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Casey M, Simmonds NJ. Why don't anti-inflammatories work in cystic fibrosis? Expert Rev Respir Med 2024; 18:1-3. [PMID: 38386416 DOI: 10.1080/17476348.2024.2323189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 02/21/2024] [Indexed: 02/24/2024]
Affiliation(s)
- Michelle Casey
- Adult Cystic Fibrosis Centre, Royal Brompton & Harefield Hospitals, part of Guys & St Thomas' NHS Foundation Trust, London, UK
| | - Nicholas J Simmonds
- Adult Cystic Fibrosis Centre, Royal Brompton & Harefield Hospitals, part of Guys & St Thomas' NHS Foundation Trust, London, UK
- National Heart and Lung Institute, Imperial College, London, UK
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2
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Bentley S, Cheong J, Gudka N, Makhecha S, Hadjisymeou-Andreou S, Standing JF. Therapeutic drug monitoring-guided dosing for pediatric cystic fibrosis patients: recent advances and future outlooks. Expert Rev Clin Pharmacol 2023; 16:715-726. [PMID: 37470695 DOI: 10.1080/17512433.2023.2238597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 07/10/2023] [Accepted: 07/17/2023] [Indexed: 07/21/2023]
Abstract
INTRODUCTION Medicine use in children with cystic fibrosis (CF) is complicated by inconsistent pharmacokinetics at variance with the general population, a lack of research into this and its effects on clinical outcomes. In the absence of established dose regimens, therapeutic drug monitoring (TDM) is a clinically relevant tool to optimize drug exposure and maximize therapeutic effect by the bedside. In clinical practice though, use of this is variable and limited by a lack of expert recommendations. AREAS COVERED We aimed to review the use of TDM in children with CF to summarize recent developments, current recommendations, and opportunities for future directions. We searched PubMed for relevant publications using the broad search terms "cystic fibrosis" in combination with the specific terms "therapeutic drug monitoring (TDM)" and "children." Further searches were undertaken using the name of identified drugs combined with the term "TDM." EXPERT OPINION Further research into the use of Bayesian forecasting and the relationship between exposure and response is required to personalize dosing, with the opportunity for the development of expert recommendations in children with CF. Use of noninvasive methods of TDM has the potential to improve accessibility to TDM in this cohort.
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Affiliation(s)
- Siân Bentley
- Pharmacy Department, Royal Brompton Hospital, London, UK
| | - Jamie Cheong
- Pharmacy Department, Royal Brompton Hospital, London, UK
| | - Nikesh Gudka
- Pharmacy Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | | | | | - Joseph F Standing
- Pharmacy Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- Infection, Immunity and Inflammation,great Ormond Street Institute of Child Health, University College London, London, UK
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3
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Milinic T, McElvaney OJ, Goss CH. Diagnosis and Management of Cystic Fibrosis Exacerbations. Semin Respir Crit Care Med 2023; 44:225-241. [PMID: 36746183 PMCID: PMC10131792 DOI: 10.1055/s-0042-1760250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
With the improving survival of cystic fibrosis (CF) patients and the advent of highly effective cystic fibrosis transmembrane conductance regulator (CFTR) therapy, the clinical spectrum of this complex multisystem disease continues to evolve. One of the most important clinical events for patients with CF in the course of this disease is acute pulmonary exacerbation (PEx). Clinical and microbial epidemiology studies of CF PEx continue to provide important insight into the disease course, prognosis, and complications. This work has now led to several large-scale clinical trials designed to clarify the treatment paradigm for CF PEx. The primary goal of this review is to provide a summary and update of the pathophysiology, clinical and microbial epidemiology, outcome and treatment of CF PEx, biomarkers for exacerbation, and the impact of highly effective modulator therapy on these events moving forward.
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Affiliation(s)
- Tijana Milinic
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Oliver J McElvaney
- Cysic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, Washington
| | - Christopher H Goss
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington
- Cysic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, Washington
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
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4
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Myer H, Chupita S, Jnah A. Cystic Fibrosis: Back to the Basics. Neonatal Netw 2023; 42:23-30. [PMID: 36631257 DOI: 10.1891/nn-2022-0007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/25/2022] [Indexed: 01/13/2023]
Abstract
Cystic fibrosis (CF) is the most common genetic disorder in Caucasian individuals, with an incidence of 1/2,500-3,500 live births. When CF was first described in 1938, most children died in infancy. Currently, the average lifespan is 28-47.7 years. Although new breakthroughs have occurred, CF is still incurable. Both early diagnosis and treatment by multidisciplinary teams are essential to optimize short- and long-term outcomes. It is imperative for neonatal clinicians to keep up to date on the most current research, treatment, and management of CF to provide the best outcomes. This article offers clinicians an updated review of the pathophysiology and clinical manifestations of CF, as well as current evidence-based diagnostics and treatment regimens.
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Systemic Corticosteroids in the Management of Pediatric Cystic Fibrosis Pulmonary Exacerbations. Ann Am Thorac Soc 2023; 20:75-82. [PMID: 36044723 DOI: 10.1513/annalsats.202203-201oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Rationale: Pulmonary exacerbation (PEx) events contribute to lung function decline in people with cystic fibrosis (CF). CF Foundation PEx guidelines note that a short course of systemic corticosteroids may offer benefit without contributing to long-term adverse effects. However, insufficient evidence exists to recommend systemic corticosteroids for PEx treatment. Objectives: To determine if systemic corticosteroids for the treatment of in-hospital pediatric PEx are associated with improved clinical outcomes compared with treatment without systemic corticosteroids. Methods: We conducted a retrospective cohort study using the CF Foundation Patient Registry-Pediatric Health Information System linked database. People with CF were included if hospitalized for a PEx between 2006 and 2018 and were 6-21 years of age. Time to next PEx was assessed by Cox proportional hazards regression. Lung function outcomes were assessed by linear mixed-effect modeling and generalized estimating equations. To address confounding by indication, inverse probability treatment weighting was used. Results: A total of 3,471 people with CF contributed 9,787 PEx for analysis. Systemic corticosteroids were used in 15% of all PEx. In our primary analysis, systemic corticosteroids were not associated with better pre- to post-PEx percent predicted forced expiratory volume in 1 second responses (mean difference, -0.36; 95% confidence interval [CI], -1.14, 0.42; P = 0.4) or a higher odds of returning to lung function baseline (odds ratio, 0.97; 95% CI, 0.84-1.12; P = 0.7) but were associated with a reduced chance of future PEx requiring intravenous antibiotics (hazard ratio, 0.91; 95% CI, 0.85-0.96; P = 0.002). When restricting the analysis to one PEx per person, lung function outcomes remained no different among PEx treated with or without systemic corticosteroids, but, in contrast to our primary analysis, the use of systemic corticosteroids was no longer associated with a reduced chance of having a future PEx requiring intravenous antibiotics (hazard ratio, 0.96; 95% CI, 0.86, 1.07; P = 0.42). Conclusions: Systemic corticosteroid treatment for in-hospital pediatric PEx was not associated with improved lung function outcomes. Prospective trials are needed to better evaluate the risks and benefits of systemic corticosteroid use for PEx treatment in children with CF.
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Abstract
Cystic fibrosis (CF) pathophysiology is hallmarked by excessive inflammation and the inability to resolve lung infections, contributing to morbidity and eventually mortality. Paradoxically, despite a robust inflammatory response, CF lungs fail to clear bacteria and are susceptible to chronic infections. Impaired mucociliary transport plays a critical role in chronic infection but the immune mechanisms contributing to the adaptation of bacteria to the lung microenvironment is not clear. CFTR modulator therapy has advanced CF life expectancy opening up the need to understand changes in immunity as CF patients age. Here, we have summarized the current understanding of immune dysregulation in CF.
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Affiliation(s)
- Emanuela M Bruscia
- Department of Pediatrics, Section of Pulmonology, Allergy, Immunology and Sleep Medicine, Yale University School of Medicine, New Haven, CT, USA.
| | - Tracey L Bonfield
- Department of Genetics and Genome Sciences, Case Western Reserve University School of Medicine, Cleveland, OH, USA.
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7
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Toward a Broader Understanding of Cystic Fibrosis Epidemiology and Its Impact on Clinical Manifestations. Clin Chest Med 2022; 43:579-590. [PMID: 36344067 DOI: 10.1016/j.ccm.2022.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The incidence of cystic fibrosis remains constant in North America and Western Europe is 1 in 3500 live births, but survival and quality of life have improved. The cystic fibrosis population has shifted toward the adult age range with a concomitant shift in the spectrum of complications. Survival increased because of aggressive symptomatic therapy, earlier diagnosis by newborn screening, and the introduction of modulators of the cystic fibrosis transmembrane conductance regulator, so that predicted median survival age is now about 50 years. In the United States, members of low socioeconomic status populations or members of racial or ethnic minorities have benefitted less from these advances.
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Guimbellot JS, Nichols DP, Brewington JJ. Novel Applications of Biomarkers and Personalized Medicine in Cystic Fibrosis. Clin Chest Med 2022; 43:617-630. [PMID: 36344070 DOI: 10.1016/j.ccm.2022.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
As routine care in cystic fibrosis (CF) becomes increasingly personalized, new opportunities to further focus care on the individual have emerged. These opportunities are increasingly filled through research in tools aiding drug selection, drug monitoring and titration, disease-relevant biomarkers, and evaluation of therapeutic benefits. Herein, we will discuss such research tools presently being translated into the clinic to improve the personalization of care in CF.
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Affiliation(s)
- Jennifer S Guimbellot
- Department of Pediatrics, Division of Pulmonary and Sleep Medicine, Gregory Fleming James Cystic Fibrosis Research Center, University of Alabama at Birmingham; 1600 7th Avenue South, ACC 620, Birmingham, AL 35233, USA
| | - David P Nichols
- Department of Pediatrics, Division of Pulmonary Medicine, Seattle Children's Hospital, University of Washington School of Medicine, Building Cure, 1920 Terry Avenue, Office 4-209, Seattle, WA 98109, USA
| | - John J Brewington
- Department of Pediatrics, University of Cincinnati College of Medicine, 3230 Eden Avenue, Cincinnati, OH 45267, USA; Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2021, Cincinnati, OH 45229, USA.
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9
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Stick SM, Foti A, Ware RS, Tiddens HAWM, Clements BS, Armstrong DS, Selvadurai H, Tai A, Cooper PJ, Byrnes CA, Belessis Y, Wainwright C, Jaffe A, Robinson P, Saiman L, Sly PD. The effect of azithromycin on structural lung disease in infants with cystic fibrosis (COMBAT CF): a phase 3, randomised, double-blind, placebo-controlled clinical trial. THE LANCET RESPIRATORY MEDICINE 2022; 10:776-784. [DOI: 10.1016/s2213-2600(22)00165-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 04/08/2022] [Accepted: 04/10/2022] [Indexed: 12/28/2022]
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10
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The Effect of CFTR Modulators on Airway Infection in Cystic Fibrosis. Int J Mol Sci 2022; 23:ijms23073513. [PMID: 35408875 PMCID: PMC8998472 DOI: 10.3390/ijms23073513] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 03/21/2022] [Accepted: 03/22/2022] [Indexed: 02/08/2023] Open
Abstract
The advent of Cystic fibrosis transmembrane receptor (CFTR) modulators in 2012 was a critical event in the history of cystic fibrosis (CF) treatment. Unlike traditional therapies that target downstream effects of CFTR dysfunction, CFTR modulators aim to correct the underlying defect at the protein level. These genotype-specific therapies are now available for an increasing number of CF patients, transforming the way we view the condition from a life-limiting disease to one that can be effectively managed. Several studies have demonstrated the vast improvement CFTR modulators have on normalization of sweat chloride, CFTR function, clinical endpoints, and frequency of pulmonary exacerbation. However, their impact on other aspects of the disease, such as pathogenic burden and airway infection, remain under explored. Frequent airway infections as a result of increased susceptibility and impaired innate immune response are a serious problem within CF, often leading to accelerated decline in lung function and disease progression. Current evidence suggests that CFTR modulators are unable to eradicate pathogenic organisms in those with already established lung disease. However, this may not be the case for those with relatively low levels of disease progression and conserved microbial diversity, such as young patients. Furthermore, it remains unknown whether the restorative effects exerted by CFTR modulators extend to immune cells, such as phagocytes, which have the potential to modulate the response of people with CF (pwCF) to infection. Throughout this review, we look at the potential impact of CFTR modulators on airway infection in CF and their ability to shape impaired pulmonary defences to pathogens.
