparticles.

RESULTS AND CONCLUSION

The combination of HPMC-PVP and EUD-PVP was found most effective to produce stable FLU nanoparticles, with particle sizes of 250 nm ±2.0 and 280 nm ±4.2 and polydispersity indices of 0.15 nm ±0.01 and 0.25 nm ±0.03, respectively. The molecular modeling studies endorsed the same results, showing highest polymer drug binding free energies for HPMC-PVP-FLU (-35.22 kcal/mol ±0.79) and EUD-PVP-FLU (-25.17 kcal/mol ±1.12). In addition, it was observed that Ethocel® favored a wrapping mechanism around the drug molecules rather than a linear conformation that was witnessed for other individual polymers. The stability studies conducted for 90 days demonstrated that HPMC-PVP-FLU nanoparticles stored at 2°C-8°C and 25°C were more stable. Crystallinity of the processed FLU nanoparticles was confirmed using differential scanning calorimetry, powder X-ray diffraction analysis and TEM. The Fourier transform infrared spectroscopy (FTIR) studies showed that there was no chemical interaction between the drug and chosen polymer system. The HPMC-PVP-FLU nanoparticles also showed enhanced dissolution rate (P<0.05) compared to the unprocessed counterpart. The in vitro antibacterial studies showed that HPMC-PVP-FLU nanoparticles displayed superior effect against gram-positive bacteria compared to the unprocessed FLU and positive control.

Glucocorticosteroids in the treatment of inflammatory bowel disease and approaches to minimizing systemic activity

Inflammatory bowel diseases (IBDs) are a group of inflammatory conditions characterized by chronic, uncontrolled inflammation of the gastrointestinal tract. Reported prevalence is high in the United States and northern Europe, while the incidence varies greatly across the rest of Europe. Glucocorticosteroids are the standard treatment for IBD, but due to adverse events their use can be limited. However, new formulations of glucocorticosteroids have been developed to reduce systemic activation. The aim of this review was to assess and summarize the efficacy and safety of new formulations of glucocorticosteroids. A MEDLINE search identified publications focused on new formulations of nonsystemic steroid-based drugs for IBD and benefits and limitations of each of the new glucocorticosteroid formulations were identified. Budesonide has good efficacy and is an established treatment for Crohn's disease; it has been shown to be beneficial for the induction of remission in these patients, although it is not recommended for the maintenance of induced remission. Glucocorticosteroids are not recommended for the maintenance of remission in patients with IBD. However, a recent study suggested that beclomethasone dipropionate may be effective for prolonged treatment in patients in the postacute phase of Crohn's disease who were treated with a short course of systemic steroids. The efficacy of fluticasone propionate and prednisolone metasulphobenzoate in IBD is not well established given the small number of patients enrolled in the few published clinical trials. While the tolerability of these glucocorticosteroids is favourable, more research comparing these new agents with traditional systemic glucocorticosteroids is warranted.

Quantification of neutrophil migration into the lungs of patients with chronic obstructive pulmonary disease

OBJECTIVE

To quantify neutrophil migration into the lungs of patients with chronic pulmonary obstructive disease (COPD).

METHODS

Neutrophil loss via airways was assessed by dedicated whole-body counting 45 min, 24 h and 2, 4, 7 and 10 days after injection of very small activities of (111)In-labelled neutrophils in 12 healthy nonsmokers, 5 healthy smokers, 16 patients with COPD (of whom 7 were ex-smokers) and 10 patients with bronchiectasis. Lung accumulation of (99m)Tc-labelled neutrophils was assessed by sequential SPECT and Patlak analysis in six COPD patients and three healthy nonsmoking subjects.

RESULTS

Whole body (111)In counts, expressed as percentages of 24 h counts, decreased in all subjects. Losses at 7 days (mean ± SD) were similar in healthy nonsmoking subjects (5.5 ± 1.5%), smoking subjects (6.5 ± 4.4%) and ex-smoking COPD patients (5.8 ± 1.5%). In contrast, currently smoking COPD patients showed higher losses (8.0 ± 3.0%) than healthy nonsmokers (p = 0.03). Two bronchiectatic patients lost 25% and 26%, indicating active disease; mean loss in the remaining eight was 6.9 ± 2.5%. The rate of accumulation of (99m)Tc-neutrophils in the lungs, determined by sequential SPECT, was increased in COPD patients (0.030-0.073 min(-1)) compared with healthy nonsmokers (0-0.002 min(-1); p = 0.02).

