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Assessment of the predictive capability of modelling and simulation to determine bioequivalence of inhaled drugs: A systematic review. Daru 2022; 30:229-243. [PMID: 35094370 PMCID: PMC9114201 DOI: 10.1007/s40199-021-00423-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 10/18/2021] [Indexed: 02/01/2023] Open
Abstract
OBJECTIVES There are a multitude of different modelling techniques that have been used for inhaled drugs. The main objective of this review was to conduct an exhaustive survey of published mathematical models in the area of asthma and chronic obstructive pulmonary disease (COPD) for inhalation drugs. Additionally, this review will attempt to assess the applicability of these models to assess bioequivalence (BE) of orally inhaled products (OIPs). EVIDENCE ACQUISITION PubMed, Science Direct, Web of Science, and Scopus databases were searched from 1996 to 2020, to find studies that described mathematical models used for inhaled drugs in asthma/COPD. RESULTS 50 articles were finally included in this systematic review. This research identified 22 articles on in silico aerosol deposition models, 20 articles related to population pharmacokinetics and 8 articles on physiologically based pharmacokinetic modelling (PBPK) modelling for inhaled drugs in asthma/COPD. Among all the aerosol deposition models, computational fluid dynamics (CFD) simulations are more likely to predict regional aerosol deposition pattern in human respiratory tracts. Across the population PK articles, body weight, gender, age and smoking status were the most common covariates that were found to be significant. Further, limited published PBPK models reported approximately 29 parameters relevant for absorption and distribution of inhaled drugs. The strengths and weaknesses of each modelling technique has also been reviewed. CONCLUSION Overall, while there are different modelling techniques that have been used for inhaled drugs in asthma and COPD, there is very limited application of these models for assessment of bioequivalence of OIPs. This review also provides a ready reference of various parameters that have been considered in various models which will aid in evaluation if one model or hybrid in silico models need to be considered when assessing bioequivalence of OIPs.
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Nistel M, Nguyen N, Atkins D, Miyazawa H, Burger C, Furuta GT, Menard-Katcher C. Ciclesonide Impacts Clinicopathological Features of Eosinophilic Esophagitis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2021; 9:4069-4074. [PMID: 34293498 DOI: 10.1016/j.jaip.2021.06.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 06/28/2021] [Accepted: 06/29/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Eosinophilic esophagitis (EoE) is a chronic allergen-mediated disease of the esophagus. Pharmacologic treatment has largely relied on repurposing corticosteroids. Ciclesonide (CIC) is a corticosteroid for the treatment of asthma with biochemical properties that improve topical potency. OBJECTIVE To determine whether CIC decreased clinicopathological features of EoE. METHODS We performed a retrospective cohort study of patients with EoE treated with CIC at a pediatric hospital from 2010 to 2019. Data were extracted from the electronic health record. Patients who were prescribed CIC with pre- and post-CIC endoscopic and histological data available were included for analysis. RESULTS A total of 281 patients were treated with CIC and 81 met criteria for inclusion. Use of CIC was associated with reduced symptoms including dysphagia (P < .001), abdominal pain (P < .001), vomiting (P = .01), heartburn (P = .02), and behavior changes (P = .02). Average composite endoscopic reference scores decreased from 2.54 to 1.37 (P < .001), with improvement in exudates, edema, and furrows (all P < .001). Peak eosinophil counts decreased from 48 to 23 eosinophils/hpf (P < .001). Forty-three patients (53%) achieved remission (<15 eosinophils/hpf). Esophageal Candida was reported in 1 patient. Fasting morning cortisol concentrations were low in 10 of 31 patients tested. Six of these 10 patients had abnormal adrenocorticotropic hormone stimulation testing, 5 of 6 diagnosed with adrenal insufficiency before transition to CIC and 3 of 6 with subsequent normalization of adrenal function on CIC therapy. CONCLUSIONS Patients with EoE treated with CIC experienced significant reductions in clinicopathological features of EoE. CIC can be considered an alternative therapy in patients with known adrenal insufficiency or at risk of developing adrenal insufficiency.
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Affiliation(s)
- Mason Nistel
- Department of Pediatrics, Gastrointestinal Eosinophilic Diseases Program, Section of Pediatric Gastroenterology, Hepatology and Nutrition, University of Colorado School of Medicine, Aurora, Colo; Digestive Health Institute, Children's Hospital Colorado, Aurora, Colo; Mucosal Inflammation Program, University of Colorado School of Medicine, Aurora, Colo.
| | - Nathalie Nguyen
- Department of Pediatrics, Gastrointestinal Eosinophilic Diseases Program, Section of Pediatric Gastroenterology, Hepatology and Nutrition, University of Colorado School of Medicine, Aurora, Colo; Digestive Health Institute, Children's Hospital Colorado, Aurora, Colo; Mucosal Inflammation Program, University of Colorado School of Medicine, Aurora, Colo
| | - Dan Atkins
- Department of Pediatrics, Gastrointestinal Eosinophilic Diseases Program, Section of Pediatric Gastroenterology, Hepatology and Nutrition, University of Colorado School of Medicine, Aurora, Colo; Digestive Health Institute, Children's Hospital Colorado, Aurora, Colo; Mucosal Inflammation Program, University of Colorado School of Medicine, Aurora, Colo
| | - Heather Miyazawa
- Department of Pediatrics, Gastrointestinal Eosinophilic Diseases Program, Section of Pediatric Gastroenterology, Hepatology and Nutrition, University of Colorado School of Medicine, Aurora, Colo; Digestive Health Institute, Children's Hospital Colorado, Aurora, Colo; Mucosal Inflammation Program, University of Colorado School of Medicine, Aurora, Colo
| | - Cassandra Burger
- Department of Pediatrics, Gastrointestinal Eosinophilic Diseases Program, Section of Pediatric Gastroenterology, Hepatology and Nutrition, University of Colorado School of Medicine, Aurora, Colo; Digestive Health Institute, Children's Hospital Colorado, Aurora, Colo; Mucosal Inflammation Program, University of Colorado School of Medicine, Aurora, Colo
| | - Glenn T Furuta
- Department of Pediatrics, Gastrointestinal Eosinophilic Diseases Program, Section of Pediatric Gastroenterology, Hepatology and Nutrition, University of Colorado School of Medicine, Aurora, Colo; Digestive Health Institute, Children's Hospital Colorado, Aurora, Colo; Mucosal Inflammation Program, University of Colorado School of Medicine, Aurora, Colo
| | - Calies Menard-Katcher
- Department of Pediatrics, Gastrointestinal Eosinophilic Diseases Program, Section of Pediatric Gastroenterology, Hepatology and Nutrition, University of Colorado School of Medicine, Aurora, Colo; Digestive Health Institute, Children's Hospital Colorado, Aurora, Colo; Mucosal Inflammation Program, University of Colorado School of Medicine, Aurora, Colo
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3
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Abstract
Synthetic glucocorticoids are widely used for their anti-inflammatory and immunosuppressive actions. A possible unwanted effect of glucocorticoid treatment is suppression of the hypothalamic-pituitary-adrenal axis, which can lead to adrenal insufficiency. Factors affecting the risk of glucocorticoid induced adrenal insufficiency (GI-AI) include the duration of glucocorticoid therapy, mode of administration, glucocorticoid dose and potency, concomitant drugs that interfere with glucocorticoid metabolism, and individual susceptibility. Patients with exogenous glucocorticoid use may develop features of Cushing's syndrome and, subsequently, glucocorticoid withdrawal syndrome when the treatment is tapered down. Symptoms of glucocorticoid withdrawal can overlap with those of the underlying disorder, as well as of GI-AI. A careful approach to the glucocorticoid taper and appropriate patient counseling are needed to assure a successful taper. Glucocorticoid therapy should not be completely stopped until recovery of adrenal function is achieved. In this review, we discuss the factors affecting the risk of GI-AI, propose a regimen for the glucocorticoid taper, and make suggestions for assessment of adrenal function recovery. We also describe current gaps in the management of patients with GI-AI and make suggestions for an approach to the glucocorticoid withdrawal syndrome, chronic management of glucocorticoid therapy, and education on GI-AI for patients and providers.
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Affiliation(s)
- Alessandro Prete
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Irina Bancos
- Division of Endocrinology, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN 55905, USA
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4
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Chen YL, Wang W, Gatien Ngounou Wetie A, Shi L, Eddy J, John Lin ZP, Sunkaraneni S. An Ultrasensitive LC-APPI-MS/MS Method for Simultaneous Determination of Ciclesonide and Active Metabolite Desisobutyryl-Ciclesonide in Human Serum and Its Application to a Clinical Study. J Appl Lab Med 2021; 5:41-53. [PMID: 31662413 DOI: 10.1373/jalm.2019.029397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2019] [Accepted: 05/28/2019] [Indexed: 11/06/2022]
Abstract
BACKGROUND The development of more efficient drug delivery devices for ciclesonide inhalation products requires an ultrasensitive bioanalytical method to measure systematic exposure of ciclesonide (CIC) and its active metabolite desisobutyryl-ciclesonide (des-CIC) in humans. METHOD Serum sample was extracted with 1-chlorobutane. A reversed-phase liquid chromatography coupled with atmospheric pressure photoionization-tandem mass spectrometry (LC-APPI-MS/MS) method was used for quantification of 1-500 pg/mL for both analytes in a 0.500-mL serum. The analysis time was 4.7 min/injection. CIC-d11 and des-CIC-d11 were used as the internal standards. RESULTS Calibration curves showed good linearity (r2 > 0.99) for both analytes. This novel method was precise and accurate with interassay precision and accuracy of all within 9.6% CV and ± 4.0% bias for regular QC samples. Extraction recovery was approximately 85% for both analytes. Serum samples are stable for 3 freeze-thaw cycles, 24 h at bench top, and up to 706 days at both -20 °C and -70 °C. This method was successfully used to support a pharmacokinetic (PK) comparison between the inhalation suspensions and an inhalation aerosol of ciclesonide in healthy participants. The method robustness was also supported by the good incurred sample reanalysis reproducibility. CONCLUSION APPI, a highly selective and sensitive ionization source, made possible for quantifying CIC and des-CIC with a lower limit of quantification (LLOQ) of 1 pg/mL in human serum by LC-MS/MS. A 10-fold sensitivity improvement from the most sensitive reported method (LLOQ, 10 pg/mL) is essential to fully characterize the PK profiles of CIC and des-CIC in support of the clinical development of the ciclesonide-related medications for patients.
