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Heudi O, Jain M, Winter S. Highly sensitive liquid chromatography-mass spectrometry method for the quantitative analysis of mometasone furoate in human plasma: Method validation and application to clinical pharmacokinetic studies. Biomed Chromatogr 2024; 38:e5871. [PMID: 38599686 DOI: 10.1002/bmc.5871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 03/05/2024] [Accepted: 03/12/2024] [Indexed: 04/12/2024]
Abstract
We report the development and the validation of a sensitive liquid chromatography-mass spectrometry (LC-MS/MS) method for mometasone furoate (MF) analysis in human plasma. Plasma samples were processed through liquid-liquid extraction and analyzed using LC-MS/MS operating in positive mode using multiple reaction monitoring of transitions m/z 520.9 → 355.0 and m/z 525.8 → 355.0 for MF and the internal standard (IS), respectively. Separation was achieved at 1.0 mL/min on a C18 column using a gradient elution of mobile phase of 0.05% ammonia in water (phase A) and acetonitrile (phase B). The assay range was 0.250-100 pg/mL and proved to be accurate and precise MF. Normalized recoveries were consistent and reproducible with a coefficient of variation (CV%) value of 6.0. The CV (%) of the IS normalized matrix factor was not observed in normal, lipemic, and hemolyzed plasmas. Dilutions of 1:10 were accurately quantified. A cycle of three freeze and thaw and stabilities at room temperature and on the autosampler were demonstrated. In addition, MF in the presence of indacaterol and glycopyrronium was proven to be stable at -70°C for at least 157 days. The present method was successfully applied to quantify MF in patients receiving MF, indacaterol, and glycopyrronium as a fixed-dose combination.
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Affiliation(s)
- Olivier Heudi
- DMPK/Bioanalytics, Novartis Pharma AG, Basel, Switzerland
| | - Monish Jain
- PK Sciences Biomedical Research, Cambridge, Massachusetts, USA
| | - Serge Winter
- DMPK/Bioanalytics, Novartis Pharma AG, Basel, Switzerland
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2
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Miculinić A, Mrkić Kobal I, Kušan T, Turkalj M, Plavec D. Current Challenges in Pediatric Asthma. CHILDREN (BASEL, SWITZERLAND) 2024; 11:632. [PMID: 38929213 PMCID: PMC11201822 DOI: 10.3390/children11060632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Revised: 05/20/2024] [Accepted: 05/22/2024] [Indexed: 06/28/2024]
Abstract
Asthma is a chronic lung disease characterized by reversible bronchoconstriction and inflammation of the bronchi. Its increasing prevalence in childhood as well as different triggers make asthma a challenging disease in several ways: defining its phenotype/endotype, the diagnostic approach (especially in younger children), therapeutic options, and systematic follow-up. Considering these problems, this review approaches the current status and limitations of guidelines used for asthma management in children. It also emphasizes the key points which could lead to a better understanding and the direction to take in future studies.
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Affiliation(s)
- Andrija Miculinić
- Children’s Hospital Srebrnjak, Srebrnjak 100, 10000 Zagreb, Croatia (M.T.)
| | - Iva Mrkić Kobal
- Clinic for Pediatric Medicine Helena, Ulica Kneza Branimira 71, 10000 Zagreb, Croatia;
- Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, Josipa Huttlera 4, 31000 Osijek, Croatia
| | - Tin Kušan
- Children’s Hospital Srebrnjak, Srebrnjak 100, 10000 Zagreb, Croatia (M.T.)
| | - Mirjana Turkalj
- Children’s Hospital Srebrnjak, Srebrnjak 100, 10000 Zagreb, Croatia (M.T.)
- Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, Josipa Huttlera 4, 31000 Osijek, Croatia
- Faculty of Medicine, Catholic University of Croatia, 10000 Zagreb, Croatia
| | - Davor Plavec
- Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, Josipa Huttlera 4, 31000 Osijek, Croatia
- Prima Nova, Healthcare Institution, Zagrebačka Cesta 132A, 10000 Zagreb, Croatia
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3
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Panettieri RA, Chipps BE, Skolnik N, George M, Murphy K, Lugogo N. The Use of Albuterol/Budesonide as Reliever Therapy to Reduce Asthma Exacerbations. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:882-888. [PMID: 38316182 DOI: 10.1016/j.jaip.2024.01.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 12/18/2023] [Accepted: 01/17/2024] [Indexed: 02/07/2024]
Abstract
Prevention of asthma exacerbations and reduction of systemic corticosteroid burden remain unmet needs in asthma. US asthma guidelines recommend concomitant short-acting β2-agonist (SABA) and inhaled corticosteroid (ICS) as an alternative reliever at step 2. The Food and Drug Administration approved a pressurized metered-dose inhaler containing albuterol and budesonide for as-needed treatment or prevention of bronchoconstriction and for reducing exacerbation risk in patients with asthma aged ≥18 years. This combination is approved for use as a reliever with or without maintenance therapy, but it is not indicated for maintenance therapy (or for single maintenance and reliever therapy). Intervening with as-needed SABA-ICS during the window of opportunity to reduce inflammation during loss of asthma control can reduce exacerbation risk, by exerting both genomic and nongenomic anti-inflammatory effects. We propose that the use of albuterol-budesonide rather than albuterol as a reliever to manage episodic symptoms driven by acute bronchoconstriction and airway inflammation can improve outcomes. This combination approach, shown to decrease asthma exacerbations and oral corticosteroid burden in patients with moderate-to-severe asthma, represents a paradigm shift for asthma treatment in the United States. Further safety and efficacy studies should provide evidence that this type of reliever should be standard of care.
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Affiliation(s)
- Reynold A Panettieri
- Rutgers Institute for Translational Medicine and Science, the State University of New Jersey, New Brunswick, NJ; Child Health Institute of New Jersey, Rutgers, the State University of New Jersey, New Brunswick, NJ
| | - Bradley E Chipps
- Capital Allergy & Respiratory Disease Center, Sacramento, Calif.
| | - Neil Skolnik
- Abington Family Medicine, Jenkintown, Pa; Department of Family and Community Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pa
| | - Maureen George
- Department of Nursing, Columbia University School of Nursing, New York, NY
| | - Kevin Murphy
- Boys Town National Research Hospital, Section of Adult and Pediatric Allergy and Pediatric Pulmonary, Boys Town, Neb
| | - Njira Lugogo
- Michigan Medicine, University of Michigan, Ann Arbor, Mich
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4
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Lee HJ, Lee JK, Park TY, Heo EY, Kim DK, Lee HW. Clinical outcomes of long-term inhaled combination therapies in patients with bronchiectasis and airflow obstruction. BMC Pulm Med 2024; 24:49. [PMID: 38263115 PMCID: PMC10804611 DOI: 10.1186/s12890-024-02867-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 01/17/2024] [Indexed: 01/25/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Few studies have reported which inhaled combination therapy, either bronchodilators and/or inhaled corticosteroids (ICSs), is beneficial in patients with bronchiectasis and airflow obstruction. Our study compared the efficacy and safety among different inhaled combination therapies in patients with bronchiectasis and airflow obstruction. METHODS Our retrospective study analyzed the patients with forced expiratory volume in 1 s (FEV1)/forced vital capacity < 0.7 and radiologically confirmed bronchiectasis in chest computed tomography between January 2005 and December 2021. The eligible patients underwent baseline and follow-up spirometric assessments. The primary endpoint was the development of a moderate-to-severe exacerbation. The secondary endpoints were the change in the annual FEV1 and the adverse events. Subgroup analyses were performed according to the blood eosinophil count (BEC). RESULTS Among 179 patients, the ICS/long-acting beta-agonist (LABA)/long-acting muscarinic antagonist (LAMA), ICS/LABA, and LABA/LAMA groups were comprised of 58 (32.4%), 52 (29.1%), and 69 (38.5%) patients, respectively. ICS/LABA/LAMA group had a higher severity of bronchiectasis and airflow obstruction, than other groups. In the subgroup with BEC ≥ 300/uL, the risk of moderate-to-severe exacerbation was lower in the ICS/LABA/LAMA group (adjusted HR = 0.137 [95% CI = 0.034-0.553]) and the ICS/LABA group (adjusted HR = 0.196 [95% CI = 0.045-0.861]) compared with the LABA/LAMA group. The annual FEV1 decline rate was significantly worsened in the ICS/LABA group compared to the LABA/LAMA group (adjusted β-coefficient=-197 [95% CI=-307--87]) in the subgroup with BEC < 200/uL. CONCLUSION In patients with bronchiectasis and airflow obstruction, the use of ICS/LABA/LAMA and ICS/LABA demonstrated a reduced risk of exacerbation compared to LABA/LAMA therapy in those with BEC ≥ 300/uL. Conversely, for those with BEC < 200/uL, the use of ICS/LABA was associated with an accelerated decline in FEV1 in comparison to LABA/LAMA therapy. Further assessment of BEC is necessary as a potential biomarker for the use of ICS in patients with bronchiectasis and airflow obstruction.
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Affiliation(s)
- Hyo Jin Lee
- Division of Respiratory and Critical Care, Department of Internal Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, South Korea
| | - Jung-Kyu Lee
- Division of Respiratory and Critical Care, Department of Internal Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, South Korea
| | - Tae Yeon Park
- Division of Respiratory and Critical Care, Department of Internal Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, South Korea
| | - Eun Young Heo
- Division of Respiratory and Critical Care, Department of Internal Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, South Korea
| | - Deog Kyeom Kim
- Division of Respiratory and Critical Care, Department of Internal Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, South Korea
| | - Hyun Woo Lee
- Division of Respiratory and Critical Care, Department of Internal Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, South Korea.
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, 20, Boramae-ro 5-gil, Dongjak-gu, Seoul, 07061, South Korea.
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5
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Price D, Henley W, Cançado JED, Fabbri LM, Kerstjens HAM, Papi A, Roche N, Şen E, Singh D, Vogelmeier CF, Nudo E, Carter V, Skinner D, Vella R, Soriano JB, Kots M, Georges G. Risk of Pneumonia in Patients with COPD Initiating Fixed Dose Inhaled Corticosteroid (ICS) / Long-Acting Bronchodilator (LABD) Formulations Containing Extrafine Beclometasone Dipropionate versus Patients Initiating LABD Without ICS. Pragmat Obs Res 2024; 15:1-16. [PMID: 38274639 PMCID: PMC10807314 DOI: 10.2147/por.s438031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 12/28/2023] [Indexed: 01/27/2024] Open
Abstract
Background Combined ICS and long-acting bronchodilators (LABD) more effectively reduce COPD exacerbations than LABD therapy alone. Corticosteroid-related adverse effects, including pneumonia, limit ICS use. Previous data suggest this risk is lower for extrafine beclometasone (ef-BDP). We compared pneumonia risk among new users of fixed dose ICS/LABD formulations containing ef-BDP, versus patients initiating LABD without any ICS. Methods A propensity-matched historical cohort study design used data from OPCRD. COPD patients with ≥1 year of continuous data who initiated LABD or ICS/LABD formulations containing ef-BDP were matched. Primary outcome was time to pneumonia event, as treated, using either sensitive (physician diagnosed) or specific (physician diagnosed and x-ray or hospital admission confirmed) definitions, with non-inferiority boundary of 15%. Results 23,898 COPD patients were matched, who were 68±11 years, 54.3% male and 56% current-smokers, while 43% were former-smokers. Initiation of ef-BDP/LABD was not associated with an increased risk of pneumonia versus LABD, for either a sensitive 0.89 (0.78-1.02), P = 0.08 or a specific 0.91 (0.78-1.05), P = 0.18 definition of pneumonia. The probability of remaining pneumonia free 1-year after ef-BDP/LABD was 98.4%, which was comparable to LABD at 97.7%, and was sustained up to 6 years of observation; non-inferiority criterion was met for both definitions. Initiation of ef-BDP/LABD was also associated with a reduced risk of developing LRTIs in the propensity matched cohort. Conclusion Risk of pneumonia when using ICS for the management of COPD reported in several randomised controlled trials may not be relevant with ef-BDP in a diverse real-world clinical population.
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Affiliation(s)
- David Price
- Observational and Pragmatic Research Institute, Singapore
- Centre of Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - William Henley
- Observational and Pragmatic Research Institute, Singapore
- Health Statistics Group, Department of Health and Community Sciences, University of Exeter Medical School, Exeter, UK
| | | | - Leonardo M Fabbri
- Respiratory Medicine, Department of Translational Medicine and for Romagna, University of Ferrara, Ferrara, Italy
| | - Huib A M Kerstjens
- Department of Pulmonary Diseases, University of Groningen and University Medical Centre Groningen, and Groningen Research Institute for Asthma and COPD (GRIAC), Groningen, the Netherlands
| | - Alberto Papi
- Respiratory Medicine, University of Ferrara, Ferrara, Italy
| | - Nicolas Roche
- Department of Respiratory Medicine, APHP-Centre University of Paris, Cochin Hospital and Institute (UMR1016), Paris, France
| | - Elif Şen
- Department of Pulmonary Medicine, Ankara University School of Medicine, Ankara, Turkey
| | - Dave Singh
- Division of Infection, Immunity & Respiratory Medicine, University of Manchester, Manchester University NHS Foundation Trust, Manchester, UK
| | - Claus F Vogelmeier
- Department of Internal Medicine, Pulmonary and Critical Care Medicine, University of Marburg, Member of the German Centre for Lung Research (DZL), Marburg, Germany
| | - Elena Nudo
- Global Medical Affairs, Chiesi Farmaceutici, S.p.A, Parma, Italy
| | | | - Derek Skinner
- Observational and Pragmatic Research Institute, Singapore
| | - Rebecca Vella
- Observational and Pragmatic Research Institute, Singapore
| | - Joan B Soriano
- Respiratory Department, Hospital Universitario de La Princesa and Facultad de Medicina, Universidad Autónoma de Madrid, Madrid, Spain
| | - Maxim Kots
- Global Medical Affairs, Chiesi Farmaceutici, S.p.A, Parma, Italy
| | - George Georges
- Global Clinical Development, Chiesi Farmaceutici, S.p.A, Parma, Italy
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6
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Izmailova ES, Kilian R, Bakker JP, Evans S, Scotina AD, Reiss TF, Singh D, Wagner JA. Study protocol: A comparison of mobile and clinic-based spirometry for capturing the treatment effect in moderate asthma. Clin Transl Sci 2023; 16:2112-2122. [PMID: 37602889 PMCID: PMC10651656 DOI: 10.1111/cts.13615] [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: 05/26/2023] [Revised: 07/20/2023] [Accepted: 08/03/2023] [Indexed: 08/22/2023] Open
Abstract
Several inefficiencies in drug development trial implementation may be improved by moving data collection from the clinic to mobile, allowing for more frequent measurements and therefore increased statistical power while aligning to a patient-centric approach to trial design. Sensor-based digital health technologies such as mobile spirometry (mSpirometry) are comparable to clinic spirometry for capturing outcomes, such as forced expiratory volume in 1 s (FEV1); however, the impact of remote spirometry measurements on the detection of treatment effect has not been investigated. A protocol for a multicenter, single-arm, open-label interventional trial of long-acting beta agonist (LABA) therapy among 60 participants with uncontrolled moderate asthma is described. Participants will complete twice-daily mSpirometry at home and clinic spirometry during weekly visits, alongside continuous use of a wrist-worn wearable and regular completion of several diaries capturing asthma symptoms as well as participant- and site-reported satisfaction and ease of use of mSpirometry. The co-primary objectives of this study are (A) to quantify the treatment effect of LABA therapy among participants with moderate asthma, using both clinical spirometry (FEV1c ) and mSpirometry (FEV1m ); and (B) to investigate whether FEV1m is as accurate as FEV1c in detecting the treatment effect using a mixed-effect model for repeated measures. Study results will help inform whether the deployment of mSpirometry and a wrist-worn wearable for remote data collection are feasible in a multicenter setting among participants with moderate asthma, which may then be generalizable to other populations with respiratory disease.
