Clinical consequences of ADRbeta2 polymorphisms

Functional Autoreactive Anti-β2 Adrenergic Antibodies May Contribute to Insulin Resistance Profile in Patients with Chronic Chagas Disease

Potential activation of β2 adrenergic receptors (β2AR) by specific autoreactive antibodies (Abs) that arise during the host reaction to Trypanosoma cruzi, could contribute to the elevated prevalence of metabolic disturbances described in patients with chronic Chagas disease (CCD). This study aimed to determine the prevalence of anti-β2AR Abs in patients with CCD, as well as the correlation of these Abs with the presence of glucose and lipid metabolism disturbances, in order to explore their association with an insulin resistance profile. Additionally, we tested the functional effects of anti-β2AR Abs employing an in vitro bioassay with neuroendocrine cells expressing β2AR. A clinical and metabolic evaluation including an OGTT was performed in 80 CCD patients and 40 controls. Anti-β2AR Abs were measured by an in-house-developed ELISA, and the β2 adrenergic activity of affinity-purified IgG fractions from patient’ sera were assayed in CRE-Luc and POMCLuc transfected AtT-20 cells. A higher proportion of dysglycemia (72.5% vs. 37.5%; p = 0.001) was observed in the CCD group, accompanied by increased HOMA2-IR (p = 0.019), especially in subjects with Abs (+). Anti-β2AR Abs reactivity (7.01 (2.39–20.5); p = 0.0004) and age >50 years (3.83 (1.30–11.25); p = 0.014) resulted as relevant for IR prediction (AUC: 0.786). Concordantly, Abs (+) CCD patients showed elevated metabolic risk scores and an increased prevalence of atherogenic dyslipidemia (p = 0.040), as compared to Abs (−) patients and controls. On functional bioassays, Abs exerted specific and dose-dependent β2-agonist effects. Our findings suggest that anti-β2AR Abs may induce the activation of β2AR in other tissues besides the heart; furthermore, we show that in patients with CCD these Abs are associated with an insulin resistance profile and atherogenic dyslipidemia, providing biological plausibility to the hypothesis that adrenergic activation by anti-β2AR Abs could contribute to the pathogenesis of metabolic disturbances described in CCD patients, increasing their cardiovascular risk.

Association between blood aluminum and beta-2 receptor gene methylation with childhood asthma control

Previous studies have shown that environmental exposure to heavy metals has been related to epigenetic changes, such as DNA methylation in receptors involved in pathogenesis of asthma. One of these receptors is beta-2 adrenergic receptor (ADRB2). We conducted this study to examine the association between blood aluminum concentration, blood ADRB2 5' untranslated region (5'-UTR) methylation level, and childhood asthma control level. Our results showed a significant positive association between high blood aluminum concentration (odds ratio, 16, 95% confidence interval (CI) [3.57 to 71.76], p < 0.001) and high blood ADRB2 5'-UTR methylation level (odds ratio, 4.75, 95% CI [1.39 to 16.2], p = 0.013), and risk of uncontrolled asthma. Multivariable logistic regression revealed that higher blood aluminum concentration was independently associated with increased risk of uncontrolled bronchial asthma (odds ratio, 9.10, 95% CI [2.38 to 34.85], p = 0.0013], after controlling for age, sex, and blood ADRB2 5'-UTR methylation level. In addition, blood ADRB2 5'-UTR methylation level significantly correlated with whole blood aluminum concentration in asthmatic children (r = 0.480, p < 0.001). We concluded that increasing blood aluminum concentration is an important independent correlate of risk for uncontrolled bronchial asthma as well as increased blood aluminum concentration caused ADRB2 5'-UTR hyper-methylation with increasing risk of uncontrolled bronchial asthma.

Epistasis between phenylethanolamine N-methyltransferase and β2-adrenergic receptor influences extracellular epinephrine level and associates with the susceptibility to allergic asthma

BACKGROUND

Reduced extracellular epinephrine level often associates with asthma-related symptoms; however, the correlation between asthma and genetic variants in genes participating in the epinephrine signalling pathway remains unclear.

OBJECTIVE

To characterize the functions of single nucleotide polymorphisms (SNPs) in phenylethanolamine N-methyltransferase (PNMT) and β2-adrenergic receptor (ADRB2), and to study the effects, including both direct and epistatic, of these SNPs on serum epinephrine level and asthma susceptibility.

METHODS

Single nucleotide polymorphisms functions were characterized through in vitro luciferase assay. ADRB2 gene expression level in peripheral blood mononuclear cell (PBMC) was measured by transcriptome sequencing and expression microarray on two separate Asian cohorts (NUS-UTAR, n = 278 and NUS-TA, n = 58). Serum epinephrine level was assessed on a Singapore Chinese cohort (NUS-SH, n = 314) with 155 asthmatic and 159 non-asthmatic subjects. A separate Singapore Chinese cohort (NUS-G, n = 3009) was genotyped to show disease association (direct and epistatic effect) of functional SNPs in PNMT and ADRB2.

RESULTS

Reduced serum epinephrine level was associated with increased asthma risk in Singapore Chinese. The minor allele of rs876493 was shown to increase PNMT promoter activity and reduce asthma risk. Multiple SNPs in ADRB2 forms a haplotype that was associated with the differential promoter activity of this gene. In this haplotype, rs11168070 was associated directly with ADRB2 expression in PBMCs. Both minor alleles from rs876493 and rs11168070 contribute synergistically to reduce asthma risk and increase serum epinephrine level.

CONCLUSION AND CLINICAL RELEVANCE

Epistatic interaction between genetic variants from PNMT (rs876493) and ADRB2 (rs11168070) is associated with serum epinephrine level and the susceptibility of asthma. Our findings improved the current understanding of the genetic basis of this disease, while genotypic states of these SNPs may serve as potential biomarkers to predict susceptibility to the disease.

