Calcium and calcium antagonists in airway disease. A review

Calcium channel blockers for lung function improvement in asthma: A systematic review and meta-analysis

BACKGROUND

For decades, calcium channel blockers (CCBs) have been believed to play a role in asthma treatment. However, the clinical efficacy of CCBs for lung function improvement in patients with asthma has not been qualitatively evaluated.

OBJECTIVE

To assess the effect of CCBs vs placebo on lung function test results in adults with asthma.

METHODS

Various databases were systematically searched to identify all randomized clinical trials with adults with asthma. We aimed to assess the influence of CCBs on forced expiratory volume in 1 second (FEV₁), forced vital capacity (FVC), peak expiratory flow rate (PEFR), and provocative concentration of bronchoconstrictive agents causing a 20% decrease in FEV₁ (PC₂₀) compared with a placebo. All effect estimates were pooled by the generic inverse variance method with random-effects meta-analysis. Subgroup analysis, sensitivity analysis, and heterogeneity investigation were performed.

RESULTS

Thirty eligible articles with 301 patients were included in this meta-analysis. Our results revealed that in a standard exercise test CCBs could produce a mean maximal percentage decrease in FEV₁ of 11.56% (95% confidence interval, 8.97%-14.16%; P < .001) and an increase in postdose FEV₁ by 80 mL (95% confidence interval, 0.02-0.15 mL; P = .01). However, there was no statistical significance for CCBs in postdose FVC, PEFR, or PC₂₀ of histamine and methacholine.

CONCLUSION

CCBs may be beneficial for lung function improvement in asthma, especially in exercise-induced asthma. However, there is a lack of evidence for CCBs protecting asthma patients from chemical irritation.

Calcium, calcium channel blockade and airways function

This review will highlight recent advances in understanding the physiological role of calcium and effects of calcium channel blockers on pathogenetic factors in asthma, including airway smooth muscle contraction, mast cell degranulation and mucus secretion. A review of clinical studies with calcium channel blockers in asthma will also be presented.

Evidence for the expression of transient receptor potential proteins in guinea pig airway smooth muscle cells

OBJECTIVE

The present study investigates the expression of transient receptor potential (TRPC) proteins in airway smooth muscle (ASM) cells in order to determine whether these proteins may be candidate molecular counterparts of plasma membrane Ca2+-permeable channels involved in the contraction of ASM.

METHODS

Expression of TRPC mRNA was detected using specific primers and RT-PCR. Expression of the TRPC1, TRPC3 and TRPC6 proteins was detected using antibodies in immunoprecipitation and Western blot.

RESULTS

Guinea pig ASM cells exhibited thapsigargin- and acetylcholine-initiated Ca2+ inflow but none by 1-oleoyl-2-acetyl-sn-glycerol. mRNA encoding each of the TRPC1 to TRPC6 proteins was detected in ASM cells. mRNA encoding TRPC1, TRPC3, TRPC4 and TRPC6 was detected in ASM cells at a concentration approximately equivalent to that in guinea pig brain. mRNA encoding TRPC2 and TRPC5 was more abundant in ASM cells than in brain. The TRPC1 protein, but not the TRPC3 or TRPC6 proteins, was detected in extracts of ASM cells, while all three proteins were detected in brain.

CONCLUSION

The results provide evidence for a low level of expression of the TRPC1 to TRPC6 proteins in ASM cells. These proteins may function as store-operated Ca2+ and/or second messenger-activated non-selective cation channels in ASM cells.

Changes in the contractile responses to carbachol and in the inhibitory effects of verapamil and nitrendipine on isolated smooth muscle preparations from rats subchronically exposed to Co2+ and Ni2+