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11
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McBennett KA, Davis PB, Konstan MW. Increasing life expectancy in cystic fibrosis: Advances and challenges. Pediatr Pulmonol 2022; 57 Suppl 1:S5-S12. [PMID: 34672432 PMCID: PMC9004282 DOI: 10.1002/ppul.25733] [Citation(s) in RCA: 38] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 09/30/2021] [Accepted: 10/03/2021] [Indexed: 01/14/2023]
Abstract
Since the first description of cystic fibrosis in 1938, there have been significant advances in both quality of life and longevity for people living with this disease. In this article we describe the milestones of the last 80 years and what we perceive to be the remaining barriers to normalcy for this population.
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Affiliation(s)
- Kimberly A McBennett
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.,Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
| | - Pamela B Davis
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Michael W Konstan
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.,Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
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12
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Lahiri T, Sullivan JS. Recent advances in the early treatment of cystic fibrosis: Bridging the gap to highly effective modulator therapy. Pediatr Pulmonol 2022; 57 Suppl 1:S60-S74. [PMID: 34473419 DOI: 10.1002/ppul.25660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 08/22/2021] [Accepted: 09/01/2021] [Indexed: 11/08/2022]
Abstract
Highly effective modulator therapy (HEMT) for cystic fibrosis (CF) has been touted as one of the greatest advances to date in CF care. As these therapies are now available for many older children and adults with CF, marked improvement of their nutritional status, pulmonary and gastrointestinal symptoms has been observed. However, most infants and younger children are not current candidates for HEMT due to age and/or cystic fibrosis transmembrane conductance regulator (CFTR) mutation. For these young children, it is essential to provide rigorous monitoring and care to avoid potential disease sequelae while awaiting HEMT availability. The following article highlights recent advances in the care of infants and young children with CF with regard to surveillance and treatment of nutritional, pulmonary, and gastrointestinal disorders. Recent clinical trials in this population are also reviewed.
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Affiliation(s)
- Thomas Lahiri
- Divisions of Pediatric Pulmonology and Gastroenterology, University of Vermont Children's Hospital, Burlington, Vermont, USA
| | - Jillian S Sullivan
- Divisions of Pediatric Pulmonology and Gastroenterology, University of Vermont Children's Hospital, Burlington, Vermont, USA
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13
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Tugcu GD, Emiralioglu N, Yalcin E, Sahiner UM, Dogru D, Sekerel BE, Ozcelik U, Kiper N, Soyer O. The controversy of drug hypersensitivity in patients with cystic fibrosis and review of the literature. Pediatr Allergy Immunol 2022; 33:e13719. [PMID: 34907613 DOI: 10.1111/pai.13719] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 12/05/2021] [Accepted: 12/08/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Cystic fibrosis (CF) is reported to be a risk factor for drug hypersensitivity. However, there are conflicting data about true prevalence of drug hypersensitivity in children with CF. METHODS The suspicious drug hypersensitivity reactions (DHRs) of children with CF were enquired by the European Network for Drug Allergy (ENDA) questionnaire, and skin tests and/or drug provocation tests were performed according to the established guidelines. RESULTS Two hundred and nineteen children (48.9% boys; median [IQR] age, 8.4 years [4.8-12.4 years]) with cystic fibrosis were included in the study, among which 22 patients with 24 suspected DHRs were evaluated. Most of the suspected DHRs were of non-immediate (n = 16, 66.6%) type, and the offending drugs were amoxicillin-clavulanic acid (n = 7), macrolides (n = 4), trimethoprim-sulfamethoxazole (TMP/SMX) (n = 2), piperacillin-tazobactam (n = 1), pancrelipase (n = 1), and ursodeoxycholic acid (n = 1). Eight (33.3%) of the DHRs were classified as immediate (ceftriaxone [n = 2], ceftazidime [n = 2], meropenem [n = 1], AmBisome [n = 2], and vancomycin [n = 1]). The main clinical presentations were maculopapular eruption (41.6%) and urticaria (37.5%), accompanied by angioedema (8.3%), flushing (12.5%), and vomiting (8.3%). Nine skin tests (with beta-lactam protocol in 6 patients) and 24 DPTs were performed, and none of the skin tests revealed a positive result; however, 2 DPTs with TMP/SMX were positive. CONCLUSION Actual drug hypersensitivity was demonstrated in 2 of 219 patients (0.9%) with non-beta-lactam antibiotics. These results conflict with previous researches that showed higher drug hypersensitivity rates but are consistent with some recent studies. Allergological diagnostic workup is mandatory in patients with cystic fibrosis in case of a suspicious DHR.
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Affiliation(s)
- Gokcen Dilsa Tugcu
- Department of Pediatric Pulmonology, Hacettepe University, School of Medicine, Ankara, Turkey
| | - Nagehan Emiralioglu
- Department of Pediatric Pulmonology, Hacettepe University, School of Medicine, Ankara, Turkey
| | - Ebru Yalcin
- Department of Pediatric Pulmonology, Hacettepe University, School of Medicine, Ankara, Turkey
| | - Umit Murat Sahiner
- Department of Pediatric Allergy, Hacettepe University, School of Medicine, Ankara, Turkey
| | - Deniz Dogru
- Department of Pediatric Pulmonology, Hacettepe University, School of Medicine, Ankara, Turkey
| | - Bulent Enis Sekerel
- Department of Pediatric Allergy, Hacettepe University, School of Medicine, Ankara, Turkey
| | - Ugur Ozcelik
- Department of Pediatric Pulmonology, Hacettepe University, School of Medicine, Ankara, Turkey
| | - Nural Kiper
- Department of Pediatric Pulmonology, Hacettepe University, School of Medicine, Ankara, Turkey
| | - Ozge Soyer
- Department of Pediatric Allergy, Hacettepe University, School of Medicine, Ankara, Turkey
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14
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Novel Immunomodulatory Therapies for Respiratory Pathologies. COMPREHENSIVE PHARMACOLOGY 2022. [PMCID: PMC8238403 DOI: 10.1016/b978-0-12-820472-6.00073-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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15
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Bojanowski CM, Lu S, Kolls JK. Mucosal Immunity in Cystic Fibrosis. JOURNAL OF IMMUNOLOGY (BALTIMORE, MD. : 1950) 2021; 207:2901-2912. [PMID: 35802761 PMCID: PMC9270582 DOI: 10.4049/jimmunol.2100424] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 10/21/2021] [Indexed: 05/27/2023]
Abstract
The highly complex and variable genotype-phenotype relationships observed in cystic fibrosis (CF) have been an area of growing interest since the discovery of the CF transmembrane conductance regulator (CFTR) gene >30 y ago. The consistently observed excessive, yet ineffective, activation of both the innate and adaptive host immune systems and the establishment of chronic infections within the lung, leading to destruction and functional decline, remain the primary causes of morbidity and mortality in CF. The fact that both inflammation and pathogenic bacteria persist despite the introduction of modulator therapies targeting the defective protein, CFTR, highlights that we still have much to discover regarding mucosal immunity determinants in CF. Gene modifier studies have overwhelmingly implicated immune genes in the pulmonary phenotype of the disease. In this context, we aim to review recent advances in our understanding of the innate and adaptive immune systems in CF lung disease.
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Affiliation(s)
- Christine M Bojanowski
- Section of Pulmonary Diseases, Critical Care, and Environmental Medicine, Department of Medicine, Tulane University School of Medicine, New Orleans, LA;
| | - Shiping Lu
- Department of Microbiology and Immunology, Tulane University School of Medicine, New Orleans, LA; and
| | - Jay K Kolls
- Center for Translational Research in Infection and Inflammation, Department of Medicine, Tulane University School of Medicine, New Orleans, LA
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16
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Elborn JS, Konstan MW, Taylor-Cousar JL, Fajac I, Horsley A, Sutharsan S, Aaron SD, Daines CL, Uluer A, Downey DG, Lucidi VV, Ahuja S, Springman E, Mershon J, Grosswald R, Rowe SM. Empire-CF study: A phase 2 clinical trial of leukotriene A4 hydrolase inhibitor acebilustat in adult subjects with cystic fibrosis. J Cyst Fibros 2021; 20:1026-1034. [PMID: 34538755 DOI: 10.1016/j.jcf.2021.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 08/15/2021] [Accepted: 08/16/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Cystic fibrosis (CF) is characterized by neutrophilic inflammation in the airways. Leukotriene B4 (LTB4) is a neutrophil chemoattractant and has been implicated in CF pathogenesis. Acebilustat, a novel, synthetic, small-molecule leukotriene A4 hydrolase inhibitor, reduces LTB4 production. We report findings from a randomized placebo-controlled trial of acebilustat in adult subjects with mild-to-moderate lung disease. METHODS Subjects were randomized (1:1:1) to once-daily acebilustat 50 mg, 100 mg or placebo for 48 weeks, concomitantly with their current therapeutic regimen. Subjects were stratified by use of concomitant CF transmembrane conductance regulator (CFTR) modulators, baseline percent predicted forced expiratory volume in 1 second (ppFEV1) 50-75 and >75, and number of pulmonary exacerbations in the past year (1 or >1). Primary endpoints were the change from baseline in ppFEV1 and safety. Secondary endpoints included the rate of pulmonary exacerbations. RESULTS Overall, 199 subjects were randomized and dosed (acebilustat 50 mg, n=67; acebilustat 100 mg, n=66; placebo, n=66). Baseline demographics and disease profile were well balanced among treatment groups. Acebilustat had no statistically significant effect on the primary endpoint of change in ppFEV1 at week 48 or the secondary endpoint pulmonary exacerbations. There was a trend towards reduced pulmonary exacerbations in subjects receiving acebilustat in pre-specified populations with ppFEV1>75 (35% rate reduction) and those on concomitant CFTR modulator therapy (20% rate reduction). Acebilustat was well tolerated. CONCLUSIONS Acebilustat did not improve lung function. A trend towards reduced pulmonary exacerbations in subjects with an earlier stage of lung disease suggests a potential effect in this population.
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Affiliation(s)
- J Stuart Elborn
- Faculty of Medicine Health and Life sciences Queens University School of Medicine, Belfast, UK
| | - Michael W Konstan
- Department of Pediatrics, Case Western Reserve University School of Medicine and Rainbow Babies & Children's Hospital, Cleveland, OH, USA
| | | | - Isabelle Fajac
- Physiology Department, Cochin Hospital, APHP Centre, Paris, France; Université de Paris, Paris, France
| | - Alexander Horsley
- Division of Infection, Immunity and Respiratory Medicine, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Sivagurunathan Sutharsan
- Division of Cystic Fibrosis, Department of Pulmonary Medicine, University Medicine EssenRuhrlandklinik, University of DuisburgEssen, Essen, Germany
| | - Shawn D Aaron
- Ottawa Health Research Institute, Ottawa, Ontario, Canada
| | - Cori L Daines
- Department of Pediatrics, University of Arizona, Tucson, AZ, USA
| | - Ahmet Uluer
- Department of Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Damian G Downey
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Vincenzina V Lucidi
- Cystic Fibrosis Center, Children's Hospital and Research Institute, Bambino Gesu, Rome, Italy
| | | | | | | | | | - Steven M Rowe
- Gregory Fleming James Cystic Fibrosis Research Center and Department of Medicine, University of Alabama at Birmingham, 1918 University Blvd, MCLM 804, Birmingham 35294, AL, USA.
