Pharmacokinetics and toxicity of inhaled human natural interferon-beta in patients with lung cancer

Rationale for COVID-19 Treatment by Nebulized Interferon-β-1b-Literature Review and Personal Preliminary Experience

The inflammatory response to COVID-19 is specifically associated with an impaired type I interferon (IFN) response and complete blockade of IFN-β secretion. Clinically, nebulization of IFN-α-2b has been historically used in China to treat viral pneumonia associated with SARS-CoV. Very recent data show that the use of inhaled type I IFN is associated with decreased mortality in Chinese COVID-19 patients. However, IFN nebulization is currently not standard in Europe and the United States. Therefore, our group has set up a project aimed to evaluate the possibility to nebulize IFN-β-1b (a drug currently used in Europe to treat multiple sclerosis via subcutaneous injections) and to assess the safety of this new mode of administration in SARS-CoV-2 infected patients. We present here literature data that allowed us to build our hypothesis and to develop collaboration between clinical pharmacists, intensivists and nebulization engineers in order to gain first pre-clinical and clinical experience of IFN-β-1b nebulization. After validation of the nebulization method and verification of droplet size compatible with nebulization, the method has been applied to four intensive care patients treated at our university hospital, for whom none of the COVID-19 therapies initially used in France led to significant clinical improvement. All patients exhibited negative viral carriage and experienced clinical improvement 7-16 days after having initiated nebulized IFN-β-1b inhalation therapy. No side effects were observed. All patients were alive within a 90-days follow-up. Although it is not possible to draw firm conclusions on treatment efficacy based on this case report, our study shows that pulmonary IFN-β-1b administration is feasible, with a good safety profile. This procedure, which presents the advantage of directly targeting the lungs and reducing the risks of systemic side effects, may represent a promising therapeutic strategy for the care of patients with severe COVID-19. However, our preliminary observation requires confirmation by randomized controlled trials.

Effect of Inhaled Interferon Beta-1a on Carbon Monoxide Transfer Factor in Healthy Volunteers

Interferon beta-1a (IFNβ-1a) 30 μg weekly by intramuscular (IM) injection is used to treat relapsing forms of multiple sclerosis. We assessed if it can be given safely by inhalation. Twenty-one healthy volunteers inhaled IFNβ-1a 300 μg, formulated for deep delivery to the lungs, in a randomized, parallel-group, repeat-dose trial. Comparators were room air and placebo. The primary outcome measure was carbon monoxide transfer factor corrected for hemoglobin (TLCOc), which measures the CO transfer from inspired gas to pulmonary capillary blood. After 3 and 4 once-weekly doses, IFNβ-1a significantly reduced TLCOc compared with room air: after the third dose, mean standard deviation (SD) change in percent predicted TLCOc was-10.9 (2.8), and after the fourth dose was-12.1 (2.7). After 2, 3, and 4 doses, IFNβ-1a significantly reduced TLCOc compared with placebo: after the second dose, mean (SD) change in percent predicted TLCOc was-8.8 (5.5), after the third dose was-10.9 (2.8), and after the fourth dose was-12.1 (2.7). Circulating IFNβ-1a concentrations were about one-third those of the intramuscular dose regimen. Tolerability of IFNβ-1a and the comparators was equally good. In conclusion, IFNβ-1a reduced TLCOc, whereas placebo and room air did not. A dose of IFNβ-1a 300 μg by inhalation may not be safe for general use.

Inhaled cytokines and cytokine antagonists

Cytokine and cytokine antagonist have provided novel and effective therapies for many human diseases. A number of approved cytokines including the interferons (alpha, beta and gamma), interleukin-2 (IL-2), granulocyte macrophage colony stimulating factor (GM-CSF) as well as novel cytokine antagonists have been administered by the pulmonary route for both local lung disease and as a non-invasive method for systemic delivery. We review the published clinical experience of inhaled cytokines and cytokine antagonists. We discuss the limitations of the existing data and the type of clinical data desired to establish the advantages and safety of inhaled cytokines and cytokine antagonists.

Primary rat alveolar epithelial cells for use in biotransformation and toxicity studies

The alveolar epithelium may function as a barrier for airborne xenobiotics, and in vitro models mimicking this barrier are useful for metabolism and toxicity studies. To gain insight into the metabolic competence of alveolar epithelial cells (AECs), we investigated transcript expression of 10 different cytochrome P450 monooxygenases as well as expression of surfactant proteins A to D. We also investigated gene expression of the transcription factors PCNA, TTF-1, HNF3beta , GATA-6, C/EBPalpha and C/EBPdelta which drive, at least in part, development and differentiation of alveolar epithelium. We further studied the metabolism of testosterone, a substrate for cytochrome P450 (CYP) monooxygenases, in cultures of AECs. Essentially, medium supplementation with 5% rat serum, as opposed to 10% FCS, promoted a high level of differentiation, as judged by the mRNA expression of CYP monooxygenases, e.g. 1A1, 1A2, 2B1 and 2J3, the expression of the surfactant proteins A, B, and C, the immunohistochemical staining for surfactant protein C, and staining for alkaline phosphatase activity. Further, AECs, when cultured in the presence of 5% rat serum, promoted metabolic competence, as evidenced by the fingerprinting of individual testosterone metabolites. We thus characterized AECs in culture and found these respiratory epithelial cells to express an array of differentiation markers and showed these cultures to be metabolically competent under optimized culture conditions.