The C79G Polymorphism of the β2-Adrenergic Receptor Gene, ADRB2, and Susceptibility to Pediatric Asthma: Meta-Analysis from Review of the Literature

Background

The ADRB2 gene encodes the β2-adrenergic receptor (β2-AR). This study aimed to determine the association between the C79G polymorphism of the ADRB2 gene and its association with pediatric asthma using a meta-analysis of the published data.

Material/Methods

Review of publications up to May 2018 was from the PubMed, EMBASE, China National Knowledge Infrastructure (CNKI), and WanFang databases. The odds ratio (ORs) with 95% confidence interval (CI) were used in evaluating the strength of the reported association between the C79G polymorphism of the ADRB2 gene and pediatric asthma.

Results

There were 18 controlled studies that included 2,982 pediatric cases of asthma and 2,651 controls. Expression of the C79G polymorphism of the ADRB2 gene was significantly associated with risk of pediatric asthma associated with the C or G allele with comparison of the co-dominant model (GG vs. CC: OR, 0.69; 95% CI, 0.55–0.88) and the recessive model (GG vs. CC+CG: OR, 0.65; 95% CI, 0.53–0.81). Subgroup analysis by ethnicity showed a significantly reduced risk of pediatric asthma in Asian patients for comparison of the co-dominant model (GG vs. CC: OR, 0.59; 95% CI, 0.45–0.78), the recessive model (GG vs. CC+CG: OR, 0.58; 95% CI, 0.45–0.76), and the allelic model (G vs. C: OR, 0.89; 95% CI, 0.79–0.99).

Conclusions

The C79G polymorphism of the ADRB2 gene encoding β2-AR was associated with a reduced risk for the development of pediatric asthma, particularly in the Asian population.

B2 adrenergic receptor gene polymorphism effect on childhood asthma severity and response to treatment

BackgroundAlterations of B2 adrenergic receptor (β₂AR) can modulate the severity of asthma and the response to treatment. Therefore, we aimed to evaluate β₂AR gene polymorphism at codons 16 and 27 and their effect on asthma severity and response to treatment in asthmatic children.MethodsCase-control study was conducted on 156 children; 104 of them had bronchial asthma and 52 were healthy children (control group). Subjects of the study underwent history taking, clinical examination, pulmonary function tests, serum IgE level assessment, and identification of β₂AR-16 A46G and β₂AR-27 C79G polymorphism using PCR-Restriction Fragment length polymorphisms (RFLP) test.ResultsThere was a higher frequency of Arg-Gly genotypes (odds ratio (OR)=6.57; confidence interval (CI): 2.42-18.81, P<0.001) and lower frequency of Arg-Arg (OR=4.7; CI: 2.05-10.95, P<0.001) among asthmatic children compared with that among controls at codon 16. The presence or absence of Gly16 or Glu27 either homozygous or heterozygous for both correlated with the grade of asthma severity. The presence of heterozygous Arg-Gly and Gln-Glu gives a better response to drug therapy than the presence of Gly-Gly and Glu-Glu genotypes at codons 16 and 27.ConclusionPolymorphism of β₂AR at codons 16 and 27 correlates with asthma severity and response to treatment in asthmatic children.

Association between ß2-adrenergic receptor gene polymorphisms and adverse events of ritodrine in the treatment of preterm labor: a prospective observational study

Background

Ritodrine, a tocolytic β2-agonist, has been used extensively in Europe and Asia despite its safety concerns. This study was designed to identify associations between β2-adrenergic receptor (ADRB2) polymorphisms and adverse drug events (ADEs) in patients with preterm labor treated with ritodrine.

Results

This follow-up study was prospectively conducted at Ewha Womans University Mokdong Hospital in Korea. Five single nucleotide polymorphisms (SNPs) of the ADRB2 gene (rs1042713, rs1042714, rs1042717, rs1042718, and rs1042719) were analyzed in 186 pregnant women with preterm labor. Patients with the AA genotype of rs1042717 had significantly lower incidence of ADEs compared to those with the G allele (p = 0.009). In multivariate analysis, one of the predictors of ADEs was the maximum infusion rate of ritodrine (AOR 4.47, 95% CI 1.31–15.25). Rs1042719 was also a significant factor for ritodrine-induced ADEs. The CC genotype carriers had 78% decreased risk of ADEs compared to those with other genotypes.

Conclusions

This study demonstrates that ADEs induced by ritodrine are associated with ADRB2 gene polymorphisms, as well as the infusion rate of ritodrine in pregnant women with preterm labor.

Cysteinyl Leukotrienes Pathway Genes, Atopic Asthma and Drug Response: From Population Isolates to Large Genome-Wide Association Studies

Genetic variants associated with asthma pathogenesis and altered response to drug therapy are discussed. Many studies implicate polymorphisms in genes encoding the enzymes responsible for leukotriene synthesis and intracellular signaling through activation of seven transmembrane domain receptors, such as the cysteinyl leukotriene 1 (CYSLTR1) and 2 (CYSLTR2) receptors. The leukotrienes are polyunsaturated lipoxygenated eicosatetraenoic acids that exhibit a wide range of pharmacological and physiological actions. Of the three enzymes involved in the formation of the leukotrienes, arachidonate 5 lipoxygenase 5 (ALOX5), leukotriene C4 synthase (LTC4S), and leukotriene hydrolase (LTA4H) are all polymorphic. These polymorphisms often result in variable production of the CysLTs (LTC4, LTD4, and LTE4) and LTB4. Variable number tandem repeat sequences located in the Sp1-binding motif within the promotor region of the ALOX5 gene are associated with leukotriene burden and bronchoconstriction independent of asthma risk. A 444A > C SNP polymorphism in the LTC4S gene, encoding an enzyme required for the formation of a glutathione adduct at the C-6 position of the arachidonic acid backbone, is associated with severe asthma and altered response to the CYSLTR1 receptor antagonist zafirlukast. Genetic variability in the CysLT pathway may contribute additively or synergistically to altered drug responses. The 601 A > G variant of the CYSLTR2 gene, encoding the Met201Val CYSLTR2 receptor variant, is associated with atopic asthma in the general European population, where it is present at a frequency of ∼2.6%. The variant was originally found in the founder population of Tristan da Cunha, a remote island in the South Atlantic, in which the prevalence of atopy is approximately 45% and the prevalence of asthma is 36%. In vitro work showed that the atopy-associated Met201Val variant was inactivating with respect to ligand binding, Ca²⁺ flux and inositol phosphate generation. In addition, the CYSLTR1 gene, located at Xq13-21.1, has been associated with atopic asthma. The activating Gly300Ser CYSLTR1 variant is discussed. In addition to genetic loci, risk for asthma may be influenced by environmental factors such as smoking. The contribution of CysLT pathway gene sequence variants to atopic asthma is discussed in the context of other genes and environmental influences known to influence asthma.