CONCLUSION

In patients with COPD, sequential SPECT showed increased lung accumulation of (99m)Tc-labelled neutrophils, while whole-body counting demonstrated subsequent higher losses of (111)In-labelled neutrophils in patients who continued to smoke. Sequential SPECT as a means of quantifying neutrophil migration deserves further evaluation.

Update on glucocorticoid action and resistance

Extensive development of inhaled and oral glucocorticoids has resulted in highly potent molecules that have been optimized to target activity to the lung and minimize systemic exposure. These have proved highly effective for most asthmatic subjects, but despite these developments, there are a number of subjects with asthma who fail to respond to even high doses of inhaled or even oral glucocorticoids. Advances in delineating the fundamental mechanisms of glucocorticoid pharmacology, especially the concepts of transactivation and transrepression and cofactor recruitment, have resulted in better understanding of the molecular mechanisms whereby glucocorticoids suppress inflammation. The existence of multiple mechanisms underlying glucocorticoid insensitivity raises the possibility that this might indeed reflect different diseases with a common phenotype, and studies examining the efficacy of potential new agents should be targeted toward subgroups of patients with severe corticosteroid-resistant asthma who clearly require effective new drugs and other approaches to improved asthma control.

Quantification of disease activity in patients undergoing leucocyte scintigraphy for suspected inflammatory bowel disease

PURPOSE

Whole-body gamma camera counting is an alternative to faecal 111In collection for quantifying disease activity in inflammatory bowel disease (IBD) but requires administration of imaging activities of 111In. The aim of this study was to explore a dedicated whole-body counter which requires 20-fold less activity than gamma camera counting.

METHODS

Thirty patients with known or suspected IBD received 99mTc-granulocytes (approximately 200 MBq) and 111In-granulocytes (approximately 0.5 MBq). The 99mTc-cells were injected 45 min after the 111In-cells and immediately after a baseline 111In whole-body count. The decay-corrected count at 120 h was expressed as a fraction of baseline to give whole-body 111In retention (WBR). One patient was excluded as the injected cells were non-viable.

RESULTS

Median 45-min intravascular 111In recovery was 35% in patients compared with 43% in six normal volunteers (p<0.05). WBR in normals ranged from 91% to 93% and in 11 patients with negative 99mTc imaging from 87% to 96%. Only one of 11 patients with negative imaging had WBR <90% while 11/12 patients with WBR <90% had abnormal imaging. Ten of 13 patients with Crohn's disease (CD) had abnormal imaging. The lowest WBR in these ten was 77% and six had values of >90%. There was a significant association between WBR and 99mTc image grade (Rs=0.73, p<0.002) in 16 patients without CD, but not in 13 patients with CD (Rs=0.54, p>0.05).

CONCLUSION

Dedicated whole-body counting is able to quantify disease activity in IBD but may give normal values in active CD.

Review article: issues in oral administration of locally acting glucocorticosteroids for treatment of inflammatory bowel disease

Inflammatory bowel diseases are treated in some cases by local administration of anti-inflammatory drugs. Local delivery of drugs in the colon following oral administration may lead to improved efficacy/side-effect profiles and may improve patient compliance. This review covers a number of issues important in the design of oral delivery systems of glucocorticosteroids for local therapy of colonic inflammation. The choice of specific glucocorticosteroids is based on the drug's physicochemical and pharmacological properties. The conditions under which an orally administered glucocorticosteroid (or other drug) must be delivered to treat ulcerative colitis are also discussed. These conditions include variations in local pH, transit throughout the gastrointestinal tract, the potential role of gut microflora, and drug dissolution in both the healthy and diseased large intestine. The effective delivery of topically-active glucocorticosteroids in ulcerative colitis and Crohn's colitis patients is complex, but if successful could improve their usefulness.

Treatment of inflammatory bowel disease from now to the millennium

After decades of therapeutic stasis, treatment advances are occurring in inflammatory bowel disease. Recognition that mesalazine was the active moiety of sulphasalazine has led to a number of new methods of delivering mesalazine without sulphapyridine, with improved toxicity ratios. Current attempts to deliver topical steroids directly to the large bowel have yet to be established as therapeutically effective. Immunosuppressive treatment has been used for many years but recent evidence has firmly established its value and cyclosporin has recently been added to the therapeutic armamentarium. Increasing understanding of the basic processes of inflammation has yielded targets for anti-inflammatory treatments aimed both at the processes of immune activation and of attraction by chemotaxis of neutrophils from the circulation to the lamina propria. Some of these novel treatments, which will be assessed in forthcoming years, involve large molecular weight bioengineered peptides and antibodies that are likely to be expensive and difficult to administer. Other treatment, e.g. 5-lipoxygenase or thromboxane synthesis inhibitors or platelet-activating factor antagonists, are conventional lower molecular weight compounds that are easier to produce and are orally active. It is predicted that 5-lipoxygenase inhibitors will be the next therapeutic advance in inflammatory bowel disease. Such a prediction may founder if blanket suppression of multiple inflammatory mechanisms, rather than targeted actions, is required in inflammation.

