1
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Pierce LR. Assessing the efficacy of Alpha 1-Proteinase inhibitor (human) augmentation therapy for Alpha 1-Antitrypsin deficiency - Related emphysema: Challenges and opportunities. Heliyon 2024; 10:e31183. [PMID: 38912501 PMCID: PMC11190464 DOI: 10.1016/j.heliyon.2024.e31183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 05/04/2024] [Accepted: 05/12/2024] [Indexed: 06/25/2024] Open
Abstract
Clinical benefit of Alpha1-Proteinase Inhibitor (Human) (A1-PI) products for Alpha1-antitrypsin deficiency (AATD) is uncertain, based on a systematic review of observational studies and randomized controlled trials (RCTs) in AATD of Alpha1-Proteinase Inhibitor (Human) (A1-PI) products. At the recommended dose, A1-PI products raise its serum concentration but do not normalize levels. Observational studies suggest A1-PI might modestly slow progression of airflow limitation in patients with intermediate airflow obstruction, a finding not confirmed by three placebo-controlled RCTs of limited power, which showed non-significant rates of forced expiratory volume in 1 s (FEV1) change favoring placebo. These RCTs found trends favoring A1-PI in loss of high-resolution computerized tomographic (HRCT) lung density. While two meta-analyses of HRCT lung density change in RCTs achieved significance favoring A1-PI arms, clinical benefit remains uncertain. HRCT lung density measurements don't distinguish changes in measured density due to fluid shifts into and out of the lungs and changes in lung inflammation from those due to progressive loss of alveolar mass. A meta-analysis of RCTs found exacerbations significantly increased in A1-PI groups compared to placebo. No RCTs have shown favorable effects of A1-PI on mortality, FEV1, 6-min walking distance, quality of life, change in diffusion capacity of carbon monoxide (DLCO), or exacerbation frequency. A fourth RCT comparing two dose regimens of A1-PI is underway. RCTs have not provided evidence of clinical benefit in terms of how patients feel, function, or survive. Results have implications for the design of future clinical trials of A1-PI and potentially other products targeting AATD-associated emphysema.
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Affiliation(s)
- L. Ross Pierce
- Ross Pierce MD, LLC, 1330 West Avenue Unit 506, Miami Beach, FL 33139, USA
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2
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Mundy C, Yao L, Shaughnessy KA, Saunders C, Shore EM, Koyama E, Pacifici M. Palovarotene Action Against Heterotopic Ossification Includes a Reduction of Local Participating Activin A-Expressing Cell Populations. JBMR Plus 2023; 7:e10821. [PMID: 38130748 PMCID: PMC10731142 DOI: 10.1002/jbm4.10821] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 09/09/2023] [Indexed: 12/23/2023] Open
Abstract
Heterotopic ossification (HO) consists of extraskeletal bone formation. One form of HO is acquired and instigated by traumas or surgery, and another form is genetic and characterizes fibrodysplasia ossificans progressiva (FOP). Recently, we and others showed that activin A promotes both acquired and genetic HO, and in previous studies we found that the retinoid agonist palovarotene inhibits both HO forms in mice. Here, we asked whether palovarotene's action against HO may include an interference with endogenous activin A expression and/or function. Using a standard mouse model of acquired HO, we found that activin A and its encoding RNA (Inhba) were prominent in chondrogenic cells within developing HO masses in untreated mice. Single-cell RNAseq (scRNAseq) assays verified that Inhba expression characterized chondroprogenitors and chondrocytes in untreated HO, in addition to its expected expression in inflammatory cells and macrophages. Palovarotene administration (4 mg/kg/d/gavage) caused a sharp inhibition of both HO and amounts of activin A and Inhba transcripts. Bioinformatic analyses of scRNAseq data sets indicated that the drug had reduced interactions and cross-talk among local cell populations. To determine if palovarotene inhibited Inhba expression directly, we assayed primary chondrocyte cultures. Drug treatment inhibited their cartilaginous phenotype but not Inhba expression. Our data reveal that palovarotene markedly reduces the number of local Inhba-expressing HO-forming cell populations. The data broaden the spectrum of HO culprits against which palovarotene acts, accounting for its therapeutic effectiveness. © 2023 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.
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Affiliation(s)
- Christina Mundy
- Translational Research Program in Pediatric Orthopaedics, Division of Orthopaedic SurgeryThe Children's Hospital of PhiladelphiaPhiladelphiaPAUSA
| | - Lutian Yao
- Translational Research Program in Pediatric Orthopaedics, Division of Orthopaedic SurgeryThe Children's Hospital of PhiladelphiaPhiladelphiaPAUSA
- Department of OrthopaedicsThe First Hospital of China Medical UniversityShenyangChina
| | - Kelly A. Shaughnessy
- Translational Research Program in Pediatric Orthopaedics, Division of Orthopaedic SurgeryThe Children's Hospital of PhiladelphiaPhiladelphiaPAUSA
| | - Cheri Saunders
- Translational Research Program in Pediatric Orthopaedics, Division of Orthopaedic SurgeryThe Children's Hospital of PhiladelphiaPhiladelphiaPAUSA
| | - Eileen M. Shore
- Departments of Orthopaedic Surgery and Genetics, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPAUSA
| | - Eiki Koyama
- Translational Research Program in Pediatric Orthopaedics, Division of Orthopaedic SurgeryThe Children's Hospital of PhiladelphiaPhiladelphiaPAUSA
| | - Maurizio Pacifici
- Translational Research Program in Pediatric Orthopaedics, Division of Orthopaedic SurgeryThe Children's Hospital of PhiladelphiaPhiladelphiaPAUSA
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3
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Mornex JF, Balduyck M, Bouchecareilh M, Cuvelier A, Epaud R, Kerjouan M, Le Rouzic O, Pison C, Plantier L, Pujazon MC, Reynaud-Gaubert M, Toutain A, Trumbic B, Willemin MC, Zysman M, Brun O, Campana M, Chabot F, Chamouard V, Dechomet M, Fauve J, Girerd B, Gnakamene C, Lefrançois S, Lombard JN, Maitre B, Maynié-François C, Moerman A, Payancé A, Reix P, Revel D, Revel MP, Schuers M, Terrioux P, Theron D, Willersinn F, Cottin V, Mal H. [French clinical practice guidelines for the diagnosis and management of lung disease with alpha 1-antitrypsin deficiency]. Rev Mal Respir 2022; 39:633-656. [PMID: 35906149 DOI: 10.1016/j.rmr.2022.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 05/31/2022] [Indexed: 11/18/2022]
Affiliation(s)
- J-F Mornex
- Université de Lyon, université Lyon 1, INRAE, EPHE, UMR754, IVPC, 69007 Lyon, France; Centre de référence coordonnateur des maladies pulmonaires rares, hospices civils de Lyon, hôpital Louis-Pradel, service de pneumologie, 69500 Bron, France.