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Affiliation(s)
| | - Rachel Kilian
- Koneksa HealthNew YorkNew YorkUSA
- SSI StrategyNew YorkNew YorkUSA
| | - Jessie P. Bakker
- Department of MedicineBrigham and Women's HospitalBostonMassachusettsUSA
- Department of NeurologyBrigham and Women's HospitalBostonMassachusettsUSA
- Division of Sleep MedicineHarvard Medical SchoolBostonMassachusettsUSA
| | - Shawna Evans
- Koneksa HealthNew YorkNew YorkUSA
- SSI StrategyNew YorkNew YorkUSA
| | | | | | - Dave Singh
- Medicines Evaluation Unit, University of ManchesterManchester University NHS Foundation TrustManchesterUK
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7
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Perez-Garcia J, Pino-Yanes M, Plender EG, Everman JL, Eng C, Jackson ND, Moore CM, Beckman KB, Medina V, Sharma S, Winnica DE, Holguin F, Rodríguez-Santana J, Villar J, Ziv E, Seibold MA, Burchard EG. Epigenomic response to albuterol treatment in asthma-relevant airway epithelial cells. Clin Epigenetics 2023; 15:156. [PMID: 37784136 PMCID: PMC10546710 DOI: 10.1186/s13148-023-01571-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 09/25/2023] [Indexed: 10/04/2023] Open
Abstract
BACKGROUND Albuterol is the first-line asthma medication used in diverse populations. Although DNA methylation (DNAm) is an epigenetic mechanism involved in asthma and bronchodilator drug response (BDR), no study has assessed whether albuterol could induce changes in the airway epithelial methylome. We aimed to characterize albuterol-induced DNAm changes in airway epithelial cells, and assess potential functional consequences and the influence of genetic variation and asthma-related clinical variables. RESULTS We followed a discovery and validation study design to characterize albuterol-induced DNAm changes in paired airway epithelial cultures stimulated in vitro with albuterol. In the discovery phase, an epigenome-wide association study using paired nasal epithelial cultures from Puerto Rican children (n = 97) identified 22 CpGs genome-wide associated with repeated-use albuterol treatment (p < 9 × 10-8). Albuterol predominantly induced a hypomethylation effect on CpGs captured by the EPIC array across the genome (probability of hypomethylation: 76%, p value = 3.3 × 10-5). DNAm changes on the CpGs cg23032799 (CREB3L1), cg00483640 (MYLK4-LINC01600), and cg05673431 (KSR1) were validated in nasal epithelia from 10 independent donors (false discovery rate [FDR] < 0.05). The effect on the CpG cg23032799 (CREB3L1) was cross-tissue validated in bronchial epithelial cells at nominal level (p = 0.030). DNAm changes in these three CpGs were shown to be influenced by three independent genetic variants (FDR < 0.05). In silico analyses showed these polymorphisms regulated gene expression of nearby genes in lungs and/or fibroblasts including KSR1 and LINC01600 (6.30 × 10-14 ≤ p ≤ 6.60 × 10-5). Additionally, hypomethylation at the CpGs cg10290200 (FLNC) and cg05673431 (KSR1) was associated with increased gene expression of the genes where they are located (FDR < 0.05). Furthermore, while the epigenetic effect of albuterol was independent of the asthma status, severity, and use of medication, BDR was nominally associated with the effect on the CpG cg23032799 (CREB3L1) (p = 0.004). Gene-set enrichment analyses revealed that epigenomic modifications of albuterol could participate in asthma-relevant processes (e.g., IL-2, TNF-α, and NF-κB signaling pathways). Finally, nine differentially methylated regions were associated with albuterol treatment, including CREB3L1, MYLK4, and KSR1 (adjusted p value < 0.05). CONCLUSIONS This study revealed evidence of epigenetic modifications induced by albuterol in the mucociliary airway epithelium. The epigenomic response induced by albuterol might have potential clinical implications by affecting biological pathways relevant to asthma.
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Grants
- R01 ES015794 NIEHS NIH HHS
- R01 HL120393 NHLBI NIH HHS
- R01ES015794, R21ES24844 NIEHS NIH HHS
- UM1 HG008901 NHGRI NIH HHS
- R01MD010443, R56MD013312 NIMHD NIH HHS
- R01 HL135156 NHLBI NIH HHS
- R01 HL128439 NHLBI NIH HHS
- R01 HL117004 NHLBI NIH HHS
- R21 ES024844 NIEHS NIH HHS
- R01 HL117626 NHLBI NIH HHS
- R56 MD013312 NIMHD NIH HHS
- R01 MD010443 NIMHD NIH HHS
- R01 HL155024 NHLBI NIH HHS
- R01HL155024-01, HHSN268201600032I, 3R01HL-117626-02S1, HHSN268201800002I, 3R01HL117004-02S3, 3R01HL-120393-02S1, R01HL117004, R01HL128439, R01HL135156, X01HL134589 NHLBI NIH HHS
- HHSN268201600032C NHLBI NIH HHS
- U24 HG008956 NHGRI NIH HHS
- Ministerio de Universidades
- Ministerio de Ciencia e Innovación
- Instituto de Salud Carlos III
- National Heart, Lung, and Blood Institute
- National Human Genome Research Institute
- National Institute of Environmental Health Sciences
- National Institute on Minority Health and Health Disparities
- The Centers for Common Disease Genomics of the Genome Sequencing Program
- Tobacco-Related Disease Research Program
- Sandler Family Foundation
- American Asthma Foundation
- Amos Medical Faculty Development Program from the Robert Wood Johnson Foundation
- Harry Wm. and Diana V. Hind Distinguished Professor in Pharmaceutical Sciences II
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Affiliation(s)
- Javier Perez-Garcia
- Genomics and Health Group, Department of Biochemistry, Microbiology, Cell Biology, and Genetics, Universidad de La Laguna (ULL), La Laguna, Tenerife, Canary Islands, Spain.
| | - Maria Pino-Yanes
- Genomics and Health Group, Department of Biochemistry, Microbiology, Cell Biology, and Genetics, Universidad de La Laguna (ULL), La Laguna, Tenerife, Canary Islands, Spain.
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain.
- Instituto de Tecnologías Biomédicas (ITB), Universidad de La Laguna (ULL), La Laguna, Spain.
| | - Elizabeth G Plender
- Center for Genes, Environment, and Health, National Jewish Health, Denver, CO, USA
| | - Jamie L Everman
- Center for Genes, Environment, and Health, National Jewish Health, Denver, CO, USA
| | - Celeste Eng
- Department of Medicine, University of California San Francisco (UCSF), San Francisco, CA, USA
| | - Nathan D Jackson
- Center for Genes, Environment, and Health, National Jewish Health, Denver, CO, USA
| | - Camille M Moore
- Center for Genes, Environment, and Health, National Jewish Health, Denver, CO, USA
- Department of Biomedical Research, National Jewish Health, Denver, CO, USA
- Department of Biostatistics and Informatics, University of Colorado, Denver, CO, USA
| | - Kenneth B Beckman
- University of Minnesota Genomics Center (UMNGC), Minneapolis, MN, USA
| | | | - Sunita Sharma
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Daniel Efrain Winnica
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Fernando Holguin
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | | | - Jesús Villar
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
- Multidisciplinary Organ Dysfunction Evaluation Research Network (MODERN), Research Unit, Hospital Universitario Dr. Negrín, Las Palmas de Gran Canaria, Spain
- Li Ka Shing Knowledge Institute at the St. Michael's Hospital, Toronto, ON, Canada
| | - Elad Ziv
- Institute for Human Genetics, University of California San Francisco (UCSF), San Francisco, CA, USA
- Department of Epidemiology and Biostatistics, University of California, San Francisco School of Medicine, San Francisco, CA, USA
| | - Max A Seibold
- Center for Genes, Environment, and Health, National Jewish Health, Denver, CO, USA
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Aurora, CO, USA
- Department of Pediatrics, National Jewish Health, Denver, CO, USA
| | - Esteban G Burchard
- Department of Medicine, University of California San Francisco (UCSF), San Francisco, CA, USA
- Department of Bioengineering and Therapeutic Sciences, University of California San Francisco (UCSF), San Francisco, CA, USA
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8
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Ren J, Wang XQ, Nakao T, Libby P, Shi GP. Differential Roles of Interleukin-6 in Severe Acute Respiratory Syndrome-Coronavirus-2 Infection and Cardiometabolic Diseases. CARDIOLOGY DISCOVERY 2023; 3:166-182. [PMID: 38152628 PMCID: PMC10750760 DOI: 10.1097/cd9.0000000000000096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2023]
Abstract
Severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) infection can lead to a cytokine storm, unleashed in part by pyroptosis of virus-infected macrophages and monocytes. Interleukin-6 (IL-6) has emerged as a key participant in this ominous complication of COVID-19. IL-6 antagonists have improved outcomes in patients with COVID-19 in some, but not all, studies. IL-6 signaling involves at least 3 distinct pathways, including classic-signaling, trans-signaling, and trans-presentation depending on the localization of IL-6 receptor and its binding partner glycoprotein gp130. IL-6 has become a therapeutic target in COVID-19, cardiovascular diseases, and other inflammatory conditions. However, the efficacy of inhibition of IL-6 signaling in metabolic diseases, such as obesity and diabetes, may depend in part on cell type-dependent actions of IL-6 in controlling lipid metabolism, glucose uptake, and insulin sensitivity owing to complexities that remain to be elucidated. The present review sought to summarize and discuss the current understanding of how and whether targeting IL-6 signaling ameliorates outcomes following SARS-CoV-2 infection and associated clinical complications, focusing predominantly on metabolic and cardiovascular diseases.
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Affiliation(s)
- Jingjing Ren
- Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115
| | - Xiao-Qi Wang
- Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115
| | - Tetsushi Nakao
- Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115
| | - Peter Libby
- Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115
| | - Guo-Ping Shi
- Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115
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9
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Niimi A, Fukunaga K, Taniguchi M, Nakamura Y, Tagaya E, Horiguchi T, Yokoyama A, Yamaguchi M, Nagata M. Executive summary: Japanese guidelines for adult asthma (JGL) 2021. Allergol Int 2023; 72:207-226. [PMID: 36959028 DOI: 10.1016/j.alit.2023.02.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 02/17/2023] [Indexed: 03/25/2023] Open
Abstract
Asthma is characterized by chronic airway inflammation, variable airway narrowing, and sensory nerve irritation, which manifest as wheezing, dyspnea, chest tightness, and cough. Longstanding asthma may result in airway remodeling and become intractable. Despite the increased prevalence of asthma in adults, asthma-associated deaths have decreased in Japan (0.94 per 100,000 people in 2020). The goals of asthma treatment include the control of symptoms and reduction of future risks. A functional partnership between physicians and patients is indispensable for achieving these goals. Long-term management with medications and the elimination of triggers and risk factors are fundamental to asthma treatment. Asthma is managed via four steps of pharmacotherapy ("controllers"), ranging from mild to intensive treatments, depending on disease severity; each step involves daily administration of an inhaled corticosteroid, which varies from low to high dosage. Long-acting β2 agonists, leukotriene receptor antagonists, sustained-release theophylline, and long-acting muscarinic antagonists are recommended as add-on drugs. Allergen immunotherapy is a new option that is employed as a controller treatment. Further, as of 2021, anti-IgE antibody, anti-IL-5 and anti-IL-5 receptor α-chain antibodies, and anti-IL-4 receptor α-chain antibodies are available for the treatment of severe asthma. Bronchial thermoplasty can be performed for asthma treatment, and its long-term efficacy has been reported. Algorithms for their usage have been revised. Comorbidities, such as allergic rhinitis, chronic rhinosinusitis, chronic obstructive pulmonary disease, and aspirin-exacerbated respiratory disease, should also be considered during the treatment of chronic asthma. Depending on the severity of episodes, inhaled short-acting β2 agonists, systemic corticosteroids, short-acting muscarinic antagonists, oxygen therapy, and other approaches are used as needed ("relievers") during exacerbation.
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Affiliation(s)
- Akio Niimi
- Department of Respiratory Medicine, Allergy and Clinical Immunology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan.
| | - Koichi Fukunaga
- Pulmonary Division, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Masami Taniguchi
- Center for Immunology and Allergology, Shonan Kamakura General Hospital, Kanagawa, Japan
| | - Yoichi Nakamura
- Medical Center for Allergic and Immune Diseases, Yokohama City Minato Red Cross Hospital, Yokohama, Japan
| | - Etsuko Tagaya
- Department of Respiratory Medicine, Tokyo Women's Medical University, Tokyo, Japan
| | - Takahiko Horiguchi
- Department of Respiratory Medicine, Toyota Regional Medical Center, Toyota, Japan
| | - Akihito Yokoyama
- Department of Respiratory Medicine and Allergology, Kochi Medical School, Kochi University, Kochi, Japan
| | - Masao Yamaguchi
- Division of Respiratory Medicine, Third Department of Medicine, Teikyo University Chiba Medical Center, Chiba, Japan
| | - Makoto Nagata
- Department of Respiratory Medicine, Saitama Medical University, Saitama, Japan; Allergy Center, Saitama Medical University Hospital, Saitama Medical University, Saitama, Japan
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10
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Optimal follow-up period after switching to another inhaled corticosteroid/long-acting β2 agonist in patients with asthma: A retrospective study using Japanese administrative claims data. PLoS One 2022; 17:e0276001. [PMID: 36227895 PMCID: PMC9560144 DOI: 10.1371/journal.pone.0276001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 09/27/2022] [Indexed: 11/07/2022] Open
Abstract
Switching inhalation devices is a reasonable option if problems with control, adherence, or inhalation technique occur in patients with asthma treated with inhaled corticosteroid (ICS)/long-acting β2 agonist (LABA). However, evidence to determine the extent to which the carefully monitored period persists after switching is insufficient. In this study, we aimed to investigate the duration of the carefully monitored period after switching to another ICS/LABA. This retrospective study used claims data from Japanese health insurance associations from May 2014 to April 2019. A total of 1,951 patients who switched to another ICS/LABA during the study period were selected for analysis. The relative risk of the first exacerbation after switching was calculated for each four-week interval after the switch compared with that before the switch in a self-controlled case series design. We further assessed patient background associated with exacerbations during the follow-up period. In the primary analysis, the risk of asthma exacerbation compared to the control period was derived from a conditional logistic regression model, which showed a significant decrease immediately after the switch (1 to 4 weeks, Odds ratio [OR] 0.37, 95% confidence interval [CI] 0.26–0.54). Subsequently, the risk increased again and was not significantly different from the control period until week 32 (OR 0.55, 95% CI 0.29–1.04). In a sensitivity analysis among patients with a history of exacerbations, up to week 20 was the period of no continuous risk reduction (OR 0.84, 95% CI 0.41–1.70). In the secondary analysis, chronic rhinosinusitis, sleep disorders, and a history of asthma exacerbation were significantly associated with asthma exacerbation. The incidence of exacerbation remained high for approximately 4 to 7 months after patients with asthma switched to another ICS/LABA. Therefore, these patients should be carefully monitored for at least 4 to 7 months and should be re-assessed at an earlier point in time, if necessary.