Male Wistar rats were exposed to subtoxic doses of Co2+ or Ni2+, receiving Co(NO3)2 or NiSO4 with drinking water for 30 days. No significant differences in the body weight and no visible changes in the behaviour of the controls and experimental animals were established. Cumulative concentration-effect curves for carbachol were obtained in ileum and trachea isolated from control and Co(2+)- or Ni(2+)-treated rats. The effect of the Ca2+ antagonists on the carbachol-induced contractions was studied by adding increasing concentrations of verapamil or nitrendipine to the bath solution 20 min prior to carbachol. The results showed that exposure of rats to subtoxic doses of Co(NO3)2 or NiSO4 altered the contractile responses to carbachol. The changes in the pD2 values and the shift to the left of the concentration-effect curves suggest a higher sensitivity to carbachol in preparations from the ileum of Co(2+)- or Ni(2+)-exposed rats. The tracheal strips isolated from control and heavy metal-treated rats showed a less potent sensitiveness to carbachol as compared to the ileal segments. An opposite tendency for decreased cholinergic reactivity was observed in tracheal strips from Co(2+)- and Ni(2+)-treated animals. The inhibitory effect of the Ca(2+)-antagonists on the contractility of ileal preparations from Co(2+)-treated rats increased at all concentrations of verapamil and at the highest concentration of nitrendipine, but decreased at lower concentrations of nitrendipine. The effect of verapamil on the preparations from Ni(2+)-exposed rats was unchanged or even decreased at higher verapamil concentrations.(ABSTRACT TRUNCATED AT 250 WORDS)

Chronic use of the calcium channel blocker nifedipine has no significant effect on bone metabolism in men

Calcium channel blockers have been reported to have such diverse effects on reduction in protein synthesis, diminished incorporation of proline into new collagen, and decreased hormone release in vitro. The chronic affect of the calcium channel blocker nifedipine was examined in vivo to determine the possible impact of pharmacologic calcium channel blockade on bone metabolism. Eleven Caucasian males treated with an average of 40 mg/d nifedipine for an average of three years were compared to 11 control males matched for age, height, weight, activity level, cardiovascular status, and calcium intake. No significant differences between groups were noted in bone mineral density at the lumbar spine (L2-4), proximal femur (femoral neck, Ward's triangle and trochanter), and proximal and distal radius. There were also no significant differences in parameters of bone turnover (alkaline phosphatase, osteocalcin, urine calcium/creatinine, and hydroxyproline/creatinine ratio), or hormones that might affect calcium metabolism and bone (testosterone, PTH, 25(OH) vitamin D, and calcitonin). In summary, chronic nifedipine use in males is not associated with either a beneficial or adverse effect on bone metabolism.

Effects of pinacidil on guinea-pig airway smooth muscle contracted by asthma mediators

Pinacidil is a new antihypertensive, direct vasodilator drug which has been classified as a K+ channel opener. The present study demonstrated a concentration-dependent relaxant activity of pinacidil in guinea-pig tracheal preparations. The potency and efficacy of pinacidil depended on the agent used to induce tracheal tone. Tracheal preparations with spontaneous tone or precontracted by different asthma mediators were completely relaxed by pinacidil. A high potency was found in spontaneously contracted preparations (EC50 = 7.8 x 10(-7) M). The EC50 values ranged from 2.3 to 5.4 x 10(-6) M in histamine-, PGF2 alpha- or LTC4-contracted preparations. When tone was induced by carbachol, the EC50 was 2.1 x 10(-5) M. In contrast, pinacidil produced incomplete relaxation and had a low potency in preparations contracted by 30 or 124 mM K+ Krebs solutions. This effect profile differed from that seen with beta 2-receptor agonists, xanthines and Ca2+ antagonists in guinea-pig trachealis and seems compatible with K+ channel opening as a primary mode of relaxation for pinacidil in airway smooth muscle.

Mode of action of calcium antagonists on responses to spasmogens and antigen challenge in human airway smooth muscle

Calcium antagonists have been shown to inhibit exercise-induced asthma. The mechanism of inhibition is unclear, but may involve inhibition of mediator release and/or blockade of the mediator effects. We studied the effects of methoxyverapamil (D600) on human airway responses to spasmogens as well as on histamine release from passively sensitized human lung challenged with ragweed antigen. The concentrations of D600 required to inhibit 50% of the spasmogen responses (IC50) were calculated from the concentration-response relationships and were: histamine 4 x 10(-6) M; KCl 7 x 10(-7) M; leukotriene C4 4 x 10(-5) M; electrical field stimulation 5 x 10(-5) M; and for ragweed antigen in passively sensitized muscle 2 x 10(-6) M. Histamine release by antigen challenge from sensitized lung fragments was not blocked by D600, up to a concentration of 10(-5) M. The data suggest that the contractile effects of agonists are mediated through voltage- and receptor-operated calcium channels. The differential inhibitory effects of D600 on antigen-induced mediator release vs the smooth muscle effects of the various agonists may suggest multiple mechanisms of release or sources of mediators in human airway anaphylaxis.

