Pharmacogenetics of beta2-agonist drugs in asthma

Pharmacogenetic Effects of Inhaled Salbutamol on 10-km Time Trial Performance in Competitive Male and Female Cyclists

OBJECTIVE

To determine the effects of single nucleotide polymorphisms (SNPs) in the adrenergic β2-receptor gene (ADRB2, rs1042713, and rs1042714) and epithelial Na channel gene (SCNN1A, rs2228576) on cycling performance after the inhalation of salbutamol.

DESIGN

Randomized double-blind, mixed-model repeated measures.

SETTING

University Research Setting.

PARTICIPANTS

Sixty-nine trained (maximal oxygen consumption: 62.3 ± 7.6 mL·kg·min) male and female cyclists, aged 19 to 40 years.

INTERVENTIONS

Participants performed two 10-km time trials 60 minutes after the inhalation of 400 μg of salbutamol or placebo. Subjects were genotyped for the three SNPs (rs1042713: AA 8, AG 30 GG 31; rs1042714: CC 19, CG 35, GG 15; rs2228576: GG: 31 GA: 34 AA: 4).

MAIN OUTCOME MEASURES

Forced expiratory volume in 1 second (FEV1) was assessed immediately before and 30 minutes after inhalation. Performance was measured by mean power output maintained over the duration of the time trial.

RESULTS

There was a significant increase in FEV1 after the inhalation of salbutamol [mean (SD) = 5.68% (4.7)] compared with placebo [0.84% (2.8); P < 0.001]; however, this did not lead to an improvement in 10-km cycling time trial performance. Neither the bronchodilatory response nor the time trial performance after salbutamol was affected by genotype at any of the 3 SNPs.

CONCLUSIONS

In cyclists, FEV1 was significantly improved after salbutamol administration regardless of genotypic variation at the ADRB2 (rs1042713 and rs1042714) and SCNN1A (rs2228576) genes. Despite this improvement in lung function, 10-km time trial performance was not altered after the inhalation of salbutamol.

CLINICAL RELEVANCE

Our findings did not show genotype-dependent differences in bronchodilatory responses and athletic performance to inhaled salbutamol, suggesting that genotype-specific drug therapy will not improve asthmatic athletes' care nor athletic performance.

Asthma: Chronopharmacotherapy and the molecular clock

Bronchial asthma is characterized by chronic airways inflammation and reversible airflow limitation. In patients with asthma, symptoms generally worsen during the early hours of the morning, and pulmonary function often deteriorates at the same time, suggesting a role for chronopharmacotherapy. Several drugs for asthma have been developed based on chronopharmacology. Most medications employed for the chronotherapy of asthma are administered once at night with the goal of preventing chronic airway inflammation or development of airflow limitation. In addition to bronchodilators, the inhaled glucocorticosteroid ciclesonide is now available with once-daily dosing, which also improves patients' compliance. Numerous investigations have demonstrated the usefulness of chronotherapy for asthma, especially for patients with nocturnal asthma. This review focuses on chronotherapy of asthma, and also provides a molecular biological explanation for the influence of asthma medications on the clock genes.

Whither autoimmunity: the lessons of anti-CCP and B cell depletion

The most difficult component to understand in autoimmune disease has been the issue of causation. In contrast, there have been enormous gains in improved diagnostics as well as improved therapy. Indeed, the use of biologics have changed the profile of numerous autoimmune diseases. In this issue, we discuss two such aspects. Firstly, we place in perspective the use of anti-citrullinated protein antibodies in rheumatoid arthritis. Second, we discuss the increasing use of B cell depletion in the treatment of autoimmunity. Clinical Reviews in Allergy and Immunology is a unique venue for these themes because it covers the spectrum of allergy through autoimmunity. Indeed, we also present a special paper on the relationships of the hepatitis B virus and autoimmunity. Although the Th1 to Th2 dichotomy is well known to both murine and human immunologists, it is really in the study of specific inflammatory responses that they are correctly placed in the perspective of the continuum of immunopathology.

Additive role of tiotropium in severe asthmatics and Arg16Gly in ADRB2 as a potential marker to predict response

BACKGROUND

Recent findings have raised new interests about the use of anticholinergics, especially tiotropium, for the treatment of asthma. This study was performed to determine whether an additional improvement in lung function is obtained when tiotropium is administrated in addition to conventional therapies in severe asthmatics, and to identify factors capable of predicting the response to tiotropium, using a pharmacogenetic approach.

METHODS

A total of 138 severe asthmatics on conventional medications and with decreased lung function were randomly recruited. Tiotropium 18 microg was added once a day and lung functions were measured every 4 weeks. Responders were defined as those with an improvement of > or = 15% (or 200 ml) in the forced expiratory volume in 1 s (FEV1) that was maintained for at least 8 successive weeks. Eleven single nucleotide polymorphisms (SNPs) in CHRM1-3 (coding muscarinic receptors one to three) which were identified by re-sequencing, and Arg16Gly and Gln27Glu in ADRB2 (coding beta(2) adrenoreceptor) were scored in 80 of the 138 asthmatics.