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17
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Muirhead CA, Lanocha N, Markwardt S, MacDonald KD. Evaluation of rescue oral glucocorticoid therapy during inpatient cystic fibrosis exacerbations. Pediatr Pulmonol 2021; 56:891-900. [PMID: 33289316 DOI: 10.1002/ppul.25204] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 11/13/2020] [Accepted: 11/30/2020] [Indexed: 11/07/2022]
Abstract
An acute pulmonary exacerbation (APE) in cystic fibrosis (CF) is characterized by increased pulmonary symptoms attributed to bacterial colonization, neutrophil recruitment, and inflammation. Antimicrobials, airway clearance, and nutrition are the mainstay of therapy. However, when patients fail to improve, corticosteroids have been added to therapy. We retrospectively examined the use of rescue steroids in a children's hospital from 2013 to 2017 during CF APE treatment following at least 1 week of inpatient therapy without expected clinical improvement. In total, 106 encounters of 53 unique patients, aged 6-20 years, who had FEV1 percent predicted (FEV1pp) data at baseline, admission, midpoint, and discharge, and had admission duration of at least 12 days were studied. Encounters treated with steroids had less improvement at midpoint percent change from admission in FEV1pp (4.9 ± 11.3) than nonsteroid group change in FEV1pp (20.1 ± 24.6; p < .001). Failure to improve as expected was the rationale for steroid use. At discharge, there was no difference in mean FEV1pp (p = .76). Delays in steroid therapy by waiting until the end of the second week increased the total length of stay (LOS). Propensity matching, comparing outcomes in patients without midpoint improvement in FEV1pp, was also evaluated. There was no difference in admission or discharge FEV1pp between groups. Equally, no difference in FEV1pp at follow-up visit or in time until the next APE was detected. Secondary analysis for associations including gender, genotype, fungal colonization, or inhaled antimicrobials was nonsignificant. These data suggest rescue use of corticosteroids during APE does not predictably impact important outcome measures during CF APE treatment.
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Affiliation(s)
- Corinne A Muirhead
- Department of Pharmacy, Oregon Health and Science University, Portland, Oregon, USA
| | - Natalie Lanocha
- Department of Pediatrics, Oregon Health and Science University, Portland, Oregon, USA
| | - Sheila Markwardt
- Department of Biostatistics, Oregon Health and Science University, Portland, Oregon, USA
| | - Kelvin D MacDonald
- Department of Pediatrics, Oregon Health and Science University, Portland, Oregon, USA
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Konstan MW, Pasta DJ, VanDevanter DR, Wagener JS, Morgan WJ. Epidemiologic Study of Cystic Fibrosis: 25 years of observational research. Pediatr Pulmonol 2021; 56:823-836. [PMID: 33434406 PMCID: PMC9123916 DOI: 10.1002/ppul.25248] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Revised: 12/19/2020] [Accepted: 12/25/2020] [Indexed: 11/09/2022]
Abstract
The Epidemiologic Study of Cystic Fibrosis (ESCF) was a prospective observational study of over 32,000 people with cystic fibrosis (CF) from 250 clinical care sites in North America from 1994 to 2005. Begun as a pharmacovigilance study in connection with the approval of dornase alfa in 1993, ESCF was open to all people with CF treated at any participating site in the United States or Canada. In addition to obtaining safety and effectiveness data on dornase alfa, ESCF collected encounter-based data to characterize the natural history and management of CF with a special focus on lung disease. During the study, 32,178 patients reported at least one encounter, contributing 869,136 encounters, 622,592 pulmonary function tests, 432,896 cultures, and 118,563 pulmonary exacerbations treated with intravenous antibiotics. Although ESCF data collection concluded in 2005, through a collaboration with the U.S. Cystic Fibrosis Foundation Patient Registry, additional follow-up data through 2017 was available for two-thirds of patients. This allowed for updating of CF genotype and survival information. Fifty-six peer-reviewed publications (cited over 3600 times) resulted from this study. In this manuscript we summarize the published ESCF manuscripts in thematic groups with key study findings and brief comments, and speculate on how ESCF findings will inform future data registries and patient care practices.
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Affiliation(s)
- Michael W Konstan
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.,UH Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
| | | | - Donald R VanDevanter
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Jeffrey S Wagener
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Wayne J Morgan
- Department of Pediatrics, University of Arizona, Tucson, Arizona, USA
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19
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Hull-Ryde EA, Minges JT, Martino MEB, Kato T, Norris-Drouin JL, Ribeiro CMP. IRE1α Is a Therapeutic Target for Cystic Fibrosis Airway Inflammation. Int J Mol Sci 2021; 22:3063. [PMID: 33802742 PMCID: PMC8002512 DOI: 10.3390/ijms22063063] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 03/14/2021] [Accepted: 03/15/2021] [Indexed: 12/15/2022] Open
Abstract
New anti-inflammatory treatments are needed for CF airway disease. Studies have implicated the endoplasmic reticulum stress transducer inositol requiring enzyme 1α (IRE1α) in CF airway inflammation. The activation of IRE1α promotes activation of its cytoplasmic kinase and RNase, resulting in mRNA splicing of X-box binding protein-1 (XBP-1s), a transcription factor required for cytokine production. We tested whether IRE1α kinase and RNase inhibition decreases cytokine production induced by the exposure of primary cultures of homozygous F508del CF human bronchial epithelia (HBE) to supernatant of mucopurulent material (SMM) from CF airways. We evaluated whether IRE1α expression is increased in freshly isolated and native CF HBE, and couples with increased XBP-1s levels. A FRET assay confirmed binding of the IRE1α kinase and RNase inhibitor, KIRA6, to the IRE1α kinase. F508del HBE cultures were exposed to SMM with or without KIRA6, and we evaluated the mRNA levels of XBP-1s, IL-6, and IL-8, and the secretion of IL-6 and IL-8. IRE1α mRNA levels were up-regulated in freshly isolated CF vs. normal HBE and coupled to increased XBP-1s mRNA levels. SMM increased XBP-1s, IL-6, and IL-8 mRNA levels and up-regulated IL-6 and IL-8 secretion, and KIRA6 blunted these responses in a dose-dependent manner. Moreover, a triple combination of CFTR modulators currently used in the clinic had no effect on SMM-increased XBP-1s levels coupled with increased cytokine production in presence or absence of KIRA6. These findings indicate that IRE1α mediates cytokine production in CF airways. Small molecule IRE1α kinase inhibitors that allosterically reduce RNase-dependent XBP-1s may represent a new therapeutic strategy for CF airway inflammation.
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Affiliation(s)
- Emily A. Hull-Ryde
- Marsico Lung Institute and Cystic Fibrosis Research Center, School of Medicine, University of North Carolina, Chapel Hill, NC 27599, USA; (E.A.H.-R.); (J.T.M.); (M.E.B.M.); (T.K.)
| | - John T. Minges
- Marsico Lung Institute and Cystic Fibrosis Research Center, School of Medicine, University of North Carolina, Chapel Hill, NC 27599, USA; (E.A.H.-R.); (J.T.M.); (M.E.B.M.); (T.K.)
| | - Mary E. B. Martino
- Marsico Lung Institute and Cystic Fibrosis Research Center, School of Medicine, University of North Carolina, Chapel Hill, NC 27599, USA; (E.A.H.-R.); (J.T.M.); (M.E.B.M.); (T.K.)
| | - Takafumi Kato
- Marsico Lung Institute and Cystic Fibrosis Research Center, School of Medicine, University of North Carolina, Chapel Hill, NC 27599, USA; (E.A.H.-R.); (J.T.M.); (M.E.B.M.); (T.K.)
| | - Jacqueline L. Norris-Drouin
- Center for Integrative Chemical Biology and Drug Discovery, Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC 27599, USA;
| | - Carla M. P. Ribeiro
- Marsico Lung Institute and Cystic Fibrosis Research Center, School of Medicine, University of North Carolina, Chapel Hill, NC 27599, USA; (E.A.H.-R.); (J.T.M.); (M.E.B.M.); (T.K.)
- Division of Pulmonary Diseases, Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill, NC 27599, USA
- Department of Cell Biology and Physiology, School of Medicine, University of North Carolina, Chapel Hill, NC 27599, USA
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20
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Dysfunctional Inflammation in Cystic Fibrosis Airways: From Mechanisms to Novel Therapeutic Approaches. Int J Mol Sci 2021; 22:ijms22041952. [PMID: 33669352 PMCID: PMC7920244 DOI: 10.3390/ijms22041952] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 02/08/2021] [Accepted: 02/12/2021] [Indexed: 12/27/2022] Open
Abstract
Cystic fibrosis (CF) is an inherited disorder caused by mutations in the gene encoding for the cystic fibrosis transmembrane conductance regulator (CFTR) protein, an ATP-gated chloride channel expressed on the apical surface of airway epithelial cells. CFTR absence/dysfunction results in defective ion transport and subsequent airway surface liquid dehydration that severely compromise the airway microenvironment. Noxious agents and pathogens are entrapped inside the abnormally thick mucus layer and establish a highly inflammatory environment, ultimately leading to lung damage. Since chronic airway inflammation plays a crucial role in CF pathophysiology, several studies have investigated the mechanisms responsible for the altered inflammatory/immune response that, in turn, exacerbates the epithelial dysfunction and infection susceptibility in CF patients. In this review, we address the evidence for a critical role of dysfunctional inflammation in lung damage in CF and discuss current therapeutic approaches targeting this condition, as well as potential new treatments that have been developed recently. Traditional therapeutic strategies have shown several limitations and limited clinical benefits. Therefore, many efforts have been made to develop alternative treatments and novel therapeutic approaches, and recent findings have identified new molecules as potential anti-inflammatory agents that may exert beneficial effects in CF patients. Furthermore, the potential anti-inflammatory properties of CFTR modulators, a class of drugs that directly target the molecular defect of CF, also will be critically reviewed. Finally, we also will discuss the possible impact of SARS-CoV-2 infection on CF patients, with a major focus on the consequences that the viral infection could have on the persistent inflammation in these patients.
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21
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Chao D, Li Q, Hu G. Research on Effect of Exosome Excreted by RAW264.7 Cell on Damage of Mice Lung Function and Its Mechanism. J BIOMATER TISS ENG 2021. [DOI: 10.1166/jbt.2021.2534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The exosome excreted by RAW264.7 cell was found to participate in the damage of lung function. Our purpose was to assess the exact mechanism. The animal experiment was adopted in our study. It was provided reference for clinical experiment. 30 healthy male rats were selected and assigned
into normal control group, normal exosome group and LPS with exosome group by random number table followed by analysis of the size and form of exosome under electron microscope, the lung structural change by hematoxylin and eosin staining, TNF-α and IL-1β secretion
by immunohistochemistry, and the expression of tightly bound protein one (ZO-1), closed protein, β-chain protein and two groups of exosome-marked protein (CD9 and CD63) by western blot. In normal control group, the lung structure was very integral with clear alveolar space. The
cell wall was smooth relatively without exudation substance in alveolar space and mesenchyme. Normal exosome group showed relatively integral lung structure and thicker cell wall. The inside of alveolar space was very clear without exudation substance in alveolar space and mesenchyme. LPS
+ exosome group presented abundant inflammatory cells in alveolar space and mesenchyme with obvious bleeding. Inflammatory factor secretion such as TNF-α (1.334 ± 0.205%) and IL-1β (0.803 ± 0.097%)was significantly higher and the content of closed protein
(0.203 ±0.017%) was lower in LPS with exosome group than the other two groups (P < 0.05). The exosome secreted by RAW264.7 cell after stimulation by lipopolysaccharide could impair the lung function in rats and is related with the decline of closed protein.