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11
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Gupta PR, Sarnaik R, Gupta N. Step-in step-down approach in the management of bronchial asthma in adolescents and adults. Lung India 2022; 39:401-407. [PMID: 36629199 PMCID: PMC9623866 DOI: 10.4103/lungindia.lungindia_591_21] [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: 10/02/2021] [Revised: 01/06/2022] [Accepted: 02/09/2022] [Indexed: 01/14/2023] Open
Abstract
Introduction Despite the step-up step-down approach of asthma management suggested by the Global Initiative for Asthma (GINA), control of asthma continues to be poor. It was hypothesized that a new "Step-in Step-down approach" could prove to be a better alternative. The present study was carried out with the objective to assess the efficacy and adverse effects of this new approach in the control of asthma. Materials and Methods All treatment-naïve asthma patients were randomly allocated to either Group I (patients received budesonide 400 μg + formoterol 6 μg twice daily via dry powder inhalation device along with as-needed salbutamol) or Group II (patients received stepwise treatment as per GINA guidelines, 2017). Patients were monitored on a fortnightly basis for control of symptoms, spirometry, and complications if any. Asthma Control Questionnaire (ACQ-7) was used to assess control of asthma. Adverse effects, if any, were recorded and managed appropriately. Step-down was attempted on achieving sustained control of asthma, i.e., ACQ score of <0.75 on two consecutive fortnight assessments in both the groups. In Group I patients, long-acting β2-agonist was withdrawn first. Subsequently, a dose of budesonide was also reduced. In Group II patients, the treatment was decreased to the next lower step medicines as per the GINA guidelines. Results After exclusions, a total of 787 patients were randomized to either Group I or II. The demographic profile of patients in the two groups was similar. Patients on "step-in step-down" approach had a statistically significant advantage over those on conventional step-up step-down approach in terms of (a) time to the first control (271 vs. 98 within first 4 weeks), (b) need for rescue steroids (two patients in Group 1 vs. 40 in Group 2), (c) number of exacerbations (30 vs. 232), and (d) use of rescue SABA (Only 30 patients in group I required > 5 inhalations per week as compared to all in group II). Adverse reactions were not observed in any of the patients in either group. Conclusion We conclude that step-in step-down approach is a more robust and safer approach for control of asthma.
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Affiliation(s)
- Prahalad Rai Gupta
- Department of Pulmonary Medicine, Shalby Hospital, Jaipur, Rajasthan, India
| | | | - Neeraj Gupta
- Department of Respiratory Diseases, Medical College, Ajmer, Rajasthan, India
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Park SY, Kang SY, Song WJ, Kim JH. Evolving Concept of Severe Asthma: Transition From Diagnosis to Treatable Traits. ALLERGY, ASTHMA & IMMUNOLOGY RESEARCH 2022; 14:447-464. [PMID: 36174989 PMCID: PMC9523415 DOI: 10.4168/aair.2022.14.5.447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 08/28/2022] [Accepted: 09/01/2022] [Indexed: 11/24/2022]
Abstract
In recent decades, the concept of severe asthma has evolved from an umbrella term encompassing patients with high-intensity treatment needs to a clinical syndrome with heterogeneous, albeit distinct, pathophysiological processes. Biased and unbiased cluster approaches have been used to identify several clinical phenotypes. In parallel, cellular and molecular approaches allow for the development of biological therapies, especially targeting type 2 (T2) cytokine pathways. Although T2-biologics have significantly improved clinical outcomes for patients with severe asthma in real-world practice, questions on the proper use of biologics remain open. Furthermore, a subset of severe asthma patients remains poorly controlled. The unmet needs require a new approach. The “treatable traits” concept has been suggested to address a diversity of pathophysiological factors in severe asthma and overcome the limitations of existing treatment strategies. With a tailored therapy that targets the treatable traits in individual patients, better personalized medical care and outcomes should be achieved.
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Affiliation(s)
- So-Young Park
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
- Division of Pulmonary, Allergy and Critical Care Medicine, Chung-Ang University Gwangmyeong Medical Center, Gwangmyeong, Korea
| | - Sung-Yoon Kang
- Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Woo-Jung Song
- Department of Allergy and Clinical Immunology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Joo-Hee Kim
- Department of Internal Medicine, Hallym University College of Medicine, Anyang, Korea
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13
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Hengeveld VS, Keijzer PB, Diamant Z, Thio BJ. An Algorithm for Strategic Continuation or Restriction of Asthma Medication Prior to Exercise Challenge Testing in Childhood Exercise Induced Bronchoconstriction. Front Pediatr 2022; 10:800193. [PMID: 35273926 PMCID: PMC8902070 DOI: 10.3389/fped.2022.800193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 01/05/2022] [Indexed: 11/23/2022] Open
Abstract
Exercise induced bronchial (EIB) constriction is a common and highly specific feature of pediatric asthma and should be diagnosed with an exercise challenge test (ECT). The impact of EIB in asthmatic children's daily lives is immense, considering the effects on both physical and psychosocial development. Monitoring childhood asthma by ECT's can provide insight into daily life disease burden and the control of asthma. Current guidelines for bronchoprovocation tests restrict both the use of reliever and maintenance asthma medication before an exercise challenge to prevent false-negative testing, as both have significant acute bronchoprotective properties. However, restricting maintenance medication before an ECT may be less appropiate to evaluate EIB symptoms in daily life when a diagnosis of asthma is well established. Rigorous of maintenance medication before an ECT according to guidelines may lead to overestimation of the real, daily life asthma burden and lead to an inappropiate step-up in therapy. The protection against EIB offered by the combined acute and chronic bronchoprotective effects of maintenance medication can be properly assessed whilst maintaining them. This may aid in achieving the goal of unrestricted participation of children in daily play and sports activities with their peers without escalation of therapy. When considering a step down in medication, a strategic wash-out of maintenance medication before an ECT aids in providing objective support of potential discontinuation of maintenance medication.
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Affiliation(s)
- Vera S Hengeveld
- Department of Paediatrics, Medisch Spectrum Twente, Enschede, Netherlands
| | - Pascal B Keijzer
- Department of Paediatrics, Medisch Spectrum Twente, Enschede, Netherlands
| | - Zuzana Diamant
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Catholic University of Leuven, Leuven, Belgium.,Department of Respiratory Medicine and Allergology, Institute for Clinical Science, Skane University Hospital, Lund University, Lund, Sweden.,Department of Respiratory Medicine, First Faculty of Medicine, Charles University and Thomayer Hospital, Prague, Czechia.,Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Boony J Thio
- Department of Paediatrics, Medisch Spectrum Twente, Enschede, Netherlands
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14
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Braido F, Corsico AG, Paleari D, Piraino A, Cavalieri L, Scichilone N. Why small particle fixed dose triple therapy? An excursus from COPD pathology to pharmacological treatment evolution. Ther Adv Respir Dis 2022; 16:17534666211066063. [PMID: 35044875 PMCID: PMC8796083 DOI: 10.1177/17534666211066063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 10/20/2021] [Indexed: 11/17/2022] Open
Abstract
Although bronchodilators are the cornerstone in chronic obstructive pulmonary disease (COPD) therapy, the treatment with a single-agent bronchodilator may not provide adequate symptoms control in COPD. The combination of drugs with different mechanisms of action may be more effective in inducing bronchodilation and preventing exacerbations, with a lower risk of side-effects in comparison with the increase of the dose of a single molecule. Several studies comparing the triple therapy with the association of long-acting ß2 agonist (LABA)/inhaled corticosteroid (ICS) or long-acting muscarinic antagonist (LAMA)/LABA reported improvement of lung function and quality of life. A significant reduction in moderate/severe exacerbations has been observed with a fixed triple combination of beclometasone dipropionate (BDP), formoterol fumarate (FF) and glycopyrronium (G) in a single inhaler. The TRILOGY, TRINITY and TRIBUTE studies have provided confirming evidence for a clinical benefit of triple therapy over ICS/LABA combination treatment, LAMA monotherapy and LABA/LAMA combination, with prevention of exacerbations being a key finding. A pooled post hoc analysis of the published clinical studies involving BDP/FF/G fixed combination demonstrated a reduction in fatal events in patients treated with ICS-containing medications, with a trend of statistical significance [hazard ratio = 0.72, 95% confidence interval (CI) 0.50-1.02, p = 0.066], that becomes significant if we consider reduction in fatal events for non-respiratory reasons (hazard ratio = 0.65, 95% CI 0.43-0.97, p = 0.037). In conclusion, a fixed combination of more drugs in a single inhaler can improve long-term adherence to the therapy, reducing the risk of exacerbations and hospital resources utilization. The twice a day administration may provide a better coverage of night, particularly in COPD patients who are highly symptomatic. The inhaled extrafine formulation that allows drug deposition in both large and small - peripheral - airways, is the value added.
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Affiliation(s)
- Fulvio Braido
- Associate Professor of Respiratory Medicine University of Genoa Head of Respiratory Unit for continuity of care IRCCS Ospedale Policlinico San Martino - Genova
| | - Angelo G. Corsico
- Division of Respiratory Diseases, Foundation IRCCS Policlinico San Matteo, University of Pavia, Pavia 27100, Italy
| | - Davide Paleari
- Medical Affairs, Chiesi Italy. Chiesi Farmaceutici S.p.A. Parma, Italy
| | - Alessio Piraino
- Medical Affairs, Chiesi Italy. Chiesi Farmaceutici S.p.A. Parma, Italy
| | - Luca Cavalieri
- Medical Affairs, Chiesi Italy. Chiesi Farmaceutici S.p.A. Parma, Italy
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15
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Sriram K, Insel MB, Insel PA. Inhaled β2 Adrenergic Agonists and Other cAMP-Elevating Agents: Therapeutics for Alveolar Injury and Acute Respiratory Disease Syndrome? Pharmacol Rev 2021; 73:488-526. [PMID: 34795026 DOI: 10.1124/pharmrev.121.000356] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 08/15/2021] [Indexed: 12/15/2022] Open
Abstract
Inhaled long-acting β-adrenergic agonists (LABAs) and short-acting β-adrenergic agonists are approved for the treatment of obstructive lung disease via actions mediated by β2 adrenergic receptors (β2-ARs) that increase cellular cAMP synthesis. This review discusses the potential of β2-AR agonists, in particular LABAs, for the treatment of acute respiratory distress syndrome (ARDS). We emphasize ARDS induced by pneumonia and focus on the pathobiology of ARDS and actions of LABAs and cAMP on pulmonary and immune cell types. β2-AR agonists/cAMP have beneficial actions that include protection of epithelial and endothelial cells from injury, restoration of alveolar fluid clearance, and reduction of fibrotic remodeling. β2-AR agonists/cAMP also exert anti-inflammatory effects on the immune system by actions on several types of immune cells. Early administration is likely critical for optimizing efficacy of LABAs or other cAMP-elevating agents, such as agonists of other Gs-coupled G protein-coupled receptors or cyclic nucleotide phosphodiesterase inhibitors. Clinical studies that target lung injury early, prior to development of ARDS, are thus needed to further assess the use of inhaled LABAs, perhaps combined with inhaled corticosteroids and/or long-acting muscarinic cholinergic antagonists. Such agents may provide a multipronged, repurposing, and efficacious therapeutic approach while minimizing systemic toxicity. SIGNIFICANCE STATEMENT: Acute respiratory distress syndrome (ARDS) after pulmonary alveolar injury (e.g., certain viral infections) is associated with ∼40% mortality and in need of new therapeutic approaches. This review summarizes the pathobiology of ARDS, focusing on contributions of pulmonary and immune cell types and potentially beneficial actions of β2 adrenergic receptors and cAMP. Early administration of inhaled β2 adrenergic agonists and perhaps other cAMP-elevating agents after alveolar injury may be a prophylactic approach to prevent development of ARDS.
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Affiliation(s)
- Krishna Sriram
- Departments of Pharmacology (K.S., P.A.I.) and Medicine (P.A.I.), University of California San Diego, La Jolla, California; Department of Medicine (M.B.I.) University of Arizona, Tucson, Arizona
| | - Michael B Insel
- Departments of Pharmacology (K.S., P.A.I.) and Medicine (P.A.I.), University of California San Diego, La Jolla, California; Department of Medicine (M.B.I.) University of Arizona, Tucson, Arizona
| | - Paul A Insel
- Departments of Pharmacology (K.S., P.A.I.) and Medicine (P.A.I.), University of California San Diego, La Jolla, California; Department of Medicine (M.B.I.) University of Arizona, Tucson, Arizona
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Kukhon FR, Festic E. Adjuvant Inhaled Corticosteroids in Community-Acquired Pneumonia: A Review Article. Med Sci (Basel) 2021; 9:34. [PMID: 34071031 PMCID: PMC8162532 DOI: 10.3390/medsci9020034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 05/19/2021] [Accepted: 05/21/2021] [Indexed: 12/15/2022] Open
Abstract
Community-acquired pneumonia is still a major cause of morbidity and mortality worldwide. Since the inflammatory response induced by the immune system is often a major contributor to the lung injury, it becomes reasonable to assess the potential benefit of anti-inflammatory agents in treating community-acquired pneumonia. The role of corticosteroids as adjunct anti-inflammatory agents in treating community-acquired pneumonia is still controversial. Several studies have assessed the benefit of their use in patients with community-acquired pneumonia. In most of those studies, the route of corticosteroids administration was systemic. The aim of this article is to provide a concise review of the role of corticosteroids in treating community-acquired pneumonia when administered via inhalational route, with the potential benefit of avoiding systemic side effects of corticosteroids while exerting the same anti-inflammatory effects on the lungs. Conclusion: the use of inhaled corticosteroids may be of benefit in certain patient subsets with community-acquired pneumonia. Further randomized controlled trials are needed for better determination of such patient subsets.
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Affiliation(s)
| | - Emir Festic
- Division of Pulmonary and Sleep Medicine, Mayo Clinic Florida, Jacksonville, FL 32224, USA;
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17
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O'Shea O, Stovold E, Cates CJ. Regular treatment with formoterol and an inhaled corticosteroid versus regular treatment with salmeterol and an inhaled corticosteroid for chronic asthma: serious adverse events. Cochrane Database Syst Rev 2021; 4:CD007694. [PMID: 33852162 PMCID: PMC8095067 DOI: 10.1002/14651858.cd007694.pub3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Asthma is characterised by chronic inflammation of the airways and recurrent exacerbations with wheezing, chest tightness, and cough. Treatment with inhaled steroids and bronchodilators can result in good control of symptoms, prevention of further morbidity, and improved quality of life. However, an increase in serious adverse events with the use of both regular formoterol and regular salmeterol (long-acting beta₂-agonists) compared with placebo for chronic asthma has been demonstrated in previous Cochrane Reviews. This increase was statistically significant in trials that did not randomise participants to an inhaled corticosteroid, but not when formoterol or salmeterol was combined with an inhaled corticosteroid. The confidence intervals were found to be too wide to ensure that the addition of an inhaled corticosteroid renders regular long-acting beta₂-agonists completely safe; few participants and insufficient serious adverse events in these trials precluded a definitive decision about the safety of combination treatments. OBJECTIVES To assess risks of mortality and non-fatal serious adverse events in trials that have randomised patients with chronic asthma to regular formoterol and an inhaled corticosteroid versus regular salmeterol and an inhaled corticosteroid. SEARCH METHODS We searched the Cochrane Airways Register of Trials, CENTRAL, MEDLINE, Embase, and two trial registries to identify reports of randomised trials for inclusion. We checked manufacturers' websites and clinical trial registers for unpublished trial data, as well as Food and Drug Administration (FDA) submissions in relation to formoterol and salmeterol. The date of the most recent search was 24 February 2021. SELECTION CRITERIA We included controlled clinical trials with a parallel design, recruiting patients of any age and severity of asthma, if they randomised patients to treatment with regular formoterol versus regular salmeterol (each with a randomised inhaled corticosteroid) and were of at least 12 weeks' duration. DATA COLLECTION AND ANALYSIS Two review authors independently selected trials for inclusion in the review, extracted outcome data from published papers and trial registries, and applied GRADE rating for the results. We sought unpublished data on mortality and serious adverse events from study sponsors and authors. The primary outcomes were all cause mortality and non-fatal serious adverse events. We chose not to calculate an average result from all the formulations of formoterol and inhaled steroid, as the doses and delivery devices are too diverse to assume a single class effect. MAIN RESULTS Twenty-one studies in 11,572 adults and adolescents and two studies in 723 children met the eligibility criteria of the review. No data were available for two studies; therefore these were not included in the analysis. Among adult and adolescent studies, seven compared formoterol and budesonide to salmeterol and fluticasone (N = 7764), six compared formoterol and beclomethasone to salmeterol and fluticasone (N = 1923), two compared formoterol and mometasone to salmeterol and fluticasone (N = 1126), two compared formoterol and fluticasone to salmeterol and fluticasone (N = 790), and one compared formoterol and budesonide to salmeterol and budesonide (N = 229). In total, five deaths were reported among adults, none of which was thought to be related to asthma. The certainty of evidence for all-cause mortality was low, as there were not enough deaths to permit any precise conclusions regarding the risk of mortality on combination formoterol versus combination salmeterol. In all, 201 adults reported non-fatal serious adverse events. In studies comparing formoterol and budesonide to salmeterol and fluticasone, there were 77 in the formoterol arm and 68 in the salmeterol arm (Peto odds ratio (OR) 1.14, 95% confidence interval (CI) 0.82 to 1.59; 5935 participants, 7 studies; moderate-certainty evidence). In the formoterol and beclomethasone studies, there were 12 adults in the formoterol arm and 13 in the salmeterol arm with events (Peto OR 0.94, 95% CI 0.43 to 2.08; 1941 participants, 6 studies; moderate-certainty evidence). In the formoterol and mometasone studies, there were 18 in the formoterol arm and 11 in the salmeterol arm (Peto OR 1.02, 95% CI 0.47 to 2.20; 1126 participants, 2 studies; moderate-certainty evidence). One adult in the formoterol and fluticasone studies in the salmeterol arm experienced an event (Peto OR 0.05, 95% CI 0.00 to 3.10; 293 participants, 2 studies; low-certainty evidence). Another adult in the formoterol and budesonide compared to salmeterol and budesonide study in the formoterol arm had an event (Peto OR 7.45, 95% CI 0.15 to 375.68; 229 participants, 1 study; low-certainty evidence). Only 46 adults were reported to have experienced asthma-related serious adverse events. The certainty of the evidence was low to very low due to the small number of events and the absence of independent assessment of causation. The two studies in children compared formoterol and fluticasone to salmeterol and fluticasone. No deaths and no asthma-related serious adverse events were reported in these studies. Four all-cause serious adverse events were reported: three in the formoterol arm, and one in the salmeterol arm (Peto OR 2.72, 95% CI 0.38 to 19.46; 548 participants, 2 studies; low-certainty evidence). AUTHORS' CONCLUSIONS Overall, for both adults and children, evidence is insufficient to show whether regular formoterol in combination with budesonide, beclomethasone, fluticasone, or mometasone has a different safety profile from salmeterol in combination with fluticasone or budesonide. Five deaths of any cause were reported across all studies and no deaths from asthma; this information is insufficient to permit any firm conclusions about the relative risks of mortality on combination formoterol in comparison to combination salmeterol inhalers. Evidence on all-cause non-fatal serious adverse events indicates that there is probably little to no difference between formoterol/budesonide and salmeterol/fluticasone inhalers. However events for the other formoterol combination inhalers were too few to allow conclusions. Only 46 non-fatal serious adverse events were thought to be asthma related; this small number in addition to the absence of independent outcome assessment means that we have very low confidence for this outcome. We found no evidence of safety issues that would affect the choice between salmeterol and formoterol combination inhalers used for regular maintenance therapy by adults and children with asthma.
