Benefits of omalizumab as add-on therapy in patients with severe persistent asthma who are inadequately controlled despite best available therapy (GINA 2002 step 4 treatment): INNOVATE

BACKGROUND

Patients with severe persistent asthma who are inadequately controlled despite Global Initiative for Asthma (GINA) 2002 step 4 therapy are a challenging population with significant unmet medical need. We determined the effect of omalizumab on clinically significant asthma exacerbations (requiring systemic corticosteroids) in the first omalizumab study to exclusively enrol patients from this difficult-to-treat patient population.

METHODS

Following a run-in phase, patients (12-75 years) inadequately controlled despite therapy with high-dose inhaled corticosteroids (ICS) and long-acting beta(2)-agonists (LABA) with reduced lung function and a recent history of clinically significant exacerbations were randomized to receive omalizumab or placebo for 28 weeks in a double-blind, parallel-group, multicentre study.

RESULTS

A total of 419 patients were included in the efficacy analyses. The clinically significant asthma exacerbation rate (primary efficacy variable), adjusted for an observed relevant imbalance in history of clinically significant asthma exacerbations, was 0.68 with omalizumab and 0.91 with placebo (26% reduction) during the 28-week treatment phase (P = 0.042). Without adjustment, a similar magnitude of effect was seen (19% reduction), but this did not reach statistical significance. Omalizumab significantly reduced severe asthma exacerbation rate (0.24 vs 0.48, P = 0.002) and emergency visit rate (0.24 vs 0.43, P = 0.038). Omalizumab significantly improved asthma-related quality of life, morning peak expiratory flow and asthma symptom scores. The incidence of adverse events was similar between treatment groups.

CONCLUSIONS

In patients with inadequately controlled severe persistent asthma, despite high-dose ICS and LABA therapy, and often additional therapy, omalizumab significantly reduced the rate of clinically significant asthma exacerbations, severe exacerbations and emergency visits. Omalizumab is effective and should be considered as add-on therapy for patients with inadequately controlled severe persistent asthma who have a significant unmet need despite best available therapy.

Efficacy and safety of a recombinant anti-immunoglobulin E antibody (omalizumab) in severe allergic asthma

BACKGROUND

Patients with severe asthma are often inadequately controlled on existing anti-asthma therapy, constituting an unmet clinical need.

OBJECTIVE

This randomized, double-blind, placebo-controlled trial evaluated the ability of omalizumab, a humanized monoclonal anti-IgE antibody, to improve disease control sufficiently to enable inhaled corticosteroid reduction in patients with severe allergic asthma.

METHODS

After a run-in period when an optimized fluticasone dose (> or =1000 microg/day) was received for 4 weeks, patients were randomized to receive subcutaneous omalizumab [minimum 0.016 mg/kg/IgE (IU/mL) per 4 weeks; n=126] or matching placebo (n=120) at intervals of 2 or 4 weeks. The study comprised a 16-week add-on phase of treatment followed by a 16-week fluticasone-reduction phase. Short-/long-acting beta(2)-agonists were allowed as needed.

RESULTS

Median reductions in fluticasone dose were significantly greater with omalizumab than placebo: 60% vs. 50% (P=0.003). Some 73.8% and 50.8% of patients, respectively, achieved a > or =50% dose reduction (P=0.001). Fluticasone dose reduction to < or =500 microg/day occurred in 60.3% of omalizumab recipients vs. 45.8% of placebo-treated patients (P=0.026). Through both phases, omalizumab reduced rescue medication requirements, improved asthma symptoms and asthma-related quality of life compared to placebo.

CONCLUSION

Omalizumab treatment improves asthma control in severely allergic asthmatics, reducing inhaled corticosteroid requirements without worsening of symptom control or increase in rescue medication use.

