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Wilson AM, Clark AB, Cahn T, Chilvers ER, Fraser W, Hammond M, Livermore DM, Maher TM, Parfrey H, Swart AM, Stirling S, Thickett DR, Whyte M. Effect of Co-trimoxazole (Trimethoprim-Sulfamethoxazole) vs Placebo on Death, Lung Transplant, or Hospital Admission in Patients With Moderate and Severe Idiopathic Pulmonary Fibrosis: The EME-TIPAC Randomized Clinical Trial. JAMA 2020; 324:2282-2291. [PMID: 33289822 PMCID: PMC7724556 DOI: 10.1001/jama.2020.22960] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
IMPORTANCE Idiopathic pulmonary fibrosis (IPF) has a poor prognosis and limited treatment options. Patients with IPF have altered lung microbiota, with bacterial burden within the lungs associated with mortality; previous studies have suggested benefit with co-trimoxazole (trimethoprim-sulfamethoxazole). OBJECTIVE To determine the efficacy of co-trimoxazole in patients with moderate and severe IPF. DESIGN, SETTING, AND PARTICIPANTS Double-blind, placebo-controlled, parallel randomized trial of 342 patients with IPF, breathlessness (Medical Research Council dyspnea scale score >1), and impaired lung function (forced vital capacity ≤75% predicted) conducted in 39 UK specialist interstitial lung disease centers between April 2015 (first patient visit) and April 2019 (last patient follow-up). INTERVENTIONS Study participants were randomized to receive 960 mg of oral co-trimoxazole twice daily (n = 170) or matched placebo (n = 172) for between 12 and 42 months. All patients received 5 mg of folic acid orally once daily. MAIN OUTCOMES AND MEASURES The primary outcome was time to death (all causes), lung transplant, or first nonelective hospital admission. There were 15 secondary outcomes, including the individual components of the primary end point respiratory-related events, lung function (forced vital capacity and gas transfer), and patient-reported outcomes (Medical Research Council dyspnea scale, 5-level EuroQol 5-dimension questionnaire, cough severity, Leicester Cough Questionnaire, and King's Brief Interstitial Lung Disease questionnaire scores). RESULTS Among 342 individuals who were randomized (mean age, 71.3 years; 46 [13%] women), 283 (83%) completed the trial. The median (interquartile range) duration of follow-up was 1.02 (0.35-1.73) years. Events per person-year of follow-up among participants randomized to the co-trimoxazole and placebo groups were 0.45 (84/186) and 0.38 (80/209), respectively, with a hazard ratio of 1.2 ([95% CI, 0.9-1.6]; P = .32). There were no statistically significant differences in other event outcomes, lung function, or patient-reported outcomes. Patients in the co-trimoxazole group had 696 adverse events (nausea [n = 89], diarrhea [n = 52], vomiting [n = 28], and rash [n = 31]) and patients in the placebo group had 640 adverse events (nausea [n = 67], diarrhea [n = 84], vomiting [n = 20], and rash [n = 20]). CONCLUSIONS AND RELEVANCE Among patients with moderate or severe IPF, treatment with oral co-trimoxazole did not reduce a composite outcome of time to death, transplant, or nonelective hospitalization compared with placebo. TRIAL REGISTRATION ISRCTN Identifier: ISRCTN17464641.
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Affiliation(s)
- Andrew M. Wilson
- Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich, Norfolk, United Kingdom
- Department of Respiratory Medicine, Norfolk and Norwich University Hospital NHS Foundation Trust, Norwich, Norfolk, United Kingdom
| | - Allan B. Clark
- Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich, Norfolk, United Kingdom
| | - Tony Cahn
- Department of Respiratory Medicine, Bedford Hospitals NHS Trust, South Wing, Bedford, United Kingdom
| | - Edwin R. Chilvers
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - William Fraser
- Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich, Norfolk, United Kingdom
- Department of Endocrinology and Clinical Biochemistry, Norfolk and Norwich University Hospital NHS Foundation Trust, Colney Lane, Norwich, Norfolk, United Kingdom
| | - Matthew Hammond
- Norwich Clinical Trials Unit, University of East Anglia, Norwich Research Park, Norwich, Norfolk, United Kingdom
| | - David M. Livermore
- Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich, Norfolk, United Kingdom
| | - Toby M. Maher
- Department of Endocrinology and Clinical Biochemistry, Norfolk and Norwich University Hospital NHS Foundation Trust, Colney Lane, Norwich, Norfolk, United Kingdom
- Hastings Centre for Pulmonary Research and Division of Pulmonary, Critical Care and Sleep Medicine, Keck School of Medicine, University of Southern California, Los Angeles
- NIHR Respiratory Clinical Research Facility, Royal Brompton Hospital, London, United Kingdom
| | - Helen Parfrey
- Royal Papworth Hospital NHS Foundation Trust, Papworth Road, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Ann Marie Swart
- Norwich Clinical Trials Unit, University of East Anglia, Norwich Research Park, Norwich, Norfolk, United Kingdom
| | - Susan Stirling
- Norwich Clinical Trials Unit, University of East Anglia, Norwich Research Park, Norwich, Norfolk, United Kingdom
| | - David R. Thickett
- Institute of Inflammation and Aging, University of Birmingham, Edgbaston, Birmingham, United Kingdom
| | - Moira Whyte
- MRC Centre for Inflammation Research, University of Edinburgh, Edinburgh, United Kingdom