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Affiliation(s)
- Orlagh O'Shea
- School of Physiotherapy, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Elizabeth Stovold
- Cochrane Airways, Population Health Research Institute, St George's, University of London, London, UK
| | - Christopher J Cates
- Cochrane Airways, Population Health Research Institute, St George's, University of London, London, UK
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Role of Airway Smooth Muscle in Inflammation Related to Asthma and COPD. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2021; 1303:139-172. [PMID: 33788192 DOI: 10.1007/978-3-030-63046-1_9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Airway smooth muscle contributes to both contractility and inflammation in the pathophysiology of asthma and COPD. Airway smooth muscle cells can change the degree of a variety of functions, including contraction, proliferation, migration, and the secretion of inflammatory mediators (phenotype plasticity). Airflow limitation, airway hyperresponsiveness, β2-adrenergic desensitization, and airway remodeling, which are fundamental characteristic features of these diseases, are caused by phenotype changes in airway smooth muscle cells. Alterations between contractile and hyper-contractile, synthetic/proliferative phenotypes result from Ca2+ dynamics and Ca2+ sensitization. Modulation of Ca2+ dynamics through the large-conductance Ca2+-activated K+ channel/L-type voltage-dependent Ca2+ channel linkage and of Ca2+ sensitization through the RhoA/Rho-kinase pathway contributes not only to alterations in the contractile phenotype involved in airflow limitation, airway hyperresponsiveness, and β2-adrenergic desensitization but also to alteration of the synthetic/proliferative phenotype involved in airway remodeling. These Ca2+ signal pathways are also associated with synergistic effects due to allosteric modulation between β2-adrenergic agonists and muscarinic antagonists. Therefore, airway smooth muscle may be a target tissue in the therapy for these diseases. Moreover, the phenotype changing in airway smooth muscle cells with focuses on Ca2+ signaling may provide novel strategies for research and development of effective remedies against both bronchoconstriction and inflammation.
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Mostafa TM, El-Azab GA, Atia GA, Lotfy NS. The Effectiveness of 3 Combined Therapeutic Regimens in Egyptian Patients with Moderate-to-Severe Chronic Obstructive Pulmonary Disease: A Randomized Double-Blind Prospective Pilot Study. CURRENT THERAPEUTIC RESEARCH 2021; 94:100625. [PMID: 34306265 PMCID: PMC8296082 DOI: 10.1016/j.curtheres.2021.100625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Accepted: 03/03/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND There are differences of opinion about both the most effective combined therapeutic strategy and the clinical benefit of inhaled corticosteroids in nonasthmatic patients with chronic obstructive pulmonary disease. Furthermore, many inflammatory cytokines are reportedly correlated with severity of the disease. OBJECTIVES To compare the effectiveness of long acting β-agonist + long-acting muscarinic antagonist (LABA + LAMA) versus LABA + inhaled corticosteroid and LAMA + inhaled corticosteroid in nonasthmatic patients with moderate-to-severe chronic obstructive pulmonary disease. To assess the changes that occurred in plasma concentrations of tumor necrosis factor α, fibrinogen, and interleukin 6, and correlate these with disease activity. METHODS In this pilot study, 45 nonasthmatic patients with moderate to severe chronic obstructive pulmonary disease were randomized into 3 groups with 15 patients in each group. Group I (LABA + inhaled corticosteroid) received formoterol/budesonide, group II (LAMA + inhaled corticosteroid) received tiotropium/budesonide and group III (LABA + LAMA) received formoterol/tiotropium for 12 weeks. Patients were assessed initially and then at 4 and 12 weeks by measuring the changes that occurred in forced expiratory volume in 1 second as a percent of predicted and in the modified Medical Research Council dyspnea scale. Plasma concentrations of tumor necrosis factor α, fibrinogen, and interleukin 6 were simultaneously measured. RESULTS The 3 study groups were statistically similar with respect to their demographic data and disease characteristics. All therapeutic options produced an improvement in forced expiratory volume in 1 second as a percent of predicted and in the modified Medical Research Council dyspnea scale as well as a reduction in plasma concentrations of the inflammatory markers. The effects produced by the three therapeutic combinations on forced expiratory volume in 1 second as a percent of predicted, plasma tumor necrosis factor α, interleukin 6, and fibrinogen concentrations were statistically similar after 4 and 12 weeks (4 weeks after treatment: P = 0.358, P = 0.284, P = 0.155, and P = 0.155, respectively, and 12 weeks after treatment: P = 0.710, P = 0.773, P = 0.240, and P = 0.076, respectively). CONCLUSIONS In nonasthmatic patients with moderate to severe chronic obstructive pulmonary disease, the 3 therapeutic combinations showed similar effectiveness. The results of this pilot study also suggest that inflammatory markers can be used to track disease activity. Clinicaltrials.gov identifier: NCT04520230. (Curr Ther Res Clin Exp. 2021; 82:XXX-XXX).
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Affiliation(s)
- Tarek M. Mostafa
- Clinical Pharmacy Department, Faculty of Pharmacy, Tanta University, Tanta, Egypt
| | - Gamal A. El-Azab
- Clinical Pharmacy Department, Faculty of Pharmacy, Tanta University, Tanta, Egypt
| | - Ghada A. Atia
- Chest Department, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Noran S. Lotfy
- Clinical Pharmacy Department, Faculty of Pharmacy, Tanta University, Tanta, Egypt
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Yang N, Singhera GK, Yan YX, Pieper MP, Leung JM, Sin DD, Dorscheid DR. Olodaterol exerts anti-inflammatory effects on COPD airway epithelial cells. Respir Res 2021; 22:65. [PMID: 33622325 PMCID: PMC7901009 DOI: 10.1186/s12931-021-01659-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 02/10/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Airway inflammation is a key feature of chronic obstructive pulmonary disease (COPD) and inhaled corticosteroids (ICS) remain the main treatment for airway inflammation. Studies have noted the increased efficacy of ICS and long-acting beta 2 agonist (LABA) combination therapy in controlling exacerbations and improving airway inflammation than either monotherapy. Further studies have suggested that LABAs may have inherent anti-inflammatory potential, but this has not been well-studied. OBJECTIVE We hypothesize that the LABA olodaterol can inhibit airway inflammation resulting from exposure to respiratory syncytial virus (RSV) via its binding receptor, the β2-adrenergic receptor. METHODS Human bronchial epithelial brushing from patients with and without COPD were cultured into air-liquid interface (ALI) cultures and treated with or without olodaterol and RSV infection to examine the effect on markers of inflammation including interleukin-8 (IL-8) and mucus secretion. The cell line NCI-H292 was utilized for gene silencing of the β2-adrenergic receptor via siRNA as well as receptor blocking via ICI 118,551 and butaxamine. RESULTS At baseline, COPD-ALIs produced greater amounts of IL-8 than control ALIs. Olodaterol reduced RSV-mediated IL-8 secretion in both COPD and control ALIs and also significantly reduced Muc5AC staining in COPD-ALIs infected with RSV. A non-significant reduction was seen in control ALIs. Gene silencing of the β2-adrenergic receptor in NCI-H292 negated the ability of olodaterol to inhibit IL-8 secretion from both RSV infection and lipopolysaccharide stimulus, as did blocking of the receptor with ICI 118,551 and butaxamine. CONCLUSIONS Olodaterol exhibits inherent anti-inflammatory properties on the airway epithelium, in addition to its bronchodilation properties, that is mediated through the β2-adrenergic receptor and independent of ICS usage.
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Affiliation(s)
- Nan Yang
- Center for Heart Lung Innovation, St. Paul's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Gurpreet K Singhera
- Center for Heart Lung Innovation, St. Paul's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Yi Xuan Yan
- Center for Heart Lung Innovation, St. Paul's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Michael P Pieper
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim am Rhein, Germany
| | - Janice M Leung
- Center for Heart Lung Innovation, St. Paul's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Don D Sin
- Center for Heart Lung Innovation, St. Paul's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Delbert R Dorscheid
- Center for Heart Lung Innovation, St. Paul's Hospital, University of British Columbia, Vancouver, BC, Canada.
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21
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Payal B, Kumar A, Saxena H. Cost-minimization Analysis of Drugs Used in the Treatment of Asthma and COPD Diseases in India. CURRENT DRUG THERAPY 2021. [DOI: 10.2174/1574885515999200813193250] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background:
Asthma and Chronic Obstructive Pulmonary Diseases (COPD) are well
known respiratory diseases affecting millions of people in India. In the market, various branded
generics, as well as generic drugs, are available for their treatment and how much cost will be saved
by utilizing generic medicine is still unclear among physicians. Thus, the main aim of the current
investigation was to perform cost-minimization analysis of generic versus branded generic (high
and low expensive) drugs and branded generic (high expensive) versus branded generic (least expensive)
used in the Department of Pulmonary Medicine of Era Medical University, Lucknow for
the treatment of asthma and COPD.
Methods:
The current index of medical stores (CIMS) was referred for the cost of branded drugs,
whereas the cost of generic drugs was taken from the Jan Aushadi scheme of India 2016. The
percentage of cost variation, particularly to Asthma and COPD regimens on substituting available
generic drugs, was calculated using standard formula and costs were presented in Indian Rupees
(as of 2019).
Results:
The maximum cost variation was found between the respules budesonide high expensive
branded generic versus least expensive branded generic drugs and generic versus high expensive
branded generic. In combination, the maximum cost variation was observed in the montelukast and
levocetirizine combination.
Conclusion:
In conclusion, this study inferred that substituting generic antiasthmatics and COPD
drugs can bring potential cost savings in patients.
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Affiliation(s)
- Billu Payal
- Department of Regulatory Toxicology, National Institute of Pharmaceutical Education and Research (NIPER-R), Lucknow (UP)-226002,India
| | - Anoop Kumar
- Department of Pharmacology and Toxicology, National Institute of Pharmaceutical Education and Research (NIPER-R), Lucknow (UP)-226002,India
| | - Harsh Saxena
- Department of Pulmonary Medicine, ERA’s Medical College and Hospital, Lucknow (UP)-226003,India
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Lugogo N, Gilbert I, Tkacz J, Gandhi H, Goshi N, Lanz MJ. Real-world patterns and implications of short-acting β 2-agonist use in patients with asthma in the United States. Ann Allergy Asthma Immunol 2021; 126:681-689.e1. [PMID: 33515710 DOI: 10.1016/j.anai.2021.01.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 12/18/2020] [Accepted: 01/19/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Short-acting β2-agonist (SABA) use is one measure reflecting asthma control. OBJECTIVE To evaluate the associations between real-world SABA use and severe asthma exacerbations in the United States. METHODS Patients with asthma 12 years of age or older receiving SABA in the IBM MarketScan research databases of US administrative claims from September 30, 2014, to September 30, 2016, were evaluated. Patients with 12 months' continuous eligibility before and after their first SABA claim (index SABA), an asthma diagnosis before through 60 days postindex, and either one additional SABA or at least 1 maintenance fill(s) were included. SABA claims postindex (including index fill) were grouped as follows: low: index only; medium: 2 to 3 canisters per year; and high: 4 or more canisters per year. Differences in SABA exposure with respect to disease severity groups and severe asthma exacerbations (hospitalizations, emergency visits, or outpatient systemic corticosteroids) were analyzed by analysis of variance and χ2 (significance, P ≤ .05). RESULTS A total of 135,540 patients were included: 62.8% women; mean (SD) age, 40.9 (18.3) years; SABA fills per 12-months postindex: 3.0(2.7). Furthermore, 28% of patients filled 1 SABA, 47% 2 to 3, and 25% 4 or more canisters per year. Despite higher maintenance medication possession ratio with increasing SABA (low, 0.53 (0.37); medium, 0.59 (0.35); high, 0.66 (0.32)), annual exacerbation rate per person per year and percent of patients within each SABA group having at least 1 exacerbation rose as SABA fills increased (low, 1.00 (1.45), 45.8%; medium, 1.20 (1.62), 54.3%; high, 1.50 (1.94), 58.7%). Mean SABA fills differed between patients with 0 exacerbation, 2.8 (2.6); 1 exacerbation, 2.9 (2.5); and 2 or more exacerbations, 3.3 (2.9). CONCLUSION Exacerbation risk increased with increasing SABA fills. Management strategies ensuring adequate anti-inflammatory therapy delivered to the airways when symptoms occur may be needed to mitigate asthma morbidity.