A genome-wide analysis of the response to inhaled β2-agonists in chronic obstructive pulmonary disease

Short-acting β2-agonist bronchodilators are the most common medications used in treating chronic obstructive pulmonary disease (COPD). Genetic variants determining bronchodilator responsiveness (BDR) in COPD have not been identified. We performed a genome-wide association study (GWAS) of BDR in 5789 current or former smokers with COPD in one African-American and four white populations. BDR was defined as the quantitative spirometric response to inhaled β2-agonists. We combined results in a meta-analysis. In the meta-analysis, single-nucleotide polymorphisms (SNPs) in the genes KCNK1 (P=2.02 × 10(-7)) and KCNJ2 (P=1.79 × 10(-7)) were the top associations with BDR. Among African Americans, SNPs in CDH13 were significantly associated with BDR (P=5.1 × 10(-9)). A nominal association with CDH13 was identified in a gene-based analysis in all subjects. We identified suggestive association with BDR among COPD subjects for variants near two potassium channel genes (KCNK1 and KCNJ2). SNPs in CDH13 were significantly associated with BDR in African Americans.The Pharmacogenomics Journal advance online publication, 27 October 2015; doi:10.1038/tpj.2015.65.

β2-Adrenergic receptor promoter haplotype influences the severity of acute viral respiratory tract infection during infancy: a prospective cohort study

BACKGROUND

Despite the significant interest in β2-Adrenergic receptor (ADRB2) polymorphisms related to asthma, whether ADRB2 genetic variants are similarly associated with acute respiratory tract infections have not been studied. We hypothesized that genetic variants in ADRB2 associated with a response to asthma therapy during an asthma exacerbation were also associated with severity of acute respiratory tract infections.

METHODS

To test this hypothesis, we genotyped 5 common polymorphisms in the promoter region and coding block of the ADRB2 gene (loci -2387, -2274, -1343, +46, and +79) from 374 Caucasian and African American term infants who were enrolled at the time of acute respiratory illness over four respiratory viral seasons. Severity of respiratory tract infections was measured using a bronchiolitis severity score (BSS; range = 0-12, clinically significant difference = 0.5) with a higher score indicating more severe disease. We assigned the promoter, coding and combined promoter and coding haplotypes to the unphased genotype data. The associations between each of these five single-nucleotide polymorphisms (SNPs) as well as the haplotypes and infant BSS were analyzed using nonparametric univariate analysis and multivariable proportional odds model separately in Caucasians and African Americans.

RESULTS

There was no significant association between infant BSS and each of the SNPs in both Caucasians and African Americans. However, promoter haplotype CCA was associated with a decreased BSS in African Americans in a dose dependent manner. The median (interquartile range) BSS of infants with no copies of the CCA haplotype, one copy, and two copies of the CCA haplotype were 5.5 (2.0, 8.0), 4.0 (1.0, 7.5), and 3.0 (1.0, 4.0), respectively. This dose dependent relationship persisted after adjusting for infant age, gender, daycare exposure, secondhand smoke exposure, prior history of breastfeeding, siblings at home, and enrollment season (adjusted odds ratio: 0.59, 95% confidence interval: 0.36, 0.98). There was no similar protective relationship of haplotype CCA on severity of respiratory tract infections identified in Caucasians.

CONCLUSIONS

ADRB2 genotype may be predictive of severity of acute respiratory tract infections in African Americans, and potentially identify a subset of infants who may respond to beta-agonist therapy.

Clinical asthma phenotyping: A trial for bridging gaps in asthma management

Asthma is a common disease affecting millions of people worldwide and exerting an enormous strain on health resources in many countries. Evidence is increasing that asthma is unlikely to be a single disease but rather a series of complex, overlapping individual diseases or phenotypes, each defined by its unique interaction between genetic and environmental factors. Asthma phenotypes were initially focused on combinations of clinical characteristics, but they are now evolving to link pathophysiological mechanism to subtypes of asthma. Better characterization of those phenotypes is expected to be most useful for allocating asthma therapies. This article reviews different published researches in terms of unbiased approaches to phenotype asthma and emphasizes how the phenotyping exercise is an important step towards proper asthma treatment. It is structured into three sections; the heterogeneity of asthma, the impact of asthma heterogeneity on asthma management and different trials for phenotyping asthma.

Asthma: Gln27Glu and Arg16Gly polymorphisms of the beta2-adrenergic receptor gene as risk factors

Background

Asthma is caused by both environmental and genetic factors. The ADRB2 gene, which encodes the beta 2-adrenergic receptor, is one of the most extensively studied genes with respect to asthma prevalence and severity. The Arg16Gly (+46A > G) and Gln27Glu (+79C > G) polymorphisms in the ADRB2 gene cause changes in the amino acids flanking the receptor ligand site, altering the response to bronchodilators and the risk of asthma through complex pathways. The ADRB2 polymorphisms affect beta-adrenergic bronchodilator action and are a tool to identify at-risk populations.

Objective

To determine the frequency of these two polymorphisms in allergic asthma patients and healthy subjects and to correlate these data with the occurrence and severity of asthma.