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Affiliation(s)
- Dong Chao
- Department of Thoracic Surgery, The 940th Hospital of Joint Logistics Support Force of Chinese People’s Liberation Army, Lanzhou, Gansu, 730050, China
| | - Qingxin Li
- Department of Thoracic Surgery, The 940th Hospital of Joint Logistics Support Force of Chinese People’s Liberation Army, Lanzhou, Gansu, 730050, China
| | - Gawei Hu
- Department of Thoracic Surgery, The 940th Hospital of Joint Logistics Support Force of Chinese People’s Liberation Army, Lanzhou, Gansu, 730050, China
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22
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Gbian DL, Omri A. Current and novel therapeutic strategies for the management of cystic fibrosis. Expert Opin Drug Deliv 2021; 18:535-552. [PMID: 33426936 DOI: 10.1080/17425247.2021.1874343] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Introduction: Cystic fibrosis (CF), is caused by mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) gene and affects thousands of people throughout the world. Lung disease is the leading cause of death in CF patients. Despite the advances in treatments, the management of CF mainly targets symptoms. Recent CFTR modulators however target common mutations in patients, alleviating symptoms of CF. Unfortunately, there is still no approved treatments for patients with rare mutations to date.Areas covered: This paper reviews current treatments of CF that mitigate symptoms and target genetic defects. The use of gene and drug delivery systems such as viral or non-viral vectors and nano-compounds to enhance CFTR expression and the activity of antimicrobials against chronic pulmonary infections respectively, will also be discussed.Expert opinion: Nano-compounds tackle biological barriers to drug delivery and revitalize antimicrobials, anti-inflammatory drugs and even genes delivery to CF patients. Gene therapy and gene editing are of particular interest because they have the potential to directly target genetic defects. Nanoparticles should be formulated to more specifically target epithelial cells, and biofilms. Finally, the development of more potent gene vectors to increase the duration of gene expression and reduce inflammation is a promising strategy to eventually cure CF.
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Affiliation(s)
- Douweh Leyla Gbian
- The Novel Drug and Vaccine Delivery Systems Facility, Department of Chemistry and Biochemistry, Laurentian University, Sudbury, Ontario, Canada
| | - Abdelwahab Omri
- The Novel Drug and Vaccine Delivery Systems Facility, Department of Chemistry and Biochemistry, Laurentian University, Sudbury, Ontario, Canada
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23
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Gillan JL, Davidson DJ, Gray RD. Targeting cystic fibrosis inflammation in the age of CFTR modulators: focus on macrophages. Eur Respir J 2020; 57:13993003.03502-2020. [PMID: 33303535 DOI: 10.1183/13993003.03502-2020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 11/18/2020] [Indexed: 11/05/2022]
Abstract
Cystic fibrosis (CF) is a life-shortening, multi-organ, autosomal recessive disease caused by mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) gene. The most prominent clinical manifestation in CF is the development of progressive lung disease characterised by an intense, chronic inflammatory airway response that culminates in respiratory failure and, ultimately, death. In recent years, a new class of therapeutics that have the potential to correct the underlying defect in CF, known as CFTR modulators, have revolutionised the field. Despite the exciting success of these drugs, their impact on airway inflammation, and its long-term consequences, remains undetermined. In addition, studies querying the absolute requirement for infection as a driver of CF inflammation have challenged the traditional consensus on CF pathogenesis, and also emphasise the need to prioritise complementary anti-inflammatory treatments in CF. Macrophages, often overlooked in CF research despite their integral role in other chronic inflammatory pathologies, have increasingly become recognised as key players in the initiation, perpetuation and resolution of CF lung inflammation, perhaps as a direct result of CFTR dysfunction. These findings suggest that macrophages may be an important target for novel anti-inflammatory interventional strategies to effectively treat CF lung function decline. This review will consider evidence for the efficacy of anti-inflammatory drugs in the treatment of CF, the potential role of macrophages, and the significance of targeting these pathways at a time when rectifying the basic defect in CF, through use of novel CFTR modulator therapies, is becoming increasingly viable.
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Affiliation(s)
- Jonathan L Gillan
- University of Edinburgh Centre for Inflammation Research, Queen's Medical Research Institute, Edinburgh, UK
| | - Donald J Davidson
- University of Edinburgh Centre for Inflammation Research, Queen's Medical Research Institute, Edinburgh, UK
| | - Robert D Gray
- University of Edinburgh Centre for Inflammation Research, Queen's Medical Research Institute, Edinburgh, UK
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24
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Airway Redox Homeostasis and Inflammation Gone Awry: From Molecular Pathogenesis to Emerging Therapeutics in Respiratory Pathology. Int J Mol Sci 2020; 21:ijms21239317. [PMID: 33297418 PMCID: PMC7731288 DOI: 10.3390/ijms21239317] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 12/05/2020] [Indexed: 02/06/2023] Open
Abstract
As aerobic organisms, we are continuously and throughout our lifetime subjected to an oxidizing atmosphere and, most often, to environmental threats. The lung is the internal organ most highly exposed to this milieu. Therefore, it has evolved to confront both oxidative stress induced by reactive oxygen species (ROS) and a variety of pollutants, pathogens, and allergens that promote inflammation and can harm the airways to different degrees. Indeed, an excess of ROS, generated intrinsically or from external sources, can imprint direct damage to key structural cell components (nucleic acids, sugars, lipids, and proteins) and indirectly perturb ROS-mediated signaling in lung epithelia, impairing its homeostasis. These early events complemented with efficient recognition of pathogen- or damage-associated recognition patterns by the airway resident cells alert the immune system, which mounts an inflammatory response to remove the hazards, including collateral dead cells and cellular debris, in an attempt to return to homeostatic conditions. Thus, any major or chronic dysregulation of the redox balance, the air-liquid interface, or defects in epithelial proteins impairing mucociliary clearance or other defense systems may lead to airway damage. Here, we review our understanding of the key role of oxidative stress and inflammation in respiratory pathology, and extensively report current and future trends in antioxidant and anti-inflammatory treatments focusing on the following major acute and chronic lung diseases: acute lung injury/respiratory distress syndrome, asthma, chronic obstructive pulmonary disease, pulmonary fibrosis, and cystic fibrosis.
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25
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Perrem L, Ratjen F. Designing Clinical Trials for Anti-Inflammatory Therapies in Cystic Fibrosis. Front Pharmacol 2020; 11:576293. [PMID: 33013419 PMCID: PMC7516261 DOI: 10.3389/fphar.2020.576293] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 08/24/2020] [Indexed: 01/15/2023] Open
Abstract
The inflammatory response in the CF airway begins early in the disease process and becomes persistent through life in most patients. Inflammation, which is predominantly neutrophilic, worsens airway obstruction and plays a critical role in the development of structural lung damage. While cystic fibrosis transmembrane regulator modulators will likely have a dramatic impact on the trajectory of CF lung disease over the coming years, addressing other important aspects of lung disease such as inflammation will nevertheless remain a priority. Considering the central role of neutrophils and their products in the inflammatory response, potential therapies should ultimately affect neutrophils and their products. The ideal anti-inflammatory therapy would exert a dual effect on the pro-inflammatory and pro-resolution arms of the inflammatory cascade, both of which contribute to dysregulated inflammation in CF. This review outlines the key factors to be considered in the design of clinical trials evaluating anti-inflammatory therapies in CF. Important lessons have been learned from previous clinical trials in this area and choosing the right efficacy endpoints is key to the success of any anti-inflammatory drug development program. Identifying and validating non-invasive biomarkers, novel imaging techniques and sensitive lung function tests capable of monitoring disease activity and therapeutic response are important areas of research and will be useful for the design of future anti-inflammatory drug trials.
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Affiliation(s)
- Lucy Perrem
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Paediatrics, University of Toronto, Toronto, ON, Canada.,Translational Medicine Program, SickKids Research Institute, Toronto, ON, Canada
| | - Felix Ratjen
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Paediatrics, University of Toronto, Toronto, ON, Canada.,Translational Medicine Program, SickKids Research Institute, Toronto, ON, Canada
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26
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Opinion: Imagine 5P3A Global Health. Ther Innov Regul Sci 2020; 54:988-990. [DOI: 10.1007/s43441-020-00118-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 10/14/2019] [Indexed: 10/25/2022]
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27
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Recchiuti A, Patruno S, Plebani R, Romano M. The Resolution Approach to Cystic Fibrosis Inflammation. Front Pharmacol 2020; 11:1129. [PMID: 32848748 PMCID: PMC7403222 DOI: 10.3389/fphar.2020.01129] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 07/10/2020] [Indexed: 01/11/2023] Open
Abstract
Despite the high expectations associated with the recent introduction of CFTR modulators, airway inflammation still remains a relevant clinical issue in cystic fibrosis (CF). The classical anti-inflammatory drugs have shown very limited efficacy, when not being harmful, raising the question of whether alternative approaches should be undertaken. Thus, a better knowledge of the mechanisms underlying the aberrant inflammation observed in CF is pivotal to develop more efficacious pharmacology. In this respect, the observation that endogenous proresolving pathways are defective in CF and that proresolving mediators, physiologically generated during an acute inflammatory reaction, do not completely suppress inflammation, but promote resolution, tissue healing and microbial clearance, without compromising immune host defense mechanisms, opens interesting therapeutic scenarios for CF. In this mini-review, we present the current knowledge and perspectives of proresolving pharmacology in CF, focusing on the specialized proresolving lipid mediators and selected peptides.
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Affiliation(s)
- Antonio Recchiuti
- Laboratory of Molecular Medicine, Center on Advanced Studies and Technology (CAST), Department of Medical, Oral e Biotechnological Sciences, "G. d'Annunzio" University of Chieti-Pescara, Chieti, Italy
| | - Sara Patruno
- Laboratory of Molecular Medicine, Center on Advanced Studies and Technology (CAST), Department of Medical, Oral e Biotechnological Sciences, "G. d'Annunzio" University of Chieti-Pescara, Chieti, Italy
| | - Roberto Plebani
- Laboratory of Molecular Medicine, Center on Advanced Studies and Technology (CAST), Department of Medical, Oral e Biotechnological Sciences, "G. d'Annunzio" University of Chieti-Pescara, Chieti, Italy
| | - Mario Romano
- Laboratory of Molecular Medicine, Center on Advanced Studies and Technology (CAST), Department of Medical, Oral e Biotechnological Sciences, "G. d'Annunzio" University of Chieti-Pescara, Chieti, Italy
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28
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Hoo ZH, Hitchcock L, Curley R, Wildman MJ. A comparison of the CFHH criteria against the Leeds criteria in determining the Pseudomonas aeruginosa status among adults with cystic fibrosis. Respir Med 2020; 171:106103. [PMID: 32758991 DOI: 10.1016/j.rmed.2020.106103] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Revised: 07/20/2020] [Accepted: 07/27/2020] [Indexed: 01/24/2023]
Abstract
BACKGROUND Pseudomonas aeruginosa (PA) status influences management decisions in cystic fibrosis (CF) but diagnostic approaches vary. We evaluated the ability of the CFHealthHub (CFHH) criteria, which consist of two major and four minor statements, in diagnosing chronic PA infection among adults with CF. METHODS In this retrospective cross-sectional analysis, we compared the CFHH criteria against the Leeds criteria. Data were collected between 1st January and 31st December 2016 from all adults with CF receiving care at Sheffield, excluding those with lung transplantation (n = 7) or on ivacaftor (n = 13). The CFHH criteria PA status were cross-tabulated against the Leeds criteria, and clinical outcomes between chronic PA vs non chronic PA for both criteria were compared. RESULTS This analysis included 186 adults with CF (90 females, median age 27 years, median baseline FEV1 78.5%). The CFHH criteria diagnosed more cases of chronic PA (116/186, 62.4% vs 79/186, 42.5%), and 37/107 cases of non-chronic PA according to the Leeds criteria were deemed chronic PA by the CFHH criteria. The magnitude of difference in %FEV1 decline between chronic PA vs non chronic PA was slightly greater for the CFHH criteria (-0.6%, 95% CI -1.8 to 0.6%) compared to the Leeds criteria (-0.2%, 95% CI -1.3 to 1.0%). CONCLUSIONS The CFHH criteria detected more chronic PA cases yet still retained similar levels of discrimination for health outcomes in comparison to the Leeds criteria. These findings provide preliminary evidence for the validity of the CFHH criteria among adults with CF.