Allogeneic transplantation for multiple myeloma: further evidence for a GVHD-associated graft-versus-myeloma effect

We report a series of 37 consecutive patients with multiple myeloma (MM) who received an allograft between 1990 and 2000 at our institution. Median age was 47 years, and nearly 70% of patients were Durie-Salmon stage III. A median of five cycles of chemotherapy were given before transplant, with a median interval between diagnosis and transplant of 9.3 months. We report a nonrelapse mortality rate of 22% with a median follow-up period of 40 months, whereas complete remission (CR) rate at 12 months is estimated at 57%. Treatment failure rate and overall survival at 40 months are estimated at 52% and 32%, respectively. The number of chemotherapy cycles prior to allotransplantation achieved borderline statistical significance as a poor prognosis factor for overall survival (P = 0.05), while the presence of chronic graft-versus-host disease (cGVHD) was significantly correlated with CR achievement (P = 0.036). Our study confirms that early allografting in MM can yield toxicity rates significantly lower than those associated with historical cohorts, and supports the hypothesis that cumulative chemotoxicity has a negative influence on mortality and survival rates. More importantly, our study clearly demonstrates an association between cGVHD and CR and brings further evidence in favor of a graft-versus-myeloma effect.

Mutations in activation-induced cytidine deaminase in patients with hyper IgM syndrome

Recent studies have shown that mutations in a newly described RNA editing enzyme, activation-induced cytidine deaminase (AID), can cause an autosomal recessive form of hyper IgM syndrome. To determine the relative frequency of mutations in AID, we evaluated a group of 27 patients with hyper IgM syndrome who did not have defects in CD40 ligand and 23 patients with common variable immunodeficiency. Three different mutations in AID were identified in 18 patients with hyper IgM syndrome, including 14 French Canadians, 2 Lumbee Indians, and a brother and sister from Okinawa. No mutations were found in the remaining 32 patients. In the group of patients with hyper IgM syndrome, the patients with mutations in AID were older at the age of diagnosis, were more likely to have positive isohemagglutinins, and were less likely to have anemia, neutropenia, or thrombocytopenia. Lymphoid hyperplasia was seen in patients with hyper IgM syndrome and normal AID as well as the patients with hyper IgM syndrome and defects in AID.

Effect of manual segmental vibration on neuromuscular excitability

OBJECTIVE

To measure the effects of manual segmental vibration (MSV) on motoneuron pool excitability.

METHODS

Seven healthy subjects were tested under five conditions: pretest, upholding static knee position (USKP), MSV, posttest 1 and posttest 2. Each test lasted 2 min, and a 2-min rest was given between pretest, USKP and MSV, whereas the last two tests were consecutive. Cutaneous pressure and vibration frequency were stabilized through training periods. The effects of MSV on motoneuron excitability were investigated by measuring the H-reflex peak-to-peak amplitude.

MEASURES

The H-reflex and M response were taken from the medial gastrocnemius electromyogram and elicited every 7 sec by a 1 ms square wave pulses to the tibial nerve. Fifteen trials were recorded for each condition. Stimulation intensity was set at 10% (+/- 2.5%) of Mmax stimulus.

RESULTS

Repeated-measures analysis of variance comparing conditions revealed no significant differences in M response [F(4,24) = 2.37, p > .05, beta = .35]. H-reflex comparisons revealed significant differences [F(4,24) = 30.39, p < .05, beta = .01] between conditions. Duncan post hoc analysis showed that MSV produced the greatest inhibition (decreases 95%) and USKP also elicited a significant inhibition (decreases 41%).

CONCLUSIONS

The inhibition may be the result of the following mechanisms: the reflex inhibition, the implication of cutaneous afferences and the higher control mechanism. Because MSV produces a reduction in neuromuscular excitability, it could also play a role in predisposing the system for changes to occur and therefore be used as an adjunct for other therapeutic applications.

PilT mutations lead to simultaneous defects in competence for natural transformation and twitching motility in piliated Neisseria gonorrhoeae

Neisseria gonorrhoeae, the Gram-negative aetiological agent of gonorrhoeae, is one of many mucosal pathogens of man that expresses competence for natural transformation. Expression of this phenotype by gonococci appears to rely on the expression of type IV pili (Tfp), but the mechanistic basis for this relationship remains unknown. During studies of gonococcal pilus biogenesis, a homologue of the PilT family of proteins, required for Tfp-dependent twitching motility in Pseudomonas aeruginosa and social gliding motility in Myxococcus xanthus, was discovered. Like the findings in these other species, we show here that gonococcal PilT mutants constructed in vitro no longer display twitching motility. In addition, we demonstrate that they have concurrently lost the ability to undergo natural transformation, despite the expression of structurally and morphologically normal Tpf. These results were confirmed by the findings that two classes of spontaneous mutants that failed to express twitching motility and transformability carried mutations in PilT. Piliated PilT mutants and a panel of pilus assembly mutants were found to be deficient in sequence-specific DNA uptake into the cell, the earliest demonstrable step in neisserial competence. The PilT-deficient strains represent the first genetically defined mutants that are defective in DNA uptake but retain Tfp expression.

