Asthma medication and risk of dental diseases in children - A prospective cohort study

BACKGROUND

Dental caries and enamel defects are the main causes of poor dental health in children, with a substantial impact on their well-being. Use of inhaled asthma medication is a suspected risk factor, but there is a lack of prospective studies investigating this and other prenatal and early life risk factors.

METHODS

Copenhagen Prospective Studies on Asthma in Childhood 2010 mother-child cohort (COPSAC2010 ) consists of 700 women who were recruited at 24 weeks of pregnancy. 588 of their children participated in a dental examination at 6 years of age (84%) at the COPSAC2010 research unit. Caries was defined as decayed, missing, or filled surfaces. Enamel defect was defined as demarcated opacity, post-eruptive enamel breakdown, and/or atypical restoration on at least one molar. Caries and enamel defects were assessed in both deciduous and permanent dentitions.

RESULTS

We found no associations between inhaled corticosteroids or β2 -agonists or asthma symptoms in early childhood and the risk of caries or enamel defects by 6 years of age. Furthermore, we found no strong pre-, peri-, or postnatal risk factors for dental diseases at 6 years, except from nominally significant associations between antibiotic use in pregnancy (OR = 1.25, [1.01-1.54]), maternal education level (OR = 1.57, [1.01-2.45]), having a dog at home (OR = 0.50, [0.27-0.93]), and risk of enamel defects.

CONCLUSIONS

Use of inhaled corticosteroids, β2 -agonists, or asthma symptoms in the first 6 years of life were not associated with the development of caries or enamel defects. This finding is reassuring for parents and physicians prescribing asthma medication for young children.

The impact of genomic variants on patient response to inhaled bronchodilators: a comprehensive update

INTRODUCTION

The bronchodilator response (BDR) depends on many factors, including genetic ones. Numerous single nucleotide polymorphisms (SNPs) influencing BDR have been identified. However, despite several studies in this field, genetic variations are not currently being utilized to support the use of bronchodilators.

AREAS COVERED

In this narrative review, the possible impact of genetic variants on BDR is discussed.

EXPERT OPINION

Pharmacogenetic studies of β₂-agonists have mainly focused on ADRB2 gene. Three SNPs, A46G, C79G, and C491T, have functional significance. However, other uncommon variants may contribute to individual variability in salbutamol response. SNPs haplotypes in ADRB2 may have a role. Many variants in genes coding for muscarinic ACh receptor (mAChR) have been reported, particularly in the M₂ and, to a lesser degree, M₃ mAChRs, but no consistent evidence for a pharmacological relevance of these SNPs has been reported. Moreover, there is a link between SNPs and ethnic and/or age profiles regarding BDR. Nevertheless, replication of pharmacogenetic results is limited and often, BDR is dissociated from what is expected based on SNP identification. Pharmacogenetic studies on bronchodilators must continue. However, they must integrate data derived from a multi-omics approach with epigenetic factors that may modify BDR.

Associations between the use of β-adrenoceptor acting drugs and the risk of dementia in older population

Objective

Age-related decline within the noradrenergic system is associated with reduced cognition. The β-adrenoceptors are widely expressed in the brain as well as in the peripheral. Medications targeting β-adrenoceptor activity have been widely used in older adults. The aim of this study was to explore the associations between β-adrenoceptor acting drugs and the risk of dementia in the older population.

Methods

The subjects' information was collected from the electronic medical record (EMR) database. A propensity score matching strategy was conducted to select control participants for users of β2-agonists or β-antagonists. Logistic regression analysis was performed to estimate the risk of dementia with the use of β2-agonists or β-antagonists.

Results

A total of 1,429 participants in the EMR database were included in the study. The use of β2-agonists was strongly associated with a decreased risk of dementia [OR = 0.324, 95% confidence interval (CI): 0.149-0.707, P = 0.005]. This decreased risk showed a statistically significant inverse time-dependent pattern (P _trend = 0.014). However, the use of non-selective β-antagonists significantly correlated with an increased dementia risk (OR = 1.961, 95% CI: 1.144-3.359, P = 0.014), although no time-dependent manner was found (P _trend = 0.220). There was no association between selective β1-antagonists usage and dementia risk (OR = 1.114, P = 0.625).

Conclusion

The use of β-adrenoceptor acting drugs seems to be associated with the risk of dementia. Pharmacological interventions modulating β2-adrenoceptor activity might be a potential target in therapeutics for dementia.

Analysis of β-blockers and β2-agonists in environmental and biological samples by magnetic solid-phase extraction combined with high-performance liquid chromatography-tandem mass spectrometry

β-Blockers and β2-agonists are commonly prescribed for therapeutic treatments and are also administered to livestock, leading to their presence in both environmental and biological samples. Hence, the development of sensitive, rapid, and reliable analytical methods for the determination of β-blockers and β2-agonists in environmental and biological samples is important. In this study, MIL-101(Cr)-NH₂ &GO-coated SiO₂ /Fe₃ O₄ magnetic particles were prepared as sorbents for magnetic solid-phase extraction and then combined with high-performance liquid chromatography-tandem mass spectrometry for the analysis of 20 β-blockers and eight β2-agonists. The experimental parameters of magnetic solid-phase extraction were studied in detail, and the optimal conditions were established. Under optimal conditions, the limits of detection were in the range of 0.002-0.007 μg/L with enrichment factors of 20.2-24.9. The developed method was successfully applied for the determination of 20 β-blockers and eight β2-agonists in river water, human urine, and freeze-dried pork liver powder. Bisoprolol and salbutamol were detected at concentrations of 2.78 mg/L in human urine and 11.5 μg/kg in freeze-dried pork liver powder.