RESULTS

Forty-six of the 138 asthmatics (33.3%) responded to tiotropium treatment. Logistic regression analyses (controlled for age, gender, and smoking status) showed that Arg16Gly in ADRB2 [P = 0.003, OR (95% CI) = 0.21 (0.07-0.59) in a minor allele-dominant model] was significantly associated with response to tiotropium.

CONCLUSIONS

As many as 30% of severe asthmatics on conventional medications with reduced lung function were found to respond to adjuvant tiotropium. The presence of Arg16Gly in ADRB2 may predict response to tiotropium.

Beta-1 and beta-2 adrenoceptor polymorphisms: functional importance, impact on cardiovascular diseases and drug responses

Beta-1 and beta-2 adrenoceptors (AR) play a pivotal role in regulation of the activity of the sympathetic nervous system and agonists and antagonists at both beta AR subtypes are frequently used in treatment of cardiovascular diseases. Both beta-1 and beta-2 AR genes have several polymorphisms that encode different amino acids. This review summarizes new insights into the functional importance of these polymorphisms, as well as their relationship to cardiovascular diseases and their impact on responses to adrenergic drug treatment. At present, it seems that, for cardiovascular diseases, beta-1 and beta-2 AR polymorphisms do not play a role as disease-causing genes; they might, however, be associated with disease-related phenotypes. In addition they could influence adrenergic drug responses. Thus, the Arg389Gly beta-1 AR polymorphism might predict responsiveness to beta-1 AR agonist and blocker treatment: patients homozygous for the Arg389 beta-1 AR polymorphism should be good responders, while patients homozygous for the Gly389 beta-1 AR polymorphism should be poor or nonresponders. Furthermore, the Arg16Gln27 beta-2 AR seems to have strong impact on long-term agonist-induced beta-2 AR desensitization. Thus, patients carrying this haplotype appear to suffer from rapid loss of therapeutic efficacy of chronic agonist treatment, as has been demonstrated in asthma patients. Moreover, the Arg16Gln27 beta-2 AR haplotype might have some predictive value for poor outcome of heart failure. Future large prospective studies have to replicate these findings in order to reach the final goal of pharmacogenomic research: to optimize and individualize drug therapy based on the patient's genetic determinants of drug efficacy.

Dangerous exercise: lessons learned from dysregulated inflammatory responses to physical activity

Exercise elicits an immunological “danger” type of stress and inflammatory response that, on occasion, becomes dysregulated and detrimental to health. Examples include anaphylaxis, exercise-induced asthma, overuse syndromes, and exacerbation of intercurrent illnesses. In dangerous exercise, the normal balance between pro- and anti-inflammatory responses is upset. A possible pathophysiological mechanism is characterized by the concept of exercise modulation of previously activated leukocytes. In this model, circulating leukocytes are rendered more responsive than normal to the immune stimulus of exercise. For example, in the case of exercise anaphylaxis, food-sensitized immune cells may be relatively innocuous until they are redistributed during exercise from gut-associated circulatory depots, like the spleen, into the central circulation. In the case of asthma, the prior activation of leukocytes may be the result of genetic or environmental factors. In the case of overuse syndromes, the normally short-lived neutrophil may, because of acidosis and hypoxia, inhibit apoptosis and play a role in prolongation of inflammation rather than healing. Dangerous exercise demonstrates that the stress/inflammatory response caused by physical activity is robust and sufficiently powerful, perhaps, to alter subsequent responses. These longer term effects may occur through as yet unexplored mechanisms of immune “tolerance” and/or by a training-associated reduction in the innate immune response to brief exercise. A better understanding of sometimes failed homeostatic physiological systems can lead to new insights with significant implication for clinical translation.

Heterogeneity in response to asthma medications

PURPOSE OF REVIEW

Evidence for the heterogeneity of response to asthma medications including inhaled corticosteroids and leukotriene receptor antagonists is mounting. beta2-Adrenoceptor gene polymorphisms may contribute to asthma responsiveness to short- and long-acting beta2-agonists. This review examines recent articles describing variability in response to inhaled corticosteroids, leukotriene receptor antagonists and short-acting beta2-agonists specifically in pediatric persistent asthmatics.

RECENT FINDINGS

In the late 1990's, differences in the response to a leukotriene receptor antagonist and an inhaled corticosteroid in adults with moderate persistent asthma were first described. Subsequently, similar findings have recently been elucidated in children with mild to moderate persistent asthma. The variability in response to these two classes of control medicines now appears to encompass all ages with persistent asthma. In general, despite the variability in response to these medications, both resulted in improved clinical and physiologic control measures.

SUMMARY

Childhood asthma is a complex disease with numerous clinical phenotypes that contribute to response variability to asthma medications.