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Affiliation(s)
- Zhe Hui Hoo
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK; Sheffield Adult CF Centre, Northern General Hospital, Sheffield, UK.
| | - Lydia Hitchcock
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK; Sheffield Adult CF Centre, Northern General Hospital, Sheffield, UK
| | - Rachael Curley
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK; Sheffield Adult CF Centre, Northern General Hospital, Sheffield, UK
| | - Martin J Wildman
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK; Sheffield Adult CF Centre, Northern General Hospital, Sheffield, UK
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29
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Mayer-Hamblett N, van Koningsbruggen-Rietschel S, Nichols DP, VanDevanter DR, Davies JC, Lee T, Durmowicz AG, Ratjen F, Konstan MW, Pearson K, Bell SC, Clancy JP, Taylor-Cousar JL, De Boeck K, Donaldson SH, Downey DG, Flume PA, Drevinek P, Goss CH, Fajac I, Magaret AS, Quon BS, Singleton SM, VanDalfsen JM, Retsch-Bogart GZ. Building global development strategies for cf therapeutics during a transitional cftr modulator era. J Cyst Fibros 2020; 19:677-687. [PMID: 32522463 DOI: 10.1016/j.jcf.2020.05.011] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 05/18/2020] [Accepted: 05/27/2020] [Indexed: 12/30/2022]
Abstract
As CFTR modulator therapy transforms the landscape of cystic fibrosis (CF) care, its lack of uniform access across the globe combined with the shift towards a new standard of care creates unique challenges for the development of future CF therapies. The advancement of a full and promising CF therapeutics pipeline remains a necessary priority to ensure maximal clinical benefits for all people with CF. It is through collaboration across the global CF community that we can optimize the evaluation and approval process of new therapies. To this end, we must identify areas for which harmonization is lacking and for which efficiencies can be gained to promote ethical, feasible, and credible study designs amidst the changing CF care landscape. This article summarizes the counsel from core advisors across multiple international regions and clinical trial networks, developed during a one-day workshop in October 2019. The goal of the workshop was to identify, in consideration of the highly transitional era of CFTR modulator availability, the drug development areas for which global alignment is currently uncertain, and paths forward that will enable advancement of CF therapeutic development.
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Affiliation(s)
- N Mayer-Hamblett
- University of Washington, Seattle, WA; Seattle Children's Hospital, Seattle, WA.
| | - S van Koningsbruggen-Rietschel
- Cystic Fibrosis Center, Children's Hospital, University of Cologne; Faculty of Medicine and University Hospital Cologne, Cologne Germany
| | - D P Nichols
- University of Washington, Seattle, WA; Seattle Children's Hospital, Seattle, WA
| | - D R VanDevanter
- Case Western Reserve University School of Medicine, Cleveland, OH
| | - J C Davies
- National Heart & Lung Institute, Imperial College London, London, UK; Royal Brompton & Harefield NHS Foundation Trust, London, UK
| | - T Lee
- Leeds Regional Paediatric Cystic Fibrosis Centre, Leeds, UK
| | | | - F Ratjen
- University of Toronto, Toronto, Canada
| | - M W Konstan
- Case Western Reserve University School of Medicine, Cleveland, OH; Rainbow Babies and Children's Hospital, Cleveland, OH
| | - K Pearson
- Seattle Children's Hospital, Seattle, WA
| | - S C Bell
- Children's Health Research Centre, The University of Queensland, Brisbane, Australia
| | - J P Clancy
- Cystic Fibrosis Foundation, Bethesda, MD
| | | | | | - S H Donaldson
- University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - D G Downey
- Centre for Experimental Medicine, Queen's University Belfast, Belfast, Northern Ireland
| | - P A Flume
- Medical University of South Carolina, Charleston, SC
| | - P Drevinek
- Charles University, Prague, Czechia, Motol University Hospital, Prague, Czechia
| | - C H Goss
- University of Washington, Seattle, WA; Seattle Children's Hospital, Seattle, WA
| | - I Fajac
- Université de Paris, Paris, France
| | - A S Magaret
- University of Washington, Seattle, WA; Seattle Children's Hospital, Seattle, WA
| | - B S Quon
- University of British Columbia, Vancouver, British Columbia
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30
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Lu B, Corey DA, Kelley TJ. Resveratrol restores intracellular transport in cystic fibrosis epithelial cells. Am J Physiol Lung Cell Mol Physiol 2020; 318:L1145-L1157. [PMID: 32267731 DOI: 10.1152/ajplung.00006.2020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
We have demonstrated previously that intracellular transport is impaired in cystic fibrosis (CF) epithelial cells. This impairment is related to both growth and inflammatory regulation in CF cell and animal models. Understanding how transport in CF cells is regulated and identifying means to manipulate that regulation are key to identifying new therapies that can address key CF phenotypes. It was hypothesized that resveratrol could replicate these benefits since it interfaces with multiple pathways identified to affect microtubule regulation in CF. It was found that resveratrol treatment significantly restored intracellular transport as determined by monitoring both cholesterol distribution and the distribution of rab7-positive organelles in CF cells. This restoration of intracellular transport is due to correction of both microtubule formation rates and microtubule acetylation in cultured CF cell models and primary nasal epithelial cells. Mechanistically, the effect of resveratrol on microtubule regulation and intracellular transport was dependent on peroxisome proliferator-activated receptor-γ signaling and its ability to act as a pan-histone deacetylase (HDAC) inhibitor. Resveratrol represents a candidate compound with known anti-inflammatory properties that can restore both microtubule formation and acetylation in CF epithelial cells.
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Affiliation(s)
- Binyu Lu
- Department of Pediatrics, Case Western Reserve University, Cleveland, Ohio
| | - Deborah A Corey
- Department of Pediatrics, Case Western Reserve University, Cleveland, Ohio
| | - Thomas J Kelley
- Department of Pediatrics, Case Western Reserve University, Cleveland, Ohio
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Farooq F, Mogayzel PJ, Lanzkron S, Haywood C, Strouse JJ. Comparison of US Federal and Foundation Funding of Research for Sickle Cell Disease and Cystic Fibrosis and Factors Associated With Research Productivity. JAMA Netw Open 2020; 3:e201737. [PMID: 32219405 DOI: 10.1001/jamanetworkopen.2020.1737] [Citation(s) in RCA: 80] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
IMPORTANCE Sickle cell disease (SCD) and cystic fibrosis (CF) are severe autosomal recessive disorders associated with intermittent disease exacerbations that require hospitalizations, progressive chronic organ injury, and substantial premature mortality. Research funding is a limited resource and may contribute to health care disparities, especially for rare diseases that disproportionally affect economically disadvantaged groups. OBJECTIVE To compare disease-specific funding between SCD and CF and the association between funding and research productivity. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study examined federal and foundation funding, publications indexed in PubMed, clinical trials registered in ClinicalTrials.gov, and new drug approvals from January 1, 2008, to December 31, 2018, in an estimated US population of approximately 90 000 individuals with SCD and approximately 30 000 individuals with CF. MAIN OUTCOMES AND MEASURES Federal and foundation funding, publications indexed in PubMed, clinical trial registrations, and new drug approvals. RESULTS From 2008 through 2018, federal funding was greater per person with CF compared with SCD (mean [SD], $2807 [$175] vs $812 [$147]; P < .001). Foundation expenditures were greater for CF than for SCD (mean [SD], $7690 [$3974] vs $102 [$13.7]; P < .001). Significantly more research articles (mean [SD], 1594 [225] vs 926 [157]; P < .001) and US Food and Drug Administration drug approvals (4 vs 1) were found for CF compared with SCD, but the total number of clinical trials was similar (mean [SD], 27.3 [6.9] vs 23.8 [6.3]; P = .22). CONCLUSIONS AND RELEVANCE The findings show that disparities in funding between SCD and CF may be associated with decreased research productivity and novel drug development for SCD. Increased federal and foundation funding is needed for SCD and other diseases that disproportionately affect economically disadvantaged groups to address health care disparities.
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Affiliation(s)
- Faheem Farooq
- Deparment of Pediatrics and Medicine, Stony Brook University Hospital, Stony Brook, New York
| | - Peter J Mogayzel
- Division of Pediatric Pulmonology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sophie Lanzkron
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Carlton Haywood
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Berman Institute of Bioethics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - John J Strouse
- Division of Hematology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina
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Weiner GA, Forno E, Weiner DJ. The effects of high-frequency chest compression on end-tidal CO 2. Pediatr Pulmonol 2020; 55:646-648. [PMID: 31765524 DOI: 10.1002/ppul.24588] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 11/11/2019] [Indexed: 12/12/2022]
Abstract
INTRODUCTION High-frequency chest compression (HFCC) is used for airway clearance, but may have other effects. We sought to determine if HFCC provides augmented ventilation. METHODS During treatment, capnometry was measured with the HFCC vest set to 6-20 Hz. End-tidal CO2 (etCO2 ) was compared using generalized estimating equations. RESULTS Twenty-four measurements were obtained from 15 subjects with mean age 15.2 ± 2.5 years and forced expiratory volume in one second (FEV1 ) % predicted 70 ± 23. EtCO2 decreased with HFCC at 6 Hz when compared with baseline (P < .001), with small changes with increasing oscillation frequency. Change in etCO2 was not predicted by FEV1 , body mass index, age, or sex. CONCLUSIONS While HFCC has been shown to be a suitable method of airway clearance, investigators have failed to demonstrate differences between techniques. Assessment of these methodologies will become important as new airway clearance devices are proposed. Other outcome measures (besides FEV1 ) may be needed to assess effects of airway clearance, and we propose that physiologic measures might be one such measure which deserves further exploration.