Methods

Eighty-eight allergic asthma patients and 141 healthy subjects were included in this study. The ADRB2 polymorphisms were analyzed using the amplification-refractory mutation system – polymerase chain reaction (ARMS-PCR) technique. The statistical analysis was performed with the SPSS 21.0 software using the Fisher’s Exact and χ² tests.

Results

The ADRB2 polymorphisms were associated with asthma occurrence. The Arg16Arg, Gln27Gln and Gln27Glu genotypes were risk factors; the odds ratios were 6.782 (CI = 3.07 to 16.03), 2.120 (CI = 1.22 to 3.71) and 8.096 (CI = 3.90 to 17.77), respectively. For the Gly16Gly and Glu27Glu genotypes, the odds ratios were 0.312 (CI = 0.17 to 0.56) and 0.084 (CI = 0.04 to 0.17), respectively. The haplotype analysis showed that there were associations between the following groups: Arg16Arg-Gln27Gln (OR = 5.108, CI = 1.82 to 16.37), Gly16Gly-Glu27Glu (OR = 2.816, CI = 1.25 to 6.54), Arg16Gly-Gln27Glu (OR = 0.048, CI = 0.01 to 0.14) and Gly16Gly-Gln27Glu (OR = 0.1036, CI = 0.02 to 0.39). The polymorphism Gln27Glu was associated with asthma severity, as the Gln27Gln genotype was a risk factor for severe asthma (OR = 2.798, CI = 1.099 to 6.674) and the Gln27Glu genotype was a protective factor for mild (OR = 3.063, CI = 1.037 to 9.041) and severe (OR = 0.182, CI = 0.048 to 0.691) asthma.

Conclusions

The Arg16Gly and Gln27Glu polymorphisms in the ADRB2 gene are associated with asthma presence and severity.

Beta-2-Adrenergic Receptor Methylation Influences Asthma Phenotype in The School Inner City Asthma Study

Asthma is the most common chronic illness of childhood and inner city residents suffer a disproportionately high rate of asthma diagnosis and asthma morbidity. The School Inner City Asthma Study investigates the school classroom based environmental exposures that may lead to asthma morbidity in inner city school children with asthma. Within this cohort, we investigated the role of methylation at the promoter region of the beta-2-adrenergic receptor in relation to asthma morbidity. We found that high levels of methylation in the region studied was significantly associated with decreased report of dyspnea and trended towards significance for lower levels of asthma symptoms and airway obstruction. This Research Highlight discusses the findings of the recent study and the investigators' active research endeavors.

β-2 adrenergic receptor gene methylation is associated with decreased asthma severity in inner-city schoolchildren: asthma and rhinitis

BACKGROUND

Genetic variation in the β-2 adrenergic receptor gene (ADRB2) has been implicated in asthma severity and control with conflicting results. Epigenetic variation in the ADRB2 may play an important role in asthma phenotype.

OBJECTIVE

We aimed to evaluate whether DNA methylation of ADRB2 is associated with asthma phenotypes in inner-city school-aged children.

METHODS

Multiple CpG sites in the promoter region of ADRB2 gene were analysed in 177 children enrolled in the School Inner-City Asthma Study. Blood- or saliva-derived DNA was measured by bisulphite-polymerase chain reaction pyrosequencing assay. Average percentage DNA methylation across the sites was evaluated for association with asthma severity (report of dyspnoea, night-time symptoms, rescue medication use, and baseline spirometry) and morbidity (school absences and unscheduled healthcare visits). Three clades composed of highly correlated methylation sites within the methylated segment of ADRB2 were further analysed.

RESULTS

Methylation of individual sites generally ranged from 0% to 6% with average percentage methylation across sites of 2.4%. Univariate analyses strongly favoured the association of higher percentage methylation with lower asthma severity measured by report of dyspnoea. Furthermore, there was a non-significant trend towards less rescue medication use, night-time symptoms, school absences, activity limitation due to asthma, and improved lung function measurements with increased methylation. Multivariate analysis demonstrated methylation of ADRB2 gene significantly associated with less dyspnoea (odds ratio (OR) 0.2, 95% confidence interval (CI), 0.1-0.6, P = 0.002). Each of the three clades of methylation sites showed a strong, but not statistically significant, effect on decreased dyspnoea.

CONCLUSIONS AND CLINICAL RELEVANCE

DNA methylation in the ADRB2 gene is associated with decreased asthma symptom severity, suggesting a role for methylation in asthma phenotypes.

Genetic polymorphisms and associated susceptibility to asthma

As complex common diseases, asthma and allergic diseases are caused by the interaction of multiple genetic variants with a variety of environmental factors. Candidate-gene studies have examined the involvement of a very large list of genes in asthma and allergy, demonstrating a role for more than 100 loci. These studies have elucidated several themes in the biology and pathogenesis of these diseases. A small number of genes have been associated with asthma or allergy through traditional linkage analyses. The publication of the first asthma-focused genome-wide association (GWA) study in 2007 has been followed by nearly 30 reports of GWA studies targeting asthma, allergy, or associated phenotypes and quantitative traits. GWA studies have confirmed several candidate genes and have identified new, unsuspected, and occasionally uncharacterized genes as asthma susceptibility loci. Issues of results replication persist, complicating interpretation and making conclusions difficult to draw, and much of the heritability of these diseases remains undiscovered. In the coming years studies of complex diseases like asthma and allergy will probably involve the use of high-throughput next-generation sequencing, which will bring a tremendous influx of new information as well as new problems in dealing with vast datasets.

