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Plaza Moral V, Alobid I, Álvarez Rodríguez C, Blanco Aparicio M, Ferreira J, García G, Gómez-Outes A, Garín Escrivá N, Gómez Ruiz F, Hidalgo Requena A, Korta Murua J, Molina París J, Pellegrini Belinchón FJ, Plaza Zamora J, Praena Crespo M, Quirce Gancedo S, Sanz Ortega J, Soto Campos JG. GEMA 5.3. Spanish Guideline on the Management of Asthma. OPEN RESPIRATORY ARCHIVES 2023; 5:100277. [PMID: 37886027 PMCID: PMC10598226 DOI: 10.1016/j.opresp.2023.100277] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2023] Open
Abstract
The Spanish Guideline on the Management of Asthma, better known by its acronym in Spanish GEMA, has been available for more than 20 years. Twenty-one scientific societies or related groups both from Spain and internationally have participated in the preparation and development of the updated edition of GEMA, which in fact has been currently positioned as the reference guide on asthma in the Spanish language worldwide. Its objective is to prevent and improve the clinical situation of people with asthma by increasing the knowledge of healthcare professionals involved in their care. Its purpose is to convert scientific evidence into simple and easy-to-follow practical recommendations. Therefore, it is not a monograph that brings together all the scientific knowledge about the disease, but rather a brief document with the essentials, designed to be applied quickly in routine clinical practice. The guidelines are necessarily multidisciplinary, developed to be useful and an indispensable tool for physicians of different specialties, as well as nurses and pharmacists. Probably the most outstanding aspects of the guide are the recommendations to: establish the diagnosis of asthma using a sequential algorithm based on objective diagnostic tests; the follow-up of patients, preferably based on the strategy of achieving and maintaining control of the disease; treatment according to the level of severity of asthma, using six steps from least to greatest need of pharmaceutical drugs, and the treatment algorithm for the indication of biologics in patients with severe uncontrolled asthma based on phenotypes. And now, in addition to that, there is a novelty for easy use and follow-up through a computer application based on the chatbot-type conversational artificial intelligence (ia-GEMA).
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Affiliation(s)
| | - Isam Alobid
- Otorrinolaringología, Hospital Clinic de Barcelona, España
| | | | | | - Jorge Ferreira
- Hospital de São Sebastião – CHEDV, Santa Maria da Feira, Portugal
| | | | - Antonio Gómez-Outes
- Farmacología clínica, Agencia Española de Medicamentos y Productos Sanitarios (AEMPS), Madrid, España
| | - Noé Garín Escrivá
- Farmacia Hospitalaria, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | | | | | - Javier Korta Murua
- Neumología Pediátrica, Hospital Universitario Donostia, Donostia-San, Sebastián, España
| | - Jesús Molina París
- Medicina de familia, semFYC, Centro de Salud Francia, Fuenlabrada, Dirección Asistencial Oeste, Madrid, España
| | | | - Javier Plaza Zamora
- Farmacia comunitaria, Farmacia Dr, Javier Plaza Zamora, Mazarrón, Murcia, España
| | | | | | - José Sanz Ortega
- Alergología Pediátrica, Hospital Católico Universitario Casa de Salud, Valencia, España
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Current Limitations and Recent Advances in the Management of Asthma. Dis Mon 2022:101483. [DOI: 10.1016/j.disamonth.2022.101483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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3
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Ghiciuc CM, Vicovan AG, Stafie CS, Antoniu SA, Postolache P. Marine-Derived Compounds for the Potential Treatment of Glucocorticoid Resistance in Severe Asthma. Mar Drugs 2021; 19:md19110586. [PMID: 34822457 PMCID: PMC8620935 DOI: 10.3390/md19110586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 10/14/2021] [Accepted: 10/15/2021] [Indexed: 02/07/2023] Open
Abstract
One of the challenges to the management of severe asthma is the poor therapeutic response to treatment with glucocorticosteroids. Compounds derived from marine sources have received increasing interest in recent years due to their prominent biologically active properties for biomedical applications, as well as their sustainability and safety for drug development. Based on the pathobiological features associated with glucocorticoid resistance in severe asthma, many studies have already described many glucocorticoid resistance mechanisms as potential therapeutic targets. On the other hand, in the last decade, many studies described the potentially anti-inflammatory effects of marine-derived biologically active compounds. Analyzing the underlying anti-inflammatory mechanisms of action for these marine-derived biologically active compounds, we observed some of the targeted pathogenic molecular mechanisms similar to those described in glucocorticoid (GC) resistant asthma. This article gathers the marine-derived compounds targeting pathogenic molecular mechanism involved in GC resistant asthma and provides a basis for the development of effective marine-derived drugs.
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Affiliation(s)
- Cristina Mihaela Ghiciuc
- Department of Morpho-Functional Sciences II—Pharmacology and Clinical Pharmacology, Faculty of Medicine, Grigore T. Popa University of Medicine and Pharmacy of Iași, 16 Universitatii Street, 700115 Iasi, Romania
- Correspondence: (C.M.G.); (A.G.V.)
| | - Andrei Gheorghe Vicovan
- Department of Morpho-Functional Sciences II—Pharmacology and Clinical Pharmacology, Faculty of Medicine, Grigore T. Popa University of Medicine and Pharmacy of Iași, 16 Universitatii Street, 700115 Iasi, Romania
- Correspondence: (C.M.G.); (A.G.V.)
| | - Celina Silvia Stafie
- Department of Preventive Medicine and Interdisciplinarity—Family Medicine Discipline, Faculty of Medicine, Grigore T. Popa University of Medicine and Pharmacy of Iasi, 16 Universitatii Street, 700115 Iasi, Romania;
| | - Sabina Antonela Antoniu
- Department of Medicine II—Palliative Care Nursing, Grigore T. Popa University of Medicine and Pharmacy of Iasi, 16 Universitatii Street, 700115 Iasi, Romania;
| | - Paraschiva Postolache
- Department of Medicine I—Pulmonary Rehabilitation Clinic, Grigore T. Popa University of Medicine and Pharmacy of Iasi, 16 Universitatii Street, 700115 Iasi, Romania;
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4
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Pinkerton JW, Kim RY, Koeninger L, Armbruster NS, Hansbro NG, Brown AC, Jayaraman R, Shen S, Malek N, Cooper MA, Nordkild P, Horvat JC, Jensen BAH, Wehkamp J, Hansbro PM. Human β-defensin-2 suppresses key features of asthma in murine models of allergic airways disease. Clin Exp Allergy 2020; 51:120-131. [PMID: 33098152 DOI: 10.1111/cea.13766] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 09/23/2020] [Accepted: 10/03/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Asthma is an airway inflammatory disease and a major health problem worldwide. Anti-inflammatory steroids and bronchodilators are the gold-standard therapy for asthma. However, they do not prevent the development of the disease, and critically, a subset of asthmatics are resistant to steroid therapy. OBJECTIVE To elucidate the therapeutic potential of human β-defensins (hBD), such as hBD2 mild to moderate and severe asthma. METHODS We investigated the role of hBD2 in a steroid-sensitive, house dust mite-induced allergic airways disease (AAD) model and a steroid-insensitive model combining ovalbumin-induced AAD with C muridarum (Cmu) respiratory infection. RESULTS In both models, we demonstrated that therapeutic intranasal application of hBD2 significantly reduced the influx of inflammatory cells into the bronchoalveolar lavage fluid. Furthermore, key type 2 asthma-related cytokines IL-9 and IL-13, as well as additional immunomodulating cytokines, were significantly decreased after administration of hBD2 in the steroid-sensitive model. The suppression of inflammation was associated with improvements in airway physiology and treatment also suppressed airway hyper-responsiveness (AHR) in terms of airway resistance and compliance to methacholine challenge. CONCLUSIONS AND CLINICAL RELEVANCE These data indicate that hBD2 reduces the hallmark features and has potential as a new therapeutic agent in allergic and especially steroid-resistant asthma.
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Affiliation(s)
- James W Pinkerton
- Priority Research Centre for Healthy Lungs, University of Newcastle, & Hunter Medical Research Institute, Newcastle, NSW, Australia.,National Heart & Lung Institute, Imperial College London, London, UK
| | - Richard Y Kim
- Priority Research Centre for Healthy Lungs, University of Newcastle, & Hunter Medical Research Institute, Newcastle, NSW, Australia.,Centre for Inflammation, Faculty of Science, School of Life Sciences, Centenary Institute and University of Technology Sydney, Sydney, NSW, Australia
| | - Louis Koeninger
- Department of Internal Medicine, University of Tübingen, Tübingen, Germany
| | | | - Nicole G Hansbro
- Priority Research Centre for Healthy Lungs, University of Newcastle, & Hunter Medical Research Institute, Newcastle, NSW, Australia.,Centre for Inflammation, Faculty of Science, School of Life Sciences, Centenary Institute and University of Technology Sydney, Sydney, NSW, Australia
| | - Alexandra C Brown
- Priority Research Centre for Healthy Lungs, University of Newcastle, & Hunter Medical Research Institute, Newcastle, NSW, Australia
| | - Ranjith Jayaraman
- Centre for Inflammation, Faculty of Science, School of Life Sciences, Centenary Institute and University of Technology Sydney, Sydney, NSW, Australia
| | - Sijie Shen
- Centre for Inflammation, Faculty of Science, School of Life Sciences, Centenary Institute and University of Technology Sydney, Sydney, NSW, Australia
| | - Nisar Malek
- Department of Internal Medicine, University of Tübingen, Tübingen, Germany
| | - Matthew A Cooper
- Institute for Molecular Bioscience, University of Queensland, Brisbane, Qld, Australia
| | - Peter Nordkild
- Department of Biology, University of Copenhagen, Copenhagen, Denmark
| | - Jay C Horvat
- Priority Research Centre for Healthy Lungs, University of Newcastle, & Hunter Medical Research Institute, Newcastle, NSW, Australia
| | - Benjamin A H Jensen
- Section for Human Genomics and Metagenomics in Metabolism, Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jan Wehkamp
- Department of Internal Medicine, University of Tübingen, Tübingen, Germany
| | - Philip M Hansbro
- Priority Research Centre for Healthy Lungs, University of Newcastle, & Hunter Medical Research Institute, Newcastle, NSW, Australia.,Centre for Inflammation, Faculty of Science, School of Life Sciences, Centenary Institute and University of Technology Sydney, Sydney, NSW, Australia
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Henderson I, Caiazzo E, McSharry C, Guzik TJ, Maffia P. Why do some asthma patients respond poorly to glucocorticoid therapy? Pharmacol Res 2020; 160:105189. [PMID: 32911071 PMCID: PMC7672256 DOI: 10.1016/j.phrs.2020.105189] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 09/01/2020] [Accepted: 09/02/2020] [Indexed: 12/27/2022]
Abstract
Glucocorticosteroids are the first-line therapy for controlling airway inflammation in asthma. They bind intracellular glucocorticoid receptors to trigger increased expression of anti-inflammatory genes and suppression of pro-inflammatory gene activation in asthmatic airways. In the majority of asthma patients, inhaled glucocorticoids are clinically efficacious, improving lung function and preventing exacerbations. However, 5–10 % of the asthmatic population respond poorly to high dose inhaled and then systemic glucocorticoids. These patients form a category of severe asthma associated with poor quality of life, increased morbidity and mortality, and constitutes a major societal and health care burden. Inadequate therapeutic responses to glucocorticoid treatment is also reported in other inflammatory conditions such as rheumatoid arthritis and inflammatory bowel disease; however, asthma represents the most studied steroid-refractory disease. Several cellular and molecular events underlying glucocorticoid resistance in asthma have been identified involving abnormalities of glucocorticoid receptor signaling pathways. These events have been strongly related to immunological dysregulation, genetic, and environmental factors such as cigarette smoking or respiratory infections. A better understanding of the multiple mechanisms associated with glucocorticoid insensitivity in asthma phenotypes could improve quality of life for people with asthma but would also provide transferrable knowledge for other inflammatory diseases. In this review, we provide an update on the molecular mechanisms behind steroid-refractory asthma. Additionally, we discuss some therapeutic options for treating those asthmatic patients who respond poorly to glucocorticoid therapy.
