Statin use and Vital Organ Failure in Patients With Asthma-Chronic Obstructive Pulmonary Disease Overlap: A Time-Dependent Population-Based Study

Targeting Mast Cells in Allergic Disease: Current Therapies and Drug Repurposing

The incidence of allergic disease has grown tremendously in the past three generations. While current treatments are effective for some, there is considerable unmet need. Mast cells are critical effectors of allergic inflammation. Their secreted mediators and the receptors for these mediators have long been the target of allergy therapy. Recent drugs have moved a step earlier in mast cell activation, blocking IgE, IL-4, and IL-13 interactions with their receptors. In this review, we summarize the latest therapies targeting mast cells as well as new drugs in clinical trials. In addition, we offer support for repurposing FDA-approved drugs to target mast cells in new ways. With a multitude of highly selective drugs available for cancer, autoimmunity, and metabolic disorders, drug repurposing offers optimism for the future of allergy therapy.

Effect of Statins on the Risk of Poststroke Pneumonia: National Population-Based Cohort Study

Purpose

Statins are widely prescribed medications for treatment of dyslipidemia and prevention of cardiovascular disease. Beyond their lipid-lowering property, statins exhibit multiple pleiotropic and antimicrobial effects. We aimed to investigate the effect of statins on the long-term risk of pneumonia after acute ischemic stroke.

Methods

This retrospective observational research was performed using South Korean National Health Insurance Service claim data, which consist of population-based random sampling. We included patients discharged with acute ischemic stroke (I63 in the ICD10) and no prior history of pneumonia. The primary outcome measure was the occurrence of pneumonia determined based on ICD10 code J09–J18. Treatment with statins during follow-up was collected as a time-dependent variable based on prescription records.

Results

A total of 7,001 subjects with acute ischemic stroke and no prior history of pneumonia were included. During the mean 3.96-year follow-up, pneumonia occurred in 1,715 subjects (24.5%). On multivariate time-dependent Cox proportional hazard–regression analyses, significant preventive benefit of treatment with statins against pneumonia was noted (adjusted HR 0.86, 95% CI 0.77–0.97). Compared to no use of statin, adjusted HRs (95% CIs) for current use of low–intermediate high-intensity statins were 0.88 (0.78–0.99) and 0.49 (0.27–0.87), respectively.

Conclusion

Our retrospective national cohort study found reduced risk of poststroke pneumonia with statin therapy after acute ischemic stroke. Our study suggests that treatment with statins may have a preventive effect against the common complication of poststroke pneumonia.

Pharmacotherapeutic management of asthma in the elderly patient

INTRODUCTION

Asthma is a heterogeneous syndrome with variable phenotypes. Reversible airway obstruction and airway hyper-responsiveness often with an atopic or eosinophilic component is common in the elderly asthmatic. Asthma chronic obstructive pulmonary disease overlap syndrome (ACOS), a combination of atopy-mediated airway hyper-responsiveness and a history of smoking or other environmental noxious exposures, can lead to some fixed airway obstruction and is also common in elderly patients. Little specific data exist for the treating the elderly asthmatic, thus requiring the clinician to extrapolate from general adult data and asthma treatment guidelines.

AREAS COVERED

A stepwise approach to pharmacotherapy of the elderly patient with asthma and ACOS is offered and the literature supporting the use of each class of drugs reviewed.

EXPERT OPINION

Inhaled, long-acting bronchodilators in combination with inhaled corticosteroids represent the backbone of treatment for the elderly patient with asthma or ACOS . Beyond these medications used as direct bronchodilators and topical anti-inflammatory agents, a stepwise approach to escalation of therapy includes multiple options such as oral leukotriene receptor antagonist or 5-lipoxygense inhibitor therapy, oral phosphodiesterase inhibitors, systemic corticosteroids, oral macrolide antibiotics and if evidence of eosinophilic/atopic component disease exists then modifying monoclonal antibody therapies.

Polymyositis/dermatomyositis is a potential risk factor for acute respiratory failure: a pulmonary heart disease

Background

Studies on the association between polymyositis/dermatomyositis (PM/DM) and acute respiratory failure (ARF) are considerably limited. We investigated whether ARF is associated with PM/DM using a nationwide cohort study.

Methods

We identified 1,374 patients with newly diagnosed PM/DM and 13,740 comparison individuals without PM/DM (non-PM/DM) randomly selected from the general population; frequency matched by age, sex, and index year using the National Health Insurance Research Database; and followed up until the end of 2011 to measure the incidence of ARF. Cox proportional hazards regression analysis was used to measure the hazard ratio (HR) of ARF for the PM/DM cohort in comparison with the non-PM/DM cohort.