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Affiliation(s)
- Njira Lugogo
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, Michigan
| | - Ileen Gilbert
- BioPharmaceuticals Medical - USA, AstraZeneca, Wilmington, Delaware.
| | - Joseph Tkacz
- Life Sciences, IBM Watson Health, Cambridge, Massachusetts
| | - Hitesh Gandhi
- BioPharmaceuticals Medical - USA, AstraZeneca, Wilmington, Delaware
| | - Nadia Goshi
- BioPharmaceuticals Global Medicines Development - US, AstraZeneca, Wilmington, DE
| | - Miguel J Lanz
- Allergy and Asthma, AAADRS Clinical Research Center, Coral Gables, Florida
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Rogliani P, Ritondo BL, Cavalli F, Giorgino F, Girolami A, Pane G, Pezzuto G, Zerillo B, Puxeddu E, Ora J. Synergy across the drugs approved for the treatment of asthma. Minerva Med 2021; 113:17-30. [PMID: 33496162 DOI: 10.23736/s0026-4806.21.07266-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Inhaled corticosteroids are the cornerstone for the treatment of stable asthma, however, when disease severity increases, escalating therapy to combinations of drugs acting on distinct signalling pathways is required. It is advantageous to providing evidence of a synergistic interaction across drug combinations, as it allows optimizing bronchodilation while lowering the dose of single agents. In the respiratory pharmacology field, two statistical models are accepted as gold standard to characterize drug interactions, namely the Bliss Independence criterion and the Unified Theory. In this review, pharmacological interactions across drugs approved for the treatment of asthma have been systematically assessed. EVIDENCE ACQUISITION A comprehensive literature search was performed in MEDLINE for studies that used a validated pharmacological method for assessing drug interaction. The results were extracted and reported via qualitative synthesis. EVIDENCE SYNTHESIS Overall, 45 studies were identified from literature search and 5 met the inclusion criteria. Current evidence coming from ex vivo models of asthma indicates that drug combinations modulating bronchial contractility induce a synergistic bronchorelaxant effect. In murine models of lung inflammation, the combination between inhaled corticosteroids and β2- adrenoceptor agonists synergistically improve lung function and the inflammatory profile. CONCLUSIONS There is still limited knowledge regarding the mechanistic basis underlying pharmacological interactions across drugs approved for asthma. The synergism elicited by combined agents is an effect of class. Specifically designed clinical trials are needed to confirm the results coming from preclinical evidence, but also to establish the minimal dose for combined agents to induce a synergistic interaction and maximize bronchodilation.
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Affiliation(s)
- Paola Rogliani
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome Tor Vergata, Rome, Italy - .,Division of Respiratory Medicine, University Hospital Policlinico Tor Vergata, Rome, Italy -
| | - Beatrice L Ritondo
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Francesco Cavalli
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Federica Giorgino
- Division of Respiratory Medicine, University Hospital Policlinico Tor Vergata, Rome, Italy
| | - Andrea Girolami
- Division of Respiratory Medicine, University Hospital Policlinico Tor Vergata, Rome, Italy
| | - Gloria Pane
- Division of Respiratory Medicine, University Hospital Policlinico Tor Vergata, Rome, Italy
| | - Gabriella Pezzuto
- Division of Respiratory Medicine, University Hospital Policlinico Tor Vergata, Rome, Italy
| | - Bartolomeo Zerillo
- Division of Respiratory Medicine, University Hospital Policlinico Tor Vergata, Rome, Italy
| | - Ermanno Puxeddu
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome Tor Vergata, Rome, Italy.,Division of Respiratory Medicine, University Hospital Policlinico Tor Vergata, Rome, Italy
| | - Josuel Ora
- Division of Respiratory Medicine, University Hospital Policlinico Tor Vergata, Rome, Italy
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Bianco A, Contoli M, Di Marco F, Saverio Mennini F, Papi A. As-needed anti-inflammatory reliever therapy for asthma management: evidence and practical considerations. Clin Exp Allergy 2020; 51:873-882. [PMID: 33247470 DOI: 10.1111/cea.13795] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 11/18/2020] [Accepted: 11/22/2020] [Indexed: 01/31/2023]
Abstract
Asthma is a chronic respiratory disease in which airway inflammation is a key feature, even in the milder expressions of the disease. The conventional pharmacological approach to mild asthma has long relied on reliever therapy with as-needed short-acting beta-agonists (SABAs), while anti-inflammatory maintenance with inhaled corticosteroids (ICSs) has been reserved for patients with more persistent asthma. Poor adherence to maintenance treatment is an important issue in asthma management, and can partly explain suboptimal symptom control. Over-reliance on SABA bronchodilators for rapid symptom relief is common in real life and potentially leads to an increased risk of asthma morbidity and mortality. Combined anti-inflammatory and reliever medications in a single inhaler have the potential to overcome these limitations. Recent studies in patients with mild asthma have shown that anti-inflammatory reliever therapy with budesonide-formoterol, given on an as-needed basis, is superior to SABA in ensuring asthma control and non-inferior to budesonide maintenance therapy in preventing exacerbations. To address the implications of these important findings for the management of patients with asthma, Italian specialists convened at a series of meetings held during the second half of 2018 across Italy. This article presents their position on these topics and includes a review of the evidence supporting the use of anti-inflammatory reliever therapy in mild asthma and the implementation of this novel approach in clinical practice.
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Affiliation(s)
- Andrea Bianco
- Department of Translational Medical Sciences, University of Campania "L. Vanvitelli", Naples, Italy
| | - Marco Contoli
- Respiratory Medicine, CEMICEF, University of Ferrara, Ferrara, Italy
| | - Fabiano Di Marco
- Department of Health Sciences, Università degli Studi di Milano, Respiratory Unit, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Francesco Saverio Mennini
- CEIS-Economic Evaluation and HTA (EEHTA), Faculty of Economics, University of Rome "Tor Vergata", Rome, Italy.,Institute for Leadership and Management in Health, Kingston University London, London, UK
| | - Alberto Papi
- Respiratory Medicine, CEMICEF, University of Ferrara, Ferrara, Italy
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Hoffman E, Murnane D, Hutter V. Investigating the Suitability of High Content Image Analysis as a Tool to Assess the Reversibility of Foamy Alveolar Macrophage Phenotypes In Vitro. Pharmaceutics 2020; 12:pharmaceutics12030262. [PMID: 32183061 PMCID: PMC7150967 DOI: 10.3390/pharmaceutics12030262] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 03/03/2020] [Accepted: 03/11/2020] [Indexed: 01/19/2023] Open
Abstract
Many potential inhaled medicines fail during development due to the induction of a highly vacuolated or “foamy” alveolar macrophage phenotype response in pre-clinical studies. There is limited understanding if this response to an inhaled stimulus is adverse or adaptive, and additionally if it is a transient or irreversible process. The aim of this study was to evaluate whether high content image analysis could distinguish between different drug-induced foamy macrophage phenotypes and to determine the extent of the reversibility of the foamy phenotypes by assessing morphological changes over time. Alveolar-like macrophages derived from the human monocyte cell line U937 were exposed for 24 h to compounds known to induce a foamy macrophage phenotype (amiodarone, staurosporine) and control compounds that are not known to cause a foamy macrophage phenotype in vitro (fluticasone and salbutamol). Following drug stimulation, the cells were rested in drug-free media for the subsequent 24 or 48 h. Cell morphometric parameters (cellular and nuclear area, vacuoles numbers and size) and phospholipid content were determined using high content image analysis. The foamy macrophage recovery was dependent on the mechanism of action of the inducer compound. Amiodarone toxicity was associated with phospholipid accumulation and morphometric changes were reversed when the stimulus was removed from culture environment. Conversely cells were unable to recover from exposure to staurosporine which initiates the apoptosis pathway. This study shows that high content analysis can discriminate between different phenotypes of foamy macrophages and may contribute to better decision making in the process of new drug development.
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Pizzichini MMM, Carvalho-Pinto RMD, Cançado JED, Rubin AS, Cerci Neto A, Cardoso AP, Cruz AA, Fernandes ALG, Blanco DC, Vianna EO, Cordeiro Junior G, Rizzo JA, Fritscher LG, Caetano LSB, Pereira LFF, Rabahi MF, Oliveira MAD, Lima MA, Almeida MBD, Stelmach R, Pitrez PM, Cukier A. 2020 Brazilian Thoracic Association recommendations for the management of asthma. J Bras Pneumol 2020; 46:e20190307. [PMID: 32130345 PMCID: PMC7462684 DOI: 10.1590/1806-3713/e20190307] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 12/07/2019] [Indexed: 02/06/2023] Open
Abstract
The pharmacological management of asthma has changed considerably in recent decades, as it has come to be understood that it is a complex, heterogeneous disease with different phenotypes and endotypes. It is now clear that the goal of asthma treatment should be to achieve and maintain control of the disease, as well as to minimize the risks (of exacerbations, disease instability, accelerated loss of lung function, and adverse treatment effects). That requires an approach that is personalized in terms of the pharmacological treatment, patient education, written action plan, training in correct inhaler use, and review of the inhaler technique at each office visit. A panel of 22 pulmonologists was invited to perform a critical review of recent evidence of pharmacological treatment of asthma and to prepare this set of recommendations, a treatment guide tailored to use in Brazil. The topics or questions related to the most significant changes in concepts, and consequently in the management of asthma in clinical practice, were chosen by a panel of experts. To formulate these recommendations, we asked each expert to perform a critical review of a topic or to respond to a question, on the basis of evidence in the literature. In a second phase, three experts discussed and structured all texts submitted by the others. That was followed by a third phase, in which all of the experts reviewed and discussed each recommendation. These recommendations, which are intended for physicians involved in the treatment of asthma, apply to asthma patients of all ages.
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Affiliation(s)
| | - Regina Maria de Carvalho-Pinto
- . Divisão de Pneumologia, Instituto do Coração - InCor - Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | | | - Adalberto Sperb Rubin
- . Universidade Federal de Ciências da Saúde de Porto Alegre - UFCSPA - Porto Alegre (RS) Brasil
- . Santa Casa de Misericórdia de Porto Alegre, Porto Alegre (RS) Brasil
| | - Alcindo Cerci Neto
- . Universidade Estadual de Londrina - UEL - Londrina (PR) Brasil
- . Pontifícia Universidade Católica do Paraná - PUCPR - Londrina (PR) Brasil
| | | | - Alvaro Augusto Cruz
- . Universidade Federal da Bahia - UFBA - Salvador (BA) Brasil
- . Fundação ProAR, Salvador (BA) Brasil
| | | | - Daniella Cavalet Blanco
- . Escola de Medicina, Pontifícia Universidade Católica do Rio Grande do Sul - PUCRS - Porto Alegre (RS), Brasil
| | - Elcio Oliveira Vianna
- . Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto (SP) Brasil
| | - Gediel Cordeiro Junior
- . Pontifícia Universidade Católica de Minas Gerais, Belo Horizonte (MG), Brasil
- . Hospital Júlia Kubitschek, Belo Horizonte (MG), Brasil
| | | | - Leandro Genehr Fritscher
- . Escola de Medicina, Pontifícia Universidade Católica do Rio Grande do Sul - PUCRS - Porto Alegre (RS), Brasil
| | | | | | - Marcelo Fouad Rabahi
- . Faculdade de Medicina, Universidade Federal de Goiás - UFG - Goiânia (GO) Brasil
| | | | | | | | - Rafael Stelmach
- . Divisão de Pneumologia, Instituto do Coração - InCor - Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | | | - Alberto Cukier
- . Divisão de Pneumologia, Instituto do Coração - InCor - Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
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Abegaz TM, Shegena EA, Gessie NF, Gebreyohannes EA, Seid MA. Barriers to and competency with the use of metered dose inhaler and its impact on disease control among adult asthmatic patients in Ethiopia. BMC Pulm Med 2020; 20:48. [PMID: 32085726 PMCID: PMC7035747 DOI: 10.1186/s12890-020-1081-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 02/07/2020] [Indexed: 12/21/2022] Open
Abstract
Background Asthma is one of the chronic diseases which affects the airway, and inhalers are the preferred medications to treat this problem. Improper inhalational technique leads to decreased efficacy of the medication by reducing its deposition in the lungs. The aim of this study was to assess the barriers to and competency with the use of Metered Dose Inhaler (MDI) and its impact on disease control among adult asthmatic patients. Methods A prospective cross-sectional study was conducted in University of Gondar comprehensive specialized hospital outpatient department (OPD) chronic follow up from 12-March-2018 to 15-May- 2018. Patients were interviewed face to face with questions which determined their competency, asthma control level and barriers for inhaler use. Result Overall, 307 asthmatic patients were included in the study. More than half of participants were females, 170 (55.4%) and lived in urban area 185 (60.3%). The mean age of the respondents was 51.77 years with a standard deviation of ±15.40. The cost of medication, 282 (91.9%) and the perception that medication should be used in response to symptoms but not on a regular basis 277 (90.2%) were the most identified barriers. Only 56 (18.2%) were competent for Metered Dose Inhaler use (MDIU) and 17 (5.5%) patients had well controlled asthma. Being not competent AOR 0.168[0.41–0.687] was one of the factors decreasing asthma control. Conclusion Generally from this study, cost of the medication and the perception that medication should be used only for symptoms were the major identified barriers that affect the MDI use among asthmatic patients. Patients show very poor competence to their MDI which in turn led to poor asthma control. So, patients need to be taught the correct inhaler technique in the hospital and pharmacy while they came for follow up every time.
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Affiliation(s)
- Tadesse Melaku Abegaz
- University of South Australia, School of Pharmacy and Medical Sciences, Adelaide, Australia.
| | - Efrata Ashuro Shegena
- University of Gondar, College of Medicine and Health Sciences, School of Pharmacy, Gondar, Ethiopia
| | - Natnael Fentie Gessie
- University of Gondar, College of Medicine and Health Sciences, School of Pharmacy, Gondar, Ethiopia
| | | | - Mohammed Assen Seid
- University of Gondar, College of Medicine and Health Sciences, School of Pharmacy, Gondar, Ethiopia
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28
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Whittaker HR, Jarvis D, Sheikh MR, Kiddle SJ, Quint JK. Inhaled corticosteroids and FEV 1 decline in chronic obstructive pulmonary disease: a systematic review. Respir Res 2019; 20:277. [PMID: 31801539 PMCID: PMC6894275 DOI: 10.1186/s12931-019-1249-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 11/25/2019] [Indexed: 12/18/2022] Open
Abstract
Rate of FEV1 decline in COPD is heterogeneous and the extent to which inhaled corticosteroids (ICS) influence the rate of decline is unclear. The majority of previous reviews have investigated specific ICS and non-ICS inhalers and have consisted of randomised control trials (RCTs), which have specific inclusion and exclusion criteria and short follow up times. We aimed to investigate the association between change in FEV1 and ICS-containing medications in COPD patients over longer follow up times. MEDLINE and EMBASE were searched and literature comparing change in FEV1 in COPD patients taking ICS-containing medications with patients taking non-ICS-containing medications were identified. Titles, abstract, and full texts were screened and information extracted using the PICO checklist. Risk of bias was assessed using the Cochrane Risk of Bias tool and a descriptive synthesis of the literature was carried out due to high heterogeneity of included studies. Seventeen studies met our inclusion criteria. We found that the difference in change in FEV1 in people using ICS and non-ICS containing medications depended on the study follow-up time. Shorter follow-up studies (1 year or less) were more likely to report an increase in FEV1 from baseline in both patients on ICS and in patients on non-ICS-containing medications, with the majority of these studies showing a greater increase in FEV1 in patients on ICS-containing medications. Longer follow-up studies (greater than 1 year) were more likely to report a decline in FEV1 from baseline in patients on ICS and in patients on non-ICS containing medications but rates of FEV1 decline were similar. Further studies are needed to better understand changes in FEV1 when ICS-containing medications are prescribed and to determine whether ICS-containing medications influence rate of decline in FEV1 in the long term. Results from inclusive trials and observational patient cohorts may provide information more generalisable to a population of COPD patients.