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Affiliation(s)
- Ishbel Henderson
- Institute of Infection, Immunity and Inflammation, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Elisabetta Caiazzo
- Institute of Infection, Immunity and Inflammation, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, United Kingdom; Department of Pharmacy, University of Naples Federico II, Naples, Italy
| | - Charles McSharry
- Institute of Infection, Immunity and Inflammation, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Tomasz J Guzik
- Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, United Kingdom; Department of Internal Medicine, Jagiellonian University, Collegium Medicum, Kraków, Poland
| | - Pasquale Maffia
- Institute of Infection, Immunity and Inflammation, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, United Kingdom; Department of Pharmacy, University of Naples Federico II, Naples, Italy; Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, United Kingdom.
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6
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Hu L, Liu F, Li L, Zhang L, Yan C, Li Q, Qiu J, Dong J, Sun J, Zhang H. Effects of icariin on cell injury and glucocorticoid resistance in BEAS-2B cells exposed to cigarette smoke extract. Exp Ther Med 2020; 20:283-292. [PMID: 32550884 PMCID: PMC7296294 DOI: 10.3892/etm.2020.8702] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 02/11/2020] [Indexed: 12/12/2022] Open
Abstract
Glucocorticoids (GCs) exert a therapeutic effect in numerous chronic inflammatory diseases. However, chronic obstructive pulmonary disease (COPD) tends to be GC-resistant. Icariin, a major component of flavonoids isolated from Epimedium brevicornum Maxim (Berberidaceae), significantly relieves symptoms in patients with COPD. However, the mechanism of action remains unclear and further investigation is required to establish whether it may serve as an alternative or complementary therapy for COPD. The aim of the present study was to determine the effects of icariin in human bronchial epithelial cells exposed to cigarette smoke extract (CSE) and to determine whether icariin reverses GC resistance. The results revealed that icariin significantly increased the proliferation of CSE-exposed cells. Furthermore, icariin significantly increased protein expression of the anti-inflammatory factor interleukin (IL)-10 and significantly decreased protein expression of the pro-inflammatory factors IL-8 and tumor necrosis factor α. Icariin also attenuated the expression of the cellular matrix remodelling biomarkers matrix metallopeptidase 9 and tissue inhibitor of metalloproteinase 1, and decreased the production of reactive oxygen species (ROS). In addition, icariin regulated the expression of GC resistance-related factors, such as GC receptors, histone deacetylase 2, nuclear factor erythroid-2-related factor 2 and nuclear factor κ B. The results obtained in the present study suggested that icariin may decrease CSE-induced inflammation, airway remodelling and ROS production by mitigating GC resistance. In conclusion, icariin may potentially be used in combination with GCs to increase therapeutic efficacy and reduce GC resistance in COPD.
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Affiliation(s)
- Lingli Hu
- Department of Integrative Medicine, Huashan Hospital, Fudan University, Shanghai 200040, P.R. China.,Institute of Integrated Traditional Chinese and Western Medicine, Fudan University, Shanghai 200040, P.R. China
| | - Feng Liu
- Department of Integrative Medicine, Huashan Hospital, Fudan University, Shanghai 200040, P.R. China.,Institute of Integrated Traditional Chinese and Western Medicine, Fudan University, Shanghai 200040, P.R. China
| | - Lulu Li
- Department of Integrative Medicine, Huashan Hospital, Fudan University, Shanghai 200040, P.R. China.,Institute of Integrated Traditional Chinese and Western Medicine, Fudan University, Shanghai 200040, P.R. China
| | - Li Zhang
- Department of Rehabilitation, Huashan Hospital, Fudan University, Shanghai 200040, P.R. China
| | - Chen Yan
- Department of Integrative Medicine, Huashan Hospital, Fudan University, Shanghai 200040, P.R. China.,Institute of Integrated Traditional Chinese and Western Medicine, Fudan University, Shanghai 200040, P.R. China
| | - Qiuping Li
- Department of Integrative Medicine, Huashan Hospital, Fudan University, Shanghai 200040, P.R. China.,Institute of Integrated Traditional Chinese and Western Medicine, Fudan University, Shanghai 200040, P.R. China
| | - Jian Qiu
- Department of Integrative Medicine, Huashan Hospital, Fudan University, Shanghai 200040, P.R. China.,Institute of Integrated Traditional Chinese and Western Medicine, Fudan University, Shanghai 200040, P.R. China
| | - Jingcheng Dong
- Department of Integrative Medicine, Huashan Hospital, Fudan University, Shanghai 200040, P.R. China.,Institute of Integrated Traditional Chinese and Western Medicine, Fudan University, Shanghai 200040, P.R. China
| | - Jing Sun
- Department of Integrative Medicine, Huashan Hospital, Fudan University, Shanghai 200040, P.R. China.,Institute of Integrated Traditional Chinese and Western Medicine, Fudan University, Shanghai 200040, P.R. China
| | - Hongying Zhang
- Department of Integrative Medicine, Huashan Hospital, Fudan University, Shanghai 200040, P.R. China.,Institute of Integrated Traditional Chinese and Western Medicine, Fudan University, Shanghai 200040, P.R. China
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Lv C, Huang L. Xenobiotic receptors in mediating the effect of sepsis on drug metabolism. Acta Pharm Sin B 2020; 10:33-41. [PMID: 31993305 PMCID: PMC6977532 DOI: 10.1016/j.apsb.2019.12.003] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 09/28/2019] [Accepted: 10/31/2019] [Indexed: 12/20/2022] Open
Abstract
Sepsis is an infection-induced systemic inflammatory syndrome. The immune response in sepsis is characterized by the activation of both proinflammatory and anti-inflammatory pathways. When sepsis occurs, the expression and activity of many inflammatory cytokines are markedly affected. Xenobiotic receptors are chemical-sensing transcription factors that play essential roles in the transcriptional regulation of drug-metabolizing enzymes (DMEs). Xenobiotic receptors mediate the functional crosstalk between sepsis and drug metabolism because the inflammatory cytokines released during sepsis can affect the expression and activity of xenobiotic receptors and thus impact the expression and activity of DMEs. Xenobiotic receptors in turn may affect the clinical outcomes of sepsis. This review focuses on the sepsis-induced inflammatory response and xenobiotic receptors such as pregnane X receptor (PXR), aryl hydrocarbon receptor (AHR), glucocorticoid receptor (GR), and constitutive androstane receptor (CAR), DMEs such as CYP1A, CYP2B6, CYP2C9, and CYP3A4, and drug transporters such as p-glycoprotein (P-gp), and multidrug resistance-associated protein (MRPs) that are affected by sepsis. Understanding the xenobiotic receptor-mediated effect of sepsis on drug metabolism will help to improve the safe use of drugs in sepsis patients and the development of new xenobiotic receptor-based therapeutic strategies for sepsis.