Genome-wide association analysis in asthma subjects identifies SPATS2L as a novel bronchodilator response gene

Bronchodilator response (BDR) is an important asthma phenotype that measures reversibility of airway obstruction by comparing lung function (i.e. FEV₁) before and after the administration of a short-acting β₂-agonist, the most common rescue medications used for the treatment of asthma. BDR also serves as a test of β₂-agonist efficacy. BDR is a complex trait that is partly under genetic control. A genome-wide association study (GWAS) of BDR, quantified as percent change in baseline FEV₁ after administration of a β₂-agonist, was performed with 1,644 non-Hispanic white asthmatic subjects from six drug clinical trials: CAMP, LOCCS, LODO, a medication trial conducted by Sepracor, CARE, and ACRN. Data for 469,884 single-nucleotide polymorphisms (SNPs) were used to measure the association of SNPs with BDR using a linear regression model, while adjusting for age, sex, and height. Replication of primary P-values was attempted in 501 white subjects from SARP and 550 white subjects from DAG. Experimental evidence supporting the top gene was obtained via siRNA knockdown and Western blotting analyses. The lowest overall combined P-value was 9.7E-07 for SNP rs295137, near the SPATS2L gene. Among subjects in the primary analysis, those with rs295137 TT genotype had a median BDR of 16.0 (IQR = [6.2, 32.4]), while those with CC or TC genotypes had a median BDR of 10.9 (IQR = [5.0, 22.2]). SPATS2L mRNA knockdown resulted in increased β₂-adrenergic receptor levels. Our results suggest that SPATS2L may be an important regulator of β₂-adrenergic receptor down-regulation and that there is promise in gaining a better understanding of the biological mechanisms of differential response to β₂-agonists through GWAS.

Bronchodilator response (BDR) is an important asthma phenotype that measures reversibility of airway obstruction by comparing lung function before and after the administration of short-acting β₂-agonists, common medications used for asthma treatment. We performed a genome-wide association study of BDR with 1,644 white asthmatic subjects from six drug clinical trials and attempted to replicate these findings in 1,051 white subjects from two independent cohorts. The most significant associated variant was near the SPATS2L gene. We knocked down SPATS2L mRNA in human airway smooth muscle cells and found that β₂-adrenergic receptor levels increased, suggesting that SPATS2L may be a regulator of BDR. Our results highlight the promise of pursuing GWAS results that do not necessarily reach genome-wide significance and are an example of how results from pharmacogenetic GWAS can be studied functionally.

Pharmacology and therapeutics of bronchodilators

Bronchodilators are central in the treatment of of airways disorders. They are the mainstay of the current management of chronic obstructive pulmonary disease (COPD) and are critical in the symptomatic management of asthma, although controversies around the use of these drugs remain. Bronchodilators work through their direct relaxation effect on airway smooth muscle cells. at present, three major classes of bronchodilators, β(2)-adrenoceptor (AR) agonists, muscarinic receptor antagonists, and xanthines are available and can be used individually or in combination. The use of the inhaled route is currently preferred to minimize systemic effects. Fast- and short-acting agents are best used for rescue of symptoms, whereas long-acting agents are best used for maintenance therapy. It has proven difficult to discover novel classes of bronchodilator drugs, although potential new targets are emerging. Consequently, the logical approach has been to improve the existing bronchodilators, although several novel broncholytic classes are under development. An important step in simplifying asthma and COPD management and improving adherence with prescribed therapy is to reduce the dose frequency to the minimum necessary to maintain disease control. Therefore, the incorporation of once-daily dose administration is an important strategy to improve adherence. Several once-daily β(2)-AR agonists or ultra-long-acting β(2)-AR-agonists (LABAs), such as indacaterol, olodaterol, and vilanterol, are already in the market or under development for the treatment of COPD and asthma, but current recommendations suggest the use of LABAs only in combination with an inhaled corticosteroid. In addition, some new potentially long-acting antimuscarinic agents, such as glycopyrronium bromide (NVA-237), aclidinium bromide, and umeclidinium bromide (GSK573719), are under development, as well as combinations of several classes of long-acting bronchodilator drugs, in an attempt to simplify treatment regimens as much as possible. This review will describe the pharmacology and therapeutics of old, new, and emerging classes of bronchodilator.

A pharmacogenetic study of ADRB2 polymorphisms and indacaterol response in COPD patients

Genetic variation in the ADRB2 gene has been hypothesized to have a role in differential response to beta-agonist (BA) therapy in asthma. However, study results have been inconsistent and the issue remains controversial. Furthermore, the impact of ADRB2 genetic variation on BA response in chronic obstructive pulmonary disease (COPD) patients has not been thoroughly studied. We carried out a large pharmacogenetic analysis testing for an association between common ADRB2 polymorphisms and indacaterol response in COPD patients. A total of 648 indacaterol-treated patients enrolled in two large randomized phase III studies were genotyped for the most commonly studied polymorphisms in the ADRB2 gene: Gly16Arg, Gln27Glu, Thr164Ile, and a variant in the 5' untranslated region (rs1042711). Our analysis showed little evidence for the association between these ADRB2 variants and indacaterol response, suggesting that ADRB2 genetic variation is unlikely to have a major role in differential response to indacaterol treatment in COPD patients.

Biochemical basis of asthma therapy

Current therapy for asthma is highly effective. β(2)-Adrenergic receptor (β(2)AR) agonists are the most effective bronchodilators and relax airway smooth muscle cells through increased cAMP concentrations and directly opening large conductance Ca(2+) channels. β(2)AR may also activate alternative signaling pathways that may have detrimental effects in asthma. Glucocorticoids are the most effective anti-inflammatory treatments and switch off multiple activated inflammatory genes through recruitment of histone deacetylase-2, activating anti-inflammatory genes, and through increasing mRNA stability of inflammatory genes. There are beneficial molecular interactions between β(2)AR and glucocorticoid-activated pathways. Understanding these signaling pathways may lead to even more effective therapies in the future.