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Affiliation(s)
- Yu-Luan Chen
- Clinical Pharmacology, Sunovion Pharmaceuticals, Marlborough, MA
| | - Weimin Wang
- Bioanalytical Services, Frontage Laboratories, Exton, PA
| | | | - Lei Shi
- Clinical Pharmacology, Sunovion Pharmaceuticals, Marlborough, MA
| | - John Eddy
- Clinical Pharmacology, Sunovion Pharmaceuticals, Marlborough, MA
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5
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Himstedt A, Braun C, Wicha SG, Borghardt JM. Towards a Quantitative Mechanistic Understanding of Localized Pulmonary Tissue Retention-A Combined In Vivo/In Silico Approach Based on Four Model Drugs. Pharmaceutics 2020; 12:E408. [PMID: 32365674 PMCID: PMC7284631 DOI: 10.3390/pharmaceutics12050408] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 04/23/2020] [Accepted: 04/27/2020] [Indexed: 01/25/2023] Open
Abstract
Increasing affinity to lung tissue is an important strategy to achieve pulmonary retention and to prolong the duration of effect in the lung. As the lung is a very heterogeneous organ, differences in structure and blood flow may influence local pulmonary disposition. Here, a novel lung preparation technique was employed to investigate regional lung distribution of four drugs (salmeterol, fluticasone propionate, linezolid, and indomethacin) after intravenous administration in rats. A semi-mechanistic model was used to describe the observed drug concentrations in the trachea, bronchi, and the alveolar parenchyma based on tissue specific affinities (Kp) and blood flows. The model-based analysis was able to explain the pulmonary pharmacokinetics (PK) of the two neutral and one basic model drugs, suggesting up to six-fold differences in Kp between trachea and alveolar parenchyma for salmeterol. Applying the same principles, it was not possible to predict the pulmonary PK of indomethacin, indicating that acidic drugs might show different pulmonary PK characteristics. The separate estimates for local Kp, tracheal and bronchial blood flow were reported for the first time. This work highlights the importance of lung physiology- and drug-specific parameters for regional pulmonary tissue retention. Its understanding is key to optimize inhaled drugs for lung diseases.
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Affiliation(s)
- Anneke Himstedt
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, 20146 Hamburg, Germany;
- Drug Discovery Sciences, Boehringer Ingelheim Pharma GmbH & Co. KG, 88397 Biberach, Germany;
| | - Clemens Braun
- Drug Discovery Sciences, Boehringer Ingelheim Pharma GmbH & Co. KG, 88397 Biberach, Germany;
| | - Sebastian Georg Wicha
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, 20146 Hamburg, Germany;
| | - Jens Markus Borghardt
- Drug Discovery Sciences, Boehringer Ingelheim Pharma GmbH & Co. KG, 88397 Biberach, Germany;
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6
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Anderson SD. Repurposing drugs as inhaled therapies in asthma. Adv Drug Deliv Rev 2018; 133:19-33. [PMID: 29906501 DOI: 10.1016/j.addr.2018.06.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Revised: 05/26/2018] [Accepted: 06/06/2018] [Indexed: 01/06/2023]
Abstract
For the first 40 years of the 20th century treatment for asthma occurred in response to an asthma attack. The treatments were given by injection or orally and included the adrenergic agonists adrenalin/epinephrine and ephedrine and a phosphodiesterase inhibitor theophylline. Epinephrine became available as an aerosol in 1930. After 1945, isoprenaline, a non-selective beta agonist, became available for oral use but it was most widely used by inhalation. Isoprenaline was short-acting with unwanted cardiac effects. More selective beta agonists, with a longer duration of action and fewer side-effects became available, including orciprenaline in 1967, salbutamol in 1969 and terbutaline in 1970. The inhaled steroid beclomethasone was available by 1972 and budesonide by 1982. Spirometry alone and in response to exercise was used to assess efficacy and duration of action of these drugs for the acute benefits of beta2 agonists and the chronic benefits of corticosteroids. Early studies comparing oral and aerosol beta2 agonists found equivalence in bronchodilator effect but the aerosol treatment was superior in preventing exercise-induced bronchoconstriction. Inhaled drugs are now widely used including the long-acting beta2 agonists, salmeterol and formoterol, and the corticosteroids, fluticasone, ciclesonide, mometasone and triamcinolone, that act locally and have low systemic bio-availability. Repurposing drugs as inhaled therapies permitted direct delivery of low doses of drug to the site of action reducing the incidence of unwanted side-effects and permitting the prophylactic treatment of asthma.
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Affiliation(s)
- Sandra D Anderson
- Clinical Professor, Central Clinical School, Sydney Medical School, University of Sydney, Sydney, NSW 2006, Australia.
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Benfante A, Basile M, Battaglia S, Spatafora M, Scichilone N. Use of ICS/LABA (extra-fine and non-extra-fine) in elderly asthmatics. Ther Clin Risk Manag 2016; 12:1553-1562. [PMID: 27789954 PMCID: PMC5072519 DOI: 10.2147/tcrm.s103709] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Age represents an exclusion criterion in randomized clinical trials designed to test the efficacy and safety of inhaled drugs in asthma. As a consequence, data on efficacy and safety of inhaled corticosteroid (ICS) and long-acting β2 agonist (LABA) combinations in elderly asthmatics are scanty. Older age is associated with an increased proportion of comorbid conditions; in addition, all organ functions undergo a process of senescence, thus reducing their ability to metabolize the agents. Overall, these age-associated conditions may variably, and often unpredictably, affect the metabolism and excretion of respiratory drugs. However, pharmacological treatment of asthma does not follow specific recommendations in the elderly. In the elderly, the ICS/LABA combinations may carry an increased risk of local indesiderable effects, primarily due to the lack of coordination between activation of the device and inhalation, and systemic adverse events, mainly due to the greater amount of active drug that is available because of the age-associated changes in organ functions as well as drug-to-drug and drug-to-concomitant disease interactions. The extra-fine formulations of ICSs/LABAs, which allow for a more favorable drug deposition in the lungs at a reduced dose, may contribute to overcome this issue. This review revises the efficacy and safety of treatment with ICSs/LABAs, focusing on the main pharmacodynamic and pharmacokinetic properties of the drugs and highlighting the potential risks in the elderly asthmatic population.
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Affiliation(s)
- Alida Benfante
- Biomedical Department of Internal and Specialist Medicine, University of Palermo, Palermo, Italy
| | - Marco Basile
- Biomedical Department of Internal and Specialist Medicine, University of Palermo, Palermo, Italy
| | - Salvatore Battaglia
- Biomedical Department of Internal and Specialist Medicine, University of Palermo, Palermo, Italy
| | - Mario Spatafora
- Biomedical Department of Internal and Specialist Medicine, University of Palermo, Palermo, Italy
| | - Nicola Scichilone
- Biomedical Department of Internal and Specialist Medicine, University of Palermo, Palermo, Italy
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8
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Lee SJ, Kim HY, Park YM, Lee JS. Clinical Effects of Intranasal Steroid Application after Silicone Tube Intubation in Nasolacrimal Duct Obstruction. JOURNAL OF THE KOREAN OPHTHALMOLOGICAL SOCIETY 2016. [DOI: 10.3341/jkos.2016.57.8.1199] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Seok Jae Lee
- Department of Ophthalmology, Pusan National University School of Medicine, Busan, Korea
| | - Ho Yoon Kim
- Department of Ophthalmology, Pusan National University School of Medicine, Busan, Korea
| | - Young Min Park
- Department of Ophthalmology, Gyeongsang National University School of Medicine, Jinju, Korea
- Department of Ophthalmology, Gyeongsang National University Changwon Hospital, Changwon, Korea
| | - Jong Soo Lee
- Department of Ophthalmology, Pusan National University School of Medicine, Busan, Korea
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9
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Borghardt JM, Weber B, Staab A, Kloft C. Pharmacometric Models for Characterizing the Pharmacokinetics of Orally Inhaled Drugs. AAPS J 2015; 17:853-70. [PMID: 25845315 PMCID: PMC4477002 DOI: 10.1208/s12248-015-9760-6] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Accepted: 03/25/2015] [Indexed: 12/12/2022] Open
Abstract
During the last decades, the importance of modeling and simulation in clinical drug development, with the goal to qualitatively and quantitatively assess and understand mechanisms of pharmacokinetic processes, has strongly increased. However, this increase could not equally be observed for orally inhaled drugs. The objectives of this review are to understand the reasons for this gap and to demonstrate the opportunities that mathematical modeling of pharmacokinetics of orally inhaled drugs offers. To achieve these objectives, this review (i) discusses pulmonary physiological processes and their impact on the pharmacokinetics after drug inhalation, (ii) provides a comprehensive overview of published pharmacokinetic models, (iii) categorizes these models into physiologically based pharmacokinetic (PBPK) and (clinical data-derived) empirical models, (iv) explores both their (mechanistic) plausibility, and (v) addresses critical aspects of different pharmacometric approaches pertinent for drug inhalation. In summary, pulmonary deposition, dissolution, and absorption are highly complex processes and may represent the major challenge for modeling and simulation of PK after oral drug inhalation. Challenges in relating systemic pharmacokinetics with pulmonary efficacy may be another factor contributing to the limited number of existing pharmacokinetic models for orally inhaled drugs. Investigations comprising in vitro experiments, clinical studies, and more sophisticated mathematical approaches are considered to be necessary for elucidating these highly complex pulmonary processes. With this additional knowledge, the PBPK approach might gain additional attractiveness. Currently, (semi-)mechanistic modeling offers an alternative to generate and investigate hypotheses and to more mechanistically understand the pulmonary and systemic pharmacokinetics after oral drug inhalation including the impact of pulmonary diseases.