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Affiliation(s)
- Hannah R Whittaker
- National Heart and Lung Institute, Imperial College London, Emmanuel Kaye Building, 1b Manresa Road, London, SW3 6LR, UK.
| | - Debbie Jarvis
- National Heart and Lung Institute, Imperial College London, Emmanuel Kaye Building, 1b Manresa Road, London, SW3 6LR, UK
| | - Mohamed R Sheikh
- National Heart and Lung Institute, Imperial College London, Emmanuel Kaye Building, 1b Manresa Road, London, SW3 6LR, UK
| | | | - Jennifer K Quint
- National Heart and Lung Institute, Imperial College London, Emmanuel Kaye Building, 1b Manresa Road, London, SW3 6LR, UK
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Fluticasone propionate/salmeterol (Wixela® Inhub®) dry-powder inhaler in asthma and COPD: a profile of its use in the USA. DRUGS & THERAPY PERSPECTIVES 2019. [DOI: 10.1007/s40267-019-00686-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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30
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Zappia CD, Soto A, Granja‐Galeano G, Fenoy I, Fernandez N, Davio CA, Shayo C, Fitzsimons CP, Goldman A, Monczor F. Azelastine potentiates antiasthmatic dexamethasone effect on a murine asthma model. Pharmacol Res Perspect 2019; 7:e00531. [PMID: 31687162 PMCID: PMC6818730 DOI: 10.1002/prp2.531] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 08/14/2019] [Accepted: 08/15/2019] [Indexed: 12/03/2022] Open
Abstract
Glucocorticoids are among the most effective drugs to treat asthma. However, the severe adverse effects associated generate the need for its therapeutic optimization. Conversely, though histamine is undoubtedly related to asthma development, there is a lack of efficacy of antihistamines in controlling its symptoms, which prevents their clinical application. We have reported that antihistamines potentiate glucocorticoids' responses in vitro and recent observations have indicated that the coadministration of an antihistamine and a synthetic glucocorticoid has synergistic effects on a murine model of allergic rhinitis. Here, the aim of this work is to establish if this therapeutic combination could be beneficial in a murine model of asthma. We used an allergen-induced model of asthma (employing ovalbumin) to evaluate the effects of the synthetic glucocorticoid dexamethasone combined with the antihistamine azelastine. Our results indicate that the cotreatment with azelastine and a suboptimal dose of dexamethasone can improve allergic lung inflammation as shown by a decrease in eosinophils in bronchoalveolar lavage, fewer peribronchial and perivascular infiltrates, and mucin-producing cells. In addition, serum levels of allergen-specific IgE and IgG1 were also reduced, as well as the expression of lung inflammatory-related genes IL-4, IL-5, Muc5AC, and Arginase I. The potentiation of dexamethasone effects by azelastine could allow to reduce the effective glucocorticoid dose needed to achieve a therapeutic effect. These findings provide first new insights into the potential benefits of glucocorticoids and antihistamines combination for the treatment of asthma and grants further research to evaluate this approach in other related inflammatory conditions.
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Affiliation(s)
- Carlos D. Zappia
- Facultad de Farmacia y BioquímicaUniversidad de Buenos AiresBuenos AiresArgentina
- Instituto de Investigaciones Farmacológicas (ININFA)CONICET – Universidad de Buenos AiresBuenos AiresArgentina
| | - Ariadna Soto
- Centro de Estudios en Salud y Medio Ambiente (CESyMA)Escuela de Ciencia y TecnologíaUniversidad Nacional de San Martín – CONICETBuenos AiresArgentina
| | - Gina Granja‐Galeano
- Facultad de Farmacia y BioquímicaUniversidad de Buenos AiresBuenos AiresArgentina
- Instituto de Investigaciones Farmacológicas (ININFA)CONICET – Universidad de Buenos AiresBuenos AiresArgentina
| | - Ignacio Fenoy
- Centro de Estudios en Salud y Medio Ambiente (CESyMA)Escuela de Ciencia y TecnologíaUniversidad Nacional de San Martín – CONICETBuenos AiresArgentina
| | - Natalia Fernandez
- Facultad de Farmacia y BioquímicaUniversidad de Buenos AiresBuenos AiresArgentina
- Instituto de Investigaciones Farmacológicas (ININFA)CONICET – Universidad de Buenos AiresBuenos AiresArgentina
| | - Carlos A. Davio
- Facultad de Farmacia y BioquímicaUniversidad de Buenos AiresBuenos AiresArgentina
- Instituto de Investigaciones Farmacológicas (ININFA)CONICET – Universidad de Buenos AiresBuenos AiresArgentina
| | - Carina Shayo
- Laboratorio de Patología y Farmacología MolecularInstituto de Biología y Medicina Experimental CONICETBuenos AiresArgentina
| | - Carlos P. Fitzsimons
- Center for NeuroscienceSwammerdam Institute for Life SciencesFaculty of ScienceUniversity of AmsterdamAmsterdamThe Netherlands
| | - Alejandra Goldman
- Centro de Estudios en Salud y Medio Ambiente (CESyMA)Escuela de Ciencia y TecnologíaUniversidad Nacional de San Martín – CONICETBuenos AiresArgentina
| | - Federico Monczor
- Facultad de Farmacia y BioquímicaUniversidad de Buenos AiresBuenos AiresArgentina
- Instituto de Investigaciones Farmacológicas (ININFA)CONICET – Universidad de Buenos AiresBuenos AiresArgentina
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31
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Abstract
Airway inflammation is a major contributing factor in both asthma and chronic obstructive pulmonary disease (COPD) and represents an important target for treatment. Inhaled corticosteroids (ICS) as monotherapy or in combination therapy with long-acting β2-agonists or long-acting muscarinic antagonists are used extensively in the treatment of asthma and COPD. The development of ICS for their anti-inflammatory properties progressed through efforts to increase topical potency and minimise systemic potency and through advances in inhaled delivery technology. Budesonide is a potent, non-halogenated ICS that was developed in the early 1970s and is now one of the most widely used lung medicines worldwide. Inhaled budesonide's physiochemical and pharmacokinetic/pharmacodynamic properties allow it to reach a rapid and high airway efficacy due to its more balanced relationship between water solubility and lipophilicity. When absorbed from the airways and lung tissue, its moderate lipophilicity shortens systemic exposure, and its unique property of intracellular esterification acts like a sustained release mechanism within airway tissues, contributing to its airway selectivity and a low risk of adverse events. There is a large volume of clinical evidence supporting the efficacy and safety of budesonide, both alone and in combination with the fast- and long-acting β2-agonist formoterol, as maintenance therapy in patients with asthma and with COPD. The combination of budesonide/formoterol can also be used as an as-needed reliever with anti-inflammatory properties, with or without regular maintenance for asthma, a novel approach that is already approved by some country-specific regulatory authorities and currently recommended in the Global Initiative for Asthma (GINA) guidelines. Budesonide remains one of the most well-established and versatile of the inhaled anti-inflammatory drugs. This narrative review provides a clinical reappraisal of the benefit:risk profile of budesonide in the management of asthma and COPD.
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Affiliation(s)
- Donald P Tashkin
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, 10833 Le Conte Avenue, Los Angeles, CA, 90095-1690, USA.
| | - Brian Lipworth
- Scottish Centre for Respiratory Research, Division of Molecular and Clinical Medicine, Ninewells Hospital and Medical School, Dundee, UK
| | - Ralph Brattsand
- Experimental Pharmacology, Budera Company, Kristinehamn, Sweden
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Lal C, Strange C. Evaluating fluticasone furoate + vilanterol for the treatment of chronic obstructive pulmonary disease (COPD). Expert Opin Pharmacother 2019; 20:1075-1085. [PMID: 30983423 DOI: 10.1080/14656566.2019.1603292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Inhaled corticosteroid/long-acting β-2 agonists (ICS/LABA) combination inhalers have been a lifeline for a generation of chronic obstructive pulmonary disease (COPD) and asthma patients. Fluticasone furoate and Vilanterol (FF/VI) as a once-daily ICS/LABA combination have an extensive clinical trial and real-world data to support its use in COPD patients. Areas covered: The authors provide pharmacological profiles of fluticasone furoate, vilanterol and the FF/VI fixed dose combination. Salient clinical trials evaluating efficacy and safety of the FF/VI combination, and studies demonstrating the impact on COPD exacerbation risk and mortality are also discussed. Expert opinion: ICS/LABA combinations provide bronchodilation and decrease the frequency of COPD exacerbations. Individualizing treatment of each COPD patient based on unique phenotypes will maximize chances of therapeutic responsiveness. Asthma-COPD overlap (ACO), patients with sputum and/or blood eosinophilia, patients with a brisk bronchodilator response, and patients with frequent exacerbations are more likely to show a therapeutic response to ICS than populations who have none of these features. FF/VI will likely remain a popular ICS/LBA combination to treat COPD, as a once-daily inhaled therapy delivered via the Ellipta device popular with COPD patients, with extensive clinical trial and real-world data to support its use.
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Affiliation(s)
- Chitra Lal
- a Pulmonary, Critical Care, Allergy and Sleep Medicine , Medical University of South Carolina , Charleston , SC , USA
| | - Charlie Strange
- a Pulmonary, Critical Care, Allergy and Sleep Medicine , Medical University of South Carolina , Charleston , SC , USA
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Backer V, Ellery A, Borzova S, Lane S, Kleiberova M, Bengtsson P, Tomala T, Basset-Stheme D, Bennett C, Lindner D, Meiners A, Overend T. Non-interventional study of the safety and effectiveness of fluticasone propionate/formoterol fumarate in real-world asthma management. Ther Adv Respir Dis 2019; 12:1753466618796987. [PMID: 30232933 PMCID: PMC6149027 DOI: 10.1177/1753466618796987] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Introduction: In recognition of the value of long-term real-world data, a postauthorization
safety study of the inhaled corticosteroid (ICS) fluticasone propionate and
long-acting β2-agonist (LABA) formoterol fumarate
(fluticasone/formoterol; Flutiform®) was conducted. Methods: This was a 12-month observational study of outpatients with asthma aged ⩾ 12
years in eight European countries. Patients were prescribed
fluticasone/formoterol according to the licensed indication, and
independently of their subsequent enrolment in the study. They were then
treated according to local standard practice. The study objectives were to
evaluate the safety and effectiveness of fluticasone/formoterol under
real-world conditions. Results: The safety population for this study comprised 2539 patients (mean age 47.7
years; 94.3% aged ⩾ 18 years; 63.4% female). Most patients (1538/2539,
60.6%) had switched to fluticasone/formoterol from another ICS/LABA,
primarily due to lack of efficacy (1150/2539, 45.3%). Three quarters (77.4%)
of patients were treated for 12 months, and 80.6% continued
fluticasone/formoterol treatment after the study. Adverse events (AEs)
occurred in 60.0% patients, and 10.2% had AEs considered possibly related to
fluticasone/formoterol [most commonly asthma exacerbation (2.0% patients),
dysphonia (1.8%) and cough (1.1%)]. Thirty-six severe AEs, but no serious
AEs, were considered possibly related to fluticasone/formoterol. The
proportion of patients with controlled asthma (based on Asthma Control Test
score ⩾ 20) increased from 29.4% at baseline to 67.4% at study end (last
observation carried forward). The proportion of patients experiencing at
least one severe exacerbation decreased from 35.8% in the year prior to
enrolment to 9.8% during the study. Improvements from baseline to study end
were also observed in Asthma Quality of Life scores and physician/patient
reports of satisfaction with treatment. Conclusion: In this real-world postauthorization safety study, fluticasone/formoterol
demonstrated a safety profile consistent with that seen in controlled
clinical trials, with effectiveness in improving asthma control.
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Affiliation(s)
- Vibeke Backer
- Department of Respiratory Medicine, Bispebjerg University Hospital, Copenhagen, Denmark
| | - Adam Ellery
- Cape Cornwall Surgery, Penzance, Cornwall, UK St. Just
| | | | - Stephen Lane
- Professorial Respiratory Centre, Tallaght Hospital, Dublin, Ireland
| | | | | | | | | | - Carla Bennett
- Mundipharma Research Limited, Cambridge Science Park, Milton Rd, Cambridge, CB4 0GW UK
| | - Dirk Lindner
- Mundipharma Research GmbH and Co. KG, Limburg, Germany
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Lee MK, Choi JW, Choi YH, Nam TJ. Pyropia yezoensis Protein Prevents Dexamethasone-Induced Myotube Atrophy in C2C12 Myotubes. Mar Drugs 2018; 16:md16120497. [PMID: 30544821 PMCID: PMC6316211 DOI: 10.3390/md16120497] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Revised: 11/28/2018] [Accepted: 12/06/2018] [Indexed: 12/21/2022] Open
Abstract
Glucocorticoids (GCs), which are endocrine hormones released under stress conditions, can cause skeletal muscle atrophy. This study investigated whether Pyropia yezoensis crude protein (PYCP) inhibits synthetic GCs dexamethasone (DEX)-induced myotube atrophy associated with proteolytic systems. Mouse skeletal muscle C2C12 myotubes were treated with DEX in the presence or absence of PYCP. DEX exposure (100 μM) for 24 h significantly decreased myotube diameter and myogenin expression, which were all increased by treatment with 20 and 40 μg/mL PYCP. Additionally, PYCP significantly reduced the nuclear expression of the forkhead box transcription factors, FoxO1 and FoxO3a, and ubiquitin-proteasome pathway activation. Further mechanistic research revealed that PYCP inhibited the autophagy-lysosome pathway in DEX-induced C2C12 myotubes. These findings indicate that PYCP prevents DEX-induced myotube atrophy through the regulation of FoxO transcription factors, followed by the inhibition of the ubiquitin-proteasome and autophagy-lysosome pathways. Therefore, we suggest that inhibiting these two proteolytic processes with FoxO transcription factors is a promising strategy for preventing DEX-related myotube atrophy.
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Affiliation(s)
- Min-Kyeong Lee
- Institute of Fisheries Sciences, Pukyong National University, Busan 46041, Korea.
| | - Jeong-Wook Choi
- Institute of Fisheries Sciences, Pukyong National University, Busan 46041, Korea.
| | - Youn Hee Choi
- Institute of Fisheries Sciences, Pukyong National University, Busan 46041, Korea.
- Department of Marine Bio-Materials & Aquaculture, Pukyong National University, Busan 48513, Korea.
| | - Taek-Jeong Nam
- Institute of Fisheries Sciences, Pukyong National University, Busan 46041, Korea.
- Department of Food Science and Nutrition, Pukyong National University, Busan 48513, Korea.
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35
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OK-432 Acts as Adjuvant to Modulate T Helper 2 Inflammatory Responses in a Murine Model of Asthma. J Immunol Res 2018; 2018:1697276. [PMID: 30402504 PMCID: PMC6196917 DOI: 10.1155/2018/1697276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 09/10/2018] [Indexed: 11/28/2022] Open
Abstract
Enhanced type 2 helper T (Th2) cell responses to inhaled harmless allergens are strongly associated with the development of allergic diseases. Antigen formulated with an appropriate adjuvant can elicit suitable systemic immunity to protect individuals from disease. Although much has been learned about Th1-favored immunomodulation of OK-432, a streptococcal preparation with antineoplastic activity, little is known about its adjuvant effect for allergic diseases. Herein, we demonstrate that OK-432 acts as an adjuvant to favor a systemic Th1 polarization with an elevation in interferon- (IFN-) γ and ovalbumin- (OVA-) immunoglobulin (Ig) G2a. Prior vaccination with OK-432 formulated against OVA attenuated lung eosinophilic inflammation and Th2 cytokine responses that were caused by challenging with OVA through the airway. This vaccination with OK-432 augmented the ratios of IFN-γ/interleukin- (IL-) 4 cytokine and IgG2a/IgG1 antibody compared to the formulation with Th2 adjuvant aluminum hydroxide (Alum) or antigen only. The results obtained in this study lead us to propose a potential novel adjuvant for clinical use such as prophylactic vaccination for pathogens and immunotherapy in atopic diseases.