| | - M Balduyck
- CHU de Lille, centre de biologie pathologie, laboratoire de biochimie et biologie moléculaire HMNO, faculté de pharmacie, EA 7364 RADEME, université de Lille, service de biochimie et biologie moléculaire, Lille, France
| | - M Bouchecareilh
- Université de Bordeaux, CNRS, Inserm U1053 BaRITon, Bordeaux, France
| | - A Cuvelier
- Service de pneumologie, oncologie thoracique et soins intensifs respiratoires, CHU de Rouen, Rouen, France; Groupe de recherche sur le handicap ventilatoire et neurologique (GRHVN), université Normandie Rouen, Rouen, France
| | - R Epaud
- Centre de références des maladies respiratoires rares, site de Créteil, Créteil, France
| | - M Kerjouan
- Service de pneumologie, CHU Pontchaillou, Rennes, France
| | - O Le Rouzic
- CHU Lille, service de pneumologie et immuno-allergologie, Lille, France; Université de Lille, CNRS, Inserm, institut Pasteur de Lille, U1019, UMR 9017, CIIL, OpInfIELD team, Lille, France
| | - C Pison
- Service de pneumologie physiologie, pôle thorax et vaisseaux, CHU de Grenoble, Grenoble, France; Université Grenoble Alpes, Saint-Martin-d'Hères, France
| | - L Plantier
- Service de pneumologie et explorations fonctionnelles respiratoires, CHRU de Tours, Tours, France; Université de Tours, CEPR, Inserm UMR1100, Tours, France
| | - M-C Pujazon
- Service de pneumologie et allergologie, pôle clinique des voies respiratoires, hôpital Larrey, Toulouse, France
| | - M Reynaud-Gaubert
- Service de pneumologie, centre de compétence pour les maladies pulmonaires rares, AP-HM, CHU Nord, Marseille, France; Aix-Marseille université, IHU-Méditerranée infection, Marseille, France
| | - A Toutain
- Service de génétique, CHU de Tours, Tours, France; UMR 1253, iBrain, université de Tours, Inserm, Tours, France
| | | | - M-C Willemin
- Service de pneumologie et oncologie thoracique, CHU d'Angers, hôpital Larrey, Angers, France
| | - M Zysman
- Service de pneumologie, CHU Haut-Lévèque, Bordeaux, France; Université de Bordeaux, centre de recherche cardiothoracique, Inserm U1045, CIC 1401, Pessac, France
| | - O Brun
- Centre de pneumologie et d'allergologie respiratoire, Perpignan, France
| | - M Campana
- Service de pneumologie, CHR d'Orléans, Orléans, France
| | - F Chabot
- Département de pneumologie, CHRU de Nancy, Vandœuvre-lès-Nancy, France; Inserm U1116, université de Lorraine, Vandœuvre-lès-Nancy, France
| | - V Chamouard
- Service pharmaceutique, hôpital cardiologique, GHE, HCL, Bron, France
| | - M Dechomet
- Service d'immunologie biologique, centre de biologie sud, centre hospitalier Lyon Sud, HCL, Pierre-Bénite, France
| | - J Fauve
- Cabinet médical, Bollène, France
| | - B Girerd
- Université Paris-Saclay, faculté de médecine, Le Kremlin-Bicêtre, France; AP-HP, centre de référence de l'hypertension pulmonaire, service de pneumologie et soins intensifs respiratoires, hôpital Bicêtre, Le Kremlin-Bicêtre, France; Inserm UMR_S 999, hôpital Marie-Lannelongue, Le Plessis-Robinson, France
| | - C Gnakamene
- Service de pneumologie, CH de Montélimar, GH Portes de Provence, Montélimar, France
| | | | | | - B Maitre
- Service de pneumologie, centre hospitalier intercommunal, Créteil, France; Inserm U952, UFR de santé, université Paris-Est Créteil, Créteil, France
| | - C Maynié-François
- Université de Lyon, collège universitaire de médecine générale, Lyon, France; Université Claude-Bernard Lyon 1, laboratoire de biométrie et biologie évolutive, UMR5558, Villeurbanne, France
| | - A Moerman
- CHRU de Lille, hôpital Jeanne-de-Flandre, Lille, France; Cabinet de médecine générale, Lille, France
| | - A Payancé
- Service d'hépatologie, CHU Beaujon, AP-HP, Clichy, France; Filière de santé maladies rares du foie de l'adulte et de l'enfant (FilFoie), CHU Saint-Antoine, Paris, France
| | - P Reix
- Service de pneumologie pédiatrique, allergologie, mucoviscidose, hôpital Femme-Mère-Enfant, HCL, Bron, France; UMR 5558 CNRS équipe EMET, université Claude-Bernard Lyon 1, Villeurbanne, France
| | - D Revel
- Université Claude-Bernard Lyon 1, Lyon, France; Hospices civils de Lyon, Lyon, France
| | - M-P Revel
- Université Paris Descartes, Paris, France; Service de radiologie, hôpital Cochin, AP-HP, Paris, France
| | - M Schuers
- Université de Rouen Normandie, département de médecine générale, Rouen, France; Sorbonne université, LIMICS U1142, Paris, France
| | | | - D Theron
- Asten santé, Isneauville, France
| | | | - V Cottin
- Université de Lyon, université Lyon 1, INRAE, EPHE, UMR754, IVPC, 69007 Lyon, France; Centre de référence coordonnateur des maladies pulmonaires rares, hospices civils de Lyon, hôpital Louis-Pradel, service de pneumologie, 69500 Bron, France
| | - H Mal
- Service de pneumologie B, hôpital Bichat-Claude-Bernard, AP-HP, Paris, France; Inserm U1152, université Paris Diderot, site Xavier Bichat, Paris, France
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4
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Ventura F, Williams E, Ikeya M, Bullock AN, ten Dijke P, Goumans MJ, Sanchez-Duffhues G. Challenges and Opportunities for Drug Repositioning in Fibrodysplasia Ossificans Progressiva. Biomedicines 2021; 9:biomedicines9020213. [PMID: 33669809 PMCID: PMC7922784 DOI: 10.3390/biomedicines9020213] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 02/08/2021] [Accepted: 02/15/2021] [Indexed: 01/05/2023] Open
Abstract
Fibrodysplasia ossificans progressiva (FOP) is an ultrarare congenital disease that progresses through intermittent episodes of bone formation at ectopic sites. FOP patients carry heterozygous gene point mutations in activin A receptor type I ACVR1, encoding the bone morphogenetic protein (BMP) type I serine/threonine kinase receptor ALK2, termed activin receptor-like kinase (ALK)2. The mutant ALK2 displays neofunctional responses to activin, a closely related BMP cytokine that normally inhibits regular bone formation. Moreover, the mutant ALK2 becomes hypersensitive to BMPs. Both these activities contribute to enhanced ALK2 signalling and endochondral bone formation in connective tissue. Being a receptor with an extracellular ligand-binding domain and intrinsic intracellular kinase activity, the mutant ALK2 is a druggable target. Although there is no approved cure for FOP yet, a number of clinical trials have been recently initiated, aiming to identify a safe and effective treatment for FOP. Among other targeted approaches, several repurposed drugs have shown promising results. In this review, we describe the molecular mechanisms underlying ALK2 mutation-induced aberrant signalling and ectopic bone formation. In addition, we recapitulate existing in vitro models to screen for novel compounds with a potential application in FOP. We summarize existing therapeutic alternatives and focus on repositioned drugs in FOP, at preclinical and clinical stages.