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Key Words
- AHR, aryl hydrocarbon receptor
- AP-1, adaptor protein 1
- ARNT, AHR nuclear translocator
- CLP, cecum ligation and puncture
- COX-2, cyclooxygenase 2
- CYPs, cytochrome P450s
- DMEs, drug-metabolizing enzymes
- DREs, dioxin response elements
- Drug metabolism
- Drug transporters
- Drug-metabolizing enzymes
- GC, glucocorticoid
- GR, glucocorticoid receptor
- GREs, glucocorticoid receptor response elements
- Gsts, phase II glutathione S-transferase
- HSP90, heat shock protein 90
- IBD, inflammatory bowel disease
- IL-1β, interleukin-1β
- IRF3, interferon regulatory factor 3
- IRF7, interferon regulatory factor 7
- Inflammatory cytokines
- LPS, lipopolysaccharide
- Mrp, phase III multidrug-resistant protein
- NF-κB, nuclear factor-kappa B
- NOS, nitric oxide synthase
- NR, nuclear receptor
- Oatp2, organic anion transport polypeptide 2
- P-gp, p-glycoprotein
- PAS, Per/ARNT/Sim
- PCN, pregnenolone-16α-carbonitrile
- PKC, protein kinase C
- PLA2, phospholipase A2
- PRRs, pattern recognition receptors
- PXR, pregnane X receptor
- SRC1, steroid receptor coactivator 1
- STAT3, signal transducers and activators of transcription 3
- Sepsis
- Sult, sulfonyl transferase
- TNF-α, tumor necrosis factor
- Ugts, UDP-glucuronic transferase
- Xenobiotic receptors
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Annane D, Bellissant E, Bollaert PE, Briegel J, Keh D, Kupfer Y, Pirracchio R, Rochwerg B. Corticosteroids for treating sepsis in children and adults. Cochrane Database Syst Rev 2019; 12:CD002243. [PMID: 31808551 PMCID: PMC6953403 DOI: 10.1002/14651858.cd002243.pub4] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Sepsis occurs when an infection is complicated by organ failure. Sepsis may be complicated by impaired corticosteroid metabolism. Thus, providing corticosteroids may benefit patients. The original review was published in 2004 and was updated in 2010 and 2015 prior to this update. OBJECTIVES To examine the effects of corticosteroids on death in children and adults with sepsis. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, LILACS, ClinicalTrials.gov, ISRCTN, and the WHO Clinical Trials Search Portal, on 25 July 2019. In addition, we conducted reference checking and citation searching, and contacted study authors, to identify additional studies as needed. SELECTION CRITERIA We included randomized controlled trials (RCTs) of corticosteroids versus placebo or usual care (antimicrobials, fluid replacement, and vasopressor therapy as needed) in children and adults with sepsis. We also included RCTs of continuous infusion versus intermittent bolus of corticosteroids. DATA COLLECTION AND ANALYSIS All review authors screened and selected studies for inclusion. One review author extracted data, which was checked by the others, and by the lead author of the primary study when possible. We obtained unpublished data from the authors of some trials. We assessed the methodological quality of trials and applied GRADE to assess the certainty of evidence. Review authors did not contribute to assessment of eligibility and risk of bias, nor to data extraction, for trials they had participated in. MAIN RESULTS We included 61 trials (12,192 participants), of which six included only children, two included children and adults, and the remaining trials included only adults. Nine studies are ongoing and will be considered in future versions of this review. We judged 19 trials as being at low risk of bias. Corticosteroids versus placebo or usual care Compared to placebo or usual care, corticosteroids probably slightly reduce 28-day mortality (risk ratio (RR) 0.91, 95% confidence interval (CI) 0.84 to 0.99; 11,233 participants; 50 studies; moderate-certainty evidence). Corticosteroids may result in little to no difference in long-term mortality (RR 0.97, 95% CI 0.91 to 1.03; 6236 participants; 7 studies; low-certainty evidence) and probably slightly reduce hospital mortality (RR 0.90, 95% CI 0.82 to 0.99; 8183 participants; 26 trials; moderate-certainty evidence). Corticosteroids reduced length of intensive care unit (ICU) stay for all participants (mean difference (MD) -1.07 days, 95% CI -1.95 to -0.19; 7612 participants; 21 studies; high-certainty evidence) and resulted in a large reduction in length of hospital stay for all participants (MD -1.63 days, 95% CI -2.93 to -0.33; 8795 participants; 22 studies; high-certainty evidence). Corticosteroids increase the risk of muscle weakness (RR 1.21, 95% CI 1.01 to 1.44; 6145 participants; 6 studies; high-certainty evidence). Corticosteroids probably do not increase the risk of superinfection (RR 1.06, 95% CI 0.95 to 1.19; 5356 participants; 25 studies; moderate-certainty evidence). Corticosteroids increase the risk of hypernatraemia (high-certainty evidence) and probably increase the risk of hyperglycaemia (moderate-certainty evidence). Moderate-certainty evidence shows that there is probably little or no difference in gastroduodenal bleeding, stroke, or cardiac events, and low-certainty evidence suggests that corticosteroids may result in little to no difference in neuropsychiatric events. Continuous infusion of corticosteroids versus intermittent bolus We are uncertain about the effects of continuous infusion of corticosteroids compared with intermittent bolus administration. Three studies reported data for this comparison, and the certainty of evidence for all outcomes was very low. AUTHORS' CONCLUSIONS Moderate-certainty evidence indicates that corticosteroids probably reduce 28-day and hospital mortality among patients with sepsis. Corticosteroids result in large reductions in ICU and hospital length of stay (high-certainty evidence). There may be little or no difference in the risk of major complications; however, corticosteroids increase the risk of muscle weakness and hypernatraemia, and probably increase the risk of hyperglycaemia. The effects of continuous versus intermittent bolus administration of corticosteroids are uncertain.
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Affiliation(s)
- Djillali Annane
- Center for Neuromuscular Diseases; Raymond Poincaré Hospital (AP‐HP)Department of Critical Care, Hyperbaric Medicine and Home Respiratory UnitFaculty of Health Sciences Simone Veil, University of Versailles SQY‐ University of Paris Saclay104 Boulevard Raymond PoincaréGarchesFrance92380
| | - Eric Bellissant
- Hôpital PontchaillouCentre d'Investigation Clinique INSERM 0203RennesFrance35033
| | | | - Josef Briegel
- Klinikum der UniversitätKlinik fur AnästhesiologieMünchenGermany81377
| | - Didier Keh
- Charité‐Campus Virchow Clinic, Charité Universitätsmedizin BerlinUniversity Clinic of Anesthesiology and Intensive Care Medicine CCM/CVKAugustenburger Platz 1BerlinGermany13353
| | - Yizhak Kupfer
- Maimonides Medical CenterDivision of Pulmonary and Critical Care Medicine4802 Tenth AvenueBrooklynNew YorkUSA11219
| | - Romain Pirracchio
- Zuckerberg San Francisco General Hospital and Trauma Center, University of CaliforniaDepartment of Anesthesia and Perioperative MedicineSan FranciscoCaliforniaUSA
| | - Bram Rochwerg
- McMaster UniversityDivision of Critical Care, Department of MedicineBox 211, Juravinski Hospital711 Concession StHamiltonOntarioCanada
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Panda L, Mabalirajan U. Recent Updates on Corticosteroid Resistance in Asthma. EUROPEAN MEDICAL JOURNAL 2018. [DOI: 10.33590/emj/10311987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Corticosteroids are one of the most effective medications available for a wide variety of inflammatory diseases, including rheumatoid arthritis, inflammatory bowel disease, autoimmune diseases, and chronic lung diseases such as asthma; however, 5–10% of asthma patients respond poorly to corticosteroids and require high doses, secondary immunosuppressants, such as calcineurin inhibitors and methotrexate, or disease-modifying biologics that can be toxic and/or expensive. Though steroid-resistant asthma affects a small percentage of patients, it consumes significant health resources and contributes to substantial morbidity and mortality. In addition, the side effects caused by excessive use of steroids dramatically impact patients’ quality of life. Recognition of patients who respond poorly to steroid therapy is important due to the persistent and considerable problems they face in managing their conditions, which bears a significant socioeconomic burden. Along with the recognition of such patients, elucidation of the molecular mechanisms of steroid resistance is equally important, so that administration of a high dosage of steroids, and the consequent adverse effects, can be avoided. This review provides an update on the mechanisms of steroid function and the possible new therapeutic modalities to treat steroid-resistant asthma.
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Affiliation(s)
- Lipsa Panda
- Molecular Pathobiology of Respiratory Diseases, Council of Scientific & Industrial Research (CSIR), Institute of Genomics and Integrative Biology, Delhi, India
| | - Ulaganathan Mabalirajan
- Molecular Pathobiology of Respiratory Diseases, Council of Scientific & Industrial Research (CSIR), Institute of Genomics and Integrative Biology, Delhi, India
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10
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Rider CF, Carlsten C. Air pollution and resistance to inhaled glucocorticoids: Evidence, mechanisms and gaps to fill. Pharmacol Ther 2018; 194:1-21. [PMID: 30138638 DOI: 10.1016/j.pharmthera.2018.08.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Substantial evidence indicates that cigarette smoke exposure induces resistance to glucocorticoids, the primary maintenance medication in asthma treatment. Modest evidence also suggests that air pollution may reduce the effectiveness of these critical medications. Cigarette smoke, which has clear parallels with air pollution, has been shown to induce glucocorticoid resistance in asthma and it has been speculated that air pollution may have similar effects. However, the literature on an association of air pollution with glucocorticoid resistance is modest to date. In this review, we detail the evidence for, and against, the effects of air pollution on glucocorticoid effectiveness, focusing on results from epidemiology and controlled human exposure studies. Epidemiological studies indicate a correlation between increased air pollution exposure and worse asthma symptoms. But these studies also show a mix of beneficial and harmful effects of glucocorticoids on spirometry and asthma symptoms, perhaps due to confounding influences, or the induction of glucocorticoid resistance. We describe mechanisms that may contribute to reductions in glucocorticoid responsiveness following air pollution exposure, including changes to phosphorylation or oxidation of the glucocorticoid receptor, repression by cytokines, or inflammatory pathways, and epigenetic effects. Possible interactions between air pollution and respiratory infections are also briefly discussed. Finally, we detail a number of therapies that may boost glucocorticoid effectiveness or reverse resistance in the presence of air pollution, and comment on the beneficial effects of engineering controls, such as air filtration and asthma action plans. We also call attention to the benefits of improved clean air policy on asthma. This review highlights numerous gaps in our knowledge of the interactions between air pollution and glucocorticoids to encourage further research in this area with a view to reducing the harm caused to those with airways disease.
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Affiliation(s)
- Christopher F Rider
- Respiratory Medicine, Faculty of Medicine, Chan-Yeung Centre for Occupational and Environmental Respiratory Disease (COERD), University of British Columbia, Vancouver, BC, Canada.
| | - Chris Carlsten
- Respiratory Medicine, Faculty of Medicine, Chan-Yeung Centre for Occupational and Environmental Respiratory Disease (COERD), University of British Columbia, Vancouver, BC, Canada; Institute for Heart and Lung Health, University of British Columbia, Vancouver, BC, Canada; School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
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Tian BP, Xia LX, Bao ZQ, Zhang H, Xu ZW, Mao YY, Cao C, Che LQ, Liu JK, Li W, Chen ZH, Ying S, Shen HH. Bcl-2 inhibitors reduce steroid-insensitive airway inflammation. J Allergy Clin Immunol 2016; 140:418-430. [PMID: 28043871 DOI: 10.1016/j.jaci.2016.11.027] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 09/12/2016] [Accepted: 11/21/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Asthmatic inflammation is dominated by accumulation of either eosinophils, neutrophils, or both in the airways. Disposal of these inflammatory cells is the key to disease control. Eosinophilic airway inflammation is responsive to corticosteroid treatment, whereas neutrophilic inflammation is resistant and increases the burden of global health care. Corticosteroid-resistant neutrophilic asthma remains mechanistically poorly understood and requires novel effective therapeutic strategies. OBJECTIVE We sought to explore the underlying mechanisms of airway inflammation persistence, as well as corticosteroid resistance, and to investigate a new strategy of effective treatment against corticosteroid-insensitive neutrophilic asthma. METHODS Mouse models of either eosinophil-dominated or neutrophil-dominated airway inflammation were used in this study to test corticosteroid sensitivity in vivo and in vitro. We also used vav-Bcl-2 transgenic mice to confirm the importance of granulocytes apoptosis in the clearance of airway inflammation. Finally, the Bcl-2 inhibitors ABT-737 or ABT-199 were tested for their therapeutic effects against eosinophilic or neutrophilic airway inflammation and airway hyperresponsiveness. RESULTS Overexpression of Bcl-2 protein was found to be responsible for persistence of granulocytes in bronchoalveolar lavage fluid after allergic challenge. This was important because allergen-induced airway inflammation aggravated and persisted in vav-Bcl-2 transgenic mice, in which nucleated hematopoietic cells were overexpressed with Bcl-2 and resistant to apoptosis. The Bcl-2 inhibitors ABT-737 or ABT-199 play efficient roles in alleviation of either eosinophilic or corticosteroid-resistant neutrophilic airway inflammation by inducing apoptosis of immune cells, such as eosinophils, neutrophils, TH2 cells, TH17 cells, and dendritic cells. Moreover, these inhibitors were found to be more efficient than steroids to induce granulocyte apoptosis ex vivo from patients with severe asthma. CONCLUSION Apoptosis of inflammatory cells is essential for clearance of allergen-induced airway inflammation. The Bcl-2 inhibitors ABT-737 or ABT-199 might be promising drugs for the treatment of airway inflammation, especially for corticosteroid-insensitive neutrophilic airway inflammation.