Calcium channel blockers

The calcium channel blockers initially were approved for the treatment of classical and variant angina pectoris. Recent studies indicate that these agents also are useful in such diverse conditions as pulmonary and systemic hypertension, hypertrophic cardiomyopathy, arrhythmias, asthma, Raynaud's syndrome, esophageal spasm, myometrial hyperactivity, cerebral arterial spasm, and migraine.

The role of calcium antagonists in bronchial reactivity

Calcium (Ca) ions play an important pathophysiologic role in allergic reactions. Thus, mediator release from mast cells, synthesis of some newly formed chemical mediators, airway smooth muscle contraction, and nerve-impulse conduction are all dependent on the availability and flux of Ca ions. It is likely, therefore, that Ca antagonists would modify allergic bronchoconstriction. In vitro, Ca antagonists have been demonstrated to inhibit mediator release (histamine, slow-reacting substance of anaphylaxis, and platelet-activating factor) from mast cells, passively sensitized human lung fragments, and leukocytes. Ca antagonists have also been found to inhibit synthesis of leukotrienes in rat lungs and cyclooxygenase products in sheep, possibly by inactivating phospholipase A2 and/or 5-lipoxygenase. In addition, nifedipine, verapamil, and gallopamil have demonstrated inhibition of airway smooth muscle contractions to histamine, carbachol, and antigen in various species. In vivo effects of Ca antagonists are variable, depending on the species, experimental design, the stimulus or the agonist, and the Ca antagonist used. Animal studies have demonstrated the inhibition of histamine, methacholine, citric acid, and prostaglandin F2 alpha-induced bronchoconstriction in guinea pigs and dogs by intravenous nifedipine. In contrast, verapamil inhibited antigen-induced bronchoconstriction in allergic sheep without any effect on histamine- and carbachol-induced responses. Ca antagonists (nifedipine and verapamil) have been of limited value in human subjects and generally have no significant bronchodilating activity. Both nifedipine and verapamil prevent the exercise-induced asthma and partly attenuate the histamine and methacholine-induced bronchoconstriction. Oral nifedipine is generally more effective than oral verapamil against acute antigen-induced bronchoconstriction; however, this efficacy may be limited by systemic side effects. Inhaled Ca antagonists may be more effective and free of systemic side effects, as demonstrated by greater efficacy of inhaled verapamil. A new Ca antagonist, gallopamil (a methoxy derivative of verapamil), is being investigated as an aerosol, and preliminary studies in animals and humans have found it fourfold to seventeenfold more potent than verapamil. In sheep, gallopamil has been found to attenuate histamine, carbachol, and platelet-activating factor-induced bronchoconstriction, as well as to inhibit early and late-phase allergic airway responses. Studies in human subjects have also demonstrated the inhibition of antigen-induced bronchoconstriction by inhaled gallopamil, with efficacy comparable or better than cromolyn sodium.(ABSTRACT TRUNCATED AT 400 WORDS)

Low potency of Ca antagonists in smooth muscle from different levels of the respiratory tract

Respiratory smooth muscle at different levels of the respiratory tract was isolated from rabbit, rat and guinea-pig and incubated with the Ca antagonists, verapamil, D-600, felodipine, and nifedipine. There was no effect of the Ca antagonists when added on top of an already developed contraction. When added before the contractile agent at high concentrations (10-100 microM) the Ca antagonists reduced the contractions. Lanthanum (2 mM) was considerably more effective to prevent contractions than the Ca antagonists. Preparations from the trachea and bronchus responded in all animals, whereas the third generation bronchus from rat and guinea-pig failed to contract and that from rabbit showed very weak contractions. The failure to contract was not specific for the agonist, as depolarization with isotonic potassium solution (124 mM) did not evoke contractions either. Microscopic investigation showed well-developed smooth muscle in the trachea and main bronchus of the rat, whereas the muscle of the third generation bronchus was inhomogenous with scattered groups of muscle cells.