Specific antigen targeting to surface IgE and IgG on mouse bone marrow-derived mast cells enhances efficiency of antigen presentation

The discovery that bone marrow-derived mast cells can express major histocompatibility complex class II molecules and act as antigen-presenting cells prompted us to evaluate this function when antigen is internalized through fluid-phase endocytosis or via specific uptake by using IgG and IgE antibodies. This study was performed using a specific T-cell hybridoma developed against Lol p 1, the major allergen of grass pollen Lolium perenne. Expression of Fc gamma R and Fc epsilon RI by mast cells led us to investigate the influence of IgG- and IgE-targeted antigen on the antigen-presenting function of mast cells. Internalization of Lol p 1 through different specific IgG monoclonal antibodies (mAb) resulted in the activation of Lol p 1-specific T-cell hybridoma at concentrations about 100-fold less than that required for T-cell stimulation by uncomplexed antigen. IgE-complexed Lol p 1, which facilitates trapping of antigen by mast cells, induced an accelerated and more efficient antigen-presenting capacity of mast cells than that obtained with uncomplexed antigen. However, aggregation of anti-dinitrophenyl (DNP) IgE mAb by the irrelevant antigen DNP-human serum albumin did not substantially increase the capacity of mast cells to present Lol p 1 to T cells. This suggests that the mere aggregation of Fc epsilon RI is not sufficient for enhanced antigen presentation mediated by IgE. Tissue distribution and strategic location of mast cells at the mucosal barriers and their capacity to process the antigen through efficient fluid-phase pinocytosis as well as IgG- and IgE-dependent targeting of antigens provide mast cells with a prominent role in immune surveillance.

Changes in IgE-mediated allergy to ubiquitous inhalants after removal from or diminution of exposure to the agent causing occupational asthma

BACKGROUND

One possibility, among others, for explaining the persistence of asthma symptoms in occupational asthma (OA) after the cessation of exposure to the causal agents may be that subjects become sensitized to ubiquitous inhalants.

OBJECTIVE

The aim of this study was to evaluate the development or increase of IgE-mediated sensitization to ubiquitous allergens, both to high- and low-molecular-weight agents, in 100 subjects with OA after cessation of exposure.

METHODS

Subjects were evaluated on a first visit, at the time of diagnosis of OA, coinciding with the cessation or diminution of exposure to the causal agent, and on a second visit, 5.8+/-3.3 years afterwards. At each visit, a history of ocular, nasal and asthmatic symptoms related to exposure to common allergens was obtained together with spirometry and assessment of bronchial responsiveness to methacholine. We analysed total IgE and specific IgE to Dermatophagoides farinae, D. pteronyssinus, birch, ragweed and timothy grass pollens, cat and dog danders, and Alternaria, using enzyme allergosorbent test (EAST) from blood samples taken on each visit.

RESULTS

Total IgE levels showed a tendency to diminish. No changes were found in the number of positive EAST (presence of detectable levels of specific IgE) or in the levels of specific IgE. Although significantly more symptoms of rhinoconjunctivitis and asthma in contact with house dust (P < 0.05) and pets (P < 0.01) were reported on the second visit than on the first, no significant changes in the frequency of symptomatic sensitized subjects were found.

CONCLUSION

Subjects with OA are unlikely to develop IgE-dependent sensitization to common inhalants after removal from exposure to occupational agents.

Immunological and biological properties of recombinant Lol p 1

BACKGROUND

Current forms of allergy diagnosis and therapies are based on the use of natural allergenic extracts. Despite strong evidence that higher therapeutic efficacy may be achieved with purified allergens, the purification of multiple allergic components from extracts is a fastidious and sometimes an impossible task. However, the use of recombinant allergens may be an alternative to overcome this problem.

OBJECTIVE

In this study, we compared the immunological properties of recombinant (r) Lol p 1 with those of the natural protein.