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Affiliation(s)
- Bao-Ping Tian
- Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China; Key Site of National Clinical Research Center for Respiratory Disease, Hangzhou, China
| | - Li-Xia Xia
- Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China; Key Site of National Clinical Research Center for Respiratory Disease, Hangzhou, China
| | - Zheng-Qiang Bao
- Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China; Key Site of National Clinical Research Center for Respiratory Disease, Hangzhou, China; Department of Pharmacology, Zhejiang University School of Medicine, Hangzhou, China
| | - Hao Zhang
- Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China; Key Site of National Clinical Research Center for Respiratory Disease, Hangzhou, China
| | - Zhi-Wei Xu
- Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China; Key Site of National Clinical Research Center for Respiratory Disease, Hangzhou, China; Department of Critical Care Medicine, Ningbo Medical Center, Lihuili Hospital, Ningbo University, Ningbo, China
| | - Yuan-Yuan Mao
- Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China; Key Site of National Clinical Research Center for Respiratory Disease, Hangzhou, China
| | - Chao Cao
- Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China; Key Site of National Clinical Research Center for Respiratory Disease, Hangzhou, China
| | - Luan-Qing Che
- Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China; Key Site of National Clinical Research Center for Respiratory Disease, Hangzhou, China
| | - Jin-Kai Liu
- Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China; Key Site of National Clinical Research Center for Respiratory Disease, Hangzhou, China
| | - Wen Li
- Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China; Key Site of National Clinical Research Center for Respiratory Disease, Hangzhou, China
| | - Zhi-Hua Chen
- Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China; Key Site of National Clinical Research Center for Respiratory Disease, Hangzhou, China
| | - Songmin Ying
- Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China; Key Site of National Clinical Research Center for Respiratory Disease, Hangzhou, China; Department of Pharmacology, Zhejiang University School of Medicine, Hangzhou, China.
| | - Hua-Hao Shen
- Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China; Key Site of National Clinical Research Center for Respiratory Disease, Hangzhou, China; State Key Laboratory of Respiratory Diseases, Guangzhou, China.
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12
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Abstract
Endotoxin is considered to be a systemic (immunological) stressor eliciting a prolonged activation of the hypothalamo-pituitary-adrenal (HPA) axis. The HPA-axis response after an endotoxin challenge is mainly due to released cytokines (IL-1, IL-6 and TNF-α) from stimulated peripheral immune cells, which in turn stimulate different levels of the HPA axis. Controversy exists regarding the main locus of action of endotoxin on glucocorticoid secretion, since the effect of endotoxin on this neuro-endocrine axis has been observed in intact animals and after ablation of the hypothalamus; however, a lack of LPS effect has been described at both pituitary and adrenocortical levels. The resulting increase in adrenal glucocorticoids has well-documented inhibitory effects on the inflammatory process and on inflammatory cytokine release. Therefore, immune activation of the adrenal gland by endotoxin is thought to occur by cytokine stimulation of corticosteroid-releasing hormone (CRH) production in the median eminence of the hypothalamus, which, in turn stimulates the secretion of ACTH from the pituitary. Acute administration of endotoxin stimulates ACTH and cortisol secretion and the release of CRH and vasopressin (AVP) in the hypophysial portal blood. During repeated endotoxemia, tolerance of both immune and HPA function develops, with a crucial role for glucocorticoids in the modulation of the HPA axis. A single exposure to a high dose of LPS can induce a long-lasting state of tolerance to a second exposure of LPS, affecting the response of plasma TNF-α and HPA hormones. Although there are gender differences in the HPA response to endotoxin and IL-1, these responses are enhanced by castration and attenuated by androgen and estrogen replacement. Estrogens attenuate the endotoxin-induced stimulation of IL-6, TNF-α and IL-1ra release and subsequent activation in postmenopausal women. There appears to be a temporal and functional relation between the HPA-axis response to endotoxin and nitric oxide formation in the neuro-endocrine hypothalamus, suggesting a stimulatory role for nitric oxide in modulating the HPA response to immune challenges.
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Affiliation(s)
- Albertus Beishuizen
- Department of Intensive Care, VU University Medical Center, Amsterdam, The Netherlands,
| | - Lambertus G. Thijs
- Department of Intensive Care, VU University Medical Center, Amsterdam, The Netherlands
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Abstract
BACKGROUND Sepsis occurs when an infection is complicated by organ failures as defined by a sequential organ failure assessment (SOFA) score of two or higher. Sepsis may be complicated by impaired corticosteroid metabolism. Giving corticosteroids may benefit patients. The original review was published in 2004 and was updated in 2010 and again in 2015. OBJECTIVES To examine the effects of corticosteroids on death at one month in patients with sepsis, and to examine whether dose and duration of corticosteroids influence patient response to this treatment. SEARCH METHODS We searched the Central Register of Controlled Trials (CENTRAL; 2014, Issue 10), MEDLINE (October 2014), EMBASE (October 2014), Latin American Caribbean Health Sciences Literature (LILACS; October 2014) and reference lists of articles, and we contacted trial authors. The original searches were performed in August 2003 and in October 2009. SELECTION CRITERIA We included randomized controlled trials of corticosteroids versus placebo or supportive treatment in patients with sepsis. DATA COLLECTION AND ANALYSIS All review authors agreed on the eligibility of trials. One review author extracted data, which were checked by the other review authors, and by the primary author of the paper when possible. We obtained some missing data from trial authors. We assessed the methodological quality of trials. MAIN RESULTS We identified nine additional studies since the last update, for a total of 33 eligible trials (n = 4268 participants). Twenty-three of these 33 trials were at low risk of selection bias, 22 were at low risk of performance and detection bias, 27 were at low risk of attrition bias and 14 were at low risk of selective reporting.Corticosteroids reduced 28-day mortality (27 trials; n = 3176; risk ratio (RR) 0.87, 95% confidence interval (CI) 0.76 to 1.00; P value = 0.05, random-effects model). The quality of evidence for this outcome was downgraded from high to low for imprecision (upper limit of 95% CI = 1) and for inconsistency (significant heterogeneity across trial results). Heterogeneity was related in part to the dosing strategy. Treatment with a long course of low-dose corticosteroids significantly reduced 28-day mortality (22 trials; RR 0.87, 95% CI 0.78 to 0.97; P value = 0.01, fixed-effect model). The quality of evidence was downgraded from high to moderate for inconsistency (owing to non-significant effects shown by one large trial). Corticosteroids also reduced mortality rate in the intensive care unit (13 trials; RR 0.82, 95% CI 0.68 to 1.00; P value = 0.04, random-effects model) and at the hospital (17 trials; RR 0.85, 95% CI 0.73 to 0.98; P value = 0.03, random-effects model). Quality of the evidence for in-hospital mortality was downgraded from high to moderate for inconsistency and imprecision (upper limit of 95% CI for RR approaching 1). Corticosteroids increased the proportion of shock reversal by day seven (12 trials; RR 1.31, 95% CI 1.14 to 1.51; P value = 0.0001) and by day 28 (seven trials; n = 1013; RR 1.11, 95% CI 1.02 to 1.21; P value = 0.01) and reduced the SOFA score by day seven (eight trials; mean difference (MD) -1.53, 95% CI -2.04 to -1.03; P value < 0.00001, random-effects model) and survivors' length of stay in the intensive care unit (10 trials; MD -2.19, 95% CI -3.93 to -0.46; P value = 0.01, fixed-effect model) without inducing gastroduodenal bleeding (19 trials; RR 1.24, 95% CI 0. 92 to 1.67; P value = 0.15, fixed-effect model), superinfection (19 trials; RR 1.02, 95% CI 0.87 to 1.20; P value = 0.81, fixed-effect model) or neuromuscular weakness (three trials; RR 0.62, 95% CI 0.21 to 1.88; P value = 0.40, fixed-effect model). Corticosteroid increased the risk of hyperglycaemia (13 trials; RR 1.26, 95% CI 1.16 to 1.37; P value < 0.00001, fixed-effect model) and hypernatraemia (three trials; RR 1.64, 95% CI 1.28 to 2.09; P value < 0.0001, fixed-effect model). AUTHORS' CONCLUSIONS Overall, low-quality evidence indicates that corticosteroids reduce mortality among patients with sepsis. Moderate-quality evidence suggests that a long course of low-dose corticosteroids reduced 28-day mortality without inducing major complications and led to an increase in metabolic disorders.
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Affiliation(s)
- Djillali Annane
- Center for Neuromuscular Diseases; Raymond Poincaré Hospital (AP‐HP)Department of Critical Care, Hyperbaric Medicine and Home Respiratory UnitFaculty of Health Sciences Simone Veil, University of Versailles SQY‐ University of Paris Saclay104 Boulevard Raymond PoincaréGarchesFrance92380
| | - Eric Bellissant
- Hôpital PontchaillouCentre d'Investigation Clinique INSERM 0203RennesFrance35033
| | | | - Josef Briegel
- Klinikum der UniversitätKlinik fur AnästhesiologieMünchenGermany81377
| | - Didier Keh
- Charité‐Campus Virchow Clinic, Charité Universitätsmedizin BerlinUniversity Clinic of Anesthesiology and Intensive Care Medicine CCM/CVKAugustenburger Platz 1BerlinGermany13353
| | - Yizhak Kupfer
- Maimonides Medical CenterDivision of Pulmonary and Critical Care Medicine4802 Tenth AvenueBrooklynUSA11219
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Suzuki M, Yoshida H, Hashizume M, Tanaka K, Matsumoto Y. Blockade of interleukin-6 receptor enhances the anti-arthritic effect of glucocorticoids without decreasing bone mineral density in mice with collagen-induced arthritis. Clin Exp Immunol 2015. [PMID: 26201536 DOI: 10.1111/cei.12685] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
In a mouse arthritis model, we investigated whether interleukin-6 receptor (IL-6R) blockade would enhance the anti-arthritic effect of glucocorticoids (GCs). DBA/1J mice were immunized with type II collagen (CII), and were treated with prednisolone (PSL) and/or anti-mouse IL-6R antibody (MR16-1). Also, the effects of IL-6 on gene expression and the nuclear translocation of glucocorticoid receptors (GRs) were examined in cultured cells treated with dexamethasone (DEX). PSL reduced the arthritis score dose-dependently in the collagen-induced arthritis (CIA) mouse model. The arthritis score in the PSL (3 mg/kg) + MR16-1 group was lower than in the PSL (3 mg/kg) group, and at the same level as in the PSL (6 mg/kg) group. Lumbar vertebra bone mineral density (BMD) was decreased significantly in CIA mice and was higher in the PSL (3 mg/kg) + MR16-1 group than in the PSL (6 mg/kg) group. In the in-vitro synovial cells, IL-6 pretreatment attenuated the inhibitory effect of DEX on cyclooxygenase (COX)-2 expression and inhibited the nuclear translocation of GR induced by DEX. In contrast, in MC3T3-E1 osteoblastic cells, IL-6 pretreatment exacerbated the decrease in expression of osteocalcin and the increase in expression of receptor activator of nuclear factor kappa-B ligand (RANKL) by DEX. We demonstrated that IL-6 signalling blockade by an anti-IL-6R antibody can augment the anti-arthritic effect of GCs and inhibit the bone loss they cause.