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Affiliation(s)
- Francesc Ventura
- Department de Ciències Fisiològiques, Universitat de Barcelona, IDIBELL, L’Hospitalet de Llobregat, 08907 Barcelona, Spain;
| | - Eleanor Williams
- Centre for Medicines Discovery, University of Oxford, Old Road Campus Research Building, Roosevelt Drive, Oxford OX3 7DQ, UK; (E.W.); (A.N.B.)
| | - Makoto Ikeya
- Department of Clinical Application, Center for iPS Cell Research and Application, Kyoto University, 53 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto 606-8507, Japan;
| | - Alex N. Bullock
- Centre for Medicines Discovery, University of Oxford, Old Road Campus Research Building, Roosevelt Drive, Oxford OX3 7DQ, UK; (E.W.); (A.N.B.)
| | - Peter ten Dijke
- Oncode Institute and Department of Cell and Chemical Biology, Leiden University Medical Center, Einthovenweg 20, 2333 ZC Leiden, The Netherlands;
| | - Marie-José Goumans
- Department of Cell and Chemical Biology, Cardiovascular Cell Biology, Leiden University Medical Center, Einthovenweg 20, 2333 ZC Leiden, The Netherlands;
| | - Gonzalo Sanchez-Duffhues
- Department of Cell and Chemical Biology, Cardiovascular Cell Biology, Leiden University Medical Center, Einthovenweg 20, 2333 ZC Leiden, The Netherlands;
- Correspondence:
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5
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McNulty MJ, Silberstein DZ, Kuhn BT, Padgett HS, Nandi S, McDonald KA, Cross CE. Alpha-1 antitrypsin deficiency and recombinant protein sources with focus on plant sources: Updates, challenges and perspectives. Free Radic Biol Med 2021; 163:10-30. [PMID: 33279618 DOI: 10.1016/j.freeradbiomed.2020.11.030] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 11/20/2020] [Accepted: 11/24/2020] [Indexed: 12/16/2022]
Abstract
Alpha-1 antitrypsin deficiency (A1ATD) is an autosomal recessive disease characterized by low plasma levels of A1AT, a serine protease inhibitor representing the most abundant circulating antiprotease normally present at plasma levels of 1-2 g/L. The dominant clinical manifestations include predispositions to early onset emphysema due to protease/antiprotease imbalance in distal lung parenchyma and liver disease largely due to unsecreted polymerized accumulations of misfolded mutant A1AT within the endoplasmic reticulum of hepatocytes. Since 1987, the only FDA licensed specific therapy for the emphysema component has been infusions of A1AT purified from pooled human plasma at the 2020 cost of up to US $200,000/year with the risk of intermittent shortages. In the past three decades various, potentially less expensive, recombinant forms of human A1AT have reached early stages of development, one of which is just reaching the stage of human clinical trials. The focus of this review is to update strategies for the treatment of the pulmonary component of A1ATD with some focus on perspectives for therapeutic production and regulatory approval of a recombinant product from plants. We review other competitive technologies for treating the lung disease manifestations of A1ATD, highlight strategies for the generation of data potentially helpful for securing FDA Investigational New Drug (IND) approval and present challenges in the selection of clinical trial strategies required for FDA licensing of a New Drug Approval (NDA) for this disease.
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Affiliation(s)
- Matthew J McNulty
- Department of Chemical Engineering, University of California, Davis, CA, USA
| | - David Z Silberstein
- Department of Chemical Engineering, University of California, Davis, CA, USA
| | - Brooks T Kuhn
- Department of Internal Medicine, University of California, Davis, CA, USA; University of California, Davis, Alpha-1 Deficiency Clinic, Sacramento, CA, USA
| | | | - Somen Nandi
- Department of Chemical Engineering, University of California, Davis, CA, USA; Global HealthShare Initiative®, University of California, Davis, CA, USA
| | - Karen A McDonald
- Department of Chemical Engineering, University of California, Davis, CA, USA; Global HealthShare Initiative®, University of California, Davis, CA, USA
| | - Carroll E Cross
- Department of Internal Medicine, University of California, Davis, CA, USA; University of California, Davis, Alpha-1 Deficiency Clinic, Sacramento, CA, USA; Department of Physiology and Membrane Biology, University of California, Davis, CA, USA.
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6
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Crossley D, Stockley J, Bolton CE, Hopkinson NS, Mahadeva R, Steiner M, Wilkinson T, Hurst JR, Gooptu B, Stockley RA. Relationship of CT densitometry to lung physiological parameters and health status in alpha-1 antitrypsin deficiency: initial report of a centralised database of the NIHR rare diseases translational research collaborative. BMJ Open 2020; 10:e036045. [PMID: 32606060 PMCID: PMC7328802 DOI: 10.1136/bmjopen-2019-036045] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVES To establish a database network for the study of alpha-1 antitrypsin deficiency (AATD) and compare the results to CT lung density as the most direct measure of emphysema. DESIGN A central electronic database was established to permit the upload of anonymised patient data from remote sites. Prospectively collected CT data were recorded onto disc, anonymised, analysed at the coordinating centre and compared with the clinical features of the disease. SETTING Tertiary referral centres with expertise in the management of AATD focused on academic Biomedical Research Units and Wellcome Clinical Research Facilities. PARTICIPANTS Data were collected from 187 patients over 1 year from eight UK academic sites. This included patient demographics, postbronchodilator physiology, health status and CT. Analysis was undertaken at the coordinating centre in Birmingham. RESULTS Patient recruitment in the 12 months reached 94% of target (set at 200) covering the whole spectrum of the disease from those with normal lung function to very severe chronic obstructive lung disease. CT scan suitable for analysis was available from 147 (79%) of the patients. CT density, analysed as the threshold for the lowest 15% of lung voxels, showed statistically significant relationships with the objective physiological parameters of lung function as determined by spirometric Global Initiative for Chronic Obstructive Lung Disease (GOLD) severity staging (p<0.001) and carbon monoxide gas transfer (p<0.01). Density also correlated with subjective measures of quality of life (p=0.02). CONCLUSIONS Establishment of the network for data collection and its transfer was highly successful facilitating future collaboration for the study of this rare disease and its management. CT densitometry correlated well with the objective clinical features of the disease supporting its role as the specific marker of the associated emphysema and its severity. Correlations with subjective measures of health, however, were generally weak indicating other factors play a role.