Calcium antagonists in the management of asthma: breakthrough or ballyhoo?

Research demonstrating the importance of intracellular calcium regulation in each of the pathophysiologic events of asthma has lead to speculation that calcium antagonists may be beneficial in the treatment of reactive airways disease. A plethora of data has been generated on the effects of verapamil, diltiazem, nifedipine, and several investigational agents on experimentally induced asthma, indicating that none of these agents significantly affects resting bronchomotor tone, and their efficacy in preventing bronchospasm is a function of the drug, dose, route of administration and method of bronchoprovocation. Most studies have demonstrated calcium antagonists have only modest and highly variable effects on airway smooth muscle contraction. Additional studies are needed to define the effects on the inflammatory component of airways obstruction, steroid requirements in steroid-dependent patients, and on the alteration of the pharmacodynamics of other agents used for the management of chronic asthma.

Asthma: emerging concepts and potential therapies

Asthma is a disease of the airways that results in reversible airflow obstruction. Recent investigations have suggested that airway inflammation is associated with increased airway responsiveness and worsening of asthmatic symptoms. The role that mast cell mediators might play in the production of asthma has been investigated by use of newer analytical techniques and by use of fiberoptic bronchoscopy with lavage to obtain lower respiratory tract fluid and cells. In addition, new investigational compounds that interfere with the synthesis or action of inflammatory mediators have been tested. Developing lines of investigation suggest that chronic activation of inflammatory cells may be important in the pathogenesis of asthma.

Nicardipine. A review of its pharmacodynamic and pharmacokinetic properties, and therapeutic efficacy, in the treatment of angina pectoris, hypertension and related cardiovascular disorders

Nicardipine is an antagonist of calcium influx through the slow channel of the cell membrane and has been shown to be an effective and relatively well-tolerated treatment for stable effort angina and rest angina due to coronary artery spasm, and mild to moderate hypertension. Although its exact mechanism of action in these disease states has not been precisely defined, the potent coronary and peripheral arterial dilator properties of nicardipine, with concomitant improvements in oxygen supply/demand and reductions in systemic vascular resistance, are of major importance. Clinical studies have shown that nicardipine appears to be effective in the treatment of chronic stable exercise-induced angina pectoris and possibly in angina at rest due to coronary artery spasm. In the treatment of stable angina, nicardipine has proved to be equally as effective as nifedipine. However, haemodynamic and clinical studies indicate that nicardipine may have a further advantage of not depressing cardiac conduction or left ventricular function, even in patients with compromised cardiac pumping ability. Nicardipine also appears to be useful as initial monotherapy or in combination with other antihypertensive drugs when used in the treatment of mild to moderate hypertension, and may have some advantages over other vasodilators in this regard in that it may not be as frequently associated with fluid retention or weight gain as other similar drugs. In the treatment of hypertension nicardipine has been shown to be as effective as drugs such as hydrochlorothiazide, cyclopenthiazide, propranolol and verapamil in short term studies although confirmation of its long term usefulness in well-designed clinical trials is still required. Similarly, although the use of nicardipine in other disorders such as congestive heart failure and cerebrovascular disease has provided encouraging preliminary results, more studies are needed to clarify its place in their treatment. Side effects appear to be dose related and more frequent within the first few weeks of therapy. Most of these effects are minor and transient in nature and include headache, flushing and peripheral oedema. Thus, there is no doubt that nicardipine provides a suitable alternative to other drugs available for the treatment of angina and hypertension. However, further well-designed comparative clinical trials are needed to clarify its relative place in the long term management of these disorders.

Acetylcholine-induced contraction in human isolated bronchial smooth muscle: role of an intracellular calcium store

The aim of this study was to investigate the role played by an intracellular calcium store in human bronchoconstriction. Human isolated bronchial smooth muscle strips (5-6 mm long, 0.4-0.5 mm wide) were taken from lung specimens during pneumonectomy. Isometric contraction was recorded after stimulation by 10(-4) M acetylcholine in physiological solutions. The amplitude of acetylcholine-induced contractions was measured in the presence and absence of calcium ions in the perfusing medium. When the perfusing medium was switched to a calcium-free solution the amplitude of the acetylcholine-induced contraction was measured with respect to the duration of calcium-free perfusion. The amplitude of the contraction was 82.1 +/- 11.3%, 77.2 +/- 15.4%, 63 +/- 10.6% of the maximum contraction after the strips were perfused in calcium-free solutions for 1, 3 and 5 min respectively. Several successive contractions could be elicited, and even after 20 min of calcium-free perfusion, acetylcholine was still able to elicit contractions. These results suggest that an intracellular calcium store may be involved in human bronchoconstriction. This finding may help further our understanding of the effects of calcium antagonists on human airways.