METHOD

We cloned directly the gene encoding Lol p 1 from genomic DNA of ryegrass pollen. This gene was subcloned into the expression vector pMAL-c and expressed as fusion protein. Subsequently, rLol p 1 was cleaved from maltose-binding protein using factor Xa. Using binding inhibition and proliferative assays, we assessed the immunological properties of the recombinant allergens. The capacity of rLol p 1 to trigger basophil histamine release and to elicit a skin reaction was also assessed and compared to those of its natural counterpart.

RESULTS

We found that the Lol p 1 gene has no introns since we amplified this gene directly from genomic DNA. We demonstrated that the binding sites of anti-Lol p 1 monoclonal antibody, specific human IgG and IgE antibody are well conserved on rLol p 1 as no difference in the binding inhibition profile was observed when using either natural or recombinant protein. At the T-cell level, rLol p 1 elicited a T-cell response in mice comparable to that observed with the natural protein. In addition, we demonstrated that the biological characteristics of rLol p 1 were comparable to those of the natural counterpart, in that rLol p 1 elicited a skin wheal reaction and induced basophil histamine release in grass-allergic patients only.

CONCLUSION

The data indicate that natural Lol p 1 and rLol p 1 shared identical immunological and biological properties.

Comparative degree and type of sensitization to common indoor and outdoor allergens in subjects with allergic rhinitis and/or asthma

BACKGROUND AND OBJECTIVES

The determinants of variability in the clinical expression of atopy are still to be documented. The goals of this study were to determine, in subjects with a clinical diagnosis of symptomatic asthma or rhinitis, what is the possible contribution of different types of indoor and outdoor allergens to the development of their disease, by looking at the prevalence and degree of sensitization to these allergens according to age and gender.

SUBJECTS AND METHODS

We analysed allergy skin prick tests to common airborne indoor and outdoor allergens in 3371 consecutive patients, grouped according to diagnosis of allergic asthma, rhinitis, or both. For each of these three groups, we calculated the prevalence of sensitization to indoor/outdoor allergens, the atopic index (AI), the number of positive responses to allergy skin prick test and the mean wheal diameter (MWD) of these responses.

RESULTS

The prevalence of atopy and the values of AI and MWD peaked in subjects aged 16 to 25 years, declining afterwards; in subjects > or = 18 years old, atopic indices were slightly higher in men than in women. In atopic subjects, the prevalence of sensitization was, in decreasing order, housedust (84.2%), cat hair-epithelium (76.5%), dog hair-dander (63.0%), house dust mite (54.2%), grasses (51.9%), trees (47.2%) and ragweed pollens (44.9%) and finally, moulds (25.4%). Among subjects sensitized only to outdoor allergens (n = 195). 73.8% had a rhinitis, 11.8% had asthma and 14.4% had both diagnoses; for those sensitized only to indoor allergens (n = 710), these values were respectively 48.6, 24.5 and 26.9%, and for those sensitized to both indoor and outdoor allergens (n = 1793), the comparable values were 55.5, 14.6 and 29.9%.

CONCLUSION

These data show that in our population of subjects with respiratory allergic symptoms, indoor allergen sensitization is strongly associated with asthma, while exclusive sensitization to pollens is associated primarily with rhinitis. Sensitization was more prevalent for indoor allergens than for outdoor allergens in all groups determined according to diagnosis or age. Indices of atopy were higher in men in the group > or = 18 years old. Prevalence and degree of sensitization were shown to peak in young adults, regardless of the allergen, and to diminish with age. This study stresses the role of indoor allergens in the development of asthma and shows the variability of allergic manifestations according to the type of sensitization.

A twelve-week comparison of salmeterol and salbutamol in the treatment of mild-to-moderate asthma: a Canadian multicenter study

BACKGROUND

A long-acting inhaled bronchodilator that is both well tolerated and effective could allow for improved control of both daytime and nighttime symptoms in patients with asthma who use frequent as-needed short-acting bronchodilators despite antiinflammatory treatment.

OBJECTIVE AND METHODS

We compared the efficacy and safety of inhaled salmeterol, 50 micrograms twice daily, with inhaled salbutamol, 200 micrograms four times daily, delivered through a metered-dose inhaler for 3 months in a multicenter, randomized, double-blind, parallel-group study of 228 patients (aged 12 to 76 years) with mild-to-moderate asthma.