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Affiliation(s)
- Diana Crossley
- College of Medical and Dental Sciences, Institute of Inflammation and Ageing, Centre for Translational Inflammation Research, Queen Elizabeth Hospital, University of Birmingham, Birmingham, UK
| | - James Stockley
- University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Edgbaston, Birmingham, UK
| | - Charlotte E Bolton
- Department of Respiratory Medicine, NIHR Nottingham BRC respiratory theme, School of Medicine, The University of Nottingham, City Hospital Campus, Nottingham, UK
| | - Nicholas S Hopkinson
- National Heart and Lung Institute, Imperial College, Royal Brompton Hospital Campus, London, UK
| | - Ravi Mahadeva
- Department of Medicine, Cambridge NIHR BRC, University of Cambridge, Leicester, UK
| | - Michael Steiner
- NIHR Leicester Biomedical Research Centre - Respiratory, Institute for Lung Health, University of Leicester, Glenfield Hospital, Leicester, UK
| | - Tom Wilkinson
- Respiratory BRU, University of Southampton, Southampton, UK
| | | | - Bibek Gooptu
- NIHR Leicester Biomedical Research Centre - Respiratory, Institute for Lung Health, University of Leicester, Glenfield Hospital, Leicester, UK
- King's College London, Guy's Hospital Site, Great Maze Pond, London
| | - Robert A Stockley
- University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Edgbaston, Birmingham, UK
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7
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Alobaidi NY, Stockley JA, Stockley RA, Sapey E. An overview of exacerbations of chronic obstructive pulmonary disease: Can tests of small airways' function guide diagnosis and management? Ann Thorac Med 2020; 15:54-63. [PMID: 32489439 PMCID: PMC7259399 DOI: 10.4103/atm.atm_323_19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Accepted: 12/20/2019] [Indexed: 12/14/2022] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is common and debilitating. Most patients with COPD experience intermittent, acute deterioration in symptoms which require additional therapy, termed exacerbations. Exacerbations are prevalent in COPD and are associated with poor clinical outcomes including death, a faster decline in lung health, and a reduced quality of life. Current guidelines highlight the need to treat exacerbations promptly and then mitigate future risk. However, exacerbations are self-reported, difficult to diagnose and are treated with pharmacological therapies which have largely been unchanged over 30 years. Recent research has highlighted how exacerbations vary in their underlying cause, with specific bacteria, viruses, and cell types implicated. This variation offers the opportunity for new targeted therapies, but to develop these new therapies requires sensitive tools to reliably identify the cause, the start, and end of an exacerbation and assess the response to treatment. Currently, COPD is diagnosed and monitored using spirometric measures, principally the forced expiratory volume in 1 s and forced vital capacity, but these tests alone cannot reliably diagnose an exacerbation. Measures of small airways' function appear to be an early marker of COPD, and some studies have suggested that these tests might also provide physiological biomarkers for exacerbations. In this review, we will discuss how exacerbations of COPD are currently defined, stratified, monitored, and treated and review the current literature to determine if tests of small airways' function might improve diagnostic accuracy or the assessment of response to treatment.
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Affiliation(s)
- Nowaf Y Alobaidi
- Centre for Translational Inflammation Research, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK.,Respiratory Therapy Department, College of Applied Medical Sciences, King Saud Bin Abdul-Aziz University for Health Sciences, Al Ahsa, Saudi Arabia
| | - James A Stockley
- Department of Lung Function and Sleep, University Hospitals Birmingham, NHS Foundation Trust, Birmingham, UK
| | - Robert A Stockley
- Department of Respiratory Medicine, University Hospitals Birmingham, NHS Foundation Trust, Birmingham, UK
| | - Elizabeth Sapey
- Centre for Translational Inflammation Research, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
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8
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Stockley RA, Edgar RG, Starkey S, Turner AM. Health status decline in α-1 antitrypsin deficiency: a feasible outcome for disease modifying therapies? Respir Res 2018; 19:137. [PMID: 30029692 PMCID: PMC6053712 DOI: 10.1186/s12931-018-0844-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 07/13/2018] [Indexed: 12/24/2022] Open
Abstract
Background Trials of disease modifying therapies in Chronic Obstructive Pulmonary Disease (COPD) provide challenges for detecting physiological and patient centred outcomes. The purpose of the current study was to monitor decline in health status in Alpha-1 antitrypsin deficiency (AATD) and determine its’ relationship to conventional physiology. Methods Patients recruited to the UK-AATD database with a median follow up of 7 years (IQR 5–10) were studied to determine annual change in St George’s Respiratory Questionnaire (SGRQ), FEV1, gas transfer and their feasibility of use in future trials. Results Annual decline in SGRQ had a wide range, was greater for patients with established COPD and correlated with decline in FEV1 (p < 0.0001). Total score decline was greater (p < 0.05) for those with accelerated FEV1 decline (median = 1.07 points/year) compared to those without (median = 0.51). Power calculations indicated effective intervention would not achieve MCID for the SGRQ unless the timeframe was extended for up to 8 years. More than 5000 patients/arm would be required for a statistically significant modest effect over 3 years even in those with rapid FEV1 decline. Conclusion Despite AATD being a rapidly declining form of COPD, deterioration in SGRQ was slow consistent with ageing and the chronic nature of disease progression. Power calculations indicate the numbers needed to detect a difference with disease modifying therapies would be prohibitive especially in this rare cause of COPD. These data have important implications for future study design of disease modifying therapies even in COPD not associated with AATD. Electronic supplementary material The online version of this article (10.1186/s12931-018-0844-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Robert A Stockley
- Lung Investigation Unit, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Edgbaston, Birmingham, B15 2GW, UK.
| | - Ross G Edgar
- Therapy Services, University Hospitals Birmingham NHS Foundation Trust Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Edgbaston, Birmingham, B15 2GW, UK.,Institute of Applied Health Research, University of Birmingham, Birmingham, B15 2TT, UK
| | - Sian Starkey
- Institute of Translational Medicine, University Hospitals Birmingham NHS Foundation Trust Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Edgbaston, Birmingham, B15 2GW, UK
| | - Alice M Turner
- Institute of Applied Health Research, University of Birmingham, Birmingham, B15 2TT, UK.,Heart of England NHS Foundation Trust, Respiratory Medicine, Bordesley Green East, Birmingham, B9 5SS, UK
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9
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Sun Z, Li F, Zhou X, Chung KF, Wang W, Wang J. Stem cell therapies for chronic obstructive pulmonary disease: current status of pre-clinical studies and clinical trials. J Thorac Dis 2018; 10:1084-1098. [PMID: 29607186 DOI: 10.21037/jtd.2018.01.46] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Chronic obstructive pulmonary disease (COPD) is a respiratory disease that has a major impact worldwide. The currently-available drugs mainly focus on relieving the symptoms of COPD patients. Novel regenerative therapeutic approaches have been investigated with the aim of repairing or replacing the injured functional structures of the respiratory system. We summarized the progress made by regenerative therapies for COPD by analyzing results from both pre-clinical studies and completed clinical trials. These approaches include the application of exogenous stem cells or small molecules to stimulate the regeneration by endogenous lung stem/progenitor cells. Exogenous mesenchymal stem cells (MSCs) have been reported to repair the structure and improve the function of the injured respiratory system in COPD models. However, the studies that used MSCs in patients with moderate-to-severe COPD patients did not lead to clear respiratory functional improvements. Exogenous human lung stem cells applied to cryo-injured (CI) lungs of mice have been shown to organize into human-like pulmonary structures, indicating a new property of stem cells that is potentially capable of curing COPD patients. Small molecules like retinoic acid has been shown to lead to regeneration and repair of the damaged lung structures in COPD mouse models probably by activation of endogenous lung stem/progenitor cells. However, retinoic acid or agonists of retinoic acid receptor administered to moderate or severe COPD patients did not improve the density and function of the damaged lung. These novel regenerative approaches have failed in preliminary clinical trials, possibly due to the advanced severity of the disease. Further work should be done to develop the current regenerative approaches for curing patients at different stages of COPD. We suggest that some modifications of the approach in the clinical studies may lead to more successful outcomes of regenerative therapy for COPD.