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Affiliation(s)
- Jens Markus Borghardt
- />Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstr. 31, 12169 Berlin, Germany
| | - Benjamin Weber
- />Department of Translational Medicine and Clinical Pharmacology, Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach, Germany
| | - Alexander Staab
- />Department of Translational Medicine and Clinical Pharmacology, Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach, Germany
| | - Charlotte Kloft
- />Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstr. 31, 12169 Berlin, Germany
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10
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Philip J. The effects of inhaled corticosteroids on growth in children. Open Respir Med J 2014; 8:66-73. [PMID: 25674176 PMCID: PMC4319193 DOI: 10.2174/1874306401408010066] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2014] [Revised: 10/21/2014] [Accepted: 10/21/2014] [Indexed: 11/24/2022] Open
Abstract
Inhaled corticosteroids (ICS) are recommended as the first-line therapy for children with persistent asthma. These agents are particularly effective in reducing underlying airway inflammation, improving lung function, decreasing airway hyper-reactivity, and reducing intensity of symptoms in asthmatics. Chronic diseases, such as asthma, have growth-suppressing effects independent of the treatment, which inevitably complicates growth studies. One year studies showed a small, dose-dependent effect of most ICS on childhood growth, with some differences across various ICS molecules, and across individual children. Some ICS at the doses studied did not affect childhood growth when rigorous study designs were used. Most studies did not conform completely with the FDA guidance. The data on effects of childhood ICS use on final adult height are conflicting, but one recent well-designed study showed such an effect, clearly warranting additional studies. In spite of these measurable effects of ICS on childhood growth, it is important to understand that the safety profile of all ICS preparations, with focal anti-inflammatory effects on the lung, is significantly better than oral glucocorticoids.
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Affiliation(s)
- Jim Philip
- Department of Endocrinology, NMC Hospital, Al Mutradeh area, AL AIN, UAE
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11
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Dobričić V, Marković B, Milenković N, Savić V, Jaćević V, Rančić N, Vladimirov S, Čudina O. Design, Synthesis, and Local Anti-Inflammatory Activity of 17β-Carboxamide Derivatives of Glucocorticoids. Arch Pharm (Weinheim) 2014; 347:786-97. [DOI: 10.1002/ardp.201400165] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2014] [Revised: 07/03/2014] [Accepted: 07/09/2014] [Indexed: 11/09/2022]
Affiliation(s)
- Vladimir Dobričić
- Faculty of Pharmacy, Department of Pharmaceutical Chemistry; University of Belgrade; Belgrade Serbia
| | - Bojan Marković
- Faculty of Pharmacy, Department of Pharmaceutical Chemistry; University of Belgrade; Belgrade Serbia
| | - Nikola Milenković
- Faculty of Pharmacy, Department of Pharmaceutical Chemistry; University of Belgrade; Belgrade Serbia
| | - Vladimir Savić
- Faculty of Pharmacy, Department of Organic Chemistry; University of Belgrade; Belgrade Serbia
| | - Vesna Jaćević
- National Poison Control Centre; Military Medical Academy; Belgrade Serbia
| | - Nemanja Rančić
- Centre for Clinical Pharmacology; Medical Faculty Military Medical Academy; University of Defence; Belgrade Serbia
| | - Sote Vladimirov
- Faculty of Pharmacy, Department of Pharmaceutical Chemistry; University of Belgrade; Belgrade Serbia
| | - Olivera Čudina
- Faculty of Pharmacy, Department of Pharmaceutical Chemistry; University of Belgrade; Belgrade Serbia
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12
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Bodzenta-Łukaszyk A, Kokot M. Pharmacological consequences of inhaled drug delivery to small airways in the treatment of asthma. Adv Ther 2014; 31:803-16. [PMID: 25116888 DOI: 10.1007/s12325-014-0143-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Indexed: 11/29/2022]
Abstract
Small peripheral airways are an important target for the anti-inflammatory treatment of asthma. To make anti-inflammatory drugs (inhaled corticosteroids [ICS]) effectively reach small airways, they should be delivered using inhalation techniques containing high proportions of fine or super-fine particles. Higher proportions of fine particles are associated with higher systemic absorption of ICS leading to an increased risk of endogenous cortisol suppression. Ciclesonide, despite the highest proportion of fine and super-fine particle fractions, is the only ICS not associated with an increased risk of systemic adverse effects, including cortisol suppression. In contrary to ICS, bronchodilators should not be administered to peripheral airways. This does not improve their efficacy and may increase their risk of cardiotoxicity. Thus, from a pharmacological point of view and the theory of aerosols' deposition, fixed combinations of ICS and long-acting beta agonists are always suboptimal. In many cases, the best solution may be to use fine-particle ciclesonide and a non-fine particle beta agonist administered from separate inhalers.
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Affiliation(s)
- Anna Bodzenta-Łukaszyk
- Clinical Department of Allergic and Internal Diseases, Medical University of Białystok, Bialystok, Poland,
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13
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Cechin SR, Buchwald P. Effects of representative glucocorticoids on TNFα- and CD40L-induced NF-κB activation in sensor cells. Steroids 2014; 85:36-43. [PMID: 24747770 PMCID: PMC4049353 DOI: 10.1016/j.steroids.2014.04.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2013] [Revised: 03/15/2014] [Accepted: 04/03/2014] [Indexed: 11/28/2022]
Abstract
Glucocorticoids are an important class of anti-inflammatory/immunosuppressive drugs. A crucial part of their anti-inflammatory action results from their ability to repress proinflammatory transcription factors such as nuclear factor-κB (NF-κB) and activator protein-1 (AP-1) upon binding to the glucocorticoid receptor (GR). Accordingly, sensor cells quantifying their effect on inflammatory signal-induced NF-κB activation can provide useful information regarding their potencies as well as their transrepression abilities. Here, we report results obtained on their effect in suppressing both the TNFα- and the CD40L-induced activation of NF-κB in sensor cells that contain an NF-κB-inducible SEAP construct. In these cells, we confirmed concentration-dependent NF-κB activation for both TNFα and CD40L at low nanomolar concentrations (EC50). Glucocorticoids tested included hydrocortisone, prednisolone, dexamethasone, loteprednol etabonate, triamcinolone acetonide, beclomethasone dipropionate, and clobetasol propionate. They all caused significant, but only partial inhibition of these activations in concentration-dependent manners that could be well described by sigmoid response-functions. Despite the limitations of only partial maximum inhibitions, this cell-based assay could be used to quantitate the suppressing ability of glucocorticoids (transrepression potency) on the expression of proinflammatory transcription factors caused by two different cytokines in parallel both in a detailed, full dose-response format as well as in a simpler single-dose format. Whereas inhibitory potencies obtained in the TNF assay correlated well with consensus glucocorticoid potencies (receptor-binding affinities, Kd, RBA, at the GR) for all compounds, the non-halogenated steroids (hydrocortisone, prednisolone, and loteprednol etabonate) were about an order of magnitude more potent than expected in the CD40 assay in this system.
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Affiliation(s)
- Sirlene R Cechin
- Diabetes Research Institute, Miller School of Medicine, University of Miami, 1450 NW 10 Ave (R-134), Miami, FL 33136, USA
| | - Peter Buchwald
- Diabetes Research Institute, Miller School of Medicine, University of Miami, 1450 NW 10 Ave (R-134), Miami, FL 33136, USA; Molecular and Cellular Pharmacology, Miller School of Medicine, University of Miami, 1600 NW 10 Ave (R-189), Miami, FL 33136, USA.
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14
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Chiu KC, Chou YL, Hsu JY, Lin MS, Lin CH, Chou PC, Chou CL, Wang CH, Kuo HP. Comparison of the efficacy of ciclesonide with that of budesonide in mild to moderate asthma patients after step-down therapy: a randomised parallel-group study. NPJ Prim Care Respir Med 2014; 24:14010. [PMID: 24841163 PMCID: PMC4373304 DOI: 10.1038/npjpcrm.2014.10] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2013] [Revised: 01/17/2014] [Accepted: 02/14/2014] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Inhaled corticosteroids (ICSs) are widely used in asthma control. Ciclesonide (CIC) is an ICS with on-site lung activation for potent anti-inflammatory activity. AIMS This study aimed to compare the clinical benefit of CIC with budesonide (BUD) in step-down therapy. METHODS A total of 150 patients with mild-to-moderate asthma well controlled by a combination of ICS and long-acting β2-agonist were randomised to receive either CIC 320 μg (n=75) once daily or 2 inhalations of BUD 200 μg (n=75) twice daily for 12 weeks. The forced expiratory volume in 1s (FEV1), maximum mid-expiratory flow (MMEF) and asthma control test (ACT) scores were measured. Ranked stratification of patients and physicians was assessed. RESULTS Drug adherence was significantly higher in the CIC group than in the BUD group (76.0% vs. 58.7%, P=0.03). The FEV1 and MMEF remained stable throughout the 12-week CIC treatment. In the BUD group, FEV1 significantly decreased at weeks 4 and 12. MMEF had a higher value in the CIC group than in the BUD group. Both patients and physicians ranked CIC over BUD. CONCLUSIONS CIC is more effective and has better drug adherence than BUD as step-down treatment when asthma is well controlled by combination therapy.