RESULTS

A single morning dose of salmeterol produced improvement in FEV1 that was significantly greater (p < or = 0.012) than that produced by two doses of salbutamol (taken 6 hours apart) when patients were assessed 3 to 6 hours and 10 to 12 hours after the dose. This greater bronchodilation was present on day 1 of the study and after 4, 8, and 12 weeks of regular treatment. Over the 12 weeks, compared with salbutamol, salmeterol treatment was associated with a greater mean improvement in morning peak expiratory flow (35 L/min vs -3 L/min, p < 0.001), a higher percentage of days with no symptoms (29% vs 15%; p = 0.012), and a higher percentage of nights with no awakenings (14% vs -1%; p < 0.001). Adverse events were similar for both treatments.

CONCLUSIONS

In this study salmeterol, 50 micrograms twice daily, was well tolerated and more effective than salbutamol, 200 micrograms four times daily, in improving symptoms and lung function in patients with mild-to-moderate asthma.

Comparison of histamine-releasing factor recovered from skin and peripheral blood mononuclear cells of patients with chronic idiopathic urticaria

BACKGROUND

The pathogenesis of chronic idiopathic urticaria is characterized by defective histamine release. Skin mast cells show an increased release of histamine while circulating basophils are less responsive to immunologic stimulus.

OBJECTIVE

The purpose of the study was to examine and compare the production of the histamine-releasing factor in the skin and within the peripheral blood of patients with chronic idiopathic urticaria and normal control subjects, as a possible factor responsible for the difference observed in the releasability of both skin mast cells and basophils.

METHODS

Using the skin chamber technique, histamine-releasing factor production and histamine concentration were assessed in normal-appearing skin of patients with chronic idiopathic urticaria (n = 12) and normal controls (n = 5) over a 2-hour observation period. In both groups, histamine-releasing factor production by peripheral blood mononuclear cells was also measured.

RESULTS

The weighted average of histamine-releasing factor production during the 2-hour observation period was higher in the non-lesional skin of patients with chronic idiopathic urticaria as compared with normal controls (5.6 +/- 1.4% versus 0.7 +/- 0.6%, P < .01). In contrast, less histamine-releasing factor was produced by peripheral blood mononuclear cells in chronic urticaria as opposed to normal controls (17.2 +/- 2.1% versus 25.7 +/- 2.8%, P < .03). Spontaneous histamine concentration was not significantly different in patients with chronic urticaria than in normal controls.

CONCLUSION

Histamine-releasing factor production is increased in the skin, and decreased in the peripheral blood of patients with chronic idiopathic urticaria when compared with nonatopic controls. The lower production of histamine releasing factor in the blood could be explained by the migration of activated T-lymphocytes in the skin.

Once daily mometasone furoate aqueous nasal spray is as effective as twice daily beclomethasone dipropionate for treating perennial allergic rhinitis patients

BACKGROUND

Perennial allergic rhinitis is chronic and persistent, may lead to a constellation of secondary complaints including sinusitis, mouth-breathing, and some symptoms resembling a permanent cold, and often requires constant medical intervention. Well-tolerated nasal corticosteroids, alone or in combination with antihistamines, have been found to be very effective in treating this condition.

OBJECTIVE

To compare the effectiveness and tolerability of mometasone furoate aqueous suspension, a new once daily nasal spray, to placebo vehicle and to beclomethasone dipropionate, administered twice daily, in patients with perennial allergic rhinitis.

METHODS

This was a randomized, double-blind, placebo-controlled, double-dummy, parallel group study, in 427 patients age 12 years and older at 24 centers in Canada and Europe. Patients allergic to at least one perennial allergen, confirmed by medical history, skin testing, and adequate symptomatology were eligible to receive one of the following regimens for 3 months: mometasone furoate, 200 micrograms only daily; beclomethasone dipropionate, 200 micrograms twice daily (400 micrograms total dose); or placebo vehicle control. The primary efficacy variable was the change from baseline in total AM plus PM diary nasal symptom score over the first 15 days of treatment.

RESULTS

Three hundred eighty-seven patients were valid for efficacy. For the primary efficacy variable, mometasone furoate was significantly (P < or = .01) more effective than placebo and was indistinguishable from beclomethasone dipropionate. Similar trends were seen among individual symptoms, physician symptom evaluations, and therapeutic response. There was no evidence of tachyphylaxis. All treatments were well tolerated.