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Affiliation(s)
- Gabriel A Weiner
- Division of Pulmonary Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Erick Forno
- Division of Pulmonary Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Daniel J Weiner
- Division of Pulmonary Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Hoo ZH, Campbell MJ, Walters SJ, Wildman MJ. Understanding FEV 1 for the purpose of cystic fibrosis registry comparisons: Does bias in annual review FEV 1 affect between-centre comparison within the UK? An analysis of registry data. J Eval Clin Pract 2020; 26:229-235. [PMID: 30681238 DOI: 10.1111/jep.13097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 12/14/2018] [Accepted: 12/17/2018] [Indexed: 11/29/2022]
Abstract
RATIONALE, AIMS, AND OBJECTIVE We previously demonstrated that annual review %FEV1 underestimates lung health of adults with CF compared with %FEV1 captured during periods of clinical stability. This has implications in the comparisons against registries with encounter-based FEV1 , such as the United States. It is uncertain whether this bias affects between-centre comparison within the United Kingdom. Previous funnel plot analyses have identified variation in annual review %FEV1 according to centre size; hence, we investigated whether paired differences between annual review and best %FEV1 also vary according to centre size. METHODS This registry analysis included 18 adult CF centres in the United Kingdom with ≥80% completeness for best FEV1 data in 2014. Mean discrepancy between annual review and best %FEV1 is a surrogate for the extent by which annual review %FEV1 underestimates lung health, and was plotted against centre size. A local polynomial regression (LOESS) curve was used to explore the relationship between the two variables. An appropriate model is fitted based on the LOESS curve to determine the strength of relationship between discrepancies in %FEV1 and centre size. RESULTS There is an inverted U-shaped relationship between mean discrepancies in %FEV1 and centre size. A regression of the paired mean difference in %FEV1 against centre size showed a significant improvement in the goodness of fit for a quadratic model (R2 = 23.8% for a quadratic model compared with 0.4% for a linear one; P = 0.048 for the quadratic term). CONCLUSIONS Annual review %FEV1 underestimated lung health of adults from small and large centres in the United Kingdom to a greater extent compared with medium-sized centres. A plot of %FEV1 against centre size (eg, funnel plot comparison) would be affected by systematic bias in annual review %FEV1 . Therefore, annual review %FEV1 is an unreliable metric to compare health outcomes of adult CF centres within the United Kingdom.
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Affiliation(s)
- Zhe Hui Hoo
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK.,Sheffield Adult CF Centre, Northern General Hospital, Sheffield, UK
| | - Michael J Campbell
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Stephen J Walters
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Martin J Wildman
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK.,Sheffield Adult CF Centre, Northern General Hospital, Sheffield, UK
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Gonda I. What kind of emphasis do we need in clinical research to enable personalised respiratory medicine? Eur Respir J 2020; 55:55/1/1901866. [PMID: 31949101 DOI: 10.1183/13993003.01866-2019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 10/02/2019] [Indexed: 11/05/2022]
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35
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Inflammation in CF: Key Characteristics and Therapeutic Discovery. Respir Med 2020. [DOI: 10.1007/978-3-030-42382-7_8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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36
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Perrem L, Ratjen F. Anti-inflammatories and mucociliary clearance therapies in the age of CFTR modulators. Pediatr Pulmonol 2019; 54 Suppl 3:S46-S55. [PMID: 31715088 DOI: 10.1002/ppul.24364] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 04/29/2019] [Accepted: 05/02/2019] [Indexed: 12/23/2022]
Abstract
Cystic fibrosis (CF) is a genetic and life-limiting disease caused by mutations in the CF transmembrane conductance regulator (CFTR) gene. This multi-system disease is characterized by progressive lung disease and pancreatic insufficiency amongst other manifestations. CFTR primarily functions as a chloride channel that transports ions across the apical membrane of epithelial cells but has other functions, including bicarbonate secretion and inhibition of sodium transport. Defective CFTR disrupts these functions, causing viscous and dehydrated mucus to accumulate, compromising the airway lumen and contributing to obstructive pulmonary disease. The combination of CFTR dysfunction, mucus obstruction, and infection drive an exaggerated and dysfunctional inflammatory response, which contributes to irreversible airway destruction and fibrosis. CFTR modulators, an exciting new class of drugs, increase the expression and/or function of CFTR variant protein and improve multiple clinical endpoints, such as lung function, pulmonary exacerbation rates, and nutritional status. However, these genotype-specific drugs are not universally available, the clinical response is variable, and lung function still declines over time when bronchiectasis is established. Consequently, even in the age of CFTR modulators, we must target other important aspects of the CF airway disease, such as inflammation and mucociliary clearance. This review highlights the mechanisms of inflammation and mucus accumulation in the CF lung and discusses anti-inflammatory and mucociliary clearance agents that are currently in development focusing on compounds for which clinical trial data have recently become available.
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Affiliation(s)
- Lucy Perrem
- Division of Respiratory Medicine, The Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada.,Translational Medicine Program, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Felix Ratjen
- Division of Respiratory Medicine, The Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada.,Translational Medicine Program, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
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Abstract
With the improving survival of cystic fibrosis (CF) patients and the advent of highly effective cystic fibrosis transmembrane conductance regulator therapy, the clinical spectrum of this complex multisystem disease continues to evolve. One of the most important clinical events for patients with CF in the course of this disease is an acute pulmonary exacerbation. Clinical and microbial epidemiology studies of CF pulmonary exacerbations continue to provide important insight into the disease course, prognosis, and complications. This work has now led to a number of large scale clinical trials with the goal of improving the treatment paradigm for CF pulmonary exacerbation. The primary goal of this review is to provide a summary of the pathophysiology, the clinical epidemiology, microbial epidemiology, outcome and the treatment of CF pulmonary exacerbation.
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Affiliation(s)
- Christopher H Goss
- CFF Therapeutics Development Network Coordinating Center, Department of Pediatrics, Seattle Children's Research Institute, Seattle, Washington.,Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine and Pediatrics, University of Washington School of Medicine, Seattle, Washington
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38
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McElvaney OJ, Wade P, Murphy M, Reeves EP, McElvaney NG. Targeting airway inflammation in cystic fibrosis. Expert Rev Respir Med 2019; 13:1041-1055. [PMID: 31530195 DOI: 10.1080/17476348.2019.1666715] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Introduction: The major cause of morbidity and mortality in patients with cystic fibrosis (CF) is lung disease. Inflammation in the CF airways occurs from a young age and contributes significantly to disease progression and shortened life expectancy. Areas covered: In this review, we discuss the key immune cells involved in airway inflammation in CF, the contribution of the intrinsic genetic defect to the CF inflammatory phenotype, and anti-inflammatory strategies designed to overcome what is a critical factor in the pathogenesis of CF lung disease. Review of the literature was carried out using the MEDLINE (from 1975 to 2018), Google Scholar and The Cochrane Library databases. Expert opinion: Therapeutic interventions specifically targeting the defective CF transmembrane conductance regulator (CFTR) protein have changed the clinical landscape and significantly improved the outlook for CF. As survival estimates for people with CF increase, long-term management has become an important focus, with an increased need for therapies targeted at specific elements of inflammation, to complement CFTR modulator therapies.
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Affiliation(s)
- Oliver J McElvaney
- Irish Centre for Genetic Lung Disease, Royal College of Surgeons in Ireland, Beaumont Hospital , Dublin , Ireland
| | - Patricia Wade
- Irish Centre for Genetic Lung Disease, Royal College of Surgeons in Ireland, Beaumont Hospital , Dublin , Ireland
| | - Mark Murphy
- Irish Centre for Genetic Lung Disease, Royal College of Surgeons in Ireland, Beaumont Hospital , Dublin , Ireland
| | - Emer P Reeves
- Irish Centre for Genetic Lung Disease, Royal College of Surgeons in Ireland, Beaumont Hospital , Dublin , Ireland
| | - Noel G McElvaney
- Irish Centre for Genetic Lung Disease, Royal College of Surgeons in Ireland, Beaumont Hospital , Dublin , Ireland
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Lands LC, Stanojevic S. Oral non-steroidal anti-inflammatory drug therapy for lung disease in cystic fibrosis. Cochrane Database Syst Rev 2019; 9:CD001505. [PMID: 31499593 PMCID: PMC6733592 DOI: 10.1002/14651858.cd001505.pub5] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Progressive lung damage causes most deaths in cystic fibrosis. Non-steroidal anti-inflammatory drugs (such as ibuprofen) may prevent progressive pulmonary deterioration and morbidity in cystic fibrosis. This is an update of a previously published review. OBJECTIVES To assess the effectiveness of treatment with oral non-steroidal anti-inflammatory drugs in cystic fibrosis. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register comprising references identified from comprehensive electronic database searches, hand searches of relevant journals and abstract books of conference proceedings. We contacted manufacturers of non-steroidal anti-inflammatory drugs and searched online trials registries.Latest search of the Group's Trials Register: 21 November 2018. SELECTION CRITERIA Randomized controlled trials comparing oral non-steroidal anti-inflammatory drugs, at any dose for at least two months, to placebo in people with cystic fibrosis. DATA COLLECTION AND ANALYSIS Two authors independently assessed trials for inclusion the review and their potential risk of bias. Two authors independently rated the quality of the evidence for each outcome using the GRADE guidelines. MAIN RESULTS The searches identified 17 trials; four are included (287 participants aged five to 39 years; maximum follow-up of four years) and one is currently awaiting classification pending publication of the full trial report and two are ongoing. Three trials compared ibuprofen to placebo (two from the same center with some of the same participants); one trial assessed piroxicam versus placebo.The three ibuprofen trials were deemed to have good or adequate methodological quality, but used various outcomes and summary measures. Reviewers considered measures of lung function, nutritional status, radiological assessment of pulmonary involvement, intravenous antibiotic usage, hospital admissions, survival and adverse effects. Combined data from the two largest ibuprofen trials showed a lower annual rate of decline for lung function, % predicted forced expiratory volume in one second (FEV1), mean difference (MD) 1.32 (95% confidence interval (CI) 0.21 to 2.42) (moderate-quality evidence); forced vital capacity (FVC), MD 1.27 (95% CI 0.26 to 2.28) (moderate-quality evidence); forced expiratory flow (FEF25%-75%), MD 1.80 (95% CI 0.15 to 3.45). The post hoc analysis of data from two trials split by age showed a slower rate of annual decline of FEV1 % predicted and FVC in the ibuprofen group in younger children, MD 1.41% (95% CI 0.03 to 2.80) (moderate-quality evidence) and MD 1.32% (95% CI 0.04 to 2.60) (moderate-quality evidence) respectively. Data from four trials demonstrated the proportion of participants with at least one hospitalization may be slightly lower in the ibuprofen group compared to placebo, Peto odds ratio 0.61 (95% CI 0.37 to 1.01) (moderate-quality evidence). In one trial, long-term use of high-dose ibuprofen was associated with reduced intravenous antibiotic usage, improved nutritional and radiological pulmonary status. No major adverse effects were reported, but the power of the trials to identify clinically important differences in the incidence of adverse effects was low.We did not have any concerns with regards to risk of bias for the trial comparing piroxicam to placebo. However, the trial did not report many data in a form that we could analyze in this review. No data were available for the review's primary outcome of lung function; available data for hospital admissions showed no difference between the groups. No analyzable data were available for any other review outcome. AUTHORS' CONCLUSIONS High-dose ibuprofen can slow the progression of lung disease in people with cystic fibrosis, especially in children, which suggests that strategies to modulate lung inflammation can be beneficial for people with cystic fibrosis.