Results

The adjusted HR of ARF was 5.05 for the PM/DM cohort compared with the non-PM/DM cohort after adjusting for sex, age, comorbidities, Charlson comorbidity index (CCI) score and medicine. The risk of ARF significantly increased irrespective of age, sex, comorbidities and medicine. Meanwhile, the PM/DM cohort with comorbidities, such as cardiac disease (hypertension), pulmonary disease (chronic obstructive pulmonary disease and pneumonia), and pulmonary vascular diseases had additive effects on the incident ARF.

Conclusions

This study determined the cross-reaction of pulmonary heart disease in the PM/DM cohort with incident ARF even without comorbidities.

The pharmacological management of asthma-chronic obstructive pulmonary disease overlap syndrome (ACOS)

Introduction: Asthma-chronic obstructive pulmonary disease overlap syndrome (ACOS) is a disease phenotype that shares T helper lymphocyte cell Th1/neutrophilic/non-Type-2 Inflammation pathways thought to be key in COPD and Th2/eosinophilic/Type-2 inflammatory pathways of asthma. The pharmacology of treating ACOS is challenging in severe circumstances.Areas covered: This review evaluates the stepwise treatment of ACOS using pharmacological treatments used in both COPD and asthma. The most common medications involve the same inhalers used to treat COPD and asthma patients. Advanced stepwise therapies for ACOS patients are based on patient characteristics and biomarkers. Very few clinical trials exist that focus specifically on ACOS patients.Expert opinion: After inhalers, advanced therapies including phosphodiesterase inhibitors, macrolides, N-acetylcysteine and statin therapy for those ACOS patients with a COPD appearance and exacerbations are available. In atopic ACOS patients with exacerbations, advanced asthma therapies (leukotriene receptor antagonists and synthesis blocking agents.) are used. ACOS patients with elevated blood eosinophil/IgE levels are considered for immunotherapy or therapeutic monoclonal antibodies blocking specific Th2/Type-2 interleukins or IgE. Symptom control, stabilization/improvement in pulmonary function and reduced exacerbations are the metrics of success. More pharmacological trials of ACOS patients are needed to better understand which patients benefit from specific treatments.Abbreviations: 5-LOi: 5-lipoxygenase inhibitor; ACOS: asthma - COPD overlap syndrome; B₂AR: Beta₂ adrenergic receptors; cAMP: cyclic adenosine monophosphate; cGMP: cyclic guanosine monophosphate; CI: confidence interval; COPD: chronic obstructive pulmonary disease; CRS : chronic rhinosinusitis; cys-LT: cysteinyl leukotrienes; DPI: dry powder inhaler; EMA: European Medicines Agency; FDA: US Food and Drug Administration; FDC: fixed-dose combination; FeNO: exhaled nitric oxide; FEV₁: forced expiratory volume in one second; FVC: forced vital capacity; GM-CSF: granulocyte-macrophage colony-stimulating factor; ICS : inhaled corticosteroids; IL: interleukin; ILC2: Type 2 innate lymphoid cells; IP₃: Inositol triphosphate; IRR: incidence rate ratio; KOLD: Korean Obstructive Lung Disease; LABA: long-acting B₂ adrenergic receptor agonist; LAMA: long-acting muscarinic receptor antagonist; LRA: leukotriene receptor antagonist; LT: leukotrienes; MDI: metered-dose inhalers; M_N: M-subtype muscarinic receptors; MRA: muscarinic receptor antagonist; NAC: N-acetylcysteine; NEB: nebulization; OR: odds ratio; PDE: phosphodiesterase; PEFR: peak expiratory flow rate; PGD2: prostaglandin D2; PRN: as needed; RR: risk ratio; SABA: short-acting B₂ adrenergic receptor agonist; SAMA: short-acting muscarinic receptor antagonist; SDMI: spring-driven mist inhaler; Th1: T helper cell 1 lymphocyte; Th2: T helper cell 2 lymphocytes; TNF-α: tumor necrosis factor alpha; US : United States.

Cytokines at the Interplay Between Asthma and Atherosclerosis?

Cardiovascular disease (CVD) is an important comorbidity in a number of chronic inflammatory diseases. However, evidence in highly prevalent respiratory disease such as asthma are still limited. Epidemiological and clinical data are not univocal in supporting the hypothesis that asthma and CVD are linked and the mechanisms of this relationship remain poorly defined. In this review, we explore the relationship between asthma and cardiovascular disease, with a specific focus on cytokine contribution to vascular dysfunction and atherosclerosis. This is important in the context of recent evidence linking broad inflammatory signaling to cardiovascular events. However inflammatory regulation in asthma is different to the one typically observed in atherosclerosis. We focus on the contribution of cytokine networks encompassing IL-4, IL-6, IL-9, IL-17A, IL-33 but also IFN-γ and TNF-α to vascular dysfunction in atherosclerosis. In doing so we highlight areas of unmet need and possible therapeutic implications.