Metabolism of verapamil in cultures of rat alveolar epithelial cells and pharmacokinetics after administration by intravenous and inhalation routes

Administration of therapeutic entities by inhalation opens new possibilities for drug entry into systemic circulation, but this requires passage through the alveolar epithelium. Little is known about the pulmonary metabolism of verapamil. Specifically, this cardiovascular drug suffers from extensive first pass metabolism. We therefore evaluated the metabolism of verapamil in cultured alveolar epithelium and compared findings with results after administration by inhalation and intravenous routes. Specifically, cell culture of alveolar epithelium was characterized by gene expression of surfactant proteins A, B, C, and D, by immunohistochemistry of surfactant protein C, by staining for laminar bodies, and by gene expression of cytochrome P450 monooxygenases. During 6 days of culture expression, all cellular differentiation markers were obvious, albeit at different levels. With testosterone as substrate, we found alveolar epithelial cells to produce several stereo- and site-specific hydroxylation products. This provided evidence for metabolic competence of cultured alveolar epithelial cells. With verapamil as substrate, only limited production of metabolites was observed in cell culture assays, and similar results were recorded after administration by inhalation and intravenous routes. Likewise, elimination of verapamil from lung tissue and plasma was similar by both routes of administration. In conclusion, administration of verapamil by inhalation-abrogated extensive first pass metabolism frequently seen after oral application, and this may well be extended to the development of drugs with similar pharmacokinetic defects.

Safety and systemic absorption of pulmonary delivered human IFN-beta1a in the nonhuman primate: comparison with subcutaneous dosing

Safety and bioavailability of pulmonary delivered interferon-beta 1a (IFN-beta1a, AVONEX, Biogen, Inc., Cambridge, MA) was evaluated in the nonhuman primate. Pulmonary bioavailability following intratracheal (i.t.) instillation of 50 microg/kg IFN-beta1a to rhesus macaques was approximately 10%. To evaluate pulmonary safety, IFN-beta1a was administered intrabronchially to rhesus and cynomolgus macaques at a dose of 60 microg/dose one, three, or seven times per week for 4 weeks. At scheduled termination, lungs were evaluated for gross and histomorphologic changes. IFN-beta1a or vehicle (human serum albumin [HSA] in phosphate-buffered saline [PBS]) treatment resulted in minimal to mild subchronic alveolitis, located primarily near the instillation sites. These responses were considered nonspecific and consistent with either instillation of a foreign protein or minor injury associated with the instillation procedure. In one rhesus macaque treated every day for 4 weeks, IFN-beta1a induced mild to moderate eosinophilic alveolitis, considered possibly an isolated type I hypersensitivity response to HSA or IFN-beta1a. Partial resolution of pulmonary lesions was seen in all recovery animals killed 2 weeks after cessation of treatment. In conclusion, this study shows that pulmonary administration of human IFN-beta1a is safe and that the pulmonary route of administration is a possible alternate route for the systemic delivery of IFN-beta1a.

Pretreatment with IFN-gamma decreases infectious complications after partial hepatectomy in the rat

Infectious postoperative complications occur commonly after hepatectomy and may lead to a long hospital stay or death. The potential beneficial effects of interferon-gamma (IFN-gamma) in this setting were evaluated in a model of hepatectomy and sepsis in rodents. Incidence of bacterial translocation was measured in animals on days 1, 2, and 5 after partial hepatectomy. Macrophage function was quantified by in vitro tumoricidal activity and superoxide anion (O2-) production. Survival after partial hepatectomy and cecal ligation and puncture (CLP) was recorded. After partial hepatectomy, bacterial translocation was decreased on days 1 and 2 in animals pretreated with IFN-gamma (p < 0.05). Macrophages from animals treated with IFN-gamma had higher in vitro tumoricidal activity and production of O2- (p < 0.05). Hepatectomized animals pretreated with IFN-gamma had an increased survival after CLP (p < 0.05). IFN-gamma may be useful in decreasing the incidence of infectious complications after partial hepatectomy.