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Affiliation(s)
- Kuo-Chin Chiu
- Division of Chest, Department of Internal Medicine, Poh-Ai Hospital, Luodong, Taiwan
| | - Yen-Li Chou
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Jeng-Yuan Hsu
- Division of Chest, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Ming-Shian Lin
- Department of Pulmonary and Critical Care Medicine, Chia-Yi Christian Hospital, Chiayi, Taiwan
| | - Ching-Hsiung Lin
- Department of Chest Medicine, Changhua Christian Hospital, Changhua, Taiwan
| | - Pai-Chien Chou
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Taipei, Taiwan
| | - Chun-Liang Chou
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Taipei, Taiwan
| | - Chun-Hua Wang
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Taipei, Taiwan
| | - Han-Pin Kuo
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Taipei, Taiwan
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A V R. Inhalational Steroids and Iatrogenic Cushing's Syndrome. Open Respir Med J 2014; 8:74-84. [PMID: 25674177 PMCID: PMC4319196 DOI: 10.2174/1874306401408010074] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2014] [Revised: 10/21/2014] [Accepted: 10/21/2014] [Indexed: 11/22/2022] Open
Abstract
Bronchial asthma (BA) and Allergic rhinitis (AR) are common clinical problems encountered in day to day practice, where inhalational corticosteroids (ICS) or intranasal steroids (INS) are the mainstay of treatment. Iatrogenic Cushing syndrome (CS) is a well known complication of systemic steroid administration. ICS /INS were earlier thought to be safe, but now more and more number of case reports of Iatrogenic Cushing syndrome have been reported, especially in those who are taking cytochrome P450 (CYP 450) inhibitors. Comparing to the classical clinical features of spontaneous Cushing syndrome, iatrogenic Cushing syndrome is more commonly associated with osteoporosis, increase in intra-ocular pressure, benign intracranial hypertension, aseptic necrosis of femoral head and pancreatitis, where as hypertension, hirsuitisum and menstrual irregularities are less common. Endocrine work up shows low serum cortisol level with evidence of HPA (hypothalamo-pituitary-adrenal) axis suppression. In all patients with features of Cushing syndrome with evidence of adrenal suppression always suspect iatrogenic CS. Since concomitant administration of cytochrome P450 inhibitors in patients on ICS/INS can precipitate iatrogenic CS, avoidance of CYP450 inhibitors, its dose reduction or substitution of ICS are the available options. Along with those, measures to prevent the precipitation of adrenal crisis has to be taken. An update on ICS-/INS- associated iatrogenic CS and its management is presented here.
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Affiliation(s)
- Raveendran A V
- Department of Internal Medicine, Government Medical College & Hospitals, Kottayam, Kerala-686008, India
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Padden J, Skoner D, Hochhaus G. Pharmacokinetics and pharmacodynamics of inhaled glucocorticoids. J Asthma 2013; 45 Suppl 1:13-24. [PMID: 19093281 DOI: 10.1080/02770900802569942] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Inhaled corticosteroids are used widely to treat asthma. A number of different steroids and inhalation devices are available. The pharmacokinetic and pharmacodynamic properties of the different inhaled corticosteroids may influence their efficacy and safety profiles. Properties of an ideal inhaled corticosteroid include low oropharyngeal deposition, low oral bioavailability, high lung deposition, long pulmonary residence times, high receptor affinity, high plasma protein binding, and efficient systemic clearance. Attention to these parameters might help clinicians optimally balance between the safety and efficacy of inhaled corticosteroids in treating individual patients with asthma.
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Affiliation(s)
- Jennifer Padden
- Mylan School of Pharmacy, Duquesne University, Pittsburgh, PA
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Petrisko MA, Skoner JD, Skoner DP. Safety and efficacy of inhaled corticosteroids (ICS) in children with asthma. J Asthma 2013; 45 Suppl 1:1-9. [PMID: 19093279 DOI: 10.1080/02770900802631361] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Inhaled corticosteroids (ICS) are the guideline-preferred preventative therapy for persistent asthma of all severity levels and for all ages, including children. While these drugs are unquestionably efficacious, concerns of adverse systemic effects limit patient compliance with treatment regimens and thus the attainable benefits. Suppression of bone growth, bone density, and HPA axis function, in addition to cataract formation and elevated intraocular pressure/glaucoma, have been associated with ICS use. This review will focus on recent developments in the safety and efficacy of ICS as compared to oral CS corticosteroids and the achievement of a balance between risk and benefit in optimizing ICS therapy.
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Allometric modeling of ciclesonide, a nonhalogenated glucocorticoid, and its active metabolite, desisobutyrylciclesonide, using animal-derived pharmacokinetic parameters. Am J Ther 2013; 20:261-6. [PMID: 19417590 DOI: 10.1097/mjt.0b013e31819df738] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Ciclesonide, a novel glucocorticosteroid, through a rapid metabolism to desisobutyryl-ciclesonide (des-ciclesonide), provides an effective treatment option for asthma episodes by the inhaled route of administration. The availability of pharmacokinetic parameters (clearance [CL/F]; volume of distribution [Vd/F]; elimination half-life [T(½)]; and elimination rate constant [Kel]) in mice, rats, rabbits, and dogs enabled the prediction of human parameter values for des-ciclesonide using the well-accepted tool of allometry after intravenous administration of ciclesonide. However, as a result of the rapid conversion of ciclesonide, it was possible to perform allometry for the CL parameter only. Simple allometry (CL = 4.781W⁰·⁷⁸⁷⁴; R² = 0.9968) appeared to predict the CL of ciclesonide in close proximity of the observed value (observed: 101.25 L/h versus predicted: 135.62 L/h). In a similar manner, simple allometry predicted the human pharmacokinetic parameters of des-ciclesonide (CL/F, Vd/F, T(½), and Kel) within a two- to threefold range of the observed values. The allometric equations for des-ciclesonide parameter values were: CL/F = 4.8166W⁰·⁴⁹² (R² = 0.8598); Vd/F = 19.052W⁰·⁶³² (R² = 0.9049); T(½) = 3.7598W⁻⁰·¹⁶¹¹(R² = 0.8551); and Kel = 0.1832W⁰·¹⁵⁹⁶ (R² = 0.8632). In conclusion, the data suggested that allometry tool may be amenable for the prediction of the pharmacokinetic parameters of des-ciclesonide despite differences in the conversion rates and bioavailability of the active metabolite in various animal species.
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Prajapati P, Vaghela V. Densitometric measurement for estimation of ciclesonide in bulk and its dosage form (rotacap) by high-performance thin-layer chromatography. JPC-J PLANAR CHROMAT 2013. [DOI: 10.1556/jpc.26.2013.5.8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Prajesh P, Vipul V. OPTIMIZED METHOD FOR RAPID ESTIMATION OF CICLESONIDE IN BULK AND ITS DOSAGE FORM (ROTACAP) BY RP-HPLC. J LIQ CHROMATOGR R T 2013. [DOI: 10.1080/10826076.2012.695314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Prajapati Prajesh
- a Institute of Research and Development , Gujarat Forensic Sciences University , Gandhinagar , Gujarat , India
| | - Vaghela Vipul
- b A.R. College of Pharmacy and G.H. Patel Institute of Pharmacy , Vallabh Vidyanagar , Gujarat , India
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Xu J, Nave R, Lahu G, Derom E, Derendorf H. Population Pharmacokinetics and Pharmacodynamics of Inhaled Ciclesonide and Fluticasone Propionate in Patients With Persistent Asthma. J Clin Pharmacol 2013; 50:1118-27. [DOI: 10.1177/0091270009354994] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Sibila O, Anzueto A, Restrepo MI. THE PARADOXICAL EFFECT ON PNEUMONIA OF CHRONIC INHALED CORTICOSTEROIDS. CLINICAL PULMONARY MEDICINE 2013; 20:10.1097/CPM.0b013e31827a2a60. [PMID: 24244086 PMCID: PMC3828120 DOI: 10.1097/cpm.0b013e31827a2a60] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Community-acquired pneumonia (CAP) is the leading infectious cause of death in developed countries. Several studies have shown that the risk of pneumonia is increased in patients with Chronic Obstructive Pulmonary Disease (COPD) who are receiving chronic inhaled corticosteroids (ICS). The impact of ICS On pneumonia prognosis is controversial. Recent studies have shown that COPD patients with prior ICS use have less mortality after developing CAP as compared with patients with COPD without prior ICS use. This review discusses the association of ICS and the risk of CAP and its association with clinical outcomes in patients with COPD and pneumonia.
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Affiliation(s)
- Oriol Sibila
- University of Texas Health Science Center at San Antonio, San Antonio, TX
- Servei de Pneumologia, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Antonio Anzueto
- University of Texas Health Science Center at San Antonio, San Antonio, TX
- South Texas Veterans Health Care System
| | - Marcos I. Restrepo
- University of Texas Health Science Center at San Antonio, San Antonio, TX
- South Texas Veterans Health Care System
- Veterans Evidence Based Research Dissemination and Implementation Center (VERDICT)
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Gaz C, Cremona G, Panunzi S, Patterson B, De Gaetano A. A geometrical approach to the PKPD modelling of inhaled bronchodilators. J Pharmacokinet Pharmacodyn 2012; 39:415-28. [PMID: 22801773 DOI: 10.1007/s10928-012-9259-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2011] [Accepted: 06/20/2012] [Indexed: 11/29/2022]
Abstract
The present work introduces a new method to model the pharmacokinetics (PK) and pharmacodynamics (PD) of an inhaled dose of bronchodilator, alternative to classic compartmental representations or computational fluid dynamics. A five compartment PK model comprising alimentary tract absorption (gut), bronchial tree mucosa, bronchial muscles, plasma, and elimination/excretion pathways has been developed. Many anatomical and physiological features of the bronchial tree depend on bronchial generation or on mean distance from the larynx. Among these are diameters, resistances, and receptor density, which determine together the local response to the inhaled drug; integrating these local responses over the whole bronchial tree allows an approximation of total bronchodilator response and airflow resistance. While the PK part of the model reflects classical compartmental assumptions, the PD part adds a simplified geometrical and functional description of the bronchial tree to a typical empirical model of local effect on bronchial muscle, leading to the direct computation of the approximate forced expiratory volume in 1 s (FEV(1)). In the present work the construction of the model is detailed, with reference to literature data. Simulation of a hypothetical asthmatic subject is employed to illustrate the behaviour of the model in representing the evolution over time of the distribution and pharmacological effect of an inhaled dose of a bronchodilator. The relevance of particle size and drug formulation diffusivity on therapeutic efficacy is discussed.