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Affiliation(s)
- Larry C Lands
- Montreal Children's HospitalDepartment of Pediatrics2300 Tupper StreetMontrealQCCanadaH3H 1PA
| | - Sanja Stanojevic
- The Hospital for Sick ChildrenDepartment of Translational Medicine555 University AvenueTorontoONCanadaM5G 1X8
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40
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Ramsey BW, Downey GP, Goss CH. Update in Cystic Fibrosis 2018. Am J Respir Crit Care Med 2019; 199:1188-1194. [PMID: 30917288 PMCID: PMC6519861 DOI: 10.1164/rccm.201902-0310up] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 03/25/2019] [Indexed: 01/03/2023] Open
Affiliation(s)
- Bonnie W. Ramsey
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
- Center for Clinical and Translational Research and
- Division of Pediatric Pulmonology, Department of Pediatrics, and
| | - Gregory P. Downey
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine
- Department of Pediatrics, and
- Department of Biomedical Research, National Jewish Health, Denver, Colorado; and
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, and
- Department of Microbiology and Immunology, University of Colorado, Aurora, Colorado
| | - Christopher H. Goss
- Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Center, Seattle Children’s Research Institute, Seattle, Washington
- Division of Pediatric Pulmonology, Department of Pediatrics, and
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington, Seattle, Washington
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41
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Safi C, Zheng Z, Dimango E, Keating C, Gudis DA. Chronic Rhinosinusitis in Cystic Fibrosis: Diagnosis and Medical Management. Med Sci (Basel) 2019; 7:medsci7020032. [PMID: 30813317 PMCID: PMC6410165 DOI: 10.3390/medsci7020032] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Revised: 02/17/2019] [Accepted: 02/18/2019] [Indexed: 11/16/2022] Open
Abstract
Chronic rhinosinusitis (CRS) is nearly ubiquitous in patients with cystic fibrosis (CF). CF CRS is a challenging entity to define, diagnose, and treat, as patients often have severe refractory sinus disease in addition to complex medical comorbidities. The purpose of this article is to review the literature on the medical management of CF CRS and determine how to best identify, diagnose, and manage CF CRS. Ultimately, the treatment of these patients requires a multi-disciplinary approach involving the pulmonologist and otolaryngologist.
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Affiliation(s)
- Chetan Safi
- Department of Otolaryngology-Head and Neck Surgery, Columbia University Irving Medical Center; New York, NY 10032, USA.
| | - Zhong Zheng
- Department of Otolaryngology-Head and Neck Surgery, Columbia University Irving Medical Center; New York, NY 10032, USA.
| | - Emily Dimango
- Department of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Irving Medical Center; New York, NY 10032, USA.
| | - Claire Keating
- Department of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Irving Medical Center; New York, NY 10032, USA.
| | - David A Gudis
- Department of Otolaryngology-Head and Neck Surgery, Columbia University Irving Medical Center; New York, NY 10032, USA.
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42
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Roesch EA, Nichols DP, Chmiel JF. Inflammation in cystic fibrosis: An update. Pediatr Pulmonol 2018; 53:S30-S50. [PMID: 29999593 DOI: 10.1002/ppul.24129] [Citation(s) in RCA: 153] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 06/25/2018] [Indexed: 12/13/2022]
Abstract
Inflammation plays a critical role in cystic fibrosis (CF) lung pathology and disease progression making it an active area of research and important therapeutic target. In this review, we explore the most recent research on the major contributors to the exuberant inflammatory response seen in CF as well as potential therapeutics to combat this response. Absence of functional cystic fibrosis transmembrane conductance regulator (CFTR) alters anion transport across CF airway epithelial cells and ultimately results in dehydration of the airway surface liquid. The dehydrated airway surface liquid in combination with abnormal mucin secretion contributes to airway obstruction and subsequent infection that may serve as a trigger point for inflammation. There is also evidence to suggest that airway inflammation may be excessive and sustained relative to the infectious stimuli. Studies have shown dysregulation of both pro-inflammatory mediators such as IL-17 and pro-resolution mediators including metabolites of the eicosanoid pathway. Recently, CFTR potentiators and correctors have garnered much attention in the CF community. Although these modulators address the underlying defect in CF, their impact on downstream consequences such as inflammation are not known. Here, we review pre-clinical and clinical data on the impact of CFTR modulators on inflammation. In addition, we examine other cell types including neutrophils, macrophages, and T-lymphocytes that express CFTR and contribute to the CF inflammatory response. Finally, we address challenges in developing anti-inflammatory therapies and highlight some of the most promising anti-inflammatory drugs under development for CF.
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Affiliation(s)
- Erica A Roesch
- Department of Pediatrics, Case Western Reserve University School of Medicine, Rainbow Babies and Children's Hospital, Cleveland, Ohio
| | - David P Nichols
- Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, Washington
| | - James F Chmiel
- Department of Pediatrics, Case Western Reserve University School of Medicine, Rainbow Babies and Children's Hospital, Cleveland, Ohio
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43
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Chandler JD, Margaroli C, Horati H, Kilgore MB, Veltman M, Liu HK, Taurone AJ, Peng L, Guglani L, Uppal K, Go YM, Tiddens HAWM, Scholte BJ, Tirouvanziam R, Jones DP, Janssens HM. Myeloperoxidase oxidation of methionine associates with early cystic fibrosis lung disease. Eur Respir J 2018; 52:13993003.01118-2018. [PMID: 30190273 DOI: 10.1183/13993003.01118-2018] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Accepted: 08/09/2018] [Indexed: 12/26/2022]
Abstract
Cystic fibrosis (CF) lung disease progressively worsens from infancy to adulthood. Disease-driven changes in early CF airway fluid metabolites may identify therapeutic targets to curb progression.CF patients aged 12-38 months (n=24; three out of 24 later denoted as CF screen positive, inconclusive diagnosis) received chest computed tomography scans, scored by the Perth-Rotterdam Annotated Grid Morphometric Analysis for CF (PRAGMA-CF) method to quantify total lung disease (PRAGMA-%Dis) and components such as bronchiectasis (PRAGMA-%Bx). Small molecules in bronchoalveolar lavage fluid (BALF) were measured with high-resolution accurate-mass metabolomics. Myeloperoxidase (MPO) was quantified by ELISA and activity assays.Increased PRAGMA-%Dis was driven by bronchiectasis and correlated with airway neutrophils. PRAGMA-%Dis correlated with 104 metabolomic features (p<0.05, q<0.25). The most significant annotated feature was methionine sulfoxide (MetO), a product of methionine oxidation by MPO-derived oxidants. We confirmed the identity of MetO in BALF and used reference calibration to confirm correlation with PRAGMA-%Dis (Spearman's ρ=0.582, p=0.0029), extending to bronchiectasis (PRAGMA-%Bx; ρ=0.698, p=1.5×10-4), airway neutrophils (ρ=0.569, p=0.0046) and BALF MPO (ρ=0.803, p=3.9×10-6).BALF MetO associates with structural lung damage, airway neutrophils and MPO in early CF. Further studies are needed to establish whether methionine oxidation directly contributes to early CF lung disease and explore potential therapeutic targets indicated by these findings.
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Affiliation(s)
- Joshua D Chandler
- Center for CF and Airways Disease Research, Children's Healthcare of Atlanta, Atlanta, GA, USA.,Division of Pulmonary, Allergy and Immunology, Cystic Fibrosis and Sleep Medicine, Dept of Pediatrics, Emory University, Atlanta, GA, USA.,Division of Pulmonary, Allergy and Critical Care Medicine, Dept of Medicine, Emory University, Atlanta, GA, USA
| | - Camilla Margaroli
- Center for CF and Airways Disease Research, Children's Healthcare of Atlanta, Atlanta, GA, USA.,Division of Pulmonary, Allergy and Immunology, Cystic Fibrosis and Sleep Medicine, Dept of Pediatrics, Emory University, Atlanta, GA, USA
| | - Hamed Horati
- Division of Respiratory Medicine and Allergology, Dept of Pediatrics, University Medical Center Rotterdam, Erasmus MC-Sophia, Rotterdam, The Netherlands
| | - Matthew B Kilgore
- Center for CF and Airways Disease Research, Children's Healthcare of Atlanta, Atlanta, GA, USA.,Division of Pulmonary, Allergy and Immunology, Cystic Fibrosis and Sleep Medicine, Dept of Pediatrics, Emory University, Atlanta, GA, USA
| | - Mieke Veltman
- Division of Respiratory Medicine and Allergology, Dept of Pediatrics, University Medical Center Rotterdam, Erasmus MC-Sophia, Rotterdam, The Netherlands
| | - H Ken Liu
- Division of Pulmonary, Allergy and Critical Care Medicine, Dept of Medicine, Emory University, Atlanta, GA, USA
| | - Alexander J Taurone
- Dept of Biostatistics, Emory University School of Public Health, Atlanta, GA, USA
| | - Limin Peng
- Dept of Biostatistics, Emory University School of Public Health, Atlanta, GA, USA
| | - Lokesh Guglani
- Center for CF and Airways Disease Research, Children's Healthcare of Atlanta, Atlanta, GA, USA.,Division of Pulmonary, Allergy and Immunology, Cystic Fibrosis and Sleep Medicine, Dept of Pediatrics, Emory University, Atlanta, GA, USA
| | - Karan Uppal
- Division of Pulmonary, Allergy and Critical Care Medicine, Dept of Medicine, Emory University, Atlanta, GA, USA
| | - Young-Mi Go
- Division of Pulmonary, Allergy and Critical Care Medicine, Dept of Medicine, Emory University, Atlanta, GA, USA
| | - Harm A W M Tiddens
- Division of Respiratory Medicine and Allergology, Dept of Pediatrics, University Medical Center Rotterdam, Erasmus MC-Sophia, Rotterdam, The Netherlands
| | - Bob J Scholte
- Division of Respiratory Medicine and Allergology, Dept of Pediatrics, University Medical Center Rotterdam, Erasmus MC-Sophia, Rotterdam, The Netherlands
| | - Rabindra Tirouvanziam
- Center for CF and Airways Disease Research, Children's Healthcare of Atlanta, Atlanta, GA, USA.,Division of Pulmonary, Allergy and Immunology, Cystic Fibrosis and Sleep Medicine, Dept of Pediatrics, Emory University, Atlanta, GA, USA.,These authors are joint senior authors
| | - Dean P Jones
- Division of Pulmonary, Allergy and Critical Care Medicine, Dept of Medicine, Emory University, Atlanta, GA, USA.,These authors are joint senior authors
| | - Hettie M Janssens
- Division of Respiratory Medicine and Allergology, Dept of Pediatrics, University Medical Center Rotterdam, Erasmus MC-Sophia, Rotterdam, The Netherlands.,These authors are joint senior authors
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Rowbotham NJ, Smith S, Prayle AP, Robinson KA, Smyth AR. Gaps in the evidence for treatment decisions in cystic fibrosis: a systematic review. Thorax 2018; 74:229-236. [PMID: 30301819 DOI: 10.1136/thoraxjnl-2017-210858] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Revised: 08/09/2018] [Accepted: 08/27/2018] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Cystic fibrosis (CF) is a multisystem disorder. Treatment is complex and evidence for treatment decisions may be absent. Characterising gaps in the research evidence will highlight treatment uncertainties and help prioritise research questions. We systematically identified the evidence gaps for treatment decisions in CF. METHODS We searched for systematic reviews and guidelines on treatment interventions in CF. Two researchers identified eligible reviews with arbitration from a third. Using a structured framework, we extracted and characterised evidence gaps. RESULTS There were 73 reviews and 21 guidelines that met our inclusion criteria. From these, we identified 148 evidence gaps across a range of treatment areas. We found 111 evidence gaps through systematic reviews and a further 37 from guidelines. The reason for an evidence gap could only be reliably characterised for systematic reviews. In most cases, there was more than one explanation-most commonly few or no trials (97/111 evidence gaps). Other important factors leading to evidence gaps were small sample size (49/111), inadequate duration of follow-up (38/111) or intervention (37/111) and factors relating to outcomes (35/111). Evidence gaps from both systematic reviews and guidelines fell into the following categories: Respiratory (91); Gastrointestinal (20); PhysiotherapyandExercise (16); Musculoskeletal (6); Endocrine (4); Basic defect of CF (8); Psychosocial (2); Ears, Nose and Throat (1). CONCLUSIONS We have compiled an up-to-date list of treatment uncertainties in CF and the reasons for these uncertainties. These can be used as a resource to aid researchers and funders when planning future trials. PROSPERO REGISTRATION NUMBER Pre-results; CRD42015030111.