SNPs in genes encoding G proteins in pharmacogenetics

Heterotrimeric guanine-binding proteins (G proteins) transmit signals from the cell surface to intracellular signal cascades and are involved in various physiological and pathophysiological processes. Polymorphisms in the genes GNB3 (encoding the Gβ3 subunit), GNAS (encoding the Gαs subunit) and GNAQ (encoding the Gαq subunit) have been the primary focus of investigation. Polymorphisms in these genes could be associated with different complex phenotypes underlining that alterations in G-protein signaling can cause multiple disorders. G proteins present a point of convergence or ‘bottleneck’ between various receptors and effectors, thus making them a sensible tool for pharmacogenetic studies. The pharmacogenetic studies performed to date mostly demonstrate an association between G-protein polymorphisms and response to therapy or occurrence of adverse drug effects. Therefore, polymorphisms in genes encoding G-protein subunits may help to individualize drug treatment in various diseases with regard to both efficacy and safety.

Unraveling the complex genetic underpinnings of asthma and allergic disorders

PURPOSE OF REVIEW

Asthma and other allergic diseases are complex genetic disorders that result from interactions between multiple genes and environmental factors. In this review, we summarize findings from candidate gene analyses, discuss the recent success of genome-wide association (GWA) studies, and outline challenges facing the field.

RECENT FINDINGS

In the past year, five GWA studies have been reported for asthma, one for atopic dermatitis, and four for intermediate phenotypes using quantitative trait loci. These results have in general been more robust to replication than prior candidate gene studies, and have allowed the identification of novel loci for both asthma (i.e. 1q31, 9q21.31) and atopic dermatitis (11q13).

SUMMARY

The integration of results from recent GWA studies with careful analyses of candidate gene associations studies has confirmed the importance of immune detection and TH2-cell mediated immune responses in the pathogenesis of allergic disease, and has raised new interest in the role of epithelial barrier function and tissue-level responses. GWA studies appear to provide a robust way to identify novel gene loci contributing to disease susceptibility. Dissecting gene-gene and gene-environment interactions, and exploring the contribution of epigenetic phenomena to allergic disease susceptibility remain important challenges to understanding the complex nature of asthma and other allergic diseases.

Pharmacogenetics and human genetic polymorphisms

The term pharmacogenetics was first used in the late 1950s and can be defined as the study of genetic factors affecting drug response. Prior to formal use of this term, there was already clinical data available in relation to variable patient responses to the drugs isoniazid, primaquine and succinylcholine. The subject area developed rapidly, particularly with regard to genetic factors affecting drug disposition. There is now comprehensive understanding of the molecular basis for variable drug metabolism by the cytochromes P450 and also for variable glucuronidation, acetylation and methylation of certain drugs. Some of this knowledge has already been translated to the clinic. The molecular basis of variation in drug targets, such as receptors and enzymes, is generally less well understood, although there is consistent evidence that polymorphisms in the genes encoding the β-adrenergic receptors and the enzyme vitamin K epoxide reductase is of clinical importance. The genetic basis of rare idiosyncratic adverse drug reactions had also been examined. Susceptibility to reactions affecting skin and liver appears to be determined in part by the HLA (human leucocyte antigen) genotype, whereas reactions affecting the heart and muscle may be determined by polymorphisms in genes encoding ion channels and transporters respectively. Genome-wide association studies are increasingly being used to study drug response and susceptibility to adverse drug reactions, resulting in identification of some novel pharmacogenetic associations.

Pharmacogenetics of chronic obstructive pulmonary disease: challenges and opportunities

Similar to other common chronic diseases, chronic obstructive pulmonary disease (COPD) is a heterogeneous disorder with multiple disease subtypes. Candidate gene studies have found genetic associations for COPD-related phenotypes that may be relevant for pharmacogenetics studies, including lung function decline and COPD exacerbations. However, few COPD pharmacogenetics studies have been completed. Most studies have focused on the role of variants in the beta(2)-adrenergic receptor gene on bronchodilator response, but the findings have been inconclusive. Candidate gene studies highlight the concept that genes for COPD susceptibility may also be relevant in COPD pharmacogenetics. Currently, there are no clinical applications of pharmacogenetics to COPD therapy, but the use of pharmacogenetics to determine initial smoking cessation therapy may be closer to clinical application.

Heterogeneity of response to asthma controller therapy: clinical implications

PURPOSE OF REVIEW

Patients with asthma exhibit heterogeneous responses to all classes of asthma medication. This review examines clinical characteristics, biomarkers of inflammation, and genetic polymorphisms associated with treatment responsiveness in studies of adults and children with asthma, with an emphasis on inhaled corticosteroids and leukotriene modifiers.

RECENT FINDINGS

Recent clinical studies extended previous observations of associations between biomarkers of allergic inflammation and responsiveness to inhaled corticosteroids, and between cigarette smoke exposure and responsiveness to montelukast. Pharmacogenetic studies revealed associations between treatment response and genetic variations in CRHR1, as well as a number of genes encoding proteins involved in the absorption, production, and action of the cysteinyl leukotrienes. Very few studies have attempted to test the ability of these phenotypic and genotypic associations to predict treatment responsiveness.

SUMMARY

Additional prospective studies of sufficient size, quality, and ethnic diversity are needed to determine how best to incorporate information about genetic variations, clinical characteristics, and biomarkers into decisions about asthma therapy for individual patients.

A retrospective characterization of African- and European American asthmatic children in a pediatric critical care unit

OBJECTIVE

To determine if African American and European American children with asthma admitted to an intensive care unit (ICU) had different characteristics, we conducted a retrospective chart review of asthma admissions to the region's only pediatric ICU.

PATIENTS AND METHODS

A chart review was performed on 125 patients with asthma admitted to the pediatric critical care unit at Vanderbilt Children's Hospital. Descriptive statistics, clinical characteristics, and disparities in care were compared using either Fisher's exact tests or Wilcoxon ranksum tests.

RESULTS

Most of the children reported previous admissions to a pediatric ICU (63%) or a hospital (82%) for asthma. Despite this, only 48% of the children were taking inhaled corticosteroids before admission. Only 28% of the children reported being followed by an asthma specialist, but, of these, 97% were taking corticosteroids. There were no racial/ethnic disparities in medication use, treatment, or outcomes.