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Affiliation(s)
- Zhongwei Sun
- Cellular Biomedicine Group, Shanghai 200233, China.,Cellular Biomedicine Group, Cupertino, CA, USA
| | - Feng Li
- Department of Respiratory Medicine, Shanghai General Hospital, Shanghai Jiaotong University, Shanghai 200080, China
| | - Xin Zhou
- Department of Respiratory Medicine, Shanghai General Hospital, Shanghai Jiaotong University, Shanghai 200080, China
| | - Kian Fan Chung
- Airway Disease Section, National Heart and Lung Institute, Imperial College London, London, UK
| | - Wen Wang
- Cellular Biomedicine Group, Shanghai 200233, China.,Cellular Biomedicine Group, Cupertino, CA, USA
| | - Jialun Wang
- Cellular Biomedicine Group, Shanghai 200233, China.,Cellular Biomedicine Group, Cupertino, CA, USA
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Crossley D, Renton M, Khan M, Low EV, Turner AM. CT densitometry in emphysema: a systematic review of its clinical utility. Int J Chron Obstruct Pulmon Dis 2018; 13:547-563. [PMID: 29445272 PMCID: PMC5808715 DOI: 10.2147/copd.s143066] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND The aim of the study was to assess the relationship between computed tomography (CT) densitometry and routine clinical markers in patients with chronic obstructive pulmonary disease (COPD) and alpha-1 anti-trypsin deficiency (AATD). METHODS Multiple databases were searched using a combination of pertinent terms and those articles relating quantitatively measured CT densitometry to clinical outcomes. Studies that used visual scoring only were excluded, as were those measured in expiration only. A thorough review of abstracts and full manuscripts was conducted by 2 reviewers; data extraction and assessment of bias was conducted by 1 reviewer and the 4 reviewers independently assessed for quality. Pooled correlation coefficients were calculated, and heterogeneity was explored. RESULTS A total of 112 studies were identified, 82 being suitable for meta-analysis. The most commonly used density threshold was -950 HU, and a significant association between CT density and all included clinical parameters was demonstrated. There was marked heterogeneity between studies secondary to large variety of disease severity within commonly included cohorts and differences in CT acquisition parameters. CONCLUSION CT density shows a good relationship to clinically relevant parameters; however, study heterogeneity and lack of longitudinal data mean that it is difficult to compare studies or derive a minimal clinically important difference. We recommend that international consensus is reached to standardize CT conduct and analysis in future COPD and AATD studies.
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Affiliation(s)
- Diana Crossley
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
- Correspondence: Diana Crossley, Institute of Inflammation and Ageing, Queen Elizabeth Hospital, Mindelsohn Way, Edgbaston, Birmingham, B15 2TH, UK, Tel +44 121 371 3885, Fax +44 121 371 3203, Email
| | - Mary Renton
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Muhammad Khan
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Emma V Low
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Alice M Turner
- Institute of Applied Health Sciences, University of Birmingham, Birmingham, UK
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Miravitlles M, Dirksen A, Ferrarotti I, Koblizek V, Lange P, Mahadeva R, McElvaney NG, Parr D, Piitulainen E, Roche N, Stolk J, Thabut G, Turner A, Vogelmeier C, Stockley RA. European Respiratory Society statement: diagnosis and treatment of pulmonary disease in α1-antitrypsin deficiency. Eur Respir J 2017; 50:50/5/1700610. [DOI: 10.1183/13993003.00610-2017] [Citation(s) in RCA: 172] [Impact Index Per Article: 24.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Accepted: 08/16/2017] [Indexed: 11/05/2022]
Abstract
α1-antitrypsin deficiency (AATD) is the most common hereditary disorder in adults. It is associated with an increased risk of developing pulmonary emphysema and liver disease. The pulmonary emphysema in AATD is strongly linked to smoking, but even a proportion of never-smokers develop progressive lung disease. A large proportion of individuals affected remain undiagnosed and therefore without access to appropriate care and treatment.The most recent international statement on AATD was published by the American Thoracic Society and the European Respiratory Society in 2003. Since then there has been a continuous development of novel, more accurate and less expensive genetic diagnostic methods. Furthermore, new outcome parameters have been developed and validated for use in clinical trials and a new series of observational and randomised clinical trials have provided more evidence concerning the efficacy and safety of augmentation therapy, the only specific treatment available for the pulmonary disease associated with AATD.As AATD is a rare disease, it is crucial to organise national and international registries and collect information prospectively about the natural history of the disease. Management of AATD patients must be supervised by national or regional expert centres and inequalities in access to therapies across Europe should be addressed.
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12
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Stockley JA, Cooper BG, Stockley RA, Sapey E. Small airways disease: time for a revisit? Int J Chron Obstruct Pulmon Dis 2017; 12:2343-2353. [PMID: 28848335 PMCID: PMC5557120 DOI: 10.2147/copd.s138540] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
It is increasingly acknowledged that delays in the diagnosis of chronic inflammatory lung conditions have hampered our understanding of pathogenesis and thus our ability to design efficacious therapies. This is particularly true for COPD, where most patients are diagnosed with moderate-to-severe airflow obstruction and little is known about the inflammatory processes present in early disease. There is great interest in developing screening tests that can identify those most at risk of developing COPD before airflow obstruction has developed for the purpose of research and clinical care. Landmark pathology studies have suggested that damage to the small airways precedes the development of airflow obstruction and emphysema and, thus, presents an opportunity to identify those at risk of COPD. However, despite a number of physiological tests being available to assess small airways function, none have been adopted into routine care in COPD. The reasons that tests of small airways have not been utilized widely include variability in test results and a lack of validated reference ranges from which to compare results for some methodologies. Furthermore, population studies have not consistently demonstrated their ability to diagnose disease. However, the landscape may be changing. As the equipment that delivers tests of small airways become more widely available, reference ranges are emerging and newer methodologies specifically seek to address variability and difficulty in test performance. Moreover, there is evidence that while tests of small airways may not be helpful across the full range of established disease severity, there may be specific groups (particularly those with early disease) where they might be informative. In this review, commonly utilized tests of small airways are critically appraised to highlight why these tests may be important, how they can be used and what knowledge gaps remain for their use in COPD.