Research on Rapid Detection Technology for β2-Agonists: Multi-Residue Fluorescence Immunochromatography Based on Dimeric Artificial Antigen

To detect two types of β2-agonist residues at the same time, we coupled two haptens of clenbuterol (CLE) and ractopamine (RAC) to the same carrier protein through diazotization to prepare dimeric artificial antigen, and a fluorescent lateral flow immunoassay method based on europium nanoparticles (EuNP-FLFIA) was established by combining polyclonal antibodies with europium nanoparticles to form probes. Under optimized conditions, the EuNP-FLFIA could simultaneously detect eight aniline-type and one phenol-type β2-agonists, and the limits of detection (LOD) were 0.11−0.19 ng/mL and 0.12 ng/mL, respectively. The recovery rate of this method was 84.00−114.00%. This method was verified by liquid chromatography−tandem mass spectrometry (LC-MS/MS), and the test results were consistent (R2 > 0.98). Therefore, the method established in this study could be used as a high-throughput screening for the efficient and sensitive detection of β2-agonists in food.

Prevalence and Prognostic Factors of Stress Hyperglycemia in a Pediatric Population with Acute Illness in Greece-A Prospective Observational Study

Background: stress hyperglycemia (SH) is a relatively frequent finding in pediatric patients. The purpose of this prospective observational study was to identify the prevalence of pediatric SH and its associated risk factors in Greece. Methods: A total of 1005 patients without diabetes who were admitted consecutively for acute illness in a Pediatric Emergency Department were included in the study. Medical history, anthropometric measurements, blood glucose levels, and the medication administered were recorded. A questionnaire was distributed to parents regarding medical and perinatal history and sociodemographic characteristics. Results: There were 72 cases of SH on admission (7.2%) and 39 (3.9%) during hospitalization. Mean age was 6.4 years; 50.3% were male. SH on admission was associated with oral corticosteroid therapy (21.1% vs. 4.7%, p < 0.001), inhaled corticosteroids (12.7% vs. 3%, p < 0.001), and inhaled β2-agonists (30.6% vs. 10.7%, p < 0.001). In-hospital hyperglycemia was associated with oral corticosteroids (adjusted OR = 3.32), inhaled corticosteroids (OR = 10.03) and inhaled β2-agonists (OR = 5.01). Children with asthma were 5.58 and 7.86 times more likely to present admission and in-hospital hyperglycemia, respectively. Conclusions: This is the first report of SH prevalence in pediatric patients in Greece. Asthma, corticosteroids, and β2-agonists significantly increase the risk of SH. No parental factors seem to predispose to SH.

Patient-Centered Discussion on End-of-Life Care for Patients with Advanced COPD

Exacerbations of chronic obstructive pulmonary disease (COPD) may lead to a rapid decline in health and subsequent death, an unfortunate tyranny of having COPD-an irreversible health condition of 16 million individuals in the USA totaling 60 million in the world. While COPD is the third largest leading cause of death, causing 3.23 million deaths worldwide in 2019 (according to the WHO), most patients with COPD do not receive adequate treatment at the end stages of life. Although death is inevitable, the trajectory towards end-of-life is less predictable in severe COPD. Thus, clinician-patient discussion for end-of-life and palliative care could bring a meaningful life-prospective to patients with advanced COPD. Here, we summarized the current understanding and treatment of COPD. This review also highlights the importance of patient-centered discussion and summarizes current status of managing patients with advanced COPD.

Wheezing Characteristics and Predicting Reactivity to Inhaled β2-Agonist in Children for Home Medical Care

Background: Given that wheezing is treated with inhaled β2-agonists, their effect should be reviewed before the condition becomes severe; however, few methods can currently predict reactivity to inhaled β2-agonists. We investigated whether preinhalation wheezing characteristics identified by lung sound analysis can predict reactivity to inhaled β2-agonists. Methods: In 202 children aged 10-153 months, wheezing was identified by auscultation. Lung sounds were recorded for 30 s in the chest region on the chest wall during tidal breathing. We analyzed the wheezing before and after β2-agonist inhalation. Wheezing was displayed as horizontal bars of intensity defined as a wheeze power band, and the wheezing characteristics (number, frequency, and maximum intensity frequency) were evaluated by lung sound analysis. The participants were divided into two groups: non-disappears (wheezing did not disappear after inhalation) and disappears (wheezing disappeared after inhalation). Wheezing characteristics before β2-agonist inhalation were compared between the two groups. The characteristics of wheezing were not affected by body size. The number of wheeze power bands of the non-responder group was significantly higher than those of the responder group (P < 0.001). The number of wheeze power bands was a predictor of reactivity to inhaled β2-agonists, with a cutoff of 11.1. The 95% confidence intervals of sensitivity, specificity, and positive and negative predictive values were 88.8, 42, 44, and 81.1% (P < 0.001), respectively. Conclusions: The number of preinhalation wheeze power bands shown by lung sound analysis was a useful indicator before treatment. This indicator could be a beneficial index for managing wheezing in young children.

Role of β2-adrenergic receptors in chronic obstructive pulmonary disease

Beta-2 adrenergic receptors (β2-ARs) have important roles in the pathogenesis and treatment of chronic obstructive pulmonary disease (COPD). In recent years, progress has been made in the study of β2-ARs. Here, we introduce the basic concepts of β2-ARs, related pathways, as well as application of blockers/agonists of β2-ARs, and β2-AR autoantibodies in COPD. Drugs targeting the β2-AR are being developed rapidly, and we expect them to improve the symptoms and prognosis of COPD patients in the future.