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36
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Pyropia yezoensis Protein Supplementation Prevents Dexamethasone-Induced Muscle Atrophy in C57BL/6 Mice. Mar Drugs 2018; 16:md16090328. [PMID: 30208614 PMCID: PMC6163250 DOI: 10.3390/md16090328] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Revised: 09/05/2018] [Accepted: 09/09/2018] [Indexed: 12/29/2022] Open
Abstract
We investigated the protective effects of Pyropia yezoensis crude protein (PYCP) against dexamethasone (DEX)-induced myotube atrophy and its underlying mechanisms. DEX (3 mg/kg body weight, intraperitoneal injection) and PYCP (150 and 300 mg/kg body weight, oral) were administrated to mice for 18 days, and the effects of PYCP on DEX-induced muscle atrophy were evaluated. Body weight, calf thickness, and gastrocnemius and tibialis anterior muscle weight were significantly decreased by DEX administration (p < 0.05), while PYCP supplementation effectively prevented the DEX-induced decrease in body weight, calf thickness, and muscle weight. PYCP supplementation also attenuated the DEX-induced increase in serum glucose, creatine kinase, and lactate dehydrogenase levels. Additionally, PYCP supplementation reversed DEX-induced muscle atrophy via the regulation of the insulin-like growth factor-I/protein kinase B/rapamycin-sensitive mTOR complex I/forkhead box O signaling pathway. The mechanistic investigation revealed that PYCP inhibited the ubiquitin-proteasome and autophagy-lysosome pathways in DEX-administrated C57BL/6 mice. These findings demonstrated that PYCP increased protein synthesis and decreased protein breakdown to prevent muscle atrophy. Therefore, PYCP supplementation appears to be useful for preventing muscle atrophy.
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37
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Panda L, Mabalirajan U. Recent Updates on Corticosteroid Resistance in Asthma. EUROPEAN MEDICAL JOURNAL 2018. [DOI: 10.33590/emj/10311987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Corticosteroids are one of the most effective medications available for a wide variety of inflammatory diseases, including rheumatoid arthritis, inflammatory bowel disease, autoimmune diseases, and chronic lung diseases such as asthma; however, 5–10% of asthma patients respond poorly to corticosteroids and require high doses, secondary immunosuppressants, such as calcineurin inhibitors and methotrexate, or disease-modifying biologics that can be toxic and/or expensive. Though steroid-resistant asthma affects a small percentage of patients, it consumes significant health resources and contributes to substantial morbidity and mortality. In addition, the side effects caused by excessive use of steroids dramatically impact patients’ quality of life. Recognition of patients who respond poorly to steroid therapy is important due to the persistent and considerable problems they face in managing their conditions, which bears a significant socioeconomic burden. Along with the recognition of such patients, elucidation of the molecular mechanisms of steroid resistance is equally important, so that administration of a high dosage of steroids, and the consequent adverse effects, can be avoided. This review provides an update on the mechanisms of steroid function and the possible new therapeutic modalities to treat steroid-resistant asthma.
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Affiliation(s)
- Lipsa Panda
- Molecular Pathobiology of Respiratory Diseases, Council of Scientific & Industrial Research (CSIR), Institute of Genomics and Integrative Biology, Delhi, India
| | - Ulaganathan Mabalirajan
- Molecular Pathobiology of Respiratory Diseases, Council of Scientific & Industrial Research (CSIR), Institute of Genomics and Integrative Biology, Delhi, India
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38
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Tashkin DP, Strange C. Inhaled corticosteroids for chronic obstructive pulmonary disease: what is their role in therapy? Int J Chron Obstruct Pulmon Dis 2018; 13:2587-2601. [PMID: 30214177 PMCID: PMC6118265 DOI: 10.2147/copd.s172240] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Inhaled corticosteroids (ICSs) are a mainstay of COPD treatment for patients with a history of exacerbations. Initial studies evaluating their use as monotherapy failed to show an effect on rate of pulmonary function decline in COPD, despite improvements in symptoms and reductions in exacerbations. Subsequently, ICS use in combination with long-acting β2-agonists (LABAs) was shown to provide improved reductions in exacerbations, lung function, and health status. ICS-LABA combination therapy is currently recommended for patients with a history of exacerbations despite treatment with long-acting bronchodilators alone. The presence of eosinophilic bronchial inflammation, detected by high blood eosinophil levels or a history of asthma or asthma-COPD overlap, may define a population of patients in whom ICSs may be of particular benefit. Prospective clinical studies to determine an appropriate threshold of eosinophil levels for predicting the beneficial effects of ICSs are needed. Further study is also required in COPD patients who continue to smoke to assess the impact of cell- and tissue-specific changes on ICS responsiveness. The safety profile of ICSs in COPD patients is confounded by comorbidities, age, and prior use of systemic corticosteroids. The risk of pneumonia in patients with COPD is increased, particularly with more advanced age and worse disease severity. ICS-containing therapy also has been shown to increase pneumonia risk; however, differences in study design and the definition of pneumonia events have led to substantial variability in risk estimates, and some data indicate that pneumonia risk may differ by the specific ICS used. In summary, treatment with ICSs has a role in dual and triple therapy for COPD to reduce exacerbations and improve symptoms. Careful assessment of COPD phenotypes related to risk factors, triggers, and comorbidities may assist in individualizing treatment while maximizing the benefit-to-risk ratio of ICS-containing COPD treatment.
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Affiliation(s)
- Donald P Tashkin
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, USA,
| | - Charlie Strange
- Department of Pulmonary and Critical Care Medicine, Medical University of South Carolina, Charleston, SC, USA
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Virchow JC, Poli G, Herpich C, Kietzig C, Ehlich H, Braeutigam D, Sommerer K, Häussermann S, Mariotti F. Lung Deposition of the Dry Powder Fixed Combination Beclometasone Dipropionate Plus Formoterol Fumarate Using NEXThaler ® Device in Healthy Subjects, Asthmatic Patients, and COPD Patients. J Aerosol Med Pulm Drug Deliv 2018; 31:269-280. [PMID: 29989511 PMCID: PMC6161336 DOI: 10.1089/jamp.2016.1359] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background: This study evaluated the lung deposition and the distribution pattern in the airways of a fixed combination of beclometasone dipropionate (BDP) and formoterol fumarate (FF) (100/6 μg) delivered as an extrafine dry powder formulation (mass median aerodynamic diameter, MMAD (μm) BDP = 1.5; FF = 1.4) through the NEXThaler® device in healthy subjects, asthmatics, and patients with COPD. Methods: Healthy subjects (n = 10), asthmatic patients (n = 9; 30%≤FEV1 < 80%), and COPD patients (n = 9; FEV1/FVC ≤70%, 30%≤FEV1 < 50%) completed this open-label, single administration (inhalation of four actuations) parallel group study. After inhalation of 99mTc-radiolabeled BDP/FF combination (radiolabeled BDP + unlabeled FF), the drug deposition was assessed using a gamma-scintigraphy technique. Patients' lung function was assessed. Results: No significant difference in drug deposition was observed between the three study groups. Mean lung deposition, extrathoracic deposition, and amount exhaled ranged, respectively, between 54.9% and 56.2%, between 41.8% and 43.2%, and between 1.6% and 3.3% of BDP emitted dose (71.7 ± 2.5 μg) for the three study groups. The central to peripheral ratio (reflecting the lung distribution pattern) ranged between 1.23 and 2.02 for the three study groups, indicating a distribution of the drug throughout the airways, including periphery. The study treatment produced a forced expiratory volume in one second (FEV1) increase over time, reaching a maximum improvement generally within 1–4 hours. Conclusions: The fixed extrafine dry powder combination BDP/FF (100/6 μg) administered through the DPI NEXThaler® achieved similar intrapulmonary deposition in healthy subjects, in asthmatic patients, and COPD patients (approximately 55% of emitted dose) irrespective of the underlying lung disease with a negligible amount of exhaled particles. The study showed high reliability of the device, reproducible dosing, and distribution throughout the lungs. The results supported the concept of efficient delivery of the combination to the target pulmonary regions, thanks to the extrafine formulation. FEV1 profile confirmed a relevant pharmacodynamic effect of the product.
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Affiliation(s)
| | - Gianluigi Poli
- 2 Global Clinical Development, Chiesi Farmaceutici S.p.A , Parma, Italy
| | | | | | | | | | | | | | - Fabrizia Mariotti
- 2 Global Clinical Development, Chiesi Farmaceutici S.p.A , Parma, Italy
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40
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Calzetta L, Matera MG, Facciolo F, Cazzola M, Rogliani P. Beclomethasone dipropionate and formoterol fumarate synergistically interact in hyperresponsive medium bronchi and small airways. Respir Res 2018; 19:65. [PMID: 29650006 PMCID: PMC5897944 DOI: 10.1186/s12931-018-0770-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Accepted: 04/02/2018] [Indexed: 12/15/2022] Open
Abstract
Background Corticosteroids increase the expression of β2-adrenoceptors (β2-ARs) and protect them against down-regulation. Conversely, β2-AR agonists improve the anti-inflammatory action of corticosteroids. Nevertheless, it is still uncertain whether adding a long-acting β2-AR agonist (LABA) to an inhaled corticosteroid (ICS) results in an additive effect, or there is true synergy. Therefore, the aim of this study was to pharmacologically characterize the interaction between the ICS beclomethasone diproprionate (BDP) and the LABA formoterol fumarate (FF) in a validated human ex vivo model of bronchial asthma. Methods Human medium and small airways were stimulated by histamine and treated with different concentrations of BDP and FF, administered alone and in combination at concentration-ratio reproducing ex vivo that of the currently available fixed-dose combination (FDC; BDP/FF 100:6 combination-ratio). Experiments were performed in non-sensitized (NS) and passively sensitized (PS) airways. The pharmacological interaction was assessed by using Bliss Independence and Unified Theory equations. Results BDP/FF synergistically increased the overall bronchorelaxation in NS and PS airways (+ 15.15% ± 4.02%; P < 0.05 vs. additive effect). At low-to-medium concentrations the synergistic interaction was greater in PS than in NS bronchioles (+ 16.68% ± 3.02% and + 7.27% ± 3.05%, respectively). In PS small airways a very strong synergistic interaction (Combination Index: 0.08; + 20.04% ± 2.18% vs. additive effect) was detected for the total concentrations of BDP/FF combination corresponding to 10.6 ng/ml. Conclusion BDP/FF combination synergistically relaxed human bronchi; the extent of such an interaction was very strong at low-to-medium concentrations in PS small airways. Trial registration Not applicable. Electronic supplementary material The online version of this article (10.1186/s12931-018-0770-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Luigino Calzetta
- Unit of Respiratory Medicine, Department of Experimental Medicine and Surgery, University of Rome "Tor Vergata", Via Montpellier 1, 00133, Rome, Italy
| | - Maria Gabriella Matera
- Unit of Pharmacology, Department of Experimental Medicine, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Francesco Facciolo
- Thoracic Surgery Unit, "Regina Elena" National Cancer Institute, Rome, Italy
| | - Mario Cazzola
- Unit of Respiratory Medicine, Department of Experimental Medicine and Surgery, University of Rome "Tor Vergata", Via Montpellier 1, 00133, Rome, Italy
| | - Paola Rogliani
- Unit of Respiratory Medicine, Department of Experimental Medicine and Surgery, University of Rome "Tor Vergata", Via Montpellier 1, 00133, Rome, Italy.
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41
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Pirożyński M, Hantulik P, Almgren-Rachtan A, Chudek J. Evaluation of the Efficiency of Single-Inhaler Combination Therapy with Budesonide/Formoterol Fumarate in Patients with Bronchial Asthma in Daily Clinical Practice. Adv Ther 2017; 34:2648-2660. [PMID: 29119403 PMCID: PMC5709454 DOI: 10.1007/s12325-017-0641-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Indexed: 11/02/2022]
Abstract
INTRODUCTION The effectiveness of single-inhaler budesonide/formoterol fumarate combination therapy for asthma has been previously shown for the original product. The aim of this nonrandomized, open-label, postauthorization efficacy study (PAES) real-life clinical assessment was to evaluate the clinical effectiveness of a second product (Bufomix Easyhaler®) in the daily clinical practice of asthma therapy. METHODS This multicenter PAES was conducted by 220 unselected allergologists and pulmonologists who enrolled 2200 adult outpatients (age 49.8 ± 17.9 years) with asthma treated with Bufomix Easyhaler® for at least 14 days before enrolment. Asthma control was assessed during three subsequent visits with 8-12-week intervals on the basis of the Asthma Control Test (ACT). Adherence was assessed with the Medication Adherence Questionnaire. In addition, patient satisfaction with Bufomix Easyhaler® was scored, and adverse drug reactions were recorded. RESULTS The percentage of patients with well-controlled asthma or total control of asthma (ACT score 20-25 points) increased from 46.6% at the first visit to 90.8% at the third visit (p < 0.001). In addition, the percentage of patients with poor control of asthma (ACT score less than 15 points) decreased from 14.9% to 1.2% (p < 0.001). The adherence rate increased from 88% at the first visit to 95.3% at the third visit. Patient satisfaction with the use of this dry powder inhaler increased with the duration of its use. Only one adverse drug reaction was reported. CONCLUSION The results obtained confirm the effectiveness of Bufomix Easyhaler® in the treatment of asthma in outpatient adults in daily clinical practice. FUNDING Orion Corporation.
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Affiliation(s)
- Michał Pirożyński
- Department of Allergology and Pulmonology, Postgraduate Centre for Medical Education, Warsaw, Poland
| | - Piotr Hantulik
- Medical Affairs, Orion Pharma Poland Co. Ltd, Warsaw, Poland
| | | | - Jerzy Chudek
- Department of Internal Medicine and Oncological Chemotherapy, Medical Faculty in Katowice, Medical University of Silesia, Katowice, Poland.
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Lo CY, Michaeloudes C, Bhavsar PK, Huang CD, Chang PJ, Wang CH, Kuo HP, Chung KF. Reduced suppressive effect of β 2-adrenoceptor agonist on fibrocyte function in severe asthma. Respir Res 2017; 18:194. [PMID: 29162108 PMCID: PMC5697384 DOI: 10.1186/s12931-017-0678-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Accepted: 11/13/2017] [Indexed: 12/16/2022] Open
Abstract
Background Patients with severe asthma have increased airway remodelling and elevated numbers of circulating fibrocytes with enhanced myofibroblastic differentiation capacity, despite being treated with high doses of corticosteroids, and long acting β2-adrenergic receptor (AR) agonists (LABAs). We determined the effect of β2-AR agonists, alone or in combination with corticosteroids, on fibrocyte function. Methods Non-adherent non-T cells from peripheral blood mononuclear cells isolated from healthy subjects and patients with non-severe or severe asthma were treated with the β2-AR agonist, salmeterol, in the presence or absence of the corticosteroid dexamethasone. The number of fibrocytes (collagen I+/CD45+ cells) and differentiating fibrocytes (α-smooth muscle actin+ cells), and the expression of CC chemokine receptor 7 and of β2-AR were determined using flow cytometry. The role of cyclic adenosine monophosphate (cAMP) was elucidated using the cAMP analogue 8-bromoadenosine 3′,5′-cyclic monophosphate (8-Br-cAMP) and the phosphodiesterase type IV (PDE4) inhibitor, rolipram. Results Salmeterol reduced the proliferation, myofibroblastic differentiation and CCR7 expression of fibrocytes from healthy subjects and non-severe asthma patients. Fibrocytes from severe asthma patients had a lower baseline surface β2-AR expression and were relatively insensitive to salmeterol but not to 8-Br-cAMP or rolipram. Dexamethasone increased β2-AR expression and enhanced the inhibitory effect of salmeterol on severe asthma fibrocyte differentiation. Conclusions Fibrocytes from patients with severe asthma are relatively insensitive to the inhibitory effects of salmeterol, an effect which is reversed by combination with corticosteroids. Electronic supplementary material The online version of this article (10.1186/s12931-017-0678-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Chun-Yu Lo
- Airway Disease Section, National Heart and Lung Institute, Imperial College London and Biomedical Research Unit, Royal Brompton Hospital, London, UK.,Department of Thoracic Medicine, Chang Gung Medical Foundation, Chang Gung University College of Medicine, Taipei, Taiwan
| | - Charalambos Michaeloudes
- Airway Disease Section, National Heart and Lung Institute, Imperial College London and Biomedical Research Unit, Royal Brompton Hospital, London, UK
| | - Pankaj K Bhavsar
- Airway Disease Section, National Heart and Lung Institute, Imperial College London and Biomedical Research Unit, Royal Brompton Hospital, London, UK. .,Airway Disease, National Heart and Lung Institute, Imperial College London, Dovehouse Street, London, SW3 6LY, UK.