Medical management of chronic inflammatory bowel disease

In the absence of a definitive cure for Crohn's disease and ulcerative colitis, the aim of therapy must be to induce and maintain clinical remission at acceptable cost to the patient in terms of adverse effects. Despite the differences in their pathogenesis, the first-line treatments for Crohn's disease and ulcerative colitis are still based upon combinations of amino-salicylic acid derivatives and corticosteroids, although the use of enteral nutrition regimes is becoming increasingly widespread in Crohn's disease. In this chapter we attempt to provide reasonably didactic guidance for the management of most cases of chronic inflammatory bowel disease. However, we have tried to go beyond this brief, motivated by the recent explosion in knowledge of inflammatory mechanisms, to suggest a rational approach to the choice of newer and less well tested therapeutic approaches in the affected child who is not responding effectively. The relative failure of cyclosporine therapy in Crohn's disease has been particularly disappointing in view of its ideal theoretical suitability. However, the encouraging early reports of treatment with anti-CD4 and anti-TNF alpha monoclonals suggest that the shift from broad spectrum immunomodulation to the targeting of critical components of the inflammatory cascade may yet field important dividends.

Development of radiolabelled white cell scanning

The use of gamma emitting radioisotope labelled white cells for imaging inflammation was introduced in 1976. It was possible to study the whole body distribution of granulocytes using this method. Cells were labelled in plasma using tropolone as chelate to avoid cell activation which causes non-physiological persistent lung uptake. Such studies revealed labelled cell uptake in bone marrow, liver and spleen in normal subjects. Intense liver activity was found in cases of cell damage resulting in cell destruction by the liver. The large splenic pool of leucocytes could be mobilized rapidly to sites of inflammation and indeed the fall in splenic activity was a measure of the degree of inflammation. Measurements of the faecal excretion of 111In-labelled granulocytes were also used to assess Crohn's disease activity. Alternatively, the whole body retention of 111In was used. Later studies have involved the use of 99mTc, initially using labelled colloids, which resulted in cell activation and later using the lipophilic complex HMPAO to label leucocytes. The several advantages over 111In for imaging inflamed bowel are described. Early imaging is important to avoid non-specific bowel activity. Newer approaches include labelling immunoglobulins, monoclonal granulocyte antibodies and targeting of activated endothelium adhesion molecules. Such techniques remain experimental and the best current technique for localizing inflammation is to use radiolabelled leucocytes.

[Treatment of Crohn disease in adults]

Corticosteroids are an efficient treatment for active Crohn's disease. The treatment has to be undertaken with a daily intake equivalent to 1 mg/kg per day of prednisolone for a 3 to 7 week period. Immunosuppressive agents are indicated in case of corticodependency or in case of large intestinal resection. Artificial nutrition (enteral or parenteral) is proposed in corticoresistant forms, and is usually followed by an immunosuppressive therapy. Surgical management is reserved for complications, including resistance to all medical therapy. Surgical resection has to be limited in order to avoid a short bowel syndrome. Surgery should not be considered as the ideal therapy as it has been demonstrated that recurrence after surgery increases at distance. 5-aminosalycilates compounds are an alternative therapy in mild attacks. Mesalazine may reduce the recurrence and could be considered as a possible maintenance treatment.

Review article: topical corticosteroids in inflammatory bowel disease

It would be ideal to treat inflammatory bowel disease with topical corticosteroids that are either not absorbed through the mucosa, or have a substantial first-pass hepatic metabolism. The topical use of hydrocortisone, prednisolone-21-phosphate or betamethasone is often associated with systemic side-effects. Newer corticosteroid preparations (prednisolone metasulphobenzoate, tixocortol pivalate, fluticasone propionate, beclomethasone dipropionate and budesonide) are usually associated with minimal systemic corticosteroid activity. This article reviews the clinical activity and safety of these newer preparations.