Organic Cation Transporters in the Lung-Current and Emerging (Patho)Physiological and Pharmacological Concepts

Organic cation transporters (OCT) 1, 2 and 3 and novel organic cation transporters (OCTN) 1 and 2 of the solute carrier 22 (SLC22) family are involved in the cellular transport of endogenous compounds such as neurotransmitters, l-carnitine and ergothioneine. OCT/Ns have also been implicated in the transport of xenobiotics across various biological barriers, for example biguanides and histamine receptor antagonists. In addition, several drugs used in the treatment of respiratory disorders are cations at physiological pH and potential substrates of OCT/Ns. OCT/Ns may also be associated with the development of chronic lung diseases such as allergic asthma and chronic obstructive pulmonary disease (COPD) and, thus, are possible new drug targets. As part of the Special Issue "Physiology, Biochemistry and Pharmacology of Transporters for Organic Cations", this review provides an overview of recent findings on the (patho)physiological and pharmacological functions of organic cation transporters in the lung.

Effects of β2-Adrenergic Agonists on Risk of Parkinson's Disease in COPD: A Population-Based Study

INTRODUCTION

Multiple studies have investigated the role of β₂ -adrenoreceptor agonists on the risk of Parkinson's disease (PD). However, whether β₂ -agonist use is associated with the risk of PD in patients with chronic obstructive pulmonary disease (COPD) has not been examined to date.

OBJECTIVES

To examine the association between use of β₂ -agonist and the risk of PD in patients with COPD.

METHODS

A case-control study nested within a cohort of patients with COPD using the British Columbia health administrative databases from 1997 to 2015 was performed. Among a cohort of patients with COPD, all cases of PD were identified, and matched each case to up to five controls by age and calendar time. The use of β₂ -agonists was assessed between the third and fourth year preceding the date of PD diagnosis, followed by additional two years of grace period (between the first and second year preceding PD incidence) to control for PD latency. The use of β₂ -agonists was categorized into three levels: regular use (≥ 1 dispensation for every 6 months), irregular use (dispensation in one to three 6-month periods), and no use. A conditional logistic regression model was used to estimate the rate ratio of PD according to β2-agonist use, rigorously controlling for confounding variables.

RESULTS

Among 242,218 COPD patients, 732 PD cases and 3660 controls were identified. Use of β₂ -agonists did not significantly affect the subsequent risk of PD (vs no use, adjusted rate ratios: regular use, 1.14 [95% CI: 0.93, 1.40, p=0.21], irregular use, 1.15 [95% CI: 0.92, 1.45, p=0.22]). Results remained consistent with competing risk sensitivity analysis.

CONCLUSION

Use of β₂ -agonists does not appear to affect the risk of PD in a real-world COPD population.

β2-adrenoceptor agonists and antagonists and risk of Parkinson's disease

BACKGROUND

β2-adrenoreceptors have recently been identified as regulators of the α-synuclein gene, which is implicated in the pathogenesis of Parkinson's disease.

OBJECTIVE

The objectives of this study were to assess the association between use of β2-agonists and β-antagonists and the risk of developing PD.

METHODS

We conducted a nested case-control study in a cohort of 1,762,164 adults without a diagnosis of PD. They were identified on January, 1, 2004, from the electronic medical records of the largest health care provider in Israel. Participants were followed up until June 30, 2017, for the occurrence of PD. Ten randomly selected controls were matched to each case of PD on age, sex, ethnic group, and duration of follow-up.

RESULTS

During follow-up 11,314 patients were newly diagnosed with PD and were matched with 113,140 controls. An increased risk of PD was seen with the use of nonselective β-antagonists (RR, 2.04 [1.90-2.20]) but not with the use of selective β1-antagonists (RR, 1.00 [0.95-1.05]). Use of β2-agonists was associated with reduced risk of PD (RR, 0.89 [0.82-0.96] for short-acting; RR, 0.84 [0.76-0.93] for long-acting; and RR, 0.49 [0.25-0.92] for ultra-long-acting β2-agonists). In an analysis of individual drugs, propranolol and salbutamol were significantly associated with PD risk, even when these drugs were ascertained 5 years prior to the index date, compared with nonusers (RR, 1.31 [1.08-1.58] and 1.89 {1.53-2.33]) in patients who filled <6 and ≥6 propranolol prescriptions, respectively; the corresponding RRs for salbutamol were 0.95 (0.83-1.08) and 0.65 (0.45-0.94), respectively.

CONCLUSIONS

Use of propranolol appears to be associated with an increased risk of PD, whereas use of β2-agonists is associated with a decreased risk of PD. © 2018 International Parkinson and Movement Disorder Society.

Unmet needs in asthma

Despite advances in the diagnosis and management of asthma, uncontrolled disease is still associated with a substantial mortality and morbidity burden. Patients often overestimate their level of asthma control while also reporting that asthma symptoms affect their quality of life and ability to work or study. There is some evidence of success with primary prevention measures in high-risk children and the secondary prevention of asthma in sensitized individuals or those at risk of developing occupational asthma. There are challenges with diagnosis – with under- and overdiagnosis and misdiagnosis being common – and in the treatment of asthma, despite clear treatment guidelines. In particular, severe asthma presents a huge challenge to the clinician, and its complex and heterogeneous nature warrants a personalized medicine approach to match therapies to individual patients. However, the tools for this are currently lacking in primary care. This article reviews the current unmet need in the diagnosis and clinical management of asthma, and provides an overview of the limitations of current therapies.