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Affiliation(s)
- Claudio Gaz
- Consiglio Nazionale Delle Ricerche, Istituto di Analisi Dei Sistemi ed Informatica A. Ruberti, Viale Manzoni, 30, 00185, Rome, Italy
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Schroeder S, Fleischer DM, Masterson JC, Gelfand E, Furuta GT, Atkins D. Successful treatment of eosinophilic esophagitis with ciclesonide. J Allergy Clin Immunol 2012; 129:1419-21. [PMID: 22480537 DOI: 10.1016/j.jaci.2012.03.007] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2012] [Revised: 02/09/2012] [Accepted: 03/09/2012] [Indexed: 12/13/2022]
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Ahmet A, Kim H, Spier S. Adrenal suppression: A practical guide to the screening and management of this under-recognized complication of inhaled corticosteroid therapy. Allergy Asthma Clin Immunol 2011; 7:13. [PMID: 21867553 PMCID: PMC3177893 DOI: 10.1186/1710-1492-7-13] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2011] [Accepted: 08/25/2011] [Indexed: 11/10/2022] Open
Abstract
Inhaled corticosteroids (ICSs) are the most effective anti-inflammatory agents available for the treatment of asthma and represent the mainstay of therapy for most patients with the disease. Although these medications are considered safe at low-to-moderate doses, safety concerns with prolonged use of high ICS doses remain; among these concerns is the risk of adrenal suppression (AS). AS is a condition characterized by the inability to produce adequate amounts of the glucocorticoid, cortisol, which is critical during periods of physiological stress. It is a proven, yet under-recognized, complication of most forms of glucocorticoid therapy that can persist for up to 1 year after cessation of corticosteroid treatment. If left unnoticed, AS can lead to significant morbidity and even mortality. More than 60 recent cases of AS have been described in the literature and almost all cases have involved children being treated with ≥500 μg/day of fluticasone. The risk for AS can be minimized through increased awareness and early recognition of at-risk patients, regular patient follow-up to ensure that the lowest effective ICS doses are being utilized to control asthma symptoms, and by choosing an ICS medication with minimal adrenal effects. Screening for AS should be considered in any child with symptoms of AS, children using high ICS doses, or those with a history of prolonged oral corticosteroid use. Cases of AS should be managed in consultation with a pediatric endocrinologist whenever possible. In patients with proven AS, stress steroid dosing during times of illness or surgery is needed to simulate the protective endogenous elevations in cortisol levels that occur with physiological stress. This article provides an overview of current literature on AS as well as practical recommendations for the prevention, screening and management of this serious complication of ICS therapy.
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Affiliation(s)
- Alexandra Ahmet
- University of Ottawa, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada.
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Simultaneous determination of ciclesonide and its active metabolite desisobutyryl-ciclesonide in human plasma by LC–APCI-MS/MS: Application to pharmacokinetic study in healthy Chinese volunteers. J Pharm Biomed Anal 2011; 55:230-5. [DOI: 10.1016/j.jpba.2011.01.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2010] [Revised: 12/14/2010] [Accepted: 01/09/2011] [Indexed: 11/24/2022]
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O'Connor BJ, Kilfeather S, Cheung D, Kafé H, Blagden MD, Schlösser N, Ayres JG, Weber HJ, Engelstätter R. Efficacy and safety of ciclesonide in patients with severe asthma: a 12-week, double-blind, randomized, parallel-group study with long-term (1-year) follow-up. Expert Opin Pharmacother 2010; 11:2791-803. [PMID: 20958119 DOI: 10.1517/14656566.2010.526603] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To investigate the efficacy and safety of ciclesonide in patients with severe asthma over a 1-year period. RESEARCH DESIGN AND METHODS Patients aged 18 - 75 years with persistent asthma were enrolled in a 12-week, double-blind, randomized study and treated with ciclesonide 320 or 640 μg twice daily (b.i.d.) with the option of continuing in a 40-week extension phase (EP). MAIN OUTCOMES MEASURES Change in morning peak expiratory flow (PEF) from baseline to 12 weeks and safety over 1 year. RESULTS 365 patients were randomized and 275 continued into the EP. During 12 weeks' treatment, morning peak expiratory flow significantly increased by 16 l/min (p < 0.001) and 14 l/min (p = 0.001) in the 320 and 640 μg b.i.d. groups, respectively. Both doses significantly reduced total asthma symptom scores by 0.29 (p < 0.0001). In both groups, the incidence of adverse effects (AEs) was low and mean cortisol levels in serum and urine were not suppressed during the EP. CONCLUSIONS Ciclesonide 320 μg b.i.d. sustained lung function and asthma symptoms in patients with severe asthma over 12 weeks' treatment, and maintained lung function during a 40-week EP; ciclesonide 640 μg b.i.d. did not provide additional benefits. Long-term use of ciclesonide was not associated with increased local AEs or negative effects on cortisol levels.
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Affiliation(s)
- Brian J O'Connor
- King's College London, School of Medicine, The London Chest Clinic, London, UK.
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Boss H, Minic P, Nave R. Similar Results in Children with Asthma for Steady State Pharmacokinetic Parameters of Ciclesonide Inhaled with or without Spacer. CLINICAL MEDICINE INSIGHTS-PEDIATRICS 2010; 4:1-10. [PMID: 23761990 PMCID: PMC3666986 DOI: 10.4137/cmped.s4311] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background: Ciclesonide is an inhaled corticosteroid administered by a metered dose inhaler (MDI) to treat bronchial asthma. After inhalation, the inactive ciclesonide is converted by esterases in the airways to active metabolite desisobutyryl-ciclesonide (des-CIC). Aim: To compare the pharmacokinetic (PK) parameters of des-CIC in children after administration of therapeutic dose of ciclesonide with and without spacer (AeroChamber Plus™). Methods: Open-label, 3 period, cross over, repeated dose, PK study in 37 children with mild to moderate stable asthma (age: 6–11 y; body weight: 20–53 kg). During each 7-day treatment period, ciclesonide was inhaled once in the morning: A) 160 μg MDI with spacer, B) 80 μg MDI with spacer, and C) 160 μg MDI without spacer. Serum PK parameters of ciclesonide and des-CIC were determined on Day 7 of each period. The primary PK parameters were the AUCτ and Cmax for des-CIC. Results: Inhaling ciclesonide with spacer led to a dose proportional systemic exposure (AUCτ) of des-CIC (0.316 μg*h/L for 80 μg and 0.663 μg*h/L for 160 μg). The dose-normalized systemic exposure for des-CIC (based on AUCτ) was 27% higher after inhalation of ciclesonide 80 μg or 160 μg with spacer than without spacer; the corresponding Cmax values for des-CIC were, respectively, 63% and 55% higher with spacer. No clinically relevant abnormalities or adverse drug reactions were observed. Conclusions: Inhalation of therapeutic ciclesonide dose with spacer led to a slight increase in the systemic exposure of des-CIC, which does not warrant dose adjustment.
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Affiliation(s)
- H Boss
- Nycomed GmbH, Byk Gulden Str. 2, 78467 Konstanz, Germany
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Benedetti MS, Whomsley R, Poggesi I, Cawello W, Mathy FX, Delporte ML, Papeleu P, Watelet JB. Drug metabolism and pharmacokinetics. Drug Metab Rev 2009; 41:344-90. [PMID: 19601718 DOI: 10.1080/10837450902891295] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
In this article, aspects of absorption, distribution, metabolism, and excretion have been described bearing in mind the pathogenesis of allergic diseases and their possible therapeutic opportunities. The importance of the routes of administration of the different therapeutic groups has been emphasized. The classical aspects of drug metabolism and disposition related to oral administration have been reviewed, but special emphasis has been given to intranasal, cutaneous, transdermal, and ocular administration as well as to the absorption and the subsequent bioavailability of drugs. Drug-metabolizing enzymes and transporters present in extrahepatic tissues, such as nasal mucosa and the respiratory tract, have been particularly discussed. As marketed antiallergic drugs include both racemates and enantiomers, aspects of stereoselective absorption, distribution, metabolism, and excretion have been discussed. Finally, a new and promising methodology, microdosing, has been presented, although it has not yet been applied to drugs used in the treatment of allergic diseases.
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Nave R. Clinical pharmacokinetic and pharmacodynamic profile of inhaled ciclesonide. Clin Pharmacokinet 2009; 48:243-52. [PMID: 19492869 DOI: 10.2165/00003088-200948040-00002] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Asthma is a chronic inflammatory disease of the airways, and inhaled corticosteroids (ICSs) are recommended as first-line therapy for persistent asthma of all severities. Ciclesonide is a novel ICS, which is administered as an aerosol solution in a metered-dose inhaler, using hydrofluoroalkane-134a as a propellant. Because of the high respirable particle fraction, high pulmonary deposition is obtained in patients, which constitutes the basis of effective therapeutic action. The parent compound, ciclesonide, is pharmacologically inactive and is activated in the target organ, the lung, to form its only pharmacologically active metabolite, desisobutyryl-ciclesonide (des-CIC). Low oral deposition combined with minimal formation of des-CIC in the oropharynx may minimize the typical oropharyngeal adverse events associated with ICSs. Low oral bioavailability, rapid clearance and high protein binding reduce pharmacologically relevant systemic exposure. The unique pharmacokinetic and pharmacodynamic profile of ciclesonide offers a rationale that supports the favourable risk-benefit profile observed in clinical trials in patients with persistent asthma.
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Affiliation(s)
- Rüdiger Nave
- Department of Pharmacometrics/Pharmacokinetics, Nycomed GmbH, Konstanz, Germany.