Some effects of prolonged treatment with nicardipine in chronic bronchial asthma

A study was carried out in 10 patients with chronic non-severe asthma to investigate the effects of prolonged treatment with the calcium blocker, nicardipine. Patients received 60 mg nicardipine daily for 3 months. Measurements were taken before and after treatment of FEV1, PaO2 and PD20 his. The results showed no statistically significant effect on FEV1. Although there was a statistically significant decrease in PaO2 this was not important clinically. There was a statistically significant increase in PD20 his, demonstrating the protective effect of nicardipine on histamine-induced bronchoconstriction. Breathlessness was reduced in 70% of the patients and the drug was well tolerated throughout the study.

Relaxant effects of xanthines, a beta 2-receptor agonist and Ca2+ antagonists in guinea-pig tracheal preparations contracted by potassium or carbachol

Potassium (124 mM K+ Krebs) produced a biphasic contractile response in the guinea-pig isolated trachea. An initial phasic contraction was followed by a larger and sustained contraction. Repeated potassium-induced contractions in spontaneously contracted guinea-pig tracheas were not reproducible. However, reproducible K+ responses were obtained in the presence of indomethacin (10(-6) M) that almost abolished the spontaneous tone. This suggested that endogenous cyclooxygenase products were variably released by K+ and interfered with its contractile effects. Both phases of K+-induced contractions were inhibited in Ca2+-free/EGTA Krebs. In contrast, about 80% of the contractile response to carbachol persisted in this medium. Tracheas contracted by potassium (indomethacin present) were completely relaxed by theophylline and enprofylline but only partly relaxed by terbutaline. All bronchodilators completely relaxed carbachol-contracted preparations. Each bronchodilator was 2-3 times less potent to relax K+- than carbachol-induced contractions. In sharp contrast, two Ca2+ antagonists, verapamil and nimodipine, preferentially relaxed K+-induced contractions. The results obtained with Ca2+ antagonists, which are poorly effective in asthma, compared to the established antiasthma drugs, xanthines and beta 2-receptor agonists, may indicate that depolarization-induced mechanisms contribute little to bronchoconstriction in asthma.

Evaluation of the pharmacodynamic and pharmacokinetic interaction between calcium antagonists and digoxin

Therapeutic uses of calcium antagonists have expanded to include not only ischemic heart disease but arrhythmias, systemic hypertension, congestive heart failure, and various pulmonary and gastrointestinal diseases. Many patients receiving a calcium antagonist concomitantly receive digoxin. Although the potential interaction between these agents has frequently been investigated, literature reports are confusing and inconsistent. We summarized the pharmacodynamics, pharmacokinetics, and mechanisms of interaction to help clinicians evaluate the potential calcium antagonist-digoxin interaction.

Comparative effects of various calcium entry blockers and anti-asthmatic compounds on antigen-induced bronchoconstriction in rat and histamine release from rat mast cells

The effects of four calcium entry blockers (diltiazem, nifedipine, mesudipine and verapamil) were studied on antigen-induced bronchoconstriction in sensitized rats and histamine release from rat mast cells, in comparison with compounds frequently used in atopic patients (theophylline, isoproterenol, disodium cromoglycate, ketotifen and clemastine). The four Ca2+ entry blockers produced a dose-related inhibition of the IgE-dependent bronchoconstriction in rat whereas the other drugs exhibited a weak effect or even were inactive. 48/80-induced histamine release was antagonized by nifedipine, verapamil and ketotifen. On the contrary, diltiazem, mesudipine, theophylline, isoproterenol, disodium cromoglycate and clemastine were not able to interfere with this release process. These data may suggest an important role of both extra- and intracellular calcium in such phenomena.