Prostaglandin E2, but not cAMP nor β2-agonists, induce tristetraprolin (TTP) in human airway smooth muscle cells

Tristetraprolin (TTP) is an anti-inflammatory molecule known to post-transcriptionally regulate cytokine production and is, therefore, an attractive drug target for chronic respiratory diseases driven by inflammation, such as asthma and chronic obstructive pulmonary disease. Our recent in vitro studies in primary human airway smooth (ASM) cells have confirmed the essential anti-inflammatory role played by TTP as a critical partner in a cytokine regulatory network. However, several unanswered questions remain. While prior in vitro studies have suggested that TTP is regulated in a cAMP-mediated manner, raising the possibility that this may be one of the ways in which β₂-agonists achieve beneficial effects beyond bronchodilation, the impact of β₂-agonists on ASM cells is unknown. Furthermore, the effect of prostaglandin E₂ (PGE₂) on TTP expression in ASM cells has not been reported. We address this herein and reveal, for the first time, that TTP is not regulated by cAMP-activating agents nor following treatment with long-acting β₂-agonists. However, PGE₂ does induce TTP mRNA expression and protein upregulation in ASM cells. Although the underlying mechanism of action remains undefined, we can confirm that PGE₂-induced TTP upregulation is not mediated via cAMP, or EP₂/EP₄ receptor activation, and occurred in a manner independent of the p38 MAPK-mediated pathway. Taken together, these data confirm that β₂-agonists do not upregulate TTP in human ASM cells and indicate that another way in which PGE₂ may achieve beneficial effects in asthma and COPD may be via upregulation of the master controller of inflammation-TTP.

The beclomethasone anti-inflammatory effect occurs in cell/mediator-dependent manner and is additively enhanced by formoterol: NFkB, p38, PKA analysis

AIMS

Beclomethasone/formoterol (BDP/FOR) has been reported to be more effective than its separate components in airway disease control and in airway inflammation improvement. However, BDP/FOR effects on cytokine-induced inflammation in structural cells have not been described and whether these effects occur in a cell- and mediator-dependent manner has not been fully elucidated. We sought to evaluate BDP and/or FOR effects on endothelial ICAM-1, E-selectin, IL-8 and on bronchial epithelial ICAM-1 and IL-8. Specific intracellular signaling pathways were also investigated.

MATERIALS AND METHODS

Surface adhesion molecule expression and IL-8 release induced by TNF-alpha were measured by ELISA. Intracellular signaling pathways were investigated by a) EMSA and Western blot analysis to evaluate NF-κB DNA-binding and MAPK-p38 phosphorylation; b) PDTC/SB203580 as NF-κB/p38 inhibitors; c) forskolin/H-89 as PKA activator/inhibitor.

KEY FINDINGS

BDP/FOR additively reduced endothelial E-selectin and IL-8 as well as bronchial epithelial ICAM-1 and IL-8. BDP/FOR and SB203580 showed the highest inhibitory effect on epithelial IL-8, whereas endothelial ICAM-1 was never affected by BDP/FOR and PDTC. TNF-alpha-induced NF-κB DNA-binding and MAPK-p38 phosphorylation were not influenced by BDP/FOR. Forskolin mimicked FOR effects; H-89 partially reversed the BDP/FOR inhibition in a mediator-dependent manner.

SIGNIFICANCE

The BDP/FOR inhibition degree was related to the inflammatory mediator- and cell-type considered. FOR additively enhanced BDP effects by partially involving both dependent- and independent-PKA mechanisms. Our results might contribute to highlight the strong relationship between specific molecular pathways and different sensitivity to the corticosteroid/β2-agonist effects and to clarify the molecular mechanisms underlying the BDP/FOR anti-inflammatory activity in vivo.

The Relationship between Hypomagnesemia and Pulmonary Function Tests in Patients with Chronic Asthma

OBJECTIVE

To investigate the relationship between serum values of magnesium and the parameters of the pulmonary function tests (PFT) in patients with chronic asthma.

SUBJECTS AND METHODS

This study recruited 50 patients with chronic stable asthma and 40 healthy individuals as a control group. Data on age, sex, severity of asthma, PFT, and details of drug therapy were obtained from each group. Serum magnesium, potassium, phosphorus, calcium, and sodium levels were also measured. To evaluate differences between groups, the Student t test or Mann-Whitney U test was performed for continuous variables, and the χ2 test for categorical variables.

RESULTS

In the asthma group, 10% (n = 9) of the patients had hypomagnesemia and 5.5% (n = 5) had hypophosphatemia. Patients with asthma were divided into two groups: the hypomagnesemic group (n = 9) and the normomagnesemic group (n = 41). Forced expiratory volume in 1 s (FEV1), FEV1%, peak expiratory flow (PEF), and PEF% were lower in the hypomagnesemic group than in the normomagnesemic group (p = 0.02). Multiple logistic regression analysis revealed a statistically significant association between hypomagnesemia and PFT in the hypomagnesemic asthmatic group. The correlations of age with FEV1, FEV1%, PEF, and PEF% were as follows: p = 0.00, r = 0.29; p = 0.00, r = 0.43; p = 0.03, r = 0.22; p = 0.00, r = 0.38; and p = 0.03, r = 0.22, respectively. The correlation of serum magnesium levels with PFT (FEV1, FEV1%, PEF, PEF%) were as follows: p = 0.001, r = 0.29; p = 0.001, r = 0.43; p = 0.03, r = 0.22; and p = 0.001, r = 0.38, respectively. The other electrolytes were within the normal range in both groups.

CONCLUSION

In this study, hypomagnesemia and hypophosphatemia were found to be the most common electrolyte abnormalities in patients with chronic stable asthma. FEV1, FEV1%, PEF, and PEF% were significantly lower in asthmatic patients with hypomagnesemia compared to asthmatic patients with normomagnesemia.