CONCLUSION

We found no racial/ethnic disparities in inpatient/outpatient medication usage, treatment, or outcomes between African American and European American children in our cohort. Recurrent admissions to the ICU among children with severe asthma are common, and inhaled corticosteroids usage is relatively low. Asthmatic children with ICU admissions should be followed and treated aggressively by an asthma specialist.

Prevalence of beta-2 adrenergic receptor (beta 2 AR) polymorphisms and its influence on a model used to assess endothelial function using pulse wave analysis (PWA)

BACKGROUND

Pulse wave analysis (PWA) combined with beta(2)-agonist challenge has recently been used to assess endothelial function. beta-2 adrenergic receptor (beta(2)AR) polymorphisms may affect response to beta(2)-agonist. We determined whether beta(2)AR polymorphisms influence endothelial response in our model using PWA and salbutamol.

METHODS

388 healthy Malay subjects (177 males, 211 females) were genotyped for 5 functionally important single nucleotide polymorphisms (SNPs) of beta(2)AR; 298 subjects proceeded with assessment of endothelial function. The parameter augmentation index (AIx) was recorded non-invasively using SphygmoCor. Recording of AIx at baseline was followed by administration of 500 microg sublingual glyceryl trinitrate (GTN). AIx recordings were repeated at 3, 5, 10, 15 and 20 min post-GTN. Subjects then inhaled 400 microg of salbutamol before AIx recordings at 5 min intervals up to 20 min. Maximum changes in AIx after GTN and salbutamol represented endothelium independent and endothelium dependent vasodilatation (EDV) respectively.

RESULTS

Allele frequencies of mutated Gly16, Glu27, Ile164, -20C and -47C were 47%, 6.8%, 0%, 30% and 9.3% respectively. No significant differences in EDV were noted between genotype groups of each studied SNPs.

CONCLUSIONS

Assessment of endothelial function using PWA and salbutamol was not influenced by beta(2)AR polymorphisms.

Genetics of chronic obstructive pulmonary disease: a succinct review, future avenues and prospective clinical applications

Chronic obstructive pulmonary disease (COPD) is influenced by genetic and environmental factors. A large number of candidate gene-association studies and genome-wide linkage scans have been conducted to elucidate the genetic architecture underlying this disease. The compilation of these studies clearly revealed the complex genetic nature of COPD. Multiple genes acting on specific environmental backgrounds are likely to be the tenet of this multifactorial disorder. Encouragingly, reproducible susceptibility genes, such as SERPINE2, were recently identified. Advances in genomic research offer unprecedented capabilities to interrogate the human genome and are likely to accelerate the discovery of new genes. A comprehensive catalogue of genes implicated in the pathogenesis of COPD has great potential to lead to the development of new therapies and explain interindividual response to treatment.

Genetic variants of GSNOR and ADRB2 influence response to albuterol in African-American children with severe asthma

African Americans are disproportionately affected by asthma. Social and economic factors play a role in this disparity, but there is evidence that genetic factors may also influence the development of asthma and response to therapy in African American children. Our hypothesis is that variations in asthma related genes contribute to the observed asthma disparities by influencing the response to asthma-specific therapy. In order to test this hypothesis, we characterized the clinical response to asthma-specific therapy in 107 African American children who presented to the emergency room in status asthmaticus, with a primary outcome indicator of length of time on continuous albuterol. Single locus analysis indicated that genotype variation in glutathione-dependent S-nitrosoglutathione reductase (GSNOR) is associated with a decreased response to asthma treatment in African American children. A post hoc multi-locus analysis revealed that a combination of four single nucleotide polymorphisms (SNPs) within GSNOR, adrenergic receptor beta 2, and carbamoyl phosphate synthetase-1 give a 70% predictive value for lack of response to therapy. This predictive model needs replication in other cohorts of patients with asthma, but suggests gene-gene interactions may have greater significance than that identified with single variants. Our findings also suggest that genetic variants may contribute to the observed population disparities in asthma.

Beta 1- and beta 2-adrenoceptor polymorphisms and cardiovascular diseases

Beta(1)- and beta(2)-adrenoceptors (AR) play a pivotal role in the regulation of cardiovascular function. Both beta-AR subtypes are polymorphic: two single nucleotide polymorphisms (SNPs) have been described for the beta(1)- (Ser49Gly, Arg389Gly) and four for the beta(2)-AR (Arg-19Cys, Arg16Gly, Gln27Glu, Thr164Ile), and they are possibly of functional relevance. In recombinant cell systems, Gly49-beta(1)-AR are more susceptible to agonist-promoted down-regulation than Ser49-beta(1)-AR, whereas Arg389-beta(1)-AR are three to four times more responsive to agonist-evoked stimulation than Gly389-beta(1)-AR. With respect to beta(2)-AR, the Cys-19 variant is associated with greater beta(2)-AR expression than the Arg-19 variant; Gly16-beta(2)-AR are more susceptible, whereas Glu27-beta(2)-AR are almost resistant to agonist-promoted down-regulation; Thr164-beta(2)-AR are three to four times more responsive to agonist-evoked stimulation than Ile164-beta(2)-AR. Several studies addressed potential phenotypic consequences of these SNPs in vivo by influencing and/or contributing to the pathophysiology of cardiovascular/pulmonary diseases such as hypertension, congestive heart failure, arrhythmias or asthma. At present, it appears that these beta-AR SNPs are very likely not disease-causing genes but possibly predictive for the responsiveness to agonists and antagonists. Patients carrying one or two alleles of the Gly389-beta(1)-AR are poor or non-responders to agonists and antagonists, whereas patients homozygous for the Arg389-beta(1)-AR are good responders. Subjects carrying the Ile164-beta(2)-AR exhibit blunted responses to beta(2)-AR stimulation. Asthma patients carrying the Arg16-Gln27-Thr164-beta(2)-AR haplotype who receive regularly short- or long-acting beta(2)-AR agonists are rather susceptible to agonist-induced desensitization and in consequence exhibit reduced bronchodilating and -protective effects and/or increased asthma exacerbations. The clinical relevance of these findings is still under debate.