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Valenzi E, Yang H, Sembrat JC, Yang L, Winters S, Nettles R, Kass DJ, Qin S, Wang X, Myerburg MM, Methé B, Fitch A, Alder JK, Benos PV, McVerry BJ, Rojas M, Morris A, Kitsios GD. Topographic heterogeneity of lung microbiota in end-stage idiopathic pulmonary fibrosis: the Microbiome in Lung Explants-2 (MiLEs-2) study. Thorax 2020; 76:239-247. [PMID: 33268457 DOI: 10.1136/thoraxjnl-2020-214770] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 09/18/2020] [Accepted: 09/25/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Lung microbiota profiles in patients with early idiopathic pulmonary fibrosis (IPF) have been associated with disease progression; however, the topographic heterogeneity of lung microbiota and their roles in advanced IPF are unknown. METHODS We performed a retrospective, case-control study of explanted lung tissue obtained at the time of lung transplantation or rapid autopsy from patients with IPF and other chronic lung diseases (connective tissue disease-associated interstitial lung disease (CTD-ILD), cystic fibrosis (CF), COPD and donor lungs unsuitable for transplant from Center for Organ Recovery and Education (CORE)). We sampled subpleural tissue and airway-based specimens (bronchial washings and airway tissue) and quantified bacterial load and profiled communities by amplification and sequencing of the 16S rRNA gene. FINDINGS Explants from 62 patients with IPF, 15 patients with CTD-ILD, 20 patients with CF, 20 patients with COPD and 20 CORE patients were included. Airway-based samples had higher bacterial load compared with distal parenchymal tissue. IPF basilar tissue had much lower bacterial load compared with CF and CORE lungs (p<0.001). No microbial community differences were found between parenchymal tissue samples from different IPF lobes. Dirichlet multinomial models revealed an IPF cluster (29%) with distinct composition, high bacterial load and low alpha diversity, exhibiting higher odds for acute exacerbation or death. INTERPRETATION IPF explants had low biomass in the distal parenchyma of all three lobes with higher bacterial load in the airways. The discovery of a distinct subgroup of patients with IPF with higher bacterial load and worse clinical outcomes supports investigation of personalised medicine approaches for microbiome-targeted interventions.
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Affiliation(s)
- Eleanor Valenzi
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Haopu Yang
- Center for Medicine and the Microbiome, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Computational and Systems Biology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,School of Medicine, Tsinghua University, Beijing, China
| | - John C Sembrat
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Libing Yang
- Center for Medicine and the Microbiome, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,School of Medicine, Tsinghua University, Beijing, China
| | - Spencer Winters
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.,Bronson Adult Critical Care, Kalamazoo, Michigan, USA
| | - Rachel Nettles
- Center for Medicine and the Microbiome, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Daniel J Kass
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Shulin Qin
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.,Center for Medicine and the Microbiome, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Xiaohong Wang
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.,Center for Medicine and the Microbiome, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Michael M Myerburg
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Barbara Methé
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.,Center for Medicine and the Microbiome, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Adam Fitch
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.,Center for Medicine and the Microbiome, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jonathan K Alder
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Panayiotis V Benos
- Department of Computational and Systems Biology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Bryan J McVerry
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.,Center for Medicine and the Microbiome, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Mauricio Rojas
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Alison Morris
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.,Center for Medicine and the Microbiome, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Georgios D Kitsios
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA .,Center for Medicine and the Microbiome, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Li X, Kim SE, Chen TY, Wang J, Yang X, Tabib T, Tan J, Guo B, Fung S, Zhao J, Sembrat J, Rojas M, Shiva S, Lafyatis R, St Croix C, Alder JK, Di YP, Kass DJ, Zhang Y. Toll interacting protein protects bronchial epithelial cells from bleomycin-induced apoptosis. FASEB J 2020; 34:9884-9898. [PMID: 32596871 DOI: 10.1096/fj.201902636rr] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 04/10/2020] [Accepted: 04/20/2020] [Indexed: 12/16/2022]
Abstract
Idiopathic pulmonary fibrosis (IPF) is characterized by altered epithelial cell phenotypes, which are associated with myofibroblast accumulation in the lung. Atypical alveolar epithelial cells in IPF express molecular markers of airway epithelium. Polymorphisms within and around Toll interacting protein (TOLLIP) are associated with the susceptibility to IPF and mortality. However, the functional role of TOLLIP in IPF is unknown. Using lung tissues from IPF and control subjects, we showed that expression of TOLLIP gene in the lung parenchyma is globally lower in IPF compared to controls. Lung cells expressing significant levels of TOLLIP include macrophages, alveolar type II, and basal cells. TOLLIP protein expression is lower in the parenchyma of IPF lungs but is expressed in the atypical epithelial cells of the distal fibrotic regions. Using overexpression and silencing approaches, we demonstrate that TOLLIP protects cells from bleomycin-induced apoptosis using primary bronchial epithelial cells and BEAS-2B cells. The protective effects are mediated by reducing mitochondrial reactive oxygen species (ROS) levels and upregulating autophagy. Therefore, global downregulation of the TOLLIP gene in IPF lungs may predispose injured lung epithelial cells to apoptosis and to the development of IPF.