Treatment response heterogeneity in asthma: the role of genetic variation

INTRODUCTION

Asthmatic patients show a large heterogeneity in response to asthma medication. Rapidly evolving genotyping technologies have led to the identification of various genetic variants associated with treatment outcomes. Areas covered: This review focuses on the current knowledge of genetic variants influencing treatment response to the most commonly used asthma medicines: short- and long-acting beta-2 agonists (SABA/LABA), inhaled corticosteroids (ICS) and leukotriene modifiers. This review shows that various genetic variants have been identified, but none are currently used to guide asthma treatment. One of the most promising genetic variants is the Arg16 variant in the ADRB2 gene to guide LABA treatment in asthmatic children. Expert commentary: Poor replication of initially promising results and the low fraction of variability accounted for by single genetic variants inhibit pharmacogenetic findings to reach the asthma clinic. Nevertheless, the identification of genetic variation influencing treatment response does provide more insights in the complex processes underlying response and might identify novel targets for treatment. There is a need to report measures of clinical validity, to perform precision-medicine guided trials, as well as to understand how genetic variation interacts with environmental factors. In addition, systems biology approaches might be able to show a more complete picture of these complex interactions.

Fixed-Dose Combination Inhalers

In asthma and chronic obstructive pulmonary disease (COPD), an important step in simplifying management and improving adherence with prescribed therapy is to reduce the dose frequency to the minimum necessary to maintain disease control. Fixed-dose combination (FDC) therapy might enhance compliance by decreasing the number of medications and/or the number of daily doses. Furthermore, they have the potential for enhancing, sensitizing, and prolonging the effects of monocomponents. Combination therapy with an inhaled corticosteroid (ICS) and a long-acting β-agonist (LABA) is considered an important approach for treating patients with asthma and patients with severe COPD who have frequent exacerbations. Several ICS/LABA FDCs are now commercially available or will become available within the next few years for the treatment of COPD and/or asthma. Several studies demonstrate that there are a number of added benefits in using combinations of β₂-agonists and antimuscarinic agents. In particular, LABA/long-acting antimuscarinic agent (LAMA) combination seems to play an important role in optimizing bronchodilation. Several once-daily and twice-daily LABA/LAMA FDCs have been developed or are in clinical development. LAMA/ICS FDCs seem to be useful in COPD and mainly in asthma, in patients with severe asthma and persistent airflow limitation. The rationale behind the ICS/LABA/LAMA FDCs seems logical because all three agents work via different mechanisms on different targets, potentially allowing for lower doses of the individual agents to be used, accompanied by improved side effect profiles. In effect, in clinical practice, concomitant use of all three compounds is common, especially in more severe COPD but also in the treatment of adults with poorly controlled asthma despite maintenance treatment with high-dose ICS and a LABA.

Muscarinic Receptor Antagonists

Parasympathetic activity is increased in patients with chronic obstructive pulmonary disease (COPD) and asthma and appears to be the major reversible component of airway obstruction. Therefore, treatment with muscarinic receptor antagonists is an effective bronchodilator therapy in COPD and also in asthmatic patients. In recent years, the accumulating evidence that the cholinergic system controls not only contraction by airway smooth muscle but also the functions of inflammatory cells and airway epithelial cells has suggested that muscarinic receptor antagonists could exert other effects that may be of clinical relevance when we must treat a patient suffering from COPD or asthma. There are currently six muscarinic receptor antagonists licenced for use in the treatment of COPD, the short-acting muscarinic receptor antagonists (SAMAs) ipratropium bromide and oxitropium bromide and the long-acting muscarinic receptor antagonists (LAMAs) aclidinium bromide, tiotropium bromide, glycopyrronium bromide and umeclidinium bromide. Concerns have been raised about possible associations of muscarinic receptor antagonists with cardiovascular safety, but the most advanced compounds seem to have an improved safety profile. Further beneficial effects of SAMAs and LAMAs are seen when added to existing treatments, including LABAs, inhaled corticosteroids and phosphodiesterase 4 inhibitors. The importance of tiotropium bromide in the maintenance treatment of COPD, and likely in asthma, has spurred further research to identify new LAMAs. There are a number of molecules that are being identified, but only few have reached the clinical development.

Roflumilast N-Oxide in Combination with Formoterol Enhances the Antiinflammatory Effect of Dexamethasone in Airway Smooth Muscle Cells

Roflumilast is an orally active phosphodiesterase 4 inhibitor approved for use in chronic obstructive pulmonary disease. Roflumilast N-oxide (RNO) is the active metabolite of roflumilast and has a demonstrated antiinflammatory impact in vivo and in vitro. To date, the effect of RNO on the synthetic function of airway smooth muscle (ASM) cells is unknown. We address this herein and investigate the effect of RNO on β₂-adrenoceptor-mediated, cAMP-dependent responses in ASM cells in vitro, and whether RNO enhances steroid-induced repression of inflammation. RNO (0.001-1,000 nM) alone had no effect on AMP production from ASM cells, and significant potentiation of the long-acting β₂-agonist formoterol-induced cAMP could only be achieved at the highest concentration of RNO tested (1,000 nM). At this concentration, RNO exerted a small, but not significantly different, potentiation of formoterol-induced expression of antiinflammatory mitogen-activated protein kinase phosphatase 1. Consequently, tumor necrosis factor-induced IL-8 secretion was unaffected by RNO in combination with formoterol. However, because there was the potential for phosphodiesterase 4 inhibitors and long-acting β₂-agonists to interact with corticosteroids to achieve superior antiinflammatory efficacy, we examined whether RNO, alone or in combination with formoterol, enhanced the antiinflammatory effect of dexamethasone by measuring the impact on IL-8 secretion. Although RNO alone did not significantly enhance the cytokine repression achieved with steroids, RNO in combination with formoterol significantly enhanced the antiinflammatory effect of dexamethasone in ASM cells. This was linked to increased mitogen-activated protein kinase phosphatase 1 expression in ASM cells, suggesting that a molecular mechanism is responsible for augmented antiinflammatory actions of combination therapeutic approaches that include RNO.