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Affiliation(s)
- M Suzuki
- Product Research Department, Fuji-Gotemba Research Laboratories, Chugai Pharmaceutical Company Ltd, Gotemba, Shizuoka, Japan
| | - H Yoshida
- Product Research Department, Fuji-Gotemba Research Laboratories, Chugai Pharmaceutical Company Ltd, Gotemba, Shizuoka, Japan
| | - M Hashizume
- Product Research Department, Fuji-Gotemba Research Laboratories, Chugai Pharmaceutical Company Ltd, Gotemba, Shizuoka, Japan
| | - K Tanaka
- Product Research Department, Fuji-Gotemba Research Laboratories, Chugai Pharmaceutical Company Ltd, Gotemba, Shizuoka, Japan
| | - Y Matsumoto
- Product Research Department, Fuji-Gotemba Research Laboratories, Chugai Pharmaceutical Company Ltd, Gotemba, Shizuoka, Japan
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Guidelines for severe uncontrolled asthma. Arch Bronconeumol 2015; 51:235-46. [PMID: 25677358 DOI: 10.1016/j.arbres.2014.12.007] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2014] [Revised: 12/02/2014] [Accepted: 12/06/2014] [Indexed: 01/29/2023]
Abstract
Since the publication, 9 years ago, of the latest SEPAR (Spanish Society of Pulmonology and Thoracic Surgery) Guidelines on Difficult-to-Control Asthma (DCA), much progress has been made in the understanding of asthmatic disease. These new data need to be reviewed, analyzed and incorporated into the guidelines according to their level of evidence and recommendation. Recently, consensus documents and clinical practice guidelines (CPG) addressing this issue have been published. In these guidelines, specific mention will be made of what the previous DCA guidelines defined as "true difficult-to-control asthma". This is asthma that remains uncontrolled after diagnosis and a systematic evaluation to rule out factors unrelated to the disease itself that lead to poor control ("false difficult-to-control asthma"), and despite an appropriate treatment strategy (Spanish Guidelines for the Management of Asthma [GEMA] steps 5 and 6): severe uncontrolled asthma. In this respect, the guidelines propose a revised definition, an attempt to classify the various manifestations of this type of asthma, a proposal for a stepwise diagnostic procedure, and phenotype-targeted treatment. A specific section has also been included on DCA in childhood, aimed at assisting healthcare professionals to improve the care of these patients.
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Song Y, Zhao F, Zhang L, Du Y, Wang T, Fu F. Ginsenoside Rg1 exerts synergistic anti-inflammatory effects with low doses of glucocorticoids in vitro. Fitoterapia 2013; 91:173-179. [DOI: 10.1016/j.fitote.2013.09.001] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2013] [Revised: 09/02/2013] [Accepted: 09/04/2013] [Indexed: 10/26/2022]
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18
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Ribeiro-Filho J, Calheiros AS, Vieira-de-Abreu A, de Carvalho KIM, da Silva Mendes D, Melo CB, Martins MA, da Silva Dias C, Piuvezam MR, Bozza PT. Curine inhibits eosinophil activation and airway hyper-responsiveness in a mouse model of allergic asthma. Toxicol Appl Pharmacol 2013. [DOI: 10.10.1016/j.taap.2013.08.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Edgar AR, Judith PY, Elisa DSM, Rafael CR. Glucocorticoids and estrogens modulate the NF-κB pathway differently in the micro- and macrovasculature. Med Hypotheses 2013; 81:1078-82. [PMID: 24199951 DOI: 10.1016/j.mehy.2013.10.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2013] [Accepted: 10/08/2013] [Indexed: 10/26/2022]
Abstract
Estrogens and glucocorticoids have synergistic effects in the micro and macrovasculature of endothelial cells (ECs), having pro-inflammatory effects in the former and inhibiting the expression of adhesion molecules in the latter. The molecular basis of these effects in the endothelium has not yet been clarified. We postulate that the ECs of the micro- and macrovasculature have different non-genomic mechanisms that regulate levels of preexisting complexes of glucocorticoids and estrogens with their respective receptors. Since these receptors are regulated by NF-κB, their expression could be critical to the activation of a pro- or anti-inflammatory response. In the macrovasculature the synergistic effects of estrogens and glucocorticoids on ECs may be through the inhibition of NF-κB, leading to the inhibition of the expression of inflammatory molecules. It seems likely that glucocorticoid-receptor and estrogen-receptor complexes directly bind to NF-κB proteins in the macrovasculature, resulting in the inhibition of an excessive proinflammatory response. Further insights into these processes may help clarify the role of the endothelial cells of different vascular beds during the inflammatory response and chronic inflammation, and thus contribute to the design of more effective therapeutic strategies for the prevention of diseases related to inflammation, including atherosclerosis, systemic lupus erythematosus and rheumatoid arthritis.
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Affiliation(s)
- Abarca-Rojano Edgar
- Laboratorio de Respiración Celular Escuela Superior de Medicina, Instituto Politécnico Nacional, Plan de San Luıis y Díaz Mirón, México, D.F., Mexico.
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Abstract
INTRODUCTION For decades glucocorticoids have been considered as the gold standard for the treatment of asthma. We present a case report of typical glucocorticoid-resistant asthma and current consensus in definitions of "severe refractory", "difficult" and "glucocorticoid-resistant" asthma. METHODS Full-text papers and abstracts were identified on the basis of a comprehensive literature search primarily in MEDLINE (1966 to June 2012) but also in the Cochrane Central Register of Controlled Trials database. RESULTS Glucocorticoid-resistant asthmatics are a small subset of patients who pose noteworthy diagnostic challenges while contributing disproportionately to health care costs. Recognition of various asthma phenotypes has aided in characterizing groups with severe asthma and given a better understanding of its pathophysiological process. The molecular mechanism of glucocorticoid action is complicated and several pathways have been identified to explain drug resistance, which in turn is crucial for drug development. Tobacco smoking appears to be the single most important contributor of glucocorticoid resistance. We present the emerging and promising concepts in the management of glucocorticoid-resistant asthma, which mainly include drugs targeting specific molecules, receptors, inflammatory cells or immune processes. CONCLUSION The challenges in making a diagnosis of glucocorticoid-resistant asthma may contribute to underestimating its prevalence and impact on patient care. Considerable progress has been made in identifying distinct phenotypes and mechanisms of glucocorticoid resistance; therefore the future of new drug development in management of asthma is promising.
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Affiliation(s)
- Divya Reddy
- Department of Pulmonary, Allergy, Sleep and Critical Care Medicine, Pulmonary Center, Boston University School of Medicine , Boston, MA , USA
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Ribeiro-Filho J, Calheiros AS, Vieira-de-Abreu A, de Carvalho KIM, da Silva Mendes D, Melo CB, Martins MA, da Silva Dias C, Piuvezam MR, Bozza PT. Curine inhibits eosinophil activation and airway hyper-responsiveness in a mouse model of allergic asthma. Toxicol Appl Pharmacol 2013; 273:19-26. [PMID: 23994558 DOI: 10.1016/j.taap.2013.08.015] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2013] [Revised: 08/12/2013] [Accepted: 08/13/2013] [Indexed: 01/16/2023]
Abstract
Allergic asthma is a chronic inflammatory airway disease with increasing prevalence around the world. Current asthma therapy includes drugs that usually cause significant side effects, justifying the search for new anti-asthmatic drugs. Curine is a bisbenzylisoquinoline alkaloid that modulates calcium influx in many cell types; however, its anti-allergic and putative toxic effects remain to be elucidated. Our aim was to investigate the effects of curine on eosinophil activation and airway hyper-responsiveness (AHR) and to characterize its potential toxic effects. We used a mouse model of allergic asthma induced by sensitization and challenge with ovalbumin (OVA) to evaluate the anti-allergic effects of oral treatment with curine. The oral administration of curine significantly inhibited eosinophilic inflammation, eosinophil lipid body formation and AHR in animals challenged with OVA compared with animals in the untreated group. The curine treatment also reduced eotaxin and IL-13 production triggered by OVA. Verapamil, a calcium channel antagonist, had similar anti-allergic properties, and curine pre-treatment inhibited the calcium-induced tracheal contractile response ex-vivo, suggesting that the mechanism by which curine exerts its effects is through the inhibition of a calcium-dependent response. A toxicological evaluation showed that orally administered curine did not significantly alter the biochemical, hematological, behavioral and physical parameters measured in the experimental animals compared with saline-treated animals. In conclusion, curine showed anti-allergic activity through mechanisms that involve inhibition of IL-13 and eotaxin and of Ca(++) influx, without inducing evident toxicity and as such, has the potential for the development of anti-asthmatic drugs.
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Affiliation(s)
- Jaime Ribeiro-Filho
- Laboratório de Imunofarmacologia, Instituto Oswaldo Cruz, FIOCRUZ, Rio de Janeiro, Brazil; Laboratório de Imunofarmacologia, Departamento de Fisiologia e Patologia, UFPB, João Pessoa, Paraíba, Brazil
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Hirano T, Matsunaga K, Sugiura H, Minakata Y, Koarai A, Akamatsu K, Ichikawa T, Furukawa K, Ichinose M. Persistent elevation of exhaled nitric oxide and modification of corticosteroid therapy in asthma. Respir Investig 2013; 51:84-91. [PMID: 23790736 DOI: 10.1016/j.resinv.2013.01.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2012] [Revised: 01/04/2013] [Accepted: 01/10/2013] [Indexed: 10/27/2022]
Abstract
BACKGROUND Persistent airway inflammation, detected by fractional exhaled nitric oxide (FENO), is occasionally observed in asthmatic patients, even in those treated with inhaled corticosteroids (ICS). However, improvement in residual airway inflammation and pulmonary function through modification of corticosteroid therapy has not been proven. METHODS Thirteen asthmatic patients whose FENO levels were over 40 parts per billion (ppb), despite dry-powder ICS therapy, were enrolled. A 3-step change in steroid treatment was undertaken until FENO was less than 40ppb. In the first step, the powder formula was changed to an ultra-fine particle compound as an equipotent ICS dose. In the second step, the ICS dose was doubled. In the third step, oral corticosteroids were added. We measured pulmonary function and FENO and alveolar NO concentrations (CAlvNO). RESULTS Doubling the ICS dose and changing the ICS formula significantly improved FVC (p<0.001), FEV1 (p<0.05), the slope of the single nitrogen washout curve (dN2) (p<0.01), FENO (p<0.001), and CAlvNO (p<0.05), relative to baseline. The reductions in FENO were significantly associated with the improvement in airflow limitation assessed by dN2 (r=0.73, p=0.007). The remaining FENO elevation, even after doubling the ICS dose, did not decrease after oral corticosteroid administration. CONCLUSIONS These results suggest that modification of ICS therapy can suppress residual FENO elevation, and that reduction in FENO levels is associated with improvement in airflow limitation. However, steroid-resistance mechanisms may exist in some asthmatic patients with sustained FENO elevations.