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Wu K, Blomgren AL, Ekholm K, Weber B, Edsbaecker S, Hochhaus G. Budesonide and Ciclesonide: Effect of Tissue Binding on Pulmonary Receptor Binding. Drug Metab Dispos 2009; 37:1421-6. [DOI: 10.1124/dmd.108.026039] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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van den Berge M, Arshad SH, Ind PW, Magnussen H, Hamelmann E, Kanniess F, Postma DS. Similar efficacy of ciclesonide versus prednisolone to treat asthma worsening after steroid tapering. Respir Med 2009; 103:1216-23. [PMID: 19297141 DOI: 10.1016/j.rmed.2009.01.024] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2008] [Revised: 01/27/2009] [Accepted: 01/27/2009] [Indexed: 11/25/2022]
Abstract
RATIONALE Oral corticosteroids effectively treat asthma exacerbations but are associated with well-described side effects. OBJECTIVE This study compared the efficacy and safety of a high dose of an inhaled corticosteroid with oral prednisolone in patients with worsening of their asthma after medication withdrawal. METHODS Patients tapered off their inhaled corticosteroids until they reached predefined criteria of "worsening asthma". Randomized patients (n=130) were treated double blind with either ciclesonide 800mug twice daily (starting with 800mug hourly for 3h after randomization) or prednisolone 40mg once daily for 2 weeks. Spirometry, daily asthma symptoms, morning and evening peak expiratory flow and blood parameters were assessed in all, methacholine challenge and inflammatory measures were determined in induced sputum in a subset of patients. RESULTS Ciclesonide was as effective as prednisolone in improving forced expiratory flow in 1s, morning peak expiratory flow and symptoms, the latter improving more rapidly with ciclesonide. No differences were found in methacholine responsiveness or inflammatory measures in sputum or blood. Ciclesonide caused significantly less reduction in morning plasma cortisol levels (p<0.0001). CONCLUSION This study shows that inhaled ciclesonide (800mug twice daily) has comparable efficacy to oral prednisolone (40mg once daily) to regain asthma control in patients with asthma worsening. The more rapid onset and smaller effect on cortisol suppression suggest a better safety profile of ciclesonide.
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Affiliation(s)
- M van den Berge
- Department of Pulmonology, University Medical Center Groningen, Groningen, The Netherlands.
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Baptist AP, Reddy RC. Inhaled corticosteroids for asthma: are they all the same? J Clin Pharm Ther 2009; 34:1-12. [PMID: 19125898 DOI: 10.1111/j.1365-2710.2008.00970.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVES To assess similarities and differences among currently available inhaled corticosteroids (ICS) for treatment of asthma, with special emphasis on factors that may affect the relative safety of these medications. METHODS PubMed was searched for relevant reviews and original articles. Information from these studies was synthesized and critically assessed. RESULTS Differences in corticosteroid formulations and delivery systems can create variations in therapeutic efficacy. Chemical properties of the various corticosteroids may also affect their relative safety. Ciclesonide and beclomethasone dipropionate are administered as prodrugs activated by enzymes present in the lungs but not the oropharynx. Corticosteroid-specific adverse effects in the oropharynx are thus avoided, although formulation-specific effects may remain. Other adverse effects require systemic availability, either via the gastrointestinal tract or the lung. Once they enter the systemic circulation, all ICS are rapidly metabolized by the liver. Oral bioavailability of ICS such as fluticasone, ciclesonide and mometasone is minimal, as a result of their essentially complete first-pass metabolism in the liver. Ciclesonide also undergoes extrahepatic metabolism that eliminates it even more rapidly. Additionally, ciclesonide and mometasone exhibit very high levels of binding to serum proteins that reduces their ability to stimulate glucocorticoid receptors outside the lung. CONCLUSIONS Despite acting by similar mechanisms, currently available ICS and their delivery systems differ in ways that can potentially affect both safety and therapeutic effectiveness for individual patients.
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Affiliation(s)
- A P Baptist
- Division of Allergy and Clinical Immunology, Department of Internal Medicine, University of Michigan Medical Center, Ann Arbor, MI, USA
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Schaffner TJ, Skoner DP. Ciclesonide: a safe and effective inhaled corticosteroid for the treatment of asthma. J Asthma Allergy 2009; 2:25-32. [PMID: 21437141 PMCID: PMC3048607 DOI: 10.2147/jaa.s4651] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Ciclesonide is a novel inhaled corticosteroid used in the continuous treatment of mild-to-severe asthma. Its formulation and mechanism of action yield a low oral and systemic bioavailability, and high pulmonary deposition. In multiple clinical trials, ciclesonide is at least as effective as either fluticasone propionate or budesonide at symptom control, while in many cases having improved safety outcomes and tolerability. The improved safety and comparable efficacy profiles of ciclesonide demonstrated in current studies could potentially yield a treatment option that may lead to improved adherence and outcome.
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Affiliation(s)
- Timothy J Schaffner
- Division of Allergy, Asthma, and Immunology, Allegheny General Hospital, Pittsburgh, PA, USA
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Couroux P, Kunjibettu S, Hall N, Wingertzahn MA. Onset of action of ciclesonide once daily in the treatment of seasonal allergic rhinitis. Ann Allergy Asthma Immunol 2009; 102:62-8. [DOI: 10.1016/s1081-1206(10)60110-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Xu J, Sabarinath SN, Derendorf H. Cortisol suppression as a surrogate marker for inhaled corticosteroid-induced growth retardation in children. Eur J Pharm Sci 2008; 36:110-21. [PMID: 19028577 DOI: 10.1016/j.ejps.2008.10.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2008] [Accepted: 09/17/2008] [Indexed: 11/19/2022]
Abstract
Exposure of inhaled corticosteroids (ICSs) in pediatrics results in adrenal suppression and growth inhibition. The objective of this study was to assess the relationship of ICS mediated growth retardation with cortisol suppression in asthmatic children. A meta-analysis approach was performed with 33 published articles. Growth velocity (GV) data were obtained from the literature for evaluation of growth. Cumulative cortisol suppression within 24h (CCS%) was calculated at steady state with a validated algorithm. Consolidated GV and CCS% data were employed for model development. A linear mixed effects model was developed to adequately describe the relationship between GV and CCS%. No impact of tested covariates was observed. Population estimate of the rate of change in GV was -0.06cm/year/CCS% (12.7%, coefficient of variation) for both stadiometry and knemometry methods. However, GV from stadiometry is expected to be approximately three fold higher than that from knemometry when cortisol suppression was not presented. The final model was evaluated with posterior predictive check and pattern check approaches. The results from this study elucidate CCS% as an excellent predictor of ICS mediated growth retardation in asthmatic children.
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Affiliation(s)
- Jian Xu
- Department of Pharmaceutics, College of Pharmacy, University of Florida, Gainesville, FL 32610, USA
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Abstract
Ciclesonide nasal spray delivers the corticosteroid ciclesonide as a hypotonic spray via a metered-dose manual pump. Systemic exposure to ciclesonide and its active metabolite desisobutyryl-ciclesonide is low after intranasal administration. High protein binding (approximately 99%) and rapid first-pass clearance further reduce systemic exposure to the drug. In well designed trials, intranasal ciclesonide 200 microg once daily for 2-4 weeks was more effective than placebo in terms of improving nasal symptoms in adolescents and adults with moderate to severe seasonal allergic rhinitis. Quality of life measures were statistically significantly improved in ciclesonide relative to placebo recipients during the first 2 weeks of therapy. Similarly, in adolescents and adults with moderately severe perennial allergic rhinitis, ciclesonide 200 microg once daily was more effective than placebo in terms of reducing nasal symptoms in well designed trials of 6 weeks' and 1 year's duration. Improvements relative to placebo in quality of life measures were not considered clinically relevant. Ciclesonide nasal spray was generally well tolerated in these clinical trials; most adverse events were mild to moderate in intensity.
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Affiliation(s)
- Sohita Dhillon
- Wolters Kluwer Health/Adis, 41 Centorian Drive, Private Bag 65901, Mairangi Bay, North Shore 0754, Auckland, New Zealand.
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Berger WE, Nayak A, Lanier BQ, Kaiser HB, LaForce C, Darken P, Hall N, Wingertzahn M. Efficacy and Safety of Once-Daily Ciclesonide Nasal Spray in Children With Allergic Rhinitis. ACTA ACUST UNITED AC 2008. [DOI: 10.1089/pai.2007.0022.73] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Buchwald P. Glucocorticoid receptor binding: a biphasic dependence on molecular size as revealed by the bilinear LinBiExp model. Steroids 2008; 73:193-208. [PMID: 18022656 DOI: 10.1016/j.steroids.2007.10.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2007] [Revised: 09/26/2007] [Accepted: 10/03/2007] [Indexed: 10/22/2022]
Abstract
For corticosteroids, receptor-binding affinity (RBA) at the glucocorticoid receptor (GR) is a major determinant of therapeutic potential. Here, the results of a comprehensive quantitative analysis of relative RBA (rRBA) data obtained from more than a hundred active structures are reported. Because of a clear biphasic size-dependence, the recently introduced linearized biexponential (LinBiExp) model provided very good fit: for steroids that satisfy the main binding criteria at the GR, it accounts for close to 80% of the variability in the free energy of binding DeltaG0 (or logrRBA) data by using only two descriptors: calculated molecular volume and an indicator variable for the presence of 6alpha/9alpha-halogen or cyclic 16,17-acetal moieties. Accordingly, binding is strongest for corticosteroids close to an ideal size that is large enough to provide as large nonspecific (van der Waals-type) interactions as possible, but is not too large to have difficulty fitting due to size-limitations at the binding site. Binding affinity is dramatically increased by 6alpha- or 9alpha-halogenation or introduction of a cyclic 16,17-acetal moiety (in average, about 7-fold), but there is no significant increase after the first substitution. Known highly active glucocorticoids, such as betamethasone 17-monopropionate, fluticasone propionate, or mometasone furoate, indeed satisfy both of these criteria. For small-enough structures, the obtained size-dependency (slope) of the free energy of binding suggest that, as long as only nonspecific interactions are involved, addition of a methylene-sized non-hydrogen atom to the ligand structure increases DeltaG0 on average by about 1.5 kJ/mol, corresponding to an almost doubling of the binding affinity.