What have we learned from prospective cohort studies of asthma in children?

Prospective cohort studies have provided a useful tool for the study of the natural history of asthma and lung function and for the development of concepts of asthma phenotypes during childhood. However, although observational epidemiology has indicated a large number of credible associations between environmental variables and asthma onset in childhood, it can be argued that it has yet to fulfill the promise of identifying modifiable, causal risk factors that are amenable to intervention for the primary or secondary prevention of disease. The development of efficient, high-throughput genotyping that can be applied to large, longitudinal cohorts with detailed data on exposures and phenotypic outcomes, opens the way for studies of genetic effects and gene-environment interactions that may come closer to identifying causal pathways between exposure and disease. Therefore, there continues to be an important role for large-scale, observational studies with careful attention to definition and evaluation of outcomes and plausible risk factors.

Gene-environment interactions in asthma

Asthma is a complex disease, and its incidence is determined by an intricate interplay of genetic and environmental factors. The identification of novel genes for asthma suggests that many genes with small effects rather than few genes with strong effects contribute to the development of asthma. These genetic effects may in part differ with respect to a subject's environmental exposures, although some genes may also exert their effect independently of the environment. Whereas the geneticist uses highly advanced, rapid, comprehensive technologies to assess even subtle changes in the human genome, the researcher interested in environmental exposures is often confronted with crude information obtained from questionnaires or interviews. There is thus substantial need to develop better tools for individual exposure assessment in all relevant environmental fields. Despite these limitations, a number of important gene-environment interactions have been identified. These interactions point to the biology of environmental exposures as the involved genetic variation is suggestive of certain underlying mechanisms. Furthermore, the identification of subjects who are particularly susceptible to environmental hazards through genetic analyses helps to estimate better the strength of effect of environmental exposures. Finally, the analysis of gene-environment interactions may result in a reconciliation of seemingly contradictory findings from studies not taking environmental exposures into account.

Genetic association analysis of COPD candidate genes with bronchodilator responsiveness

Airflow limitation in COPD patients is not fully reversible. However, there may be large variability in bronchodilator responsiveness (BDR) among COPD patients, and familial aggregation of BDR suggests a genetic component. Therefore, we investigated the association between six candidate genes and BDR in subjects with severe COPD. A total of 389 subjects from the National Emphysema Treatment Trial (NETT) were analyzed. Bronchodilator responsiveness to albuterol was expressed in three ways: absolute change in FEV(1), change in FEV(1) as a percent of baseline FEV(1), and change in FEV(1) as a percent of predicted FEV(1). Genotyping was completed for 122 single nucleotide polymorphisms (SNPs) in six candidate genes (EPHX1, SFTPB, TGFB1, SERPINE2, GSTP1, ADRB2). Associations between BDR phenotypes and SNP genotypes were tested using linear regression, adjusting for age, sex, pack-years of smoking, and height. Genes associated with BDR phenotypes in the NETT subjects were assessed for replication in 127 pedigrees from the Boston Early-Onset COPD (EOCOPD) Study. Three SNPs in EPHX1 (p=0.009-0.04), three SNPs in SERPINE2 (p=0.004-0.05) and two SNPs in ADRB2 (0.04-0.05) were significantly associated with BDR phenotypes in NETT subjects. One SNP in EPHX1 (rs1009668, p=0.04) was significantly replicated in EOCOPD subjects. SNPs in SFTPB, TGFB1, and GSTP1 genes were not associated with BDR. In conclusion, a polymorphism of EPHX1 was associated with bronchodilator responsiveness phenotypes in subjects with severe COPD.

Genes in asthma: new genes and new ways

PURPOSE OF REVIEW

Asthma is a disease of unknown aetiology characterized by intermittent inflammation of the small airways of the lung. Asthma is familial due to an interaction between strong genetic and environmental factors. This article aims to review the current understanding of the genetic factors underlying asthma, looking historically as well as highlighting the latest developments in the field.

RECENT FINDINGS

Findings from recent candidate gene studies and microsatellite genome screens have continued to highlight the importance of the epithelial barrier and its defence mechanisms in asthma. Completion of the human genome sequence and the advent of genome-wide association studies have resulted in the identification of two novel asthma susceptibility genes, ORMDL3 and CHI3L1, in the past year.

SUMMARY

With the advances in genetics and genomics substantial steps have been taken in the last decade in understanding the genetic factors underlying asthma. Studies have highlighted the importance of the role of the epithelium with many of the genes so far identified being expressed in this key barrier. With the application of genome-wide expression, microRNA studies, metagenomics, proteomics and metabolomics the next decade will undoubtedly result in a further substantial increment in our understanding of the mechanisms underlying asthma.

Endotyping asthma: new insights into key pathogenic mechanisms in a complex, heterogeneous disease

Clinical asthma is very widely assumed to be the net result of excessive inflammation driven by aberrant T-helper-2 (Th2) immunity that leads to inflamed, remodelled airways and then functional derangement that, in turn, causes symptoms. This notion of disease is actually poorly supported by data, and there are substantial discrepancies and very poor correlation between inflammation, damage, functional impairment, and degree of symptoms. Furthermore, this problem is compounded by the poor understanding of the heterogeneity of clinical disease. Failure to recognise and discover the underlying mechanisms of these major variants or endotypes of asthma is, arguably, the major intellectual limitation to progress at present. Fortunately, both clinical research and animal models are very well suited to dissecting the cellular and molecular basis of disease endotypes. This approach is already suggesting entirely novel pathways to disease-eg, alternative macrophage specification, steroid refractory innate immunity, the interleukin-17-regulatory T-cell axis, epidermal growth factor receptor co-amplification, and Th2-mimicking but non-T-cell, interleukins 18 and 33 dependent processes that can offer unexpected therapeutic opportunities for specific patient endotypes.