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Affiliation(s)
| | | | | | - Elizabeth Sapey
- Institute of Inflammation and Ageing, Centre for Translational Inflammation Research, University of Birmingham, Edgbaston, Birmingham, UK
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13
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Stockley RA. Antitrypsin Deficiency Assessment and Programme for Treatment (ADAPT): The United Kingdom Registry. COPD 2016; 12 Suppl 1:63-8. [PMID: 25938295 DOI: 10.3109/15412555.2015.1021911] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The study of rare diseases is compromised by its rarity. The establishment of national and international registries can overcome many of the problems and be used for many monogenetic conditions with relatively consistent outcomes and thus lead to a consistency of clinical management by centres of excellence. However, in Alpha-1 antitrypsin deficiency (AATD), the outcome is highly variable in terms of the organ(s) most affected and the diversity of disease penetration and progression. This creates the added difficulty of understanding the disease sufficiently to monitor and advise the patients to the standard required and importantly design and deliver clinical trials that address the many facets of the disease. The development of research registries and centres of excellence provides the necessary expertise and data to further the understanding and management of diseases like AATD though with significant cost implications. The ADAPT programme was established in 1996 with extensive core funding to enable patients to be seen from all regions of the United Kingdom as an addition to the National Health Service without appointment time constraints and with the purpose of collecting extensive state of the art demographics. The model has proven to be highly productive providing new insights especially into the lung disease, generating and delivering on clinical trials and importantly establishing active patient groups and participation.
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Affiliation(s)
- Robert A Stockley
- ADAPT Project, Queen Elizabeth Hospital Birmingham , Birmingham , United Kingdom
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14
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Barjaktarevic IZ, Arredondo AF, Cooper CB. Positioning new pharmacotherapies for COPD. Int J Chron Obstruct Pulmon Dis 2015; 10:1427-42. [PMID: 26244017 PMCID: PMC4521666 DOI: 10.2147/copd.s83758] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
COPD imposes considerable worldwide burden in terms of morbidity and mortality. In recognition of this, there is now extensive focus on early diagnosis, secondary prevention, and optimizing medical management of the disease. While established guidelines recognize different grades of disease severity and offer a structured basis for disease management based on symptoms and risk, it is becoming increasingly evident that COPD is a condition characterized by many phenotypes and its control in a single patient may require clinicians to have access to a broader spectrum of pharmacotherapies. This review summarizes recent developments in COPD management and compares established pharmacotherapy with new and emerging pharmacotherapies including long-acting muscarinic antagonists, long-acting β-2 sympathomimetic agonists, and fixed-dose combinations of long-acting muscarinic antagonists and long-acting β-2 sympathomimetic agonists as well as inhaled cortiocosteroids, phosphodiesterase inhibitors, and targeted anti-inflammatory drugs. We also review the available oral medications and new agents with novel mechanisms of action in early stages of development. With several new pharmacological agents intended for the management of COPD, it is our goal to familiarize potential prescribers with evidence relating to the efficacy and safety of new medications and to suggest circumstances in which these therapies could be most useful.
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Affiliation(s)
- Igor Z Barjaktarevic
- Department of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Anthony F Arredondo
- Department of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Christopher B Cooper
- Department of Medicine, University of California, Los Angeles, Los Angeles, CA, USA ; Department of Physiology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
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15
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Staring M, Bakker ME, Stolk J, Shamonin DP, Reiber JHC, Stoel BC. Towards local progression estimation of pulmonary emphysema using CT. Med Phys 2014; 41:021905. [PMID: 24506626 DOI: 10.1118/1.4851535] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
PURPOSE Whole lung densitometry on chest CT images is an accepted method for measuring tissue destruction in patients with pulmonary emphysema in clinical trials. Progression measurement is required for evaluation of change in health condition and the effect of drug treatment. Information about the location of emphysema progression within the lung may be important for the correct interpretation of drug efficacy, or for determining a treatment plan. The purpose of this study is therefore to develop and validate methods that enable the local measurement of lung density changes, which requires proper modeling of the effect of respiration on density. METHODS Four methods, all based on registration of baseline and follow-up chest CT scans, are compared. The first naïve method subtracts registered images. The second employs the so-called dry sponge model, where volume correction is performed using the determinant of the Jacobian of the transformation. The third and the fourth introduce a novel adaptation of the dry sponge model that circumvents its constant-mass assumption, which is shown to be invalid. The latter two methods require a third CT scan at a different inspiration level to estimate the patient-specific density-volume slope, where one method employs a global and the other a local slope. The methods were validated on CT scans of a phantom mimicking the lung, where mass and volume could be controlled. In addition, validation was performed on data of 21 patients with pulmonary emphysema. RESULTS The image registration method was optimized leaving a registration error below half the slice increment (median 1.0 mm). The phantom study showed that the locally adapted slope model most accurately measured local progression. The systematic error in estimating progression, as measured on the phantom data, was below 2 gr/l for a 70 ml (6%) volume difference, and 5 gr/l for a 210 ml (19%) difference, if volume correction was applied. On the patient data an underlying linearity assumption relating lung volume change with density change was shown to hold (fitR(2) = 0.94), and globalized versions of the local models are consistent with global results (R(2) of 0.865 and 0.882 for the two adapted slope models, respectively). CONCLUSIONS In conclusion, image matching and subsequent analysis of differences according to the proposed lung models (i) has good local registration accuracy on patient data, (ii) effectively eliminates a dependency on inspiration level at acquisition time, (iii) accurately predicts progression in phantom data, and (iv) is reasonably consistent with global results in patient data. It is therefore a potential future tool for assessing local emphysema progression in drug evaluation trials and in clinical practice.
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Affiliation(s)
- M Staring
- Department of Radiology, Division of Image Processing, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, The Netherlands
| | - M E Bakker
- Department of Radiology, Division of Image Processing, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, The Netherlands
| | - J Stolk
- Department of Pulmonology, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, The Netherlands
| | - D P Shamonin
- Department of Radiology, Division of Image Processing, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, The Netherlands
| | - J H C Reiber
- Department of Radiology, Division of Image Processing, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, The Netherlands
| | - B C Stoel
- Department of Radiology, Division of Image Processing, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, The Netherlands
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17
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Stockley RA. Biomarkers in chronic obstructive pulmonary disease: confusing or useful? Int J Chron Obstruct Pulmon Dis 2014; 9:163-77. [PMID: 24532968 PMCID: PMC3923613 DOI: 10.2147/copd.s42362] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
The field of biomarker research has almost reached unmanageable proportions in chronic obstructive pulmonary disease (COPD). The developments of new technology platforms have generated a huge information data base, both cross sectionally and increasingly, longitudinally. The knowledge emerging provides an enormous potential for understanding the disease pathophysiology, for developing markers specific for long-term outcomes, and for developing new therapeutic strategies. However, the excitement must be tempered with an understanding of the limitations of the data collection techniques, and of the variations in disease state, activity, impact, and progression. Nevertheless, the most crucial aspect in interpreting the current literature is the recognition of the relatively superficial characterization of what is a complex group of pathological processes with a common end point of airflow limitation. The current review explores some of these issues together with those areas where real progress appears to have been made, and provides caution on interpretation.