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Affiliation(s)
- Peter Buchwald
- Molecular and Cellular Pharmacology and Diabetes Research Institute, Miller School of Medicine, University of Miami, 1450 NW 10 Avenue (R-134), Miami, FL 33136, United States.
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Skoner DP, Maspero J, Banerji D. Assessment of the long-term safety of inhaled ciclesonide on growth in children with asthma. Pediatrics 2008; 121:e1-14. [PMID: 18070931 DOI: 10.1542/peds.2006-2206] [Citation(s) in RCA: 90] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To assess the effects of the new inhaled corticosteroid ciclesonide on growth in children with asthma. METHODS We performed a multicenter, randomized, double-blind, placebo-controlled study to assess the effects of inhaled ciclesonide on growth in children with mild, persistent asthma. After a 6-month run-in period, 661 prepubertal children who were aged 5.0 to 8.5 years were randomly assigned to once-daily morning treatment for 1 year with ciclesonide 40 or 160 microg (ex-actuator) or placebo, followed by a 2-month follow-up period. The primary end point was the linear growth velocity (linear regression estimate) over the double-blind treatment period. Growth was recorded as the median of 4 stadiometer measurements. Adverse events and 10-hour overnight and 24-hour urinary free cortisol levels were also assessed. RESULTS Mean linear growth velocity during run-in was comparable between groups: 160 microg, 6.20 cm/year; 40 microg, 6.59 cm/year; placebo, 6.49 cm/year. Mean differences from placebo (5.75 cm/year) in growth velocity over the double-blind treatment period were -0.02 cm/year for ciclesonide 40 microg and -0.15 cm/year for ciclesonide 160 microg. Both ciclesonide treatments were noninferior to placebo with respect to growth velocity. The overall incidence of adverse events was comparable between groups, and no significant changes in 10-hour overnight or 24-hour urinary free cortisol levels were noted between groups during the double-blind treatment period. CONCLUSIONS Ciclesonide demonstrated no detectable effect on childhood growth velocity, even at the highest dosage, which may ease concerns about systemic adverse events.
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Affiliation(s)
- David P Skoner
- Allegheny General Hospital, Department of Pediatrics, 320 E North Ave, South Tower, Seventh Floor, Pittsburgh, PA 15212, USA.
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Böhmer GM, Drollmann A, Gleiter CH, Nave R. Effect of Coadministered Ketoconazole, a Strong Cytochrome P450 3A4 Enzyme Inhibitor, on the Pharmacokinetics of Ciclesonide and its Active Metabolite Desisobutyryl-Ciclesonide. Clin Pharmacokinet 2008; 47:343-9. [DOI: 10.2165/00003088-200847050-00005] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Magnussen H, Hofman J, Staneta P, Lawo JP, Hellwig M, Engelstätter R. Similar efficacy of ciclesonide once daily versus fluticasone propionate twice daily in patients with persistent asthma. J Asthma 2007; 44:555-63. [PMID: 17885859 DOI: 10.1080/02770900701537081] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
This 12-week, double-blind, parallel-group study compared the efficacy and safety of once daily ciclesonide and twice daily fluticasone propionate in patients aged 12-75 years with persistent asthma. Patients were randomized to once-daily ciclesonide 80 micro g (n = 278) or 160 micro g (n = 271), or twice daily fluticasone propionate 88 micro g (n = 259) (all ex-actuator). Significant improvements from baseline were seen in all three treatment groups for forced expiratory volume in 1 second, asthma symptom scores and rescue medication use (all p < 0.0001). Asthma exacerbation rates were low (each ciclesonide group, n = 2; fluticasone group, n = 1). Adverse event reporting indicated good tolerability. Once daily ciclesonide 80 micro g or 160 micro g showed comparable efficacy and tolerability to twice daily fluticasone propionate 88 micro g in persistent asthma.
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Affiliation(s)
- Helgo Magnussen
- Center for Pneumology and Thoracic Surgery, Pulmonary Research Institute, Hospital Grosshansdorf, Grosshansdorf, Germany.
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Randomized comparison of ciclesonide 160 and 640 microg/day in severe asthma. Pulm Pharmacol Ther 2007; 21:489-98. [PMID: 18178494 DOI: 10.1016/j.pupt.2007.11.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2007] [Revised: 10/19/2007] [Accepted: 11/18/2007] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Demonstrating clinical benefit of higher doses of inhaled corticosteroids in asthma is frequently problematic owing to their relatively flat dose-response curve in this condition. In this study we compared the efficacy and safety of a fourfold difference in the dose of ciclesonide-ciclesonide 320 microg twice daily (CIC640) versus ciclesonide 160 microg once daily (CIC160)-in patients with severe persistent asthma. METHODS Patients with bronchial asthma (6 months) were included in this randomized, double-blind study. After receiving fluticasone propionate 250 microg twice daily during run-in, patients were randomized to CIC160 (n=339) or CIC640 (n=341) for 12 weeks. Primary endpoints were time to first asthma exacerbation and forced expiratory volume in 1s (FEV(1)). Secondary endpoints included other lung function variables, asthma symptom scores and rescue medication use (RMU). RESULTS Asthma exacerbations occurred in 12.7% of patients receiving CIC160 and 6.7% receiving CIC640. CIC640 was superior for time to first exacerbation (p=0.0050, one-sided). FEV(1) increased significantly with CIC160 and CIC640 (least squares mean+/-SE of mean: 269+/-31 and 332+/-31 mL, respectively; p<0.0001), with no significant difference between groups. Change in % predicted FEV(1) and morning peak expiratory flow (PEF) were significantly higher with CIC640 (p<0.05). Asthma symptom score sums and RMU decreased in both groups; CIC640 was statistically superior (p=0.0108 and 0.0005, respectively). No unexpected adverse events were reported in either group and the majority of the events reported were mild or moderate in intensity. No significant changes in serum cortisol were observed from the baseline to the study end. Small decreases in creatinine-adjusted 24h urine cortisol levels from baseline were seen in both the treatment groups, which, due to the large patient numbers, were statistically significant (p<0.05); however, no dose-response effect was seen and the difference between groups was not significant (p=0.7892). CONCLUSION CIC640 was superior to CIC160 for time to first exacerbation, % predicted FEV1, morning PEF, asthma symptom score sum and RMU in patients with severe asthma; both doses had similar tolerability profiles and no significant changes in serum cortisol were seen in either treatment group.
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Key barriers to optimal management of adult asthma in Australia: physician and patient perspectives. Curr Med Res Opin 2007; 23:1799-807. [PMID: 17597555 DOI: 10.1185/030079907x210714] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Despite recent advances in asthma treatment, its management in many patients remains sub-optimal. The aim of the Global Asthma Physicians and Patient (GAPP) survey was to identify barriers to optimal asthma management and to explore the content and dynamics of physician-patient communications. Here we present the key findings for adults with asthma in Australia. RESEARCH DESIGN AND METHODS Patients with asthma aged > or = 18 years and physicians who treat adults (generalists; specialists) participated in telephone interviews conducted in May-June 2005, using close-end questionnaires. The survey examined physicians' beliefs and prescribing habits; patients' experiences with asthma; doctor-patient communication; satisfaction with asthma medications and interest in new asthma treatment. RESULTS A total of 101 adults with asthma and 100 physicians treating asthma patients in Australia completed the survey. Overall, key barriers to optimal asthma management included medication side effects, treatment compliance and patient education. These barriers may be exacerbated by poor patient-physician communication that fails to address patients concerns regarding side effects and may lead to poor treatment compliance. Both physicians and patients expressed safety concerns regarding the long-term use of inhaled corticosteroid and both groups would welcome new treatment options with improved safety profiles, efficacy and once-daily dosing. CONCLUSION From both a physician and patient perspective, the safety profile of asthma medication constitutes a key factor in promoting treatment compliance and, ultimately, treatment outcomes. The results highlight discrepancies in perceived patient-physician communication and a need for improved patient education in asthma management.
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Zdanowicz MM. Pharmacotherapy of asthma. AMERICAN JOURNAL OF PHARMACEUTICAL EDUCATION 2007; 71:98. [PMID: 17998995 PMCID: PMC2064896 DOI: 10.5688/aj710598] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2007] [Accepted: 04/23/2007] [Indexed: 05/09/2023]
Abstract
The pharmacotherapy of asthma is a complex and evolving topic. A detailed understanding of the pathophysiologic processes involved in the asthmatic response forms the basis for understanding the actions of drugs used to treat this condition. Likewise, a solid comprehension of the medicinal chemistry and pharmacologic properties of the numerous agents involved in the treatment of asthma is critical for rationalizing drug choices and understanding potential side effects. Asthma is addressed at several points in the PharmD curriculum at South University including in the Pathophysiology (quarter 2), Integrated Sequence III (quarter 6), and Critical Care (quarter 9) courses. Various teaching strategies are employed throughout, along with weekly case-based recitations. The content presented here includes a synopsis of the pathophysiology and pharmacology from our Integrated Sequence III block on inflammatory diseases and asthma. A short review of pertinent pathophysiology is followed by a detailed presentation on the various classes of asthma drugs which includes their chemistry, mechanism of action, pharmacokinetics, toxicity, and interactions. This presentation is designed to prepare students for asthma therapeutics, which follows next in the schedule. The complexities of asthma pharmacotherapy are stressed along with current controversies and future drug development.
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Affiliation(s)
- Martin M Zdanowicz
- Department of Pharmaceutical Sciences, South University School of Pharmacy, Savannah, GA 31406, USA.