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Affiliation(s)
- Xiaoyun Li
- Division of Pulmonary, Allergy and Critical Care Medicine and the Dorothy P. and Richard P. Simmons Center for Interstitial Lung Disease, University of Pittsburgh, Pittsburgh, PA, USA
| | - Sharon E Kim
- Division of Pulmonary, Allergy and Critical Care Medicine and the Dorothy P. and Richard P. Simmons Center for Interstitial Lung Disease, University of Pittsburgh, Pittsburgh, PA, USA
| | - Ting-Yun Chen
- Division of Pulmonary, Allergy and Critical Care Medicine and the Dorothy P. and Richard P. Simmons Center for Interstitial Lung Disease, University of Pittsburgh, Pittsburgh, PA, USA.,Institute of Allied Health Sciences, National Cheng Kung University, Tainan, Taiwan
| | - Juan Wang
- Division of Pulmonary, Allergy and Critical Care Medicine and the Dorothy P. and Richard P. Simmons Center for Interstitial Lung Disease, University of Pittsburgh, Pittsburgh, PA, USA.,Department of Pulmonary Medicine, Tianjin Medical University, Tianjin, China
| | - Xia Yang
- Division of Pulmonary, Allergy and Critical Care Medicine and the Dorothy P. and Richard P. Simmons Center for Interstitial Lung Disease, University of Pittsburgh, Pittsburgh, PA, USA.,Department of Pulmonary Medicine, Tianjin Medical University, Tianjin, China
| | - Tracy Tabib
- Division of Rheumatology and Clinical Immunology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jiangning Tan
- Division of Pulmonary, Allergy and Critical Care Medicine and the Dorothy P. and Richard P. Simmons Center for Interstitial Lung Disease, University of Pittsburgh, Pittsburgh, PA, USA
| | - Brandon Guo
- Division of Pulmonary, Allergy and Critical Care Medicine and the Dorothy P. and Richard P. Simmons Center for Interstitial Lung Disease, University of Pittsburgh, Pittsburgh, PA, USA
| | - Sonia Fung
- Division of Pulmonary, Allergy and Critical Care Medicine and the Dorothy P. and Richard P. Simmons Center for Interstitial Lung Disease, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jing Zhao
- Department of Physiology and Cell Biology, Ohio State University, Columbus, OH, USA
| | - John Sembrat
- Division of Pulmonary, Allergy and Critical Care Medicine and the Dorothy P. and Richard P. Simmons Center for Interstitial Lung Disease, University of Pittsburgh, Pittsburgh, PA, USA
| | - Mauricio Rojas
- Division of Pulmonary, Allergy and Critical Care Medicine and the Dorothy P. and Richard P. Simmons Center for Interstitial Lung Disease, University of Pittsburgh, Pittsburgh, PA, USA
| | - Sruti Shiva
- Vascular Medicine Institute and Department of Pharmacology & Chemical Biology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Robert Lafyatis
- Division of Rheumatology and Clinical Immunology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Claudette St Croix
- Center for Biological Imaging, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jonathan K Alder
- Division of Pulmonary, Allergy and Critical Care Medicine and the Dorothy P. and Richard P. Simmons Center for Interstitial Lung Disease, University of Pittsburgh, Pittsburgh, PA, USA
| | - Y Peter Di
- Department of Environmental and Occupational Health, University of Pittsburgh, PA, USA
| | - Daniel J Kass
- Division of Pulmonary, Allergy and Critical Care Medicine and the Dorothy P. and Richard P. Simmons Center for Interstitial Lung Disease, University of Pittsburgh, Pittsburgh, PA, USA
| | - Yingze Zhang
- Division of Pulmonary, Allergy and Critical Care Medicine and the Dorothy P. and Richard P. Simmons Center for Interstitial Lung Disease, University of Pittsburgh, Pittsburgh, PA, USA.,Department of Human Genetics, University of Pittsburgh, Pittsburgh, PA, USA
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