Concerns with beta2-agonists in pediatric asthma - a clinical perspective

Beta2-adrenoreceptor agonists (β2-agonists) are extensively used in the treatment of childhood asthma. However, there have been concerns regarding their adverse effects and safety. In 2005, the FDA commissioned a "Black Box Warning" communicating the potential for an increased risk for serious asthma exacerbations or asthma related deaths, with the regular use of LABAs. In a meta-analysis of controlled clinical trials, the incidence of severe adverse events appeared to be highest in the 4-11 year age group. Several mechanisms have been proposed regarding the risk of regular use of β2-agonists, such as masking patients' perception of worsening asthma, desensitization and downregulation of the β2-adrenoreceptor, pro-inflammatory effects of β2-agonists, pharmacogenetic effects of β2-adrenoreceptor polymorphisms and age related differences in pathophysiology of asthma. In this paper, we review β2-receptor pharmacology, discuss the concerns regarding treatment with β2-agonists in childhood asthma, and provide suggestions for clinical pediatric practice in the light of current literature.

β2-Adrenergic agonists attenuate organic dust-induced lung inflammation

Agricultural dust exposure results in significant lung inflammation, and individuals working in concentrated animal feeding operations (CAFOs) are at risk for chronic airway inflammatory diseases. Exposure of bronchial epithelial cells to aqueous extracts of hog CAFO dusts (HDE) leads to inflammatory cytokine production that is driven by protein kinase C (PKC) activation. cAMP-dependent protein kinase (PKA)-activating agents can inhibit PKC activation in epithelial cells, leading to reduced inflammatory cytokine production following HDE exposure. β2-Adrenergic receptor agonists (β2-agonists) activate PKA, and we hypothesized that β2-agonists would beneficially impact HDE-induced adverse airway inflammatory consequences. Bronchial epithelial cells were cultured with the short-acting β2-agonist salbutamol or the long-acting β2-agonist salmeterol prior to stimulation with HDE. β2-Agonist treatment significantly increased PKA activation and significantly decreased HDE-stimulated IL-6 and IL-8 production in a concentration- and time-dependent manner. Salbutamol treatment significantly reduced HDE-induced intracellular adhesion molecule-1 expression and neutrophil adhesion to epithelial cells. Using an established intranasal inhalation exposure model, we found that salbutamol pretreatment reduced airway neutrophil influx and IL-6, TNF-α, CXCL1, and CXCL2 release in bronchoalveolar lavage fluid following a one-time exposure to HDE. Likewise, when mice were pretreated daily with salbutamol prior to HDE exposure for 3 wk, HDE-induced neutrophil influx and inflammatory mediator production were also reduced. The severity of HDE-induced lung pathology in mice repetitively exposed to HDE for 3 wk was also decreased with daily salbutamol pretreatment. Together, these results support the need for future clinical investigations to evaluate the utility of β2-agonist therapies in the treatment of airway inflammation associated with CAFO dust exposure.

Striving for optimal bronchodilation: focus on olodaterol

β2-agonists were introduced in the 1940s as bronchodilators to be used in obstructive respiratory diseases. Long-acting β2-agonists have been a mainstay of bronchodilating treatment for decades. Recently, agents extending their effect to 24 hours and thus allowing the once-daily administration were introduced, defined as very-long-acting β2-agonists. Olodaterol is a new very-long-acting β2-agonist that has been shown, in controlled trials, to improve lung function as well as clinical outcomes and quality of life. Most of these trials included patients with moderate, severe, or very severe chronic obstructive pulmonary disease (COPD). Olodaterol has a rapid onset of action (comparable to formoterol) and provides bronchodilation over 24 hours. In controlled trials, olodaterol was shown to be as effective as formoterol twice daily, but significantly superior in terms of quality of life in patients with COPD. The safety profile of olodaterol was very good, with a rate of adverse events, including the cardiac events that are particularly important for β2-agonists, comparable to placebo. Also, the efficiency of the Respimat(®) device concurs to the effectiveness of treatment.

Differential pharmacology and clinical utility of long-acting bronchodilators in COPD - focus on olodaterol

Olodaterol (BI 1744 CL) is a novel, once-daily long-acting β₂-agonist (LABA) designed with the aim of improving β₂-adrenoreceptor selectivity and intrinsic activity. Phase III pivotal trials have documented that olodaterol Respimat Soft Mist inhaler 5 μg induces fast onset of bronchodilation, comparable with formoterol at day 1. Moreover, significant lung function improvements have been documented up to 48 weeks in patients with moderate to very severe chronic obstructive pulmonary disease (COPD). Olodaterol was generally well tolerated and had an acceptable cardiovascular and respiratory adverse event profile. Regrettably, the clinical development of olodaterol is however still too partial to draw any firm conclusions on the positioning of this ultra-LABA as monotherapy in the management of COPD. Waiting for further data on the impact of olodaterol on different patient-reported outcomes, which however are widely available for indacaterol, and mainly for a head-to-head comparison between these two ultra-LABAs and between olodaterol long-acting antimuscarinic antagonists other than tiotropium, we believe it is correct to follow the clinical indications of indacaterol also for olodaterol. In any case, the parallel bronchodilating modes of action of olodaterol and tiotropium make them an attractive combination in COPD. The results from the ongoing large TOviTO Phase III trial program have documented the efficacy and safety of olodaterol/tiotropium fixed-dose combination as maintenance therapy in patients with moderate to very severe COPD. In particular, olodaterol/tiotropium fixed-dose combination provides a convincing alternative for patients remaining symptomatic with olodaterol monotherapy.