Intranasal administration of IFN-alpha/beta inhibits the development of visceral tumor metastases

Intranasal administration of 10(4) U of murine interferon (IFN)-alpha/beta prolonged the survival time of DBA/2 mice injected i.v. with 10(5) (> 20,000 LD50) IFN-alpha/beta-resistant 3C18 Friend leukemia cells (FLC). Long-term survivors rejected a second challenge with 3C18 FLC without additional IFN-alpha/beta treatment. IFN-alpha/beta administered intranasally was not effective in 3C18 FLC-challenged DBA/2 mice pretreated with antibody to IFN-alpha/beta. Recombinant human IFN-alpha BDBB, which is cross-reactive on mouse cells, also increased the survival time of 3C18 FLC-challenged DBA/2 mice. Placing 10(4) U IFN-alpha/beta twice a day into the nostrils also prolonged the survival time of DBA/2 mice with 3-day established 3C18 FLC tumors. Administration of 10(4) U IFN-alpha/beta into the nasopharynx was equally effective or more effective than an equivalent amount of IFN-alpha/beta given by the i.p or oral routes or by gavage. Intranasally administered IFN-alpha/beta also increased the survival time of C57B1/6 mice challenged i.v. with EL4 T cell lymphoma cells, DBA/2 mice challenged i.v. with L1210R B cell lymphoma cells, and C57B1/6 (H-2b) and DBA/2 (H-2d) mice challenged i.v. with B16 melanoma cells (H-2b). These results may be important in devising novel therapeutic strategies for malignant disease using type I IFN.

An anti-cytokine bioactivity assay for interferons-alpha, -beta and -omega

Interferons-alpha and -beta (IFN-alpha and -beta) are cytokines that are widely known to induce potent anti-viral activity. However, it has become increasingly apparent that IFN-alpha and -beta exert a variety of other biological effects, including anti-tumour and immunomodulatory activities and are increasingly used clinically to treat a range of malignancies, myelodysplasias and autoimmune diseases, e.g., IFN-beta for multiple sclerosis. The most widely used bioassays for the IFNs are based on their anti-viral activity, but these do not predict the biological activity of the IFNs in anti-tumour and immunomodulatory therapies. Thus, we have developed anti-cytokine-based bioassays that may be more reflective of such activity and which have several advantages over existing anti-viral bioassays. The anti-cytokine bioassay is based on the ability of IFN-alpha, -beta and -omega to inhibit granulocyte-macrophage-colony-stimulating factor (GM-CSF) induced proliferation of the erythroleukaemic cell line TF-1. This assay can take only 24 h, is sensitive to 200 fg (0.04 IU) IFN-alpha or -beta and 100 fg (0.02 IU) IFN-omega and is able to detect down to these levels in serum or plasma samples. The usefulness of anti-cytokine bioassays for IFN-alpha, -beta and -omega is not restricted to the GM-CSF/TF-1 cell format and other alternatives are available, such as erythropoietin (EPO)/TF-1 cells and EPO/UT-7-EPO cells. These assays can be made specific for each of the IFNs by including neutralising antibodies in the bioassay.

Stability of recombinant consensus interferon to air-jet and ultrasonic nebulization

The stability of recombinant consensus alpha-interferon (rConIFN) to air-jet and ultrasonic nebulization was evaluated. Volumes of 10 mL of 0.5 mg/mL rConIFN in phosphate-buffered saline (PBS) at pH 6.3 were nebulized with a Collison three-jet nebulizer at 40 psig (10 L/min) for up to 25 min. The effects of pH (3.0, 6.3, and 9.0), additive (0.1% w/v Tween 80, 0.1% w/v Tween 20, and 1% w/v PEG 8000), and ionic strength (0, 0.25, and 1.0) were examined. The effects of ultrasonic nebulization were studied using three devices (DeVilbiss "Aerosonic"; Mountain Medical "Microstat", and Medix "Easimist"). Stability of rConIFN was assessed by size exclusion chromatography and native and sodium dodecyl sulfate (SDS) polyacrylamide gel electrophoresis (PAGE). Structural effects were examined by circular dichroism spectroscopy and bioactivity was assessed by an in vitro mitogenic inhibition bioassay. rConIFN is destabilized by air-jet nebulization. Insoluble noncovalent aggregates are produced rapidly, and only approximately 25% of the initial monomeric protein remains after 25 min of nebulization. This correlates with a decrease in in vitro bioactivity. Aggregation during nebulization is influenced by pH (9.0 < 6.3 < 3.0) but even at the highest pH, > 25% aggregation is observed. Ionic strength does not appear to influence aggregation. rConIFN is also seen to adhere to glass after nebulization. Samples from a rinse of the emptied reservoir with 0.1% w/v SDS, after thorough rinsing with water (three times), show a strong rConIFN band on SDS-PAGE gels. The use of PEG 8000 and Tween mitigate aggregate formation and adhesion (< 20%). The cumulative output collected as a wet or dry aerosol is not aggregated to the same extent as the residual protein remaining in the nebulizer. Ultrasonic nebulization also results in aggregation, but the extent of denaturation is dependent upon the nebulizer used and is related to the heating of nebulizer solutions. Cooling of the nebulizer solution during operation (< 30 degrees C) minimizes aggregation (< 5%), and bioactivity is retained.