| | - Chien-Da Huang
- Department of Thoracic Medicine, Chang Gung Medical Foundation, Chang Gung University College of Medicine, Taipei, Taiwan
| | - Po-Jui Chang
- Airway Disease Section, National Heart and Lung Institute, Imperial College London and Biomedical Research Unit, Royal Brompton Hospital, London, UK.,Department of Thoracic Medicine, Chang Gung Medical Foundation, Chang Gung University College of Medicine, Taipei, Taiwan
| | - Chun-Hua Wang
- Department of Thoracic Medicine, Chang Gung Medical Foundation, Chang Gung University College of Medicine, Taipei, Taiwan
| | - Han-Pin Kuo
- Department of Thoracic Medicine, Chang Gung Medical Foundation, Chang Gung University College of Medicine, Taipei, Taiwan
| | - Kian Fan Chung
- Airway Disease Section, National Heart and Lung Institute, Imperial College London and Biomedical Research Unit, Royal Brompton Hospital, London, UK
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Particle interactions of fluticasone propionate and salmeterol xinafoate detected with single particle aerosol mass spectrometry (SPAMS). Int J Pharm 2017; 532:218-228. [DOI: 10.1016/j.ijpharm.2017.08.113] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 08/23/2017] [Accepted: 08/24/2017] [Indexed: 11/22/2022]
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Inoue H, Niimi A, Matsumoto H, Ito I, Oguma T, Otsuka K, Takeda T, Nakaji H, Tajiri T, Iwata T, Nagasaki T, Mishima M. A 12-week, randomized, parallel-group, proof-of-concept study of tulobuterol patch and salmeterol inhaler as add-on therapy in adult-onset mild-to-moderate asthma. Clin Exp Pharmacol Physiol 2017; 44:21-29. [PMID: 27718262 DOI: 10.1111/1440-1681.12683] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Revised: 08/31/2016] [Accepted: 10/04/2016] [Indexed: 11/29/2022]
Abstract
Patch formulation of tulobuterol has been used in asthma treatment as a long-acting β2 -agonist (LABA) through sustained skin absorption. Its treatment efficacy, especially in small airways, remains poorly understood. The study aim was to investigate LABA add-on effects of tulobuterol patch (TP) and salmeterol inhaler (SA) on pulmonary function, asthma control and health status. Patients who had adult-onset under-control asthma, despite taking inhaled corticosteroids, were enrolled in a randomized, open-label, parallel-group, proof-of-concept study of 12-week add-on treatment with TP (n=16) or SA (n=17). Spirometry, impulse oscillometry (IOS), exhaled nitric oxide levels, and clinical questionnaires of asthma control, health status (St. George's Respiratory Questionnaire: SGRQ), and symptoms were evaluated every 4 weeks. Add-on treatment of SA significantly improved the spirometric indices of small airway obstruction (forced expiratory flow between 25% and 75% of FVC: FEF25-75 , and maximum expiratory flow at 25% of FVC: MEF25 ) and IOS indices of whole respiratory resistance (resistance at 5 Hz) as compared to TP. In intra-group comparisons, add-on treatment of TP improved the scores of the asthma control test and the total SGRQ, as well as the symptom and impact components of the SGRQ. SA add-on treatment improved FEV1 and IOS parameters of resistance at 20 Hz and reactance at 5 Hz. Neither of the treatments improved exhaled nitric oxide levels. In conclusion, add-on treatment of TP improved asthma control and health status, whereas SA improved pulmonary function measures associated with large and small airway involvement among patients with adult-onset mild-to-moderate asthma.
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Affiliation(s)
- Hideki Inoue
- Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Akio Niimi
- Department of Respiratory Medicine, Allergy and Clinical Immunology, Graduate School of Medical Sciences, Nagoya City University, Nagoya, Aichi, Japan
| | - Hisako Matsumoto
- Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Isao Ito
- Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Tsuyoshi Oguma
- Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kojiro Otsuka
- Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Tomoshi Takeda
- Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Hitoshi Nakaji
- Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Tomoko Tajiri
- Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Toshiyuki Iwata
- Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Tadao Nagasaki
- Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Michiaki Mishima
- Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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Abstract
Glucocorticosteroids are the most effective anti-inflammatory therapy for asthma but are relatively ineffective in COPD. Glucocorticoids are broad-spectrum anti-inflammatory drugs that suppress inflammation via several molecular mechanisms. Glucocorticoids suppress the multiple inflammatory genes that are activated in asthma by reversing histone acetylation of activated inflammatory genes through binding of ligand-bound glucocorticoid receptors (GR) to coactivator molecules and recruitment of histone deacetylase-2 (HDAC2) to the activated inflammatory gene transcription complex (trans-repression). At higher concentrations of glucocorticoids GR homodimers interact with DNA recognition sites to activate transcription through increased histone acetylation of anti-inflammatory genes and transcription of several genes linked to glucocorticoid side effects (trans-activation). Glucocorticoids also have post-transcriptional effects and decrease stability of some proinflammatory mRNAs. Decreased glucocorticoid responsiveness is found in patients with severe asthma and asthmatics who smoke, as well as in all patients with COPD. Several molecular mechanisms of glucocorticoid resistance have now been identified which involve phosphorylation and other post-translational modifications of GR. HDAC2 is markedly reduced in activity and expression as a result of oxidative/nitrative stress and pi3 kinase-δ inhibition, so that inflammation is resistant to the anti-inflammatory actions of glucocorticoids. Dissociated glucocorticoids and selective GR modulators which show improved trans-repression over trans-activation effects have been developed to reduce side effects, but so far it has been difficult to dissociate anti-inflammatory effects from adverse effects. In patients with glucocorticoid resistance alternative anti-inflammatory treatments are being investigated as well as drugs that may reverse the molecular mechanisms of glucocorticoid resistance.
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Yeh HW, Chen DR. In vitro release profiles of PLGA core-shell composite particles loaded with theophylline and budesonide. Int J Pharm 2017; 528:637-645. [PMID: 28619455 DOI: 10.1016/j.ijpharm.2017.06.032] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Revised: 05/31/2017] [Accepted: 06/12/2017] [Indexed: 10/19/2022]
Abstract
We investigated the effects of drug loading location, matrix material and shell thickness on the in vitro release of combinational drugs from core-shell PLGA (i.e., poly(lactic-co-glycolic acid)) particles. Budesonide and Theophylline were selected as highly hydrophobic and hydrophilic model drugs, respectively. The dual-capillary electrospray (ES) technique, operated at the cone-jet mode, was used to produce samples of drug-loaded core-shell composite particles with selected overall sizes, polymer materials, and shell thicknesses. Theophylline and Budesonide were loaded at different locations in a PLGA composite particle. This study illustrated how the aforementioned factors affect the release rates of Budesonide and Theophylline loaded in core-shell PLGA composites. We further identified that core-shell composite particles with both model drugs loaded in the core and with matrix PLGA polymers of low molecular weights and low LA/GA ratios are the best formulation for the sustained release of highly hydrophilic and hydrophobic active pharmaceutical ingredients from PLGA composite particles. The formulation strategy obtained in this study can be in principle generalized for biopharmaceutical applications in fixed-dose combination therapy.
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Affiliation(s)
- Hsi-Wei Yeh
- Department of Mechanical and Nuclear Engineering, Virginia Commonwealth University, Richmond, VA 23284, United States
| | - Da-Ren Chen
- Department of Mechanical and Nuclear Engineering, Virginia Commonwealth University, Richmond, VA 23284, United States.
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Dhillon S. Extrafine beclometasone dipropionate/formoterol fumarate metered-dose and dry-powder inhalers in asthma and chronic obstructive pulmonary disease: a profile of their use. DRUGS & THERAPY PERSPECTIVES 2017. [DOI: 10.1007/s40267-017-0397-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Ferraro M, Gjomarkaj M, Siena L, Di Vincenzo S, Pace E. Formoterol and fluticasone propionate combination improves histone deacetylation and anti-inflammatory activities in bronchial epithelial cells exposed to cigarette smoke. Biochim Biophys Acta Mol Basis Dis 2017; 1863:1718-1727. [PMID: 28483577 DOI: 10.1016/j.bbadis.2017.05.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Revised: 04/20/2017] [Accepted: 05/04/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND The addition of long-acting beta2-agonists (LABAs) to corticosteroids improves asthma control. Cigarette smoke exposure, increasing oxidative stress, may negatively affect corticosteroid responses. The anti-inflammatory effects of formoterol (FO) and fluticasone propionate (FP) in human bronchial epithelial cells exposed to cigarette smoke extracts (CSE) are unknown. AIMS This study explored whether FP, alone and in combination with FO, in human bronchial epithelial cellline (16-HBE) and primary bronchial epithelial cells (NHBE), counteracted some CSE-mediated effects and in particular some of the molecular mechanisms of corticosteroid resistance. METHODS 16-HBE and NHBE were stimulated with CSE, FP and FO alone or combined. HDAC3 and HDAC2 activity, nuclear translocation of GR and NF-κB, pERK1/2/tERK1/2 ratio, IL-8, TNF-α, IL-1β mRNA expression, and mitochondrial ROS were evaluated. Actin reorganization in neutrophils was assessed by fluorescence microscopy using the phalloidin method. RESULTS In 16-HBE, CSE decreased expression/activity of HDAC3, activity of HDAC2, nuclear translocation of GR and increased nuclear NF-κB expression, pERK 1/2/tERK1/2 ratio, and mRNA expression of inflammatory cytokines. In NHBE, CSE increased mRNA expression of inflammatory cytokines and supernatants from CSE exposed NHBE increased actin reorganization in neutrophils. FP combined with FO reverted all these phenomena in CSE stimulated 16-HBE cells as well as in NHBE cells. CONCLUSIONS The present study provides compelling evidences that FP combined with FO may contribute to revert some processes related to steroid resistance induced by oxidative stress due to cigarette smoke exposure increasing the anti-inflammatory effects of FP.
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Affiliation(s)
- M Ferraro
- Istituto di Biomedicina e Immunologia Molecolare, Consiglio Nazionale delle Ricerche, Palermo, Italy.
| | - M Gjomarkaj
- Istituto di Biomedicina e Immunologia Molecolare, Consiglio Nazionale delle Ricerche, Palermo, Italy
| | - L Siena
- Istituto di Biomedicina e Immunologia Molecolare, Consiglio Nazionale delle Ricerche, Palermo, Italy
| | - S Di Vincenzo
- Istituto di Biomedicina e Immunologia Molecolare, Consiglio Nazionale delle Ricerche, Palermo, Italy
| | - E Pace
- Istituto di Biomedicina e Immunologia Molecolare, Consiglio Nazionale delle Ricerche, Palermo, Italy
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49
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Jenkins CR, Eriksson G, Bateman ED, Reddel HK, Sears MR, Lindberg M, O'Byrne PM. Efficacy of budesonide/formoterol maintenance and reliever therapy compared with higher-dose budesonide as step-up from low-dose inhaled corticosteroid treatment. BMC Pulm Med 2017; 17:65. [PMID: 28427362 PMCID: PMC5397768 DOI: 10.1186/s12890-017-0401-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Accepted: 03/28/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Asthma management may involve a step up in treatment when symptoms are not well controlled. We examined whether budesonide/formoterol maintenance and reliever therapy (MRT) is as effective as higher, fixed-dose budesonide plus as-needed terbutaline in patients requiring step-up from Step 2 treatment (low-dose inhaled corticosteroids), stratified by baseline reliever use. METHODS A post-hoc analysis utilized data from three clinical trials of 6-12 months' duration. Patients aged ≥12 years with symptomatic asthma uncontrolled despite Step 2 treatment were included. Severe exacerbation rate, lung function and reliever use were analysed, stratified by baseline reliever use (<1, 1-2 and >2 occasions/day). RESULTS Overall, 1239 patients were included. Reductions in severe exacerbation rate with budesonide/formoterol MRT versus fixed-dose budesonide were similar across baseline reliever use levels, and were statistically significant in patients using 1-2 (42%, p = 0.01) and >2 (39%, p = 0.02) reliever occasions/day, but not <1 reliever occasion/day (35%, p = 0.11). Both treatments significantly increased mean FEV1 from baseline; improvements were significantly greater for budesonide/formoterol MRT in all reliever use groups. Reductions in reliever use from baseline were significantly greater with budesonide/formoterol MRT versus fixed-dose budesonide in patients using 1-2 and >2 reliever occasions/day (-0.33 and -0.74 occasions/day, respectively). CONCLUSIONS Treatment benefit with budesonide/formoterol MRT versus higher, fixed-dose budesonide plus short-acting β2-agonist was found in Step 2 patients with relatively low reliever use, supporting the proposal that budesonide/formoterol MRT may be useful when asthma is uncontrolled with low-dose inhaled corticosteroid.
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Affiliation(s)
- Christine R Jenkins
- Department of Thoracic Medicine, Concord Hospital and The George Institute for Global Health, PO Box M201, Missenden Rd, Sydney, NSW, 2050, Australia.
| | - Göran Eriksson
- Department of Respiratory Medicine and Allergology, University Hospital, Lund, Sweden
| | - Eric D Bateman
- Division of Pulmonology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Helen K Reddel
- Clinical Management Group, Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia
| | - Malcolm R Sears
- Michael G DeGroote School of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Canada
| | - Magnus Lindberg
- Biometrics and Information Sciences (B&I), AstraZeneca R&D, Mölndal, Sweden
| | - Paul M O'Byrne
- Michael G DeGroote School of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Canada
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Efficacy and safety of budesonide/formoterol pMDI vs budesonide pMDI in asthmatic children (6-<12 years). Ann Allergy Asthma Immunol 2017; 118:489-499.e1. [PMID: 28256307 DOI: 10.1016/j.anai.2017.01.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Revised: 01/18/2017] [Accepted: 01/22/2017] [Indexed: 11/20/2022]
Abstract
BACKGROUND The efficacy and safety of budesonide/formoterol pressurized metered-dose inhaler (pMDI) have been demonstrated in patients with asthma at least 12 years old. OBJECTIVE To evaluate the efficacy of 2 formoterol doses added to budesonide as fixed combinations vs budesonide alone in children 6 to younger than 12 years with asthma. METHODS This randomized, double-blinded, parallel-group, multicenter study (NCT02091986; CHASE 3) included children 6 to younger than 12 years with asthma previously receiving a medium-dose inhaled corticosteroid (ICS) or an ICS plus a long-acting β2-agonist. Children symptomatic during a 7-28-day run-in on low-dose ICS, 1 inhalation of budesonide dry powder inhaler 90 μg twice daily (BID), were randomized to receive 2 inhalations of budesonide/formoterol pMDI 80/4.5 μg (160/9 μg) BID (n = 92), budesonide/formoterol pMDI 80/2.25 μg (160/4.5 μg) BID (n = 95), or budesonide pMDI 80 μg (160 μg) BID (n = 92) for 12 weeks. RESULTS Change in forced expiratory volume in 1 second from baseline to 1 hour after dosing (primary end point), change in forced expiratory volume in 1 second 15 minutes after dosing, and peak expiratory flow 1 hour after dosing at week 12 were statistically significantly greater for budesonide/formoterol 160/9 μg vs budesonide (P ≤ .015 for all comparisons), but not for budesonide/formoterol 160/4.5 μg vs budesonide. Bronchodilator effects, evident 15 minutes after the dose on day 1, were maintained at week 12. Incidence of protocol-defined asthma exacerbations and improvements in asthma symptom-related and quality-of-life outcomes were similar across treatments. There were no notable safety differences among treatments. CONCLUSION Budesonide/formoterol pMDI 160/9 μg showed statistically significant and clinically meaningful lung function improvements vs budesonide pMDI 160 μg, demonstrating appropriateness as a therapeutic option for children 6 to younger than 12 years with asthma symptomatic on ICS alone. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02091986.
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