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Affiliation(s)
- Robert A Stockley
- Queen Elizabeth Hospital Birmingham, Lung Function and Sleep Department, Birmingham, UK
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18
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α-1-Antitrypsin deficiency: clinical variability, assessment, and treatment. Trends Mol Med 2013; 20:105-15. [PMID: 24380646 DOI: 10.1016/j.molmed.2013.11.006] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2013] [Revised: 11/25/2013] [Accepted: 11/26/2013] [Indexed: 12/21/2022]
Abstract
The recognition of α-1-antitrypsin deficiency, its function, and its role in predisposition to the development of severe emphysema was a watershed in our understanding of the pathophysiology of the condition. This led to the concept and development of intravenous replacement therapy used worldwide to protect against lung damage induced by neutrophil elastase. Nevertheless, much remained unknown about the deficiency and its impact, although in recent years the genetic and clinical variations in manifestation have provided new insights into assessing impact, efficacy of therapy, and development of new therapeutic strategies, including gene therapy, and outcome measures, such as biomarkers and computed tomography. The current article reviews this progress over the preceding 50 years.
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20
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Stockley RA, Miravitlles M, Vogelmeier C. Augmentation therapy for alpha-1 antitrypsin deficiency: towards a personalised approach. Orphanet J Rare Dis 2013; 8:149. [PMID: 24063809 PMCID: PMC3852071 DOI: 10.1186/1750-1172-8-149] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2013] [Accepted: 09/13/2013] [Indexed: 11/28/2022] Open
Abstract
Background Intravenous augmentation therapy is the only specific treatment available for emphysema associated with alpha-1 antitrypsin deficiency. Despite large observational studies and limited interventional studies there remains controversy about the efficacy of this treatment due to the impracticality of conducting adequately powered studies to evaluate the rate of decline in lung function, due to the low prevalence and the slow progression of the disease. However, measurement of lung density by computed tomography is a more specific and sensitive marker of the evolution of emphysema and two small placebo-controlled clinical trials have provided evidence supporting a reduction in the rate of decline in lung density with augmentation therapy. The problem Where augmentation therapy has become available there has been little consideration of a structured approach to therapy which is often introduced on the basis of functional impairment at diagnosis. Data from registries have shown a great variability in the evolution of lung disease according to patient acquisition and the presence of recognised risk factors. Avoidance of risk factors may, in many cases, stabilise the disease. Since augmentation therapy itself will at best preserve the presenting level of lung damage yet require intravenous administration for life with associated costs, identification of patients at risk of continued rapid or long term progression is essential to select those for whom this treatment can be most appropriate and hence generally more cost-effective. This represents a major reconsideration of the current practice in order to develop a consistent approach to management world wide. Purpose of this review The current review assesses the evidence for efficacy of augmentation therapy and considers how the combination of age, physiological impairment, exacerbation history and rate of decline in spirometry and other measures of emphysema may be used to improve therapeutic decision making, until a reliable predictive biomarker of the evolution of lung impairment can be identified. In addition, individual pharmacokinetic studies may permit the selection of the best regimen of administration for those who need it. Summary The rarity and variable characteristics of the disease imply the need for an individualised approach to therapy in specialised centres with sufficient experience to apply a systematic approach to monitoring and management.
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Affiliation(s)
- Robert A Stockley
- Lung Investigation Unit, Queen Elizabeth Hospital Birmingham, Mindelsohn way, Edgbaston, Birmingham B15 2WB, UK.
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Matera MG, Calzetta L, Segreti A, Cazzola M. Emerging drugs for chronic obstructive pulmonary disease. Expert Opin Emerg Drugs 2012; 17:61-82. [DOI: 10.1517/14728214.2012.660917] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Devillier P, Jebrak G, Morel H, Chinet T, Didier A, Roche N. [Treatment of distal airways involvement in COPD]. Rev Mal Respir 2011; 28:1340-56. [PMID: 22152941 DOI: 10.1016/j.rmr.2011.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2011] [Accepted: 08/06/2011] [Indexed: 11/18/2022]
Abstract
INTRODUCTION The current pharmacological treatment of COPD provides only partial beneficial effects on symptoms, exercise tolerance, frequency of exacerbations and quality of life. This could be related to poor targeting of the distal airways by current treatments, yet these airways are particularly involved in airflow obstruction and its consequences such as hyperinflation. BACKGROUND Many treatments used in COPD could have effects on distal airways, including bronchodilators, corticosteroids, mucolytics and antibiotics. However, these possible effects remain poorly understood. VIEWPOINTS New treatments targeting more specifically the mechanisms of inflammation, oxidative stress and tissue remodeling that characterize COPD, could prove useful in its management, but most are still only in the early stages of their development. Advances could also come from improvements in inhalation devices, delivering more of the medication to the distal airways. CONCLUSIONS Improvement in the management of COPD could come from progress in terms of both molecules and their mode of administration.
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Affiliation(s)
- P Devillier
- UPRES EA 220, pôle des maladies respiratoires, hôpital Foch, 11 rue Guillaume-Lenoir, Suresnes, France
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Influence of inspiration level on bronchial lumen measurements with computed tomography. Respir Med 2011; 106:677-86. [PMID: 22154247 DOI: 10.1016/j.rmed.2011.11.013] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2011] [Revised: 11/14/2011] [Accepted: 11/16/2011] [Indexed: 11/21/2022]
Abstract
BACKGROUND Bronchial dimensions measured in CT images generally do not take inspiration level into consideration. However, some studies showed that the bronchial membrane is distensible with airway inflation. Therefore, re-examination of the elasticity of bronchi is needed. PURPOSE To assess the influence of respiration on bronchial lumen area (defined as distensibility) in different segmental bronchi and to explore the correlations between distensibility and both lung function and emphysema severity. MATERIAL AND METHODS In 44 subjects with COPD related to alpha-1-antitrypsin deficiency (AATD), bronchial lumen area was measured in CT images, acquired at different inspiration levels. Measurements were done at matched locations in one apical and two basal segmental airways (RB1, RB10 and LB10). Airway distensibility was calculated as lumen area difference divided by lung volume difference. RESULTS Bronchial lumen area in the lower lobes (RB10 and LB10) correlated positively with FEV(1)%predicted (p=0.027 for RB10; and p=0.037 for LB10, respectively). Lumen area is influenced by respiration (p=0.006, p=0.045, and, p=0.005 for RB1, RB10 and LB10, respectively). Airway distensibility was different between upper and lower bronchi (p<0.001), but it was not correlated with lung function. CONCLUSION Lumen area of third generation bronchi is dependent on inspiration level and this distensibility is different between bronchi in the upper and lower lobes. Therefore, changes in lumen area over time should be studied whilst accounting for the lung volume changes, in order to estimate the progression of bronchial disease while excluding the effects of hyperinflation.