Double blind trial of oral fluticasone propionate v prednisolone in the treatment of active ulcerative colitis

Fluticasone propionate is a corticosteroid with the potential for topical treatment of ulcerative colitis because of low systemic bioavailability. The drug was compared with prednisolone in the management of active left sided or total ulcerative colitis. Two hundred and five patients were studied in the multicentre four week double blind study. Prednisolone was given in a dose of 40 mg daily orally, reducing over four weeks to 10 or 20 mg. Fluticasone propionate was given in an oral daily dose of 20 mg. The primary end point was the investigator's overall assessment of response. Patient's assessment, sigmoidoscopic appearance, and histology were also studied. Patients improved more rapidly with prednisolone. Differences between the two groups were significant at two weeks. At four weeks differences were not significant, but there was a trend in favour of prednisolone. Corticosteroid side effects were minimal in the fluticasone propionate group, and there was minimal suppression of the hypothalamic pituitary adrenal axis. Fluticasone propionate 20 mg daily is not as effective in the treatment of active ulcerative colitis as prednisolone tapering from 40 mg daily to 10 or 20 mg. The complete absence of suppression of the corticoadrenal axis by fluticasone propionate was encouraging, however, and a higher dosage schedule should be assessed.

Current management of inflammatory bowel disease

The aetiology of ulcerative colitis and Crohn's disease remains unknown. While this remains so, treatment must be directed towards pathogenetic mechanisms. Corticosteroids, sulphasalazine and the new salicylates, the immunosuppressants azathioprine, 6-MP and, more recently, cyclosporin and metronidazole have become the accepted and standard forms of treatment. The importance of maintaining nutritional status is often overlooked but must be considered in every patient. Recognition of the occurrence of disease in all age groups, and in particular in children and adolescents, is also important, as is an appreciation of the special problems involved. The possibility of surgery at some stage of the disease should be raised with the patient. As the pathogenetic mechanisms of inflammatory bowel disease are further elucidated, new forms of treatment will be developed. This is already happening, with studies looking at such agents as immunoglobulin G, eicosapentaenoic acid and a new specific inhibitor of 5-lipoxygenase. These offer hope of more potent drugs with low side-effect profiles that may complement or replace the currently available agents used in the management of inflammatory bowel disease.

New developments in the pharmacotherapy of inflammatory bowel disease

In this article the clinical features and aetiology of inflammatory bowel diseases are described and current pharmacotherapeutic possibilities are explored. Also reviewed are recent developments and future prospects for the pharmacotherapy of inflammatory bowel diseases, including aminosalicylates, corticosteroids, immunosuppressants, lipoxygenase inhibitors, fish oil, sucralfate, bismuth compounds, free radical scavengers, (hydroxy)chloroquine, sodium cromoglycate and methotrexate.

Drug therapy for inflammatory bowel disease: Part I

In a two-part series, recent improvements in drug therapy for inflammatory bowel disease are reviewed. Part I summarizes aminosalicylates and corticosteroids. The active moiety of sulfasalazine, which is 5-aminosalicylic acid (mesalamine), in topical or oral form is as effective as sulfasalazine for treatment and prophylaxis of ulcerative colitis and is tolerated by 80% of sulfasalazine-intolerant patients. Coated forms of mesalamine have a potential advantage in the treatment of Crohn's ileitis in that these forms do not require bacterial cleavage for activity. New rapidly metabolized corticosteroids (budesonide, tixocortol pivalate, beclomethasone dipropionate) in topical and oral forms are emerging as equivalent therapy to standard corticosteroids but are associated with less adrenal suppression.

Intranasal fluticasone propionate. A review of its pharmacodynamic and pharmacokinetic properties, and therapeutic potential in allergic rhinitis

Fluticasone propionate is a potent topical anti-inflammatory corticosteroid with low systemic activity. Available pharmacodynamic data are only preliminary; however, large placebo- and drug-controlled clinical studies involving almost 4000 patients with seasonal allergic rhinitis and 1500 with perennial allergic and nonallergic rhinitis have confirmed the efficacy of intranasal fluticasone propionate in the control of nasal symptoms. Fluticasone propionate generally demonstrated similar efficacy compared with intranasal beclomethasone dipropionate, flunisolide acetonide and oral astemizole and better or a trend towards better efficacy compared with oral loratadine, terfenadine, cetirizine and intranasal sodium cromoglycate (cromolyn sodium) against nasal symptoms. The incidence of adverse effects in association with intranasal fluticasone propionate appears to be comparable to that observed with placebo; the most frequently reported effects are nasal dryness/burning, epistaxis and headache. Consistent with its minimal systemic availability, intranasal fluticasone propionate in a dosage of up to 4 mg/day does not cause adrenal suppression. Thus, based on early data from large clinical trials, fluticasone propionate administered once daily offers an effective and convenient treatment option in patients with seasonal and perennial allergic rhinitis, and is distinguished by its low oral bioavailability.