Stress Cardiomyopathy in the Setting of COPD Exacerbation

Introduction. Stress cardiomyopathy, or takotsubo cardiomyopathy, is an acute, reversible left ventricular dysfunction usually initiated by a psychological or physical stress. We report this case of stress cardiomyopathy following a chronic obstructive pulmonary disease exacerbation and the subsequent treatment. Case Description. A 49-year-old white female with a history of chronic obstructive pulmonary disease presented to the emergency room via emergency medical services with worsening severe shortness of breath and productive cough for 2 weeks but denied any chest pain on arrival. On presentation, she was noted to be tachypneic, using her accessory muscles and with bilateral coarse expiratory wheezing on lung auscultation. Initial electrocardiogram demonstrated sinus tachycardia. She was treated with multiple albuterol treatments. Soon afterwards, the course was complicated by hypoxic respiratory failure eventually requiring intubation. Her repeat electrocardiogram showed acute changes consistent with myocardial infarction, and an echocardiograph demonstrated apical akinesia with an ejection fraction of 25% to 30%. The patient was urgently taken for cardiac catheterization, which showed no angiographic evidence of coronary artery disease. Three days after initial presentation, a repeat transthoracic echocardiogram showed overall left ventricular systolic function improvement. Discussion. This case provided a unique look at the difficulty of balancing catecholamines in a patient with bronchospasm and stress cardiomyopathy.

The importance of β2-agonists in myocardial infarction: Findings from the Eastern Danish Heart Registry

PURPOSE

β2-Agonists are widely used for relief of respiratory symptoms. Studies so far have reported conflicting results regarding use of β2-agonists and risk of myocardial infarction (MI). Yet, coronary angiographical data and longitudinal outcomes data are sparse and could help explain if there is an association between use of β2-agonists and MI.

METHODS

Using a novel data-linkage of the Eastern Danish Heart Registry and nationwide administrative registries we identified a cohort of patients referred for acute coronary angiography due to ST-elevation MI (STEMI). Clinical and angiographical findings were compared between β2-agonist users and non-users.

RESULTS

Among 66,234 patients undergoing coronary angiography, 9857 patients had STEMI. Of these, 933 (9%) patients used β2-agonists. β2-Agonist users were more often without significant coronary stenosis (15% in β2-agonist users vs 9% in non-users; p<0.0001), odds ratio (OR) 1.68 (95% confidence interval (CI) 1.37-2.07; p<0.0001). The association was correlated to the number of filled prescriptions. One prescription: OR=1.00 (CI 95% 0.66-1.50; p=1.00)), 2-5 prescriptions: OR= 2.02 (CI 95% 1.47-2.78; p<0.0001), more than five prescriptions: OR=2.30 (CI 95% 1.69-3.12; p<0.0001). All-cause mortality during up to 14 years of follow-up was significantly higher among the β2-agonist-user group compared to the non-user group (34% vs 23%; p<0.0001), hazard ratio 1.36, 95% CI 1.18-1.56; p<0.0001).

CONCLUSION

Among patients referred to urgent coronary angiography for STEMI, use of β2-agonists was associated with a lower frequency of significant coronary stenosis and a higher mortality compared with non-users.

Continuous Inhalation of Ipratropium Bromide for Acute Asthma Refractory to β2-agonist Treatment

To present the case of a patient with persistent bronchospasm, refractory to treatment with β2-agonists, that resolved promptly with continuous inhalation of large dose (1000 mcg/hr) ipratropium bromide, and to discuss the possibility of tolerance to β2-agonists as the cause for his failure to respond to adrenergic medications. The patient had received multiple doses of albuterol, as well as subcutaneous terbutaline (0.3 mg), intravenous magnesium sulfate (1 g) and intravenous dexamethasone (10 mg) prior to his admission to the intensive care unit. He remained symptomatic despite systemic intravenous steroids, continuous intravenous terbutaline (up to 0.6 mcg/kg/min), and continuous nebulized albuterol (up to 20 mg/hr for 57 hr) followed by 49 hours of continuous levalbuterol (7 mg/hr). Due to the lack of response, all β2-agonists were discontinued at 106 hours post-admission, and he was started on large dose ipratropium bromide (1000 mcg/hr) by continuous nebulization. Clinical improvement was evident within 1 hour and complete resolution of his symptoms within 4 hours. Continuous inhalation of large dose ipratropium bromide may be an effective regimen for the treatment of patients hospitalized with acute asthma who are deemed to be nonresponsive and/or tolerant to β2-agonist therapy.