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Affiliation(s)
- Nicola Jane Rowbotham
- Evidence Based Child Health Group, Division of Child Health, Obstetrics and Gynaecology, University of Nottingham, Nottingham, UK
| | - Sherie Smith
- Evidence Based Child Health Group, Division of Child Health, Obstetrics and Gynaecology, University of Nottingham, Nottingham, UK
| | - Andrew P Prayle
- Evidence Based Child Health Group, Division of Child Health, Obstetrics and Gynaecology, University of Nottingham, Nottingham, UK
| | - Karen A Robinson
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Alan Robert Smyth
- Evidence Based Child Health Group, Division of Child Health, Obstetrics and Gynaecology, University of Nottingham, Nottingham, UK
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Elborn JS, Ahuja S, Springman E, Mershon J, Grosswald R, Rowe SM. EMPIRE-CF: A phase II randomized placebo-controlled trial of once-daily, oral acebilustat in adult patients with cystic fibrosis - Study design and patient demographics. Contemp Clin Trials 2018; 72:86-94. [PMID: 30056216 DOI: 10.1016/j.cct.2018.07.014] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Revised: 07/23/2018] [Accepted: 07/23/2018] [Indexed: 12/15/2022]
Abstract
Inflammation causes irreparable damage in the cystic fibrosis (CF) lung. Despite high standards of care and the advent of new therapies, inflammation continues to cause significant loss of lung function and morbidity. Acebilustat is a once-daily, oral molecule with anti-inflammatory activity through the inhibition of LTA4 hydrolase and modulation of LTB4. It has potential to reduce lung function decline and pulmonary exacerbations in patients with CF and is currently being tested in a Phase II multicenter, randomized, double-blind, placebo-controlled, parallel-group study (EMPIRE-CF). Strict inclusion criteria based on modeling of the Cystic Fibrosis Foundation Patient Registry data were selected to enrich the trial with patients most likely to benefit from chronic anti-inflammatory therapy that reduces lung function decline. 200 patients between 18 and 30 years of age, with an FEV1 percent predicted (pp) ≥50%, and ≥1 exacerbation in the past year have been enrolled. Patients are randomized 1:1:1 to placebo, acebilustat 50 mg or 100 mg for 48 weeks, taken concomitantly with their current standard of care, and stratified based on concomitant CFTR modulator use, baseline FEV1pp (50% to 75% and >75%), and number of exacerbations in the past year (1 or >1). The primary endpoints are absolute change from baseline in FEV1pp and safety outcomes. Secondary endpoints include rate of pulmonary exacerbations and time to first pulmonary exacerbation. Biomarkers of inflammation will also be assessed. EMPIRE-CF is expected to identify the optimal patient population, dose, duration and endpoints for future acebilustat trials, and widen understanding of the drug's efficacy in patients with CF.
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Affiliation(s)
- J Stuart Elborn
- National Heart and Lung Institute, Imperial College and Royal Brompton Hospital, London, UK.
| | - Sanjeev Ahuja
- Celtaxsys, Inc., 201 17th St NW #530, Atlanta, GA, USA.
| | | | - John Mershon
- Celtaxsys, Inc., 201 17th St NW #530, Atlanta, GA, USA.
| | | | - Steven M Rowe
- Departments of Medicine, Pediatrics, Cell Developmental, and Integrative Biology, University of Alabama at Birmingham, Birmingham, AL, USA; Cystic Fibrosis Research Center, University of Alabama at Birmingham, Birmingham, AL, USA.
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Abstract
INTRODUCTION Cystic fibrosis (CF) outcomes and survival have improved over the last century primarily due to advancements in antibiotics, nutritional, and pulmonary therapies. Reviewed here are the significant unmet needs that exist for individuals with CF. Areas covered: With the recent development of medications that address the underlying defect in the CF protein, there is hope that there will be continued improvement in CF outcomes. However, there remains a need to prevent or stop progression of CF-related complications, as the CF protein is important to several body systems. As end stage lung disease is the primary cause of mortality in CF, a need exists for advancements in pulmonary therapies to reduce time burden, identification of best practices for the treatment of pulmonary exacerbations, further development of anti-infective and anti-inflammatory therapies, and appropriately timed referral for lung transplantation at end-stage lung disease. Extra-pulmonary complications are increasingly recognized and better understanding of such problems as CF related liver disease is needed. Expert commentary: While CFTR modulators are available for the majority of CF patients, there remains a need for effective therapies to address infection, inflammation, irreversible lung disease, and extrapulmonary complications of CF.
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Affiliation(s)
- Natalie E West
- a Department of Medicine, Division of Pulmonary and Critical Care Medicine , Johns Hopkins University , Baltimore , USA
| | - Patrick A Flume
- b Departments of Medicine and Pediatrics , Medical University of South Carolina , Charleston , SC , USA
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Hoo ZH, El-Gheryani MS, Curley R, Wildman MJ. Using different methods to process forced expiratory volume in one second (FEV 1) data can impact on the interpretation of FEV 1 as an outcome measure to understand the performance of an adult cystic fibrosis centre: A retrospective chart review. F1000Res 2018; 7:691. [PMID: 30443343 PMCID: PMC6213785 DOI: 10.12688/f1000research.14981.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/30/2018] [Indexed: 10/05/2023] Open
Abstract
Background: Forced expiratory volume in one second (FEV 1) is an important cystic fibrosis (CF) prognostic marker and an established endpoint for CF clinical trials. FEV 1 is also used in observation studies, e.g. to compare different centre's outcomes. We wished to evaluate whether different methods of processing FEV 1 data can impact on a centre's outcome. Methods: This is a single-centre retrospective analysis of routinely collected data from 2013-2016 which included 208 adults with CF. Year-to-year %FEV 1 change was calculated by subtracting best %FEV 1 at Year 1 from Year 2 (i.e. negative values indicate %FEV 1 decline), and compared using Friedman test. Three methods were used to process %FEV 1 data. First, %FEV 1 calculated with Knudson equation was extracted directly from spirometer machines. Second, FEV 1 volume were extracted then converted to %FEV 1 using clean height data and Knudson equation. Third, FEV 1 volume were extracted then converted to %FEV 1 using clean height data and GLI equation. In addition, %FEV 1 decline calculated using GLI equation was adjusted for baseline %FEV 1 to understand the impact of case-mix adjustment. Results: There was a trend of reduction in %FEV 1 decline with all three data processing methods but the magnitude of %FEV 1 decline differed. Median change in %FEV 1 for 2013-2014, 2014-2015 and 2015-2016 was -2.0, -1.0 and 0.0 respectively using %FEV 1 in Knudson equation whereas the median change was -1.1, -0.9 and -0.3 respectively using %FEV 1 in the GLI equation. A statistically significant p-value (0.016) was only obtained when using %FEV 1 in Knudson equation extracted directly from spirometer machines. Conclusions: Although the trend of reduction in %FEV 1 decline was robust, different data processing methods yielded varying results when %FEV 1 decline was compared using a standard related group non-parametric statistical test. Observational studies with %FEV 1 decline as an outcome measure should carefully consider and clearly specify the data processing methods used.
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Affiliation(s)
- Zhe Hui Hoo
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, S1 4DP, UK
- Sheffield Adult Cystic Fibrosis Centre, Northern General Hospital NHS Trust, Sheffield, S5 7AU, UK
| | - Muhaned S.A. El-Gheryani
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, S1 4DP, UK
- Sheffield Adult Cystic Fibrosis Centre, Northern General Hospital NHS Trust, Sheffield, S5 7AU, UK
| | - Rachael Curley
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, S1 4DP, UK
- Sheffield Adult Cystic Fibrosis Centre, Northern General Hospital NHS Trust, Sheffield, S5 7AU, UK
| | - Martin J. Wildman
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, S1 4DP, UK
- Sheffield Adult Cystic Fibrosis Centre, Northern General Hospital NHS Trust, Sheffield, S5 7AU, UK
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48
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Hoo ZH, El-Gheryani MS, Curley R, Wildman MJ. Using different methods to process forced expiratory volume in one second (FEV 1) data can impact on the interpretation of FEV 1 as an outcome measure to understand the performance of an adult cystic fibrosis centre: A retrospective chart review. F1000Res 2018; 7:691. [PMID: 30443343 PMCID: PMC6213785 DOI: 10.12688/f1000research.14981.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/14/2018] [Indexed: 11/25/2022] Open
Abstract
Background: Forced expiratory volume in one second (FEV 1) is an important cystic fibrosis (CF) prognostic marker and an established endpoint for CF clinical trials. FEV 1 is also used in observation studies, e.g. to compare different centre's outcomes. We wished to evaluate whether different methods of processing FEV 1 data can impact on centre outcome. Methods: This is a single-centre retrospective analysis of routinely collected data from 2013-2016 among 208 adults. Year-to-year %FEV 1 change was calculated by subtracting best %FEV 1 at Year 1 from Year 2 (i.e. negative values indicate fall in %FEV 1), and compared using Friedman test. Three methods were used to process %FEV 1 data. First, %FEV 1 calculated with Knudson equation was extracted directly from spirometer machines. Second, FEV 1 volume were extracted then converted to %FEV 1 using clean height data and Knudson equation. Third, FEV 1 volume were extracted then converted to %FEV 1 using clean height data and GLI equation. In addition, year-to-year variation in %FEV 1 calculated using GLI equation was adjusted for baseline %FEV 1 to understand the impact of case-mix adjustment. Results: Year-to-year fall in %FEV 1 reduced with all three data processing methods but the magnitude of this change differed. Median change in %FEV 1 for 2013-2014, 2014-2015 and 2015-2016 was -2.0, -1.0 and 0.0 respectively using %FEV 1 in Knudson equation whereas the median change was -1.1, -0.9 and -0.3 respectively using %FEV 1 in the GLI equation. A statistically significant p-value (0.016) was only obtained when using %FEV 1 in Knudson equation extracted directly from spirometer machines. Conclusions: Although the trend of reduced year-to-year fall in %FEV 1 was robust, different data processing methods yielded varying results when year-to-year variation in %FEV 1 was compared using a standard related group non-parametric statistical test. Observational studies with year-to-year variation in %FEV 1 as an outcome measure should carefully consider and clearly specify the data processing methods used.
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Affiliation(s)
- Zhe Hui Hoo
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, S1 4DP, UK
- Sheffield Adult Cystic Fibrosis Centre, Northern General Hospital NHS Trust, Sheffield, S5 7AU, UK
| | - Muhaned S.A. El-Gheryani
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, S1 4DP, UK
- Sheffield Adult Cystic Fibrosis Centre, Northern General Hospital NHS Trust, Sheffield, S5 7AU, UK
| | - Rachael Curley
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, S1 4DP, UK
- Sheffield Adult Cystic Fibrosis Centre, Northern General Hospital NHS Trust, Sheffield, S5 7AU, UK
| | - Martin J. Wildman
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, S1 4DP, UK
- Sheffield Adult Cystic Fibrosis Centre, Northern General Hospital NHS Trust, Sheffield, S5 7AU, UK
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49
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West NE, Goss CH, Nichols DP. The Long and the Short of It in Cystic Fibrosis Clinical Research Outcomes. Ann Am Thorac Soc 2018; 15:430-431. [PMID: 29600892 PMCID: PMC5879146 DOI: 10.1513/annalsats.201801-056ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 01/24/2018] [Indexed: 11/20/2022] Open
Affiliation(s)
- Natalie E. West
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Christopher H. Goss
- Department of Medicine and
- Department of Pediatrics, University of Washington, Seattle, Washington; and
- Seattle Children’s Hospital/Research Institute, Seattle, Washington
| | - David P. Nichols
- Department of Pediatrics, University of Washington, Seattle, Washington; and
- Seattle Children’s Hospital/Research Institute, Seattle, Washington
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