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Emerging roles for retinoids in regeneration and differentiation in normal and disease states. Biochim Biophys Acta Mol Cell Biol Lipids 2011; 1821:213-21. [PMID: 21855651 DOI: 10.1016/j.bbalip.2011.08.002] [Citation(s) in RCA: 116] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2011] [Revised: 07/29/2011] [Accepted: 08/02/2011] [Indexed: 12/22/2022]
Abstract
The vitamin A (retinol) metabolite, all-trans retinoic acid (RA), is a signaling molecule that plays key roles in the development of the body plan and induces the differentiation of many types of cells. In this review the physiological and pathophysiological roles of retinoids (retinol and related metabolites) in mature animals are discussed. Both in the developing embryo and in the adult, RA signaling via combinatorial Hox gene expression is important for cell positional memory. The genes that require RA for the maturation/differentiation of T cells are only beginning to be cataloged, but it is clear that retinoids play a major role in expression of key genes in the immune system. An exciting, recent publication in regeneration research shows that ALDH1a2 (RALDH2), which is the rate-limiting enzyme in the production of RA from retinaldehyde, is highly induced shortly after amputation in the regenerating heart, adult fin, and larval fin in zebrafish. Thus, local generation of RA presumably plays a key role in fin formation during both embryogenesis and in fin regeneration. HIV transgenic mice and human patients with HIV-associated kidney disease exhibit a profound reduction in the level of RARβ protein in the glomeruli, and HIV transgenic mice show reduced retinol dehydrogenase levels, concomitant with a greater than 3-fold reduction in endogenous RA levels in the glomeruli. Levels of endogenous retinoids (those synthesized from retinol within cells) are altered in many different diseases in the lung, kidney, and central nervous system, contributing to pathophysiology. This article is part of a Special Issue entitled Retinoid and Lipid Metabolism.
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Hind M, Maden M. Is a regenerative approach viable for the treatment of COPD? Br J Pharmacol 2011; 163:106-15. [PMID: 21265829 PMCID: PMC3085872 DOI: 10.1111/j.1476-5381.2011.01246.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2010] [Revised: 01/03/2011] [Accepted: 01/06/2011] [Indexed: 12/23/2022] Open
Abstract
Degenerative lung diseases such as chronic obstructive pulmonary disease (COPD) are common with huge worldwide morbidity. Anti-inflammatory drug development strategies have proved disappointing and current treatment is aimed at symptomatic relief. Only lung transplantation with all its attendant difficulties offers hope of cure and the outlook for affected patients is bleak. Lung regeneration therapies aim to reverse the structural and functional deficits in COPD either by delivery of exogenous lung cells to replace lost tissue, delivery of exogenous stem cells to induce a local paracrine effect probably through an anti-inflammatory action or by the administration of small molecules to stimulate the endogenous regenerative ability of lung cells. In animal models of emphysema and disrupted alveolar development each of these strategies has shown some success but there are potential tumour-inducing dangers with a cellular approach. Small molecules such as all-trans retinoic acid have been successful in animal models although the mechanism is not completely understood. There are currently two Pharma-sponsored trials in progress concerning patients with COPD, one of a specific retinoic acid receptor gamma agonist and another using mesenchymal stem cells.
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Affiliation(s)
- Matthew Hind
- Royal Brompton Hospital, National Heart and Lung Institute, Imperial College, London, UK.
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Stoel BC, Dirksen A, Stockley RA, Parr D, Piitulainen E, Shaker SB, Russi EW, Bakker ME, Reiber JHC, Stolk J. Eureka? Radiology 2011; 259:610-1; author reply 611-2. [PMID: 21502395 DOI: 10.1148/radiol.11102262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Molecular basis of lung tissue regeneration. Gen Thorac Cardiovasc Surg 2011; 59:231-44. [PMID: 21484549 DOI: 10.1007/s11748-010-0757-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2010] [Accepted: 12/05/2010] [Indexed: 12/29/2022]
Abstract
Recent advances have expanded our understanding of lung endogenous stem cells, and this knowledge provides us with new ideas for future regenerative therapy for lung diseases. In studies using animal models for lung regeneration, compensatory lung growth, and lung repair, promising reagents for lung regeneration have been discovered. Stem or progenitor cells are needed for alveolar regeneration, lung growth, and lung repair after injury. Endogenous progenitor cells mainly participate in alveologenesis. However, human lung endogenous progenitor cells have not yet been clearly defined. Recently discovered human alveolar epithelial progenitor cells may give us a new perspective for understanding the pathogenesis of lung diseases. In parallel with such basic research, projects geared toward clinical application are proceeding. Cell therapy using mesenchymal stem cells to treat acute lung injury is one of the promising areas for this research. The creation of bioartificial lungs, which are based on decellularized lungs, is another interesting approach for future clinical applications. Although lungs are the most challenging organ for regenerative medicine, our cumulative knowledge of lung regeneration and of endogenous progenitor cells makes clear the possibilities and limitations of regenerative medicine for lung diseases.
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Omachi TA, Eisner MD, Rames A, Markovtsova L, Blanc PD. Matrix metalloproteinase-9 predicts pulmonary status declines in α1-antitrypsin deficiency. Respir Res 2011; 12:35. [PMID: 21429222 PMCID: PMC3073899 DOI: 10.1186/1465-9921-12-35] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2010] [Accepted: 03/23/2011] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Matrix metalloproteinase-9 (MMP-9) may be important in the progression of emphysema, but there have been few longitudinal clinical studies of MMP-9 including pulmonary status and COPD exacerbation outcomes. METHODS We utilized data from the placebo arm (n=126) of a clinical trial of patients with alpha1-antitrypsin deficiency (AATD) and emphysema to examine the links between plasma MMP-9 levels, pulmonary status, and COPD exacerbations over a one year observation period. Pulmonary function, computed tomography lung density, incremental shuttle walk test (ISWT), and COPD exacerbations were assessed at regular intervals over 12 months. Prospective analyses used generalized estimating equations to incorporate repeated longitudinal measurements of MMP-9 and all endpoints, controlling for age, gender, race-ethnicity, leukocyte count, and tobacco history. A secondary analysis also incorporated highly-sensitive C-reactive protein levels in predictive models. RESULTS At baseline, higher plasma MMP-9 levels were cross-sectionally associated with lower FEV1 (p=0.03), FVC (p<0.001), carbon monoxide transfer factor (p=0.03), resting oxygen saturation (p=0.02), and ISWT distance walked (p=0.02) but were not associated with radiographic lung density or total lung capacity (TLC). In longitudinal analyses, MMP-9 predicted a further decline in transfer factor (p=0.04) and oxygen saturation (p<0.001). MMP-9 also predicted worsening lung density (p=0.003), increasing TLC (p=0.02), and more frequent COPD exacerbations over follow-up (p=0.003). Controlling additionally for hs-CRP levels did not substantively change the longitudinal associations between MMP-9 and these outcomes. CONCLUSIONS Increased plasma MMP-9 levels generally predicted pulmonary status declines, including worsening transfer factor and lung density as well as greater COPD exacerbations in AATD-associated emphysema.
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Affiliation(s)
- Theodore A Omachi
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, USA.
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