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Affiliation(s)
- Tsunahiko Hirano
- Third Department of Internal Medicine, Wakayama Medical University, School of Medicine, 811-1 Kimiidera, Wakayama 641-0012, Japan
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Abstract
Glucocorticoids remain a recommended therapy in advanced septic shock despite the often unpredictable response, and our understanding of the mechanisms regulating the steroid and stress response remains limited. Since the initial sequencing of the human glucocorticoid receptor α and β gene (hGRα and hGRβ), only three additional splice variants have been identified--all of which have been postulated to contribute to steroid resistance. During a survey of 97 healthy humans' blood, we identified two novel hGR splice isoforms (hGR-S1 and hGR-S1(-349A) retaining intron H between exons 8 and 9. Human GR-S1(-349A) contained a base deletion causing an early termination and a truncated protein of 118 amino acids, whereas hGR-S1 had an early termination occurring within intron H and resulted in a 745-amino acid protein. Both isoforms had decreased transactivation potentials compared with hGRα when tested in the absence of exogenous steroids. However, after treating with exogenous steroids, dose-response studies showed hGR-S1(-349A) had a substantial augmentation in activity at higher concentrations of hydrocortisone and methylprednisolone when compared with hGRα, whereas hGR-S1 did not. Removal of the 3' untranslated region (3'UTR) of the hGR-S1(-349A) mRNA sequence resulted in a loss of the augmented response. The isoform hGR-S1(-349A) augments the response to steroids, and this significant response appears to be critically regulated by the 3'UTR. The identification and evaluation of these unique hGR isoforms helps further the understanding of the complex genetic regulation of the stress and steroid response.
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Abstract
Steroid-resistant asthma (SRA) refers to patients with symptoms consistent with asthma who show very poor or no response at all to high doses of inhaled or even of systemic corticosteroids. The current article reviews the SRA related literature focusing on the problems associated with the definition of SRA (especially its association with difficult to control, or severe asthma), its various phenotypes, its molecular basis, and the potential treatment options. The article also discusses the limitations of some of the key criteria used for the determination of SRA and proposes a modified set of criteria that are more applicable to children.
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Affiliation(s)
- Robert P Yim
- Division of Pulmonary & Sleep Medicine, Children's National Medical Center, Washington DC 20010, USA
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Jiang N, Xin W, Wang T, Zhang L, Fan H, Du Y, Li C, Fu F. Protective effect of aescin from the seeds of Aesculus hippocastanum on liver injury induced by endotoxin in mice. PHYTOMEDICINE : INTERNATIONAL JOURNAL OF PHYTOTHERAPY AND PHYTOPHARMACOLOGY 2011; 18:1276-1284. [PMID: 21802269 DOI: 10.1016/j.phymed.2011.06.011] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/21/2010] [Revised: 03/03/2011] [Accepted: 06/16/2011] [Indexed: 05/31/2023]
Abstract
To investigate the effect and underlying mechanism of aescin on acute liver injury induced by endotoxin, liver injury was established by injecting lipopolysaccharide (LPS) in mice. Animals were assigned to seven groups: the control group and groups treated with LPS (40 mg/kg), aescin (3.6 mg/kg), LPS plus dexamethasone (4 mg/kg) and LPS plus aescin (0.9, 1.8 or 3.6 mg/kg). Hepatic histopathological changes were examined under a light microscope. Activities of alanine aminotransferase (ALT) and aspartate aminotransferase (AST) in serum were determined. Levels of tumor necrosis factor-α (TNF-α), interleukin-1β (IL-1β), nitric oxide (NO) and antioxidative parameters in liver homogenate were measured. Glucocorticoid receptor (GR), 11 beta-hydroxysteroid dehydrogenase type 1 (11β-HSD1) and 11 beta-hydroxysteroid dehydrogenase type 2 (11β-HSD2) expressions in liver were determined by western blotting. Treatment with escin could inhibit immigration of inflammatory cells, alleviate the degree of necrosis, and decrease serum ALT and AST activities. Aescin also down-regulated levels of inflammation mediators (TNF-α, IL-1β and NO) and 11β-HSD2 expression in liver, up-regulated GR expression, enhanced endogenous antioxidative capacity, but have no obvious effect on 11β-HSD1 expression in liver. The findings suggest aescin has protective effects on endotoxin-induced liver injury, and the underlying mechanisms were associated with its anti-inflammatory effects, up-regulating GR expression, down-regulating 11β-HSD2 experssion, and antixoidation.
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Affiliation(s)
- Na Jiang
- Department of Pharmacology, School of Pharmacy, Yantai University, Yantai, PR China
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26
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Wang H, Gottfries J, Barrenäs F, Benson M. Identification of novel biomarkers in seasonal allergic rhinitis by combining proteomic, multivariate and pathway analysis. PLoS One 2011; 6:e23563. [PMID: 21887273 PMCID: PMC3160968 DOI: 10.1371/journal.pone.0023563] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2011] [Accepted: 07/20/2011] [Indexed: 01/24/2023] Open
Abstract
Background Glucocorticoids (GCs) play a key role in the treatment of seasonal allergic rhinitis (SAR). However, some patients show a low response to GC treatment. We hypothesized that proteins that correlated to discrimination between symptomatic high and low responders (HR and LR) to GC treatment might be regulated by GCs and therefore suitable as biomarkers for GC treatment. Methodology/Principal Findings We identified 953 nasal fluid proteins in symptomatic HR and LR with a LC MS/MS based-quantitative proteomics analysis and performed multivariate analysis to identify a combination of proteins that best separated symptomatic HR and LR. Pathway analysis showed that those proteins were most enriched in the acute phase response pathway. We prioritized candidate biomarkers for GC treatment based on the multivariate and pathway analysis. Next, we tested if those candidate biomarkers differed before and after GC treatment in nasal fluids from 40 patients with SAR using ELISA. Several proteins including ORM (P<0.0001), APOH (P<0.0001), FGA (P<0.01), CTSD (P<0.05) and SERPINB3 (P<0.05) differed significantly before and after GC treatment. Particularly, ORM (P<0.01), FGA (P<0.05) and APOH (P<0.01) that belonged to the acute phase response pathway decreased significantly in HR but not LR before and after GC treatment. Conclusions/Significance We identified several novel biomarkers for GC treatment response in SAR with combined proteomics, multivariate and pathway analysis. The analytical principles may be generally applicable to identify biomarkers in clinical studies of complex diseases.
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Affiliation(s)
- Hui Wang
- The Unit for Clinical Systems Biology, University of Gothenburg, Gothenburg, Sweden.
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Xin W, Zhang L, Fan H, Jiang N, Wang T, Fu F. Escin attenuates acute lung injury induced by endotoxin in mice. Eur J Pharm Sci 2010; 42:73-80. [PMID: 21040784 DOI: 10.1016/j.ejps.2010.10.008] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2010] [Accepted: 10/21/2010] [Indexed: 11/27/2022]
Abstract
Endotoxin causes multiple organ dysfunctions, including acute lung injury (ALI). The current therapeutic strategies for endotoxemia are designed to neutralize one or more of the inflammatory mediators. Accumulating experimental evidence suggests that escin exerts anti-inflammatory and anti-edematous effects. The aim of this study was to evaluate the effect of escin on ALI induced by endotoxin in mice. ALI was induced by injection of lipopolysaccharide (LPS) intravenously. The mice were given dexamethasone or escin before injection of LPS. The mortality rate was recorded. Tumor necrosis factor-α (TNF-α), interleukin 1β (IL-1β) and nitric oxide (NO) were measured. Pulmonary superoxide dismutase (SOD), glutathione peroxidase (GPx) activity, glutathione (GSH), malondialdehyde (MDA) contents, and myeloperoxidase (MPO) activity were also determined. The expression of glucocorticoid receptor (GR) level was detected by Western blotting. Pretreatment with escin could decrease the mortality rate, attenuate lung injury resulted from LPS, down-regulate the level of the inflammation mediators, including NO, TNF-α, and IL-1β, enhance the endogenous antioxidant capacity, and up-regulating the GR expression in lung. The results suggest that escin may have potent protective effect on the LPS-induced ALI by inhibiting of the inflammatory response, and its mechanism involves in up-regulating the GR and enhancing the endogenous antioxidant capacity.
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Affiliation(s)
- Wenyu Xin
- Department of Pharmacology, School of Pharmacy, Yantai University, Yantai, Shandong, PR China
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Sexual dimorphism: Is it relevant to steroid resistance or asthma control? J Allergy Clin Immunol 2009; 124:688-90. [PMID: 19815113 DOI: 10.1016/j.jaci.2009.08.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2009] [Accepted: 08/18/2009] [Indexed: 01/26/2023]
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Yu M, Watanabe S, Kudo M, Kanai KI, Suzaki H. Glucocorticoid receptor immunoreactivity of eosinophils in nasal polyps. Acta Otolaryngol 2009:95-100. [PMID: 19848249 DOI: 10.1080/00016480902915723] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
CONCLUSION The higher level of glucocorticoid receptor (GR) expression in cases of chronic sinusitis with bronchial asthma or allergic rhinitis suggests that glucocorticoids may exert a greater influence on eosinophils, thereby making them more effective in the treatment of polyps or chronic sinusitis. OBJECTIVES The GR immunoreactivity of eosinophils in nasal polyps was investigated to elucidate the mechanism by which glucocorticoids interact with eosinophils. MATERIALS AND METHODS Nasal polyp specimens were divided into 3 groups: 7 patients with chronic sinusitis alone (CS only group), 12 patients with chronic sinusitis complicated by perennial allergic rhinitis (CS/AR group), and 6 patients with chronic sinusitis complicated by bronchial asthma except for aspirin-induced asthma (CS/asthma group). Immunofluorescent staining with an anti-GR polyclonal antibody and anti-major basic protein (MBP) monoclonal antibody was used. RESULTS The total number of MBP+ cells, GR+ cells, and MBP+/GR+ cells in the CS/asthma group was significantly higher than that in the other two groups. The total number of these cells in the CS/AR group was also higher than that in the CS only group The ratio of MBP+/GR+ cells to GR+ cells was highest in the CS/asthma group. The ratio of MBP+/GR+ cells to MBP+ cells in the CS only group was lower than those in the other two groups.