CONCLUSIONS

Mometasone furoate nasal spray adequately controls symptoms of perennial allergic rhinitis, offers the advantage of once daily treatment, and is well tolerated.

Effects of systemic corticosteroids on cutaneous histamine secretion and histamine-releasing factor in patients with chronic idiopathic urticaria

BACKGROUND

Enhanced skin mast cell releasability of histamine, increased production of histamine releasing factor (HRF), and cutaneous inflammatory process are the hallmarks of chronic idiopathic urticaria (CU). Although H1-antihistamines are known to alleviate the symptoms effectively in most cases, systemic corticosteroids (CS) are given in more resistant patients. Their mode of action remains a matter of controversy.

OBJECTIVES

In the present study, the effects of a 7-day course of CS or placebo on histamine content and HRF production in non-lesional skin of 19 CU patients were examined.

METHODS

Using the skin chamber technique, HRF production and histamine content were assessed in normal-appearing skin of patients with CU over a 2-h observation period. Those two parameters were measured before and after treatment, in a double-blind fashion.

RESULTS

No significant changes occurred in any parameters after placebo treatment. In contrast with this, significant decrease of HRF activity was observed after 1 week of oral methylprednisolone while no change was documented for histamine secretion.

CONCLUSION

These data suggest that CS therapy improves symptoms of CU in association with a decreased production of HRF in uninvolved skin.

Isolation of prostatic kallikrein hK2, also known as hGK-1, in human seminal plasma

To demonstrate the presence of kallikrein hK2 in the human prostate and seminal plasma, we used mouse monoclonal antibodies (MAb) against a recombinant hK2-fusion protein. Using one of these MAb 9D5, we detected the presence of several major immunoreactive spots of 22 kDa and minor ones of 31 and 55 kDa in prostate cytosol and seminal plasma. After ion exchange and immunoaffinity chromatography of seminal plasma proteins, the 22-kDa immunoreactive proteins were isolated along with 55- and 75-kDa proteins. The NH2-terminal amino acid sequencing permitted identification of fragments of hK2 and protein C inhibitor, respectively, in the 22- ad 55-kDa bands. Furthermore, immunoblotting experiments in one and two-D gels with two different anti-hK2 MAbs and one polyclonal anti-PCI antibody suggested that the major 55- and 75-kDa bands were covalent hK2-PCI complexes containing either the full-length hK2 chain or only its carboxyterminal fragment in the presence of mercaptoethanol. These results demonstrate for the first time the existence of kallikrein hK2 and suggest that PCI may regulate its activity in seminal plasma.

A natural mutation of the amino acid residue at position 60 destroys staphylococcal enterotoxin A murine T-cell mitogenicity

A variety of techniques have been used to identify the amino acid residues of bacterial superantigens involved in their interactions with major histocompatibility complex (MHC) class II and T-cell receptor (TCR). In this study, we isolated a naturally mutated staphylococcal enterotoxin A (SEA) from three different Staphylococcus aureus strains, in which the amino acid at position 60 has been changed from aspartic acid (D) to asparagine (N). We then studied the influence of this change on the immunological activities of SEA. Our results demonstrated that this mutation does not affect the capacity of SEA to bind MHC class II molecules and consequently activates human monocytes and peripheral blood lymphocytes. In contrast, mutated SEA failed to stimulate the proliferation of murine splenic lymphocytes of two different strains, and when presented by human MHC class II molecules, it also failed to activate murine cell line 3DT, which expresses the SEA-specific TCR V beta element (V beta 1). These results indicate that this mutation alters the interaction between SEA and murine TCR. The reactivity patterns of the mutated SEA with two specific anti-SEA monoclonal antibodies suggested that the observed effect of the isolated mutation in the murine system might be due to certain conformational changes in the SEA molecule introduced upon changing the D at position 60 to N. Site-directed mutagenesis of the N residue to D or to glycine reconstituted the ability of SEA to stimulate murine splenic lymphocytes. The different effects of this natural mutation at position 60 on the immunological activities of SEA with murine and human cells highlight the relevance of the affinity and avidity in SEA-TCR interactions in the function of different species or may reflect a difference in epitope specificity.