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Boero S, Sabatini F, Silvestri M, Petecchia L, Nachira A, Pezzolo A, Scarso L, Rossi GA. Modulation of human lung fibroblast functions by ciclesonide: evidence for its conversion into the active metabolite desisobutyryl-ciclesonide. Immunol Lett 2007; 112:39-46. [PMID: 17707916 DOI: 10.1016/j.imlet.2007.06.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2007] [Revised: 06/21/2007] [Accepted: 06/26/2007] [Indexed: 10/23/2022]
Abstract
BACKGROUND Ciclesonide, an inhaled corticosteroid administered as inactive compound with almost no binding affinity for the glucocorticoid receptor, is clinically effective in asthma being converted by airway epithelial cells into its active metabolite desisobutyryl-(des)-ciclesonide. AIM To evaluate whether ciclesonide could directly modulate in vitro bronchial fibroblast functions being converted into des-ciclesonide by these pluripotent cells involved in the regulation of airway inflammation and remodelling. METHODS Ciclesonide (0.09-9.0 microM) was added to a human adult lung fibroblast cell line (CCL-202), seeded in medium in the presence of the following cytokines and growth factors: (a) basic fibroblast growth factor (bFGF) for cell proliferation, measured by tritiated thymidine ([3H]TdR) incorporation; (b) tumour necrosis factor (TNF)-alpha, to stimulate intercellular adhesion molecule (ICAM)-1 expression and monocyte chemoattractant protein-1 (MCP-1) and eotaxin release, evaluated by flow cytometry and ELISA, respectively; (c) transforming growth factor (TGF)-beta1, for induction of alpha smooth muscle actin (alpha-SMA) protein expression and modification of the organization of alpha-SMA stress fibres, evaluated by Western blot analysis and fluorescence microscopy. RESULTS The presence of ciclesonide in cell cultures induced a significant downregulation of: (a) bFGF-induced fibroblast proliferation and TNF-alpha-induced ICAM-1 expression, at the 0.3-9.0 microM concentrations (p<0.05); (b) TNF-alpha-induced MCP-1 release, at all the concentrations tested (p<0.05); (c) TNF-alpha-induced eotaxin release, at the three highest concentrations (0.9-9.0 microM) (p<0.05); (d) TGF-beta1-induced of alpha-SMA protein expression at the 0.3-3.0 microM concentrations, associated with a reduction in the organization of alpha-SMA stress fibres. CONCLUSIONS These data show at cellular level an effective anti-inflammatory activity of ciclesonide on human lung fibroblasts and support the hypothesis that also these cells, in addition to airway epithelial cells, may be involved in converting the parental compound into its active metabolite in the airways.
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Affiliation(s)
- Silvia Boero
- Pulmonary Disease Unit, G. Gaslini Institute, Largo G. Gaslini 5, 16147 Genoa, Italy
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Gulliver T, Morton R, Eid N. Inhaled corticosteroids in children with asthma: pharmacologic determinants of safety and efficacy and other clinical considerations. Paediatr Drugs 2007; 9:185-94. [PMID: 17523699 DOI: 10.2165/00148581-200709030-00007] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The role of inhaled corticosteroids (ICS) in the treatment of childhood asthma has been well established. An ideal corticosteroid should demonstrate high pulmonary deposition and residency time, in addition to a low systemic bioavailability and rapid systemic clearance. The lung depositions of the ICS have been compared, with beclomethasone (beclometasone)-hydrofluoroalkane (HFA) and ciclesonide showing the highest lung deposition. Lung deposition is influenced by not only the inhalation device and type of propellant (HFA or chlorofluorocarbon), but also by whether the aerosol is a solution or suspension, and the particle size of the respirable fraction. Pulmonary residency time increases when budesonide and des-ciclesonide undergo reversible fatty acid esterification. The bioavailability of the drug depends on the oral bioavailable fraction and the amount absorbed directly from the pulmonary vasculature. The clearance rate of des-ciclesonide is very high (228 L/h), increasing its safety profile by utilizing extra-hepatic clearance mechanisms. Both des-ciclesonide and mometasone have a high protein binding fraction (98-99%). The volume of distribution (Vd) is proportional to the lipophilicity of the drug, with the Vd of fluticasone being 332L compared with 183L for budesonide. Increasing the Vd will also increase the elimination half-life of a drug. The pharmacodynamics of ICS depend on both the receptor binding affinity and the dose-response curve. Among the ICS, fluticasone and mometasone have the highest receptor binding affinity (1800 and 2200, respectively), followed by budesonide at 935 (relative to dexamethasone = 100). Compared with other nonsteroid asthma medications (long-acting beta-agonists, theophylline, and montelukast) ICS have proven superiority in improving lung function, symptom-free days, and inflammatory markers. One study suggests that early intervention with ICS reduces the loss in lung function (forced expiratory volume in 1 second) over 3 years. Whether airway remodeling is reduced or prevented in the long term is unknown. Potential adverse drug effects of ICS include adrenal and growth suppression. While in low-to-medium doses ICS have shown little suppression of the adrenal pituitary axis, in high doses the potential for significant adrenal suppression and adrenal crisis exists. Several longitudinal studies evaluating the effect of ICS on growth have shown a small decrement in growth velocity (approximate 1-2 cm) during the first year of treatment. However, when investigators followed children treated with budesonide for up to 10 years, no change in target adult height was noted. In conclusion, the development of optimal delivery devices for young children, as well as optimizing favorable pharmacokinetic properties of ICS should be priorities for future childhood asthma management.
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Affiliation(s)
- Tanya Gulliver
- John Hunter Children's Hospital, Newcastle, New South Wales, Australia
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Gu Z, Zhao XG, Nave R, Liu DDW, Feng H, Wu J, Howell SR, Guo Z. Comparative in vitro metabolism of 14C-ciclesonide in hepatocytes from the mouse, rat, rabbit, dog, and human. Am J Ther 2007; 14:280-90. [PMID: 17515705 DOI: 10.1097/01.mjt.0000209691.75442.de] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The in vitro metabolism of ciclesonide, a novel inhaled nonhalogenated glucocorticoid for the treatment of asthma, was compared in cryopreserved hepatocytes from mice, rats, rabbits, dogs, and humans. Incubations of C-ciclesonide with individual hepatocyte suspensions revealed similar metabolite profiles in all 5 in vitro systems used. Ciclesonide was rapidly converted to its active metabolite, desisobutyryl-ciclesonide (des-CIC). Des-CIC was then extensively metabolized to pharmacologically inactive metabolites through oxidation and reduction, followed by glucuronidation. A total of 12 groups of metabolites derived from des-CIC were characterized and identified by liquid chromatography/radioactivity monitor/mass spectrometry. Oxidation occurred on both the cyclohexane ring and the steroid moiety. Hippuric acid formation by cleavage of the cyclohexylmethyl moiety of ciclesonide, followed by aromatization of the cyclohexane ring through multiple steps of hydroxylation, dehydration, and conjugation with glycine, was found in rat, rabbit, and human hepatocyte incubations. The results indicated that ciclesonide and its active metabolite, des-CIC, were extensively metabolized in vitro in animal and human hepatocytes and that the metabolite profiles in mouse, rat, rabbit, and dog hepatocytes were similar to the profiles in human hepatocytes.
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Affiliation(s)
- Zheming Gu
- XenoBiotic Laboratories Inc, Plainsboro, NJ, USA
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Abdullah AK, Khan S. Evidence-based selection of inhaled corticosteroid for treatment of chronic asthma. J Asthma 2007; 44:1-12. [PMID: 17365197 DOI: 10.1080/02770900601118099] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Published literature relevant to comparison of various inhaled corticosteroids (ICSs) was reviewed. Marked heterogeneity was found in the reported results. The efficacy and side effects of ICSs depend on their formulation, dosing and device used, and the subjects' age, severity of asthma, and inhaler technique. All these factors have not been included uniformly in most study designs. Notwithstanding this limitation, it appears that fluticasone is generally very effective and safe in low-to-medium doses and may be used for most patients. Budesonide is the only Pregnancy Category B ICSs, all others being Category C, and it is available as nebulizer suspension suitable for use in children over 6 months of age. Budesonide, also available as dry powder inhaler, and beclomethasone, available as metered-dose inhaler, are equal in efficacy, and side effects and may be chosen according to the patient's ability to handle the device. Flunisolide causes fewer side effects but is also relatively less effective. Triamcinolone is generally less effective and causes more side effects than most of the other ICSs. Mometasone may be preferred if once-daily dosing is desired. Ciclesonide has been found highly effective in once-daily dose and without side effects even in high doses. Further studies comparing it with other ICSs over longer periods of use will determine its place in treatment of chronic asthma.
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Affiliation(s)
- Anwar K Abdullah
- Virginia Center for Behavioral Rehabilitation. Petersburg, Virginia, USA.
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50
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Derendorf H. Pharmacokinetic and pharmacodynamic properties of inhaled ciclesonide. J Clin Pharmacol 2007; 47:782-9. [PMID: 17412829 DOI: 10.1177/0091270007299763] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Inhaled corticosteroids are recommended first-line therapy for persistent asthma of all severities; however, oropharyngeal and systemic adverse events can be a concern. Inhaled corticosteroids exert their therapeutic and adverse effects by interacting with glucocorticoid receptors within and outside the lungs, respectively. Ciclesonide is a novel inhaled corticosteroid that possesses a unique pharmacokinetic and pharmacodynamic profile. Ciclesonide is inactive itself and converted to its pharmacologically active metabolite, desisobutyryl-ciclesonide, in the target organ, the lungs. Pulmonary activation combined with low oral deposition may minimize oropharyngeal adverse events, and low oral bioavailability, rapid clearance, and high protein binding may reduce systemic exposure. In addition, high pulmonary deposition due to the highly respirable particles, combined with the potential for prolonged lung retention via lipid conjugation, provides for effective therapeutic action.
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Affiliation(s)
- Hartmut Derendorf
- Department of Pharmaceutics, University of Florida, Gainesville, FL 32610, USA.
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