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Abstract
Glucocorticoid resistance or insensitivity is a major barrier to the treatment of several common inflammatory diseases-including chronic obstructive pulmonary disease and acute respiratory distress syndrome; it is also an issue for some patients with asthma, rheumatoid arthritis, and inflammatory bowel disease. Several molecular mechanisms of glucocorticoid resistance have now been identified, including activation of mitogen-activated protein (MAP) kinase pathways by certain cytokines, excessive activation of the transcription factor activator protein 1, reduced histone deacetylase-2 (HDAC2) expression, raised macrophage migration inhibitory factor, and increased P-glycoprotein-mediated drug efflux. Patients with glucocorticoid resistance can be treated with alternative broad-spectrum anti-inflammatory treatments, such as calcineurin inhibitors and other immunomodulators, or novel anti-inflammatory treatments, such as inhibitors of phosphodiesterase 4 or nuclear factor kappaB, although these drugs are all likely to have major side-effects. An alternative treatment strategy is to reverse glucocorticoid resistance by blocking its underlying mechanisms. Some examples of this approach are inhibition of p38 MAP kinase, use of vitamin D to restore interleukin-10 response, activation of HDAC2 expression by use of theophylline, antioxidants, or phosphoinositide-3-kinase-delta inhibitors, and inhibition of macrophage migration inhibitory factor and P-glycoprotein.
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Affiliation(s)
- Peter J Barnes
- National Heart and Lung Institute, Imperial College, London, UK.
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Zhou J, Oakley RH, Cidlowski JA. DAX-1 (dosage-sensitive sex reversal-adrenal hypoplasia congenita critical region on the X-chromosome, gene 1) selectively inhibits transactivation but not transrepression mediated by the glucocorticoid receptor in a LXXLL-dependent manner. Mol Endocrinol 2008; 22:1521-34. [PMID: 18417736 DOI: 10.1210/me.2007-0273] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
The glucocorticoid receptor (GR) mediates virtually all actions of glucocorticoids, and the nature and magnitude of a cell's response to these steroids are determined primarily by hormone concentration and GR signaling capacity. DAX-1 (dosagesensitive sex reversal-adrenal hypoplasia congenita critical region on the X-chromosome, gene 1) is an orphan nuclear receptor that functions as a corepressor, and deletion or mutation of DAX-1 causes a decrease in glucocorticoid production. However it is unclear whether DAX-1 also alters GR function as a transcription factor. Here, we demonstrate that DAX-1 acts as a novel selective GR modulator. It specifically inhibits ligand-dependent GR transactivation with little effect on GR-mediated transrepression. As demonstrated by coimmunoprecipitation and glutathione- S-transferase pull-down assays, DAX-1 physically interacts with GR, but this interaction does not influence either ligand-induced GR nuclear translocation or subsequent GR association with glucocorticoid-responsive elements. Instead, DAX-1 competes with coactivators such as GR-interacting protein 1 for binding to the receptor. Specifically, suppression of GR transactivation is mediated by the N-terminal half of DAX-1, and in particular the LXXLL motifs. Thus we demonstrate that DAX-1 directly modulates GR signaling in addition to affecting glucocorticoid hormone levels.
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Affiliation(s)
- Junguo Zhou
- Laboratory of Signal Transduction, NIEHS/NIH, Research Triangle Park, NC 27709, USA
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Thompson PJ, Misso NL, Woods J. Omalizumab (Xolair) in patients with steroid-resistant asthma: lessons to be learnt. Respirology 2008; 12 Suppl 3:S29-34; discussion S45-7. [PMID: 17956517 DOI: 10.1111/j.1440-1843.2007.01017.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Very severe asthma and local pulmonary steroid resistance causes major problems for patients, physicians and the health system at large. It usually results in multiple admissions to hospital and high morbidity. Omalizumab was used to treat such patients with success. However, in doing so, it raised a number of issues relating to the best methods of using this treatment in such patients.
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Affiliation(s)
- Philip J Thompson
- Lung Institute of Western Australia and Centre for Asthma, Allergy and Respiratory Research, The University of Western Australia, Perth, Western Australia, Australia.
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Sliwinska-Stanczyk P, Pazdur J, Ziolkowska M, Jaworski J, Kaminska-Tchorzewska E, Lacki JK. The effect of methylprednisolone on proliferation of PBMCs obtained from steroid-sensitive and steroid-resistant rheumatoid arthritis patients. Scand J Rheumatol 2007; 36:167-71. [PMID: 17657668 DOI: 10.1080/03009740601154111] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
OBJECTIVE Glucocorticoids (GCs) are among the most frequently used drugs for the treatment of rheumatoid arthritis (RA). Unfortunately, up to 30% of patients with RA fail to respond to the treatment. We investigated the hypothesis that patients with RA who did not respond to GC treatment have steroid-resistant peripheral blood mononuclear cells (PBMCs). METHODS Forty-four patients with RA were enrolled in the study. PBMCs were isolated from blood samples. The effect of methylprednisolone (MP) on the proliferation of stimulated cells was measured. After taking the blood samples, 10 days of MP therapy (20 mg i.v.) was started, in order to classify the patients into either a GC-sensitive (RA/GCS) or a GC-resistant (RA/GCR) group. RESULTS A quarter of our patients did not show any improvement after short-term GC therapy and were assigned to the RA/GCR group. The inhibition of PBMC proliferation after MP treatment was significantly lower in the RA/GCR as compared to the RA/GCS group. CONCLUSION Based on the close relationship between clinically observed GC resistance and a diminished response of PBMCs to MP treatment, we conclude that measurement of the steroid sensitivity of PBMCs may be a useful tool in predicting the therapeutic effect of GC in patients with RA.
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Alpha glucocorticoid receptor expression in different experimental rat models of acute lung injury. Pulm Pharmacol Ther 2007; 21:214-21. [PMID: 17467318 DOI: 10.1016/j.pupt.2007.03.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2006] [Revised: 03/02/2007] [Accepted: 03/07/2007] [Indexed: 10/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Acute respiratory distress syndrome (ARDS) is a frequent form of hypoxiemic respiratory failure caused by the acute development of diffuse lung inflammation. Dysregulated systemic inflammation with persistent elevation of circulating inflammatory cytokines is the pathogenetic mechanism for pulmonary and extrapulmonary organ dysfunction in patients with ARDS. Glucocorticoids (GCs) have a broad range of inhibitory inflammatory effects, including inhibition of cytokines transcription, cellular activation and growth factor production. They inhibit the inflammatory pathways through two specific intracellular glucocorticoid receptors (GRs), named GR alpha and GR beta. The aim of our study was to evaluate the histologic evidence of inflammatory injury and the GR alpha uptake of resident and inflammatory cells in different experimental models of acute lung injury (ALI). METHODS We studied four groups of rats: three different experimental rat models of lung injury and a control group. The ALI was caused by barotrauma (due to an overventilation), oleic acid injection and mechanical ventilation. Results were compared to nonventilated rat control group. The duration of mechanical ventilation was of 2.5h. At the end of each experiment, rats were sacrificed. Lung biopsies were evaluated for morphologic changes. The immunohistochemistry was performed to study GR alpha expression. RESULTS Histologic evidence of lung injury (alveolar and interstitial edema, vascular congestion, alveolar haemorrhage, emphysema, number of interstitial cells and neutrophils, and destruction of alveolar attachments) were present in all ventilated groups. Barotrauma lead to an additional inflammatory response. GR alpha expression significantly increased in the three ventilated groups compared with nonventilated groups. GR alpha expression was highest in barotrauma group. CONCLUSIONS These data indicate that ALI is associated with diffuse alveolar damage, up-regulation of the inflammatory response and GR alpha overexpression. Barotrauma is the most effective mechanism inducing acute lung inflammation and GR alpha overexpression.
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Lu NZ, Wardell SE, Burnstein KL, Defranco D, Fuller PJ, Giguere V, Hochberg RB, McKay L, Renoir JM, Weigel NL, Wilson EM, McDonnell DP, Cidlowski JA. International Union of Pharmacology. LXV. The pharmacology and classification of the nuclear receptor superfamily: glucocorticoid, mineralocorticoid, progesterone, and androgen receptors. Pharmacol Rev 2007; 58:782-97. [PMID: 17132855 DOI: 10.1124/pr.58.4.9] [Citation(s) in RCA: 267] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
MESH Headings
- Animals
- Hormone Antagonists/adverse effects
- Hormone Antagonists/therapeutic use
- Humans
- Ligands
- Mutation
- Receptors, Androgen/genetics
- Receptors, Androgen/physiology
- Receptors, Cytoplasmic and Nuclear/classification
- Receptors, Cytoplasmic and Nuclear/genetics
- Receptors, Cytoplasmic and Nuclear/physiology
- Receptors, Glucocorticoid/genetics
- Receptors, Glucocorticoid/physiology
- Receptors, Mineralocorticoid/genetics
- Receptors, Mineralocorticoid/physiology
- Receptors, Progesterone/genetics
- Receptors, Progesterone/physiology
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Affiliation(s)
- Nick Z Lu
- Molecular Endocrinology Group, Laboratory of Signal Transduction, National Institute of Environmental Health Sciences, National Institutes of Health, Department of Health and Human Services, Research Triangle Park, North Carolina 27709, USA
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Abstract
Acute exacerbations of asthma may represent reactions to airway irritants or failures of chronic treatment. The costs to both the patient and society are high. Exacerbations often are frightening episodes that can cause significant morbidity and sometimes death. The emergency department (ED) visits and hospitalizations often required lead to significant health care expenses. Thus, preventing and optimizing management of acute exacerbations is critical. Corticosteroids are a cornerstone of asthma therapy. They have been shown to lower admission rates and reduce risk of relapse. This article provides an overview of the role of corticosteroids (including betamethasone, dexamethasone, methylprednisolone, and prednisolone) in the management of acute asthma exacerbations, with an aim toward effective decision making about the choice of therapy.
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Affiliation(s)
- Stanley B Fiel
- Department of Medicine, Morristown Memorial Hospital, Morristown, New Jersey, USA.