Development, validation and application to real samples of a multiresidue LC-MS/MS method for determination of β2 -agonists and anabolic steroids in bovine hair

β(2) -agonists are often abused in cattle breeding because of their effects on animal growth and meat properties. The use of β(2) -agonists as growth promoters is forbidden in the European Union (Council Directive 96/23/EC classifies them into group A of Annex I), due to their toxicity and carcinogenic properties, as for anabolic steroids, which are often administered in combination with β(2) -agonists, to promote the storage of proteins and increase muscle size. A unique confirmatory liquid chromatography-tandem mass spectrometry (LC-MS/MS) method for the quantitative detection of 13 β(2) -agonists and anabolic steroids plus the qualitative identification of other three analytes in bovine hair was developed and validated, according to Decision 2002/657/CE. Hair samples were washed with dichloromethane, digested within a NaOH solution and subjected to liquid-liquid extraction. The analysis was performed by high performance liquid chromatography coupled to a triple quadrupole mass spectrometer operating in the selected reaction monitoring mode. The absence of matrix interferents, together with good repeatability of both retention times and relative abundances of diagnostic transitions, allowed the correct identification of all analytes. The quantitative calibrations obtained from spiked blank hair samples proved linear in the range tested. CCα and CCβ ranged from 0.5 ng/g to 30 ng/g. Intralaboratory reproducibility (CV%) ranged between 5.0 and 17.7 and trueness between 96% ± 7% and 105% ± 8%. The applicability of the method to real positive samples was demonstrated for both β(2) -agonists and anabolic steroids. 17α-boldenone was found in most (70%) hair samples obtained from untreated animals, supporting the hypothesis of endogenous production of this steroid.

New developments in the management of COPD: clinical utility of indacaterol 75 μg

Chronic obstructive pulmonary disease (COPD) is a global health challenge and a major cause of mortality worldwide. Bronchodilators, particularly long-acting β₂-agonists and long-acting antimuscarinic agents, used singly or in combination, aim to improve lung function, reduce symptoms, prevent exacerbations, and enhance quality of life of COPD patients. Indacaterol is a novel, inhaled, long-acting β₂-agonist, with rapid onset of action and once-daily dosing providing 24-hour bronchodilation. Currently, the recommended dose differs between Europe (150 μg; maximum 300 μg) and USA (75 μg), the latter is lower than that assessed in the majority of the conducted studies. This review summarises published evidence regarding the efficacy, tolerability, and safety of indacaterol at a dose of 75 μg. Indacaterol 75 μg was found to be superior than placebo regarding lung function, dyspnea, health status, use of rescue medication, and rate of exacerbations. Furthermore, indacaterol 75 μg was well tolerated, while the most frequent adverse effect was deterioration of COPD occurring at a frequency similar to placebo, without major cardiovascular adverse effects. In conclusion, indacaterol 75 μg, administered once daily, is efficacious and has an excellent tolerability and safety profile, and is therefore a valid alternative in the treatment of COPD patients.

Impact of beta2-agonists, beta-blockers, and their combination on cardiac function in elderly male patients with chronic obstructive pulmonary disease

Purpose

This study was undertaken to determine the association between cardiac function and therapy with beta2-adrenoceptor agonists (β₂-agonists), β-blockers, or β-blocker–β-agonist combination therapy in elderly male patients with chronic obstructive pulmonary disease (COPD).

Patients and methods

This was a retrospective cohort study of 220 elderly male COPD patients (mean age 84.1 ± 6.9 years). The patients were divided into four groups on the basis of the use of β-blockers and β₂-agonists. N-terminal fragment pro-B-type natriuretic peptide (NT pro-BNP), left ventricular ejection fraction (LVEF), and other relevant parameters were measured and recorded. At follow-up, the primary end point was all-cause mortality.

Results

Multiple linear regression analysis revealed no significant associations between NT pro-BNP and the use of β₂-agonists (β = 35.502, P = 0.905), β-blockers (β = 3.533, P = 0.989), or combination therapy (β = 298.635, P = 0.325). LVEF was not significantly associated with the use of β₂-agonists (β = −0.360, P = 0.475), β-blockers (β = −0.411, P = 0.284), or combination therapy (β = −0.397, P = 0.435). Over the follow-up period, 52 patients died, but there was no significant difference in mortality among the four groups (P = 0.357). Kaplan–Meier analysis showed no significant difference among the study groups (log-rank test, P = 0.362). After further multivariate adjustment, use of β₂-agonists (hazard ratio [HR] 0.711, 95% confidence interval [CI] 0.287–1.759; P = 0.460), β-blockers (HR 0.962, 95% CI 0.405–2.285; P = 0.930), or combination therapy (HR 0.638, 95% CI 0.241–1.689; P < 0.366) were likewise not correlated with mortality.

Conclusion

There was no association between the use of β₂-agonists, β-blockers, or β-blocker-β₂-agonist combination therapy with cardiac function and all-cause mortality in elderly male COPD patients, which indicated that they may be used safely in this population.

MDI versus Nebulizers for Acute Asthma

OBJECTIVE

To evaluate studies comparing metered dose inhalers with holding chambers to nebulizers in the emergency department for the treatment of asthma exacerbation.

DATA SOURCE

Primary articles and systematic review provided by the Cochrane Airways Review Group of the Cochrane Library identified by MEDLINE search (1966-February 2004) and through secondary sources.

DATA SYNTHESIS

The Cochrane review included 21 randomized clinical trials conducted in hospital emergency departments comparing clinical outcomes following β(2) agonist administration via a nebulizer or a metered dose inhaler with holding chamber. Although the relative risk ratio of hospital admission with metered dose inhaler and holding chamber did not differ in children or in adults compared to the nebulizer delivery, none of the individual studies reviewed were powered to detect a difference in the rate of hospital admission. Specific factors in the treatment of acute asthma such as assessment of severity, appropriate outcome selection, appropriate dose selection, and appropriate delivery systems need to be considered to critically evaluate the literature.

CONCLUSION

Although available randomized clinical trials suggest equivalency of metered dose inhaler plus holding chambers and nebulized delivery of inhaled β(2) agonists, these trials are biased to show no difference in response. There is no data to support the advantage of one method over the other in mild to moderate asthmatic patients either clinically or economically.