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Ito K, Chung KF, Adcock IM. Update on glucocorticoid action and resistance. J Allergy Clin Immunol 2006; 117:522-43. [PMID: 16522450 DOI: 10.1016/j.jaci.2006.01.032] [Citation(s) in RCA: 278] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2006] [Revised: 01/25/2006] [Accepted: 01/25/2006] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Kazuhiro Ito
- Cell and Molecular Biology, Airways Disease Section, National Heart and Lung Institute, Imperial College London, UK
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Bel E, ten Brinke A. A rational approach to the management of severe refractory asthma. ACTA ACUST UNITED AC 2006; 4:365-79. [PMID: 16336023 DOI: 10.2165/00151829-200504060-00002] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Severe refractory asthma is a heterogeneous condition with different patterns of severity and different reasons for loss of asthma control. The three main patterns include asthma with frequent exacerbations, asthma with irreversible airway obstruction, and asthma with reduced sensitivity or resistance to corticosteroids. Each of these patterns has distinct risk factors. The assessment of patients with severe asthma requires a systematic, diagnostic and management protocol. The majority of patients will benefit from thorough analysis and treatment of aggravating factors. In some patients with severe refractory asthma, in particular those with concomitant chronic rhinosinusitis, long-term administration of systemic corticosteroids may be necessary. In these patients all efforts should be directed towards reducing the dose of corticosteroids as much as possible. Although several corticosteroid-sparing agents and immunosuppressants have been proposed in the literature, none of these has gained complete acceptance in clinical practice, either because of limited efficacy or unacceptable adverse effects. Novel potent anti-inflammatory therapies aimed at reducing the need for systemic corticosteroids in patients with severe, refractory asthma are urgently needed.
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Affiliation(s)
- Elisabeth Bel
- Department of Pulmonary Diseases, Leiden University Medical Center, Leiden, The Netherlands.
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López-Viña A, Agüero-Balbín R, Aller-Alvarez JL, Bazús-González T, Cosio BG, García-Cosio FB, de Diego-Damiá A, Martínez-Moragón E, Pereira-Vega A, Plaza-Moral V, Rodríguez-Trigo G, Villa-Asensi JR. [Guidelines for the diagnosis and management of difficult-to-control asthma]. Arch Bronconeumol 2005; 41:513-23. [PMID: 16194515 DOI: 10.1016/s1579-2129(06)60272-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- A López-Viña
- Servicio de Neumología, Hospital Universitario Puerta de Hierro, Madrid, Spain.
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Kroegel C, Bergmann N, Foerster M, Workalemahu G, Machnik A, Mock B, Reissig A. Interferon-alphacon-1 treatment of three patients with severe glucocorticoid-dependent asthma. Effect on disease control and systemic glucocorticosteroid dose. Respiration 2005; 73:566-70. [PMID: 16195656 DOI: 10.1159/000088660] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2004] [Accepted: 03/30/2005] [Indexed: 11/19/2022] Open
Abstract
We report herein the therapeutic effect of interferon (IFN)-alphacon in three patients with severe persistent asthma and long-term oral glucocorticoid treatment. IFN-alphacon (9 microg) administered subcutaneously thrice a week over a period of more than 24 months led to a substantial clinical improvement with regard to the number of daily asthma attacks, nighttime disturbance, emergency visits and hospitalizations. In addition, lung function and exercise capacity improved. At the same time, treatment with IFN allowed discontinuation of the daily glucocorticoid dose in all patients for the first time in more than 8 years. Our findings suggest that IFN-alphacon leads to a significant clinical improvement while at the same time allowing reduction and discontinuation of the glucocorticoid treatment in severe persistent glucocorticoid-dependent asthma.
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Affiliation(s)
- Claus Kroegel
- Department of Pneumology and Allergy, Medical Clinic I, Friedrich-Schiller University, Jena, Germany.
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Pelaia G, Cuda G, Vatrella A, Gallelli L, Caraglia M, Marra M, Abbruzzese A, Caputi M, Maselli R, Costanzo FS, Marsico SA. Mitogen-activated protein kinases and asthma. J Cell Physiol 2005; 202:642-53. [PMID: 15316926 DOI: 10.1002/jcp.20169] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Mitogen-activated protein kinases (MAPKs) are evolutionary conserved enzymes which play a key role in signal transduction mediated by cytokines, growth factors, neurotransmitters and various types of environmental stresses. In the airways, these extracellular stimuli elicit complex inflammatory and structural changes leading to the typical features of asthma including T cell activation, eosinophil and mast cell infiltration, as well as bronchial hyperresponsiveness and airway remodelling. Because MAPKs represent an important point of convergence for several different signalling pathways, they affect multiple aspects of normal airway function and also significantly contribute to asthma pathophysiology. Therefore, this review focuses on the crucial involvement of MAPKs in asthma pathogenesis, thus also discussing their emerging role as molecular targets for anti-asthma drugs.
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Affiliation(s)
- Girolamo Pelaia
- Department of Experimental and Clinical Medicine, University Magna Graecia of Catanzaro, Italy.
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Pelaia G, Vatrella A, Gallelli L, Cazzola M, Maselli R, Marsico SA. Potential genetic influences on the response to asthma treatment. Pulm Pharmacol Ther 2005; 17:253-61. [PMID: 15477120 DOI: 10.1016/j.pupt.2004.04.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2003] [Revised: 03/10/2004] [Accepted: 04/26/2004] [Indexed: 10/26/2022]
Abstract
Genetic factors play a key role in determining the widely heterogeneous response to pharmacological treatment detectable among asthmatics. In particular, polymorphisms of the genes encoding relevant anti-asthma drug targets contribute significantly to such a variability. Therefore, it is very important to characterize asthmatic patient's genotypes and the related phenotypic patterns, in order to predict the individual therapeutic outcome. This pharmacogenetic approach will eventually help clinicians to optimize and personalize anti-asthma treatment, and will also provide useful information with regard to pre- and post-marketing evaluation of both effectiveness and side effects of newly introduced drugs.
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Affiliation(s)
- Girolamo Pelaia
- Department of Experimental and Clinical Medicine, University Magna Gaecia of Catanzaro, Catanzaro, Italy.
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Keh D, Sprung CL. Use of corticosteroid therapy in patients with sepsis and septic shock: an evidence-based review. Crit Care Med 2005; 32:S527-33. [PMID: 15542960 DOI: 10.1097/01.ccm.0000142983.15421.11] [Citation(s) in RCA: 90] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE In 2003, critical care and infectious disease experts representing 11 international organizations developed management guidelines for the use of corticosteroid therapy in patients with sepsis and septic shock that would be of practical use for the bedside clinician, under the auspices of the Surviving Sepsis Campaign, an international effort to increase awareness and improve outcome in severe sepsis. DESIGN The process included a modified Delphi method, a consensus conference, several subsequent smaller meetings of subgroups and key individuals, teleconferences, and electronic-based discussion among subgroups and among the entire committee. METHODS The modified Delphi methodology used for grading recommendations built upon a 2001 publication sponsored by the International Sepsis Forum. We undertook a systematic review of the literature graded along five levels to create recommendation grades from A to E, with A being the highest grade. Pediatric considerations to contrast adult and pediatric management are in the article by Parker et al. on p. S591. CONCLUSIONS Low doses of corticosteroids are recommended in patients with septic shock. In the absence of vasopressor requirement, corticosteroids should not be used to treat sepsis. High-dose corticosteroids are not recommended in severe sepsis. The use of adrenal function tests to guide decisions on corticosteroid therapy, the weaning of steroids at the end of the treatment period, the decision to discontinue steroids earlier with resolution of shock, and the addition of oral fludrocortisone are considered optional approaches.
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Affiliation(s)
- Didier Keh
- Klinik für Anaesthesiologie und Operative Intensivmedizin, Charité-Virchow-Klinikum, Berlin, Germany
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Affiliation(s)
- B G Cosío
- Servicio de Neumología, Hospital Universitario Son Dureta, Palma de Mallorca, Baleares, Spain.
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Lu NZ, Cidlowski JA. The origin and functions of multiple human glucocorticoid receptor isoforms. Ann N Y Acad Sci 2004; 1024:102-23. [PMID: 15265776 DOI: 10.1196/annals.1321.008] [Citation(s) in RCA: 140] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Glucocorticoid hormones are necessary for life and are essential in all aspects of human health and disease. The actions of glucocorticoids are mediated by the glucocorticoid receptor (GR), which binds glucocorticoid hormones and regulates gene expression, cell signaling, and homeostasis. Decades of research have focused on the mechanisms of action of one isoform of GR, GRa. However, in recent years, increasing numbers of human GR (hGR) isoforms have been reported. Evidence obtained from this and other laboratories indicates that multiple hGR isoforms are generated from one single hGR gene via mutations and/or polymorphisms, transcript alternative splicing, and alternative translation initiation. Each hGR protein, in turn, is subject to a variety of posttranslational modifications, and the nature and degree of posttranslational modification affect receptor function. We summarize here the processes that generate and modify various hGR isoforms with a focus on those that impact the ability of hGR to regulate target genes. We speculate that unique receptor compositions and relative receptor proportions within a cell determine the specific response to glucocorticoids. Unchecked expression of some isoforms, for example hGRbeta, has been implicated in various diseases.
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Affiliation(s)
- Nick Z Lu
- The Laboratory of Signal Transduction, Molecular Endocrinology Group, National Institute of Environmental Health Sciences, National Institutes of Health, Department of Health and Human Services, 111 Alexander Drive, Research Triangle Park, NC 27709, USA
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Meduri GU, Yates CR. Systemic Inflammation-Associated Glucocorticoid Resistance and Outcome of ARDS. Ann N Y Acad Sci 2004; 1024:24-53. [PMID: 15265772 DOI: 10.1196/annals.1321.004] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Dysregulated systemic inflammation with excess activation of pro-inflammatory transcription factor nuclear factor-kappaB (NF-kappaB)-activated by inflammatory signals-compared to the anti-inflammatory transcription factor glucocorticoid receptor-alpha (GRalpha)-activated by endogenous or exogenous glucocorticoids (GCs)-is an important pathogenetic mechanism for pulmonary and extrapulmonary organ dysfunction in patients with acute respiratory distress syndrome (ARDS). Activation of one transcription factor in excess of the binding (inhibitory) capacity of the other shifts cellular responses toward increased (dysregulated) or decreased (regulated) transcription of inflammatory mediators over time. Recent data indicate that failure to improve in ARDS (unresolving ARDS) is frequently associated with failure of the activated GRs to downregulate the transcription of inflammatory cytokines despite elevated levels of circulating cortisol, a condition defined as systemic inflammation-associated acquired GC resistance; it is potentially reversible with prolonged GC supplementation. In the first part of this paper, after a brief description of inflammation in ARDS and our model of translational research, we review the two cellular signaling pathways that are central to the regulation of inflammation-the stimulatory NF-alphaB and the inhibitory GRalpha. In the second part, we review findings of recent studies indicating that excessive inflammatory activity in patients with unresolving ARDS may induce noncompensated GC resistance in target organs. In the third part, we review factors affecting cellular response to GC and potential mechanisms involved in inflammation-associated GC resistance.
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Affiliation(s)
- G Umberto Meduri
- Department of Medicine, University of Tennessee Health Science Center, Memphis, TN 38163, USA.
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Affiliation(s)
- J Briegel
- Klinik für Anaesthesiologie, Klinikum der Universität München.
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