Methotrexate as a steroid sparing agent for asthma in adults

Luobitong Potentiates MTX's Anti-Rheumatoid Arthritis Activity via Targeting Multiple Inflammatory Pathways

Background

The LuoBiTong (LBT) capsule, a novel traditional Chinese medicine formulation, is currently in Phase III clinical trials. Preliminary preclinical and Phase II clinical studies suggest its efficacy and safety in treating rheumatoid arthritis (RA). However, the underlying mechanisms of its action remain to be elucidated.This research aims to explore the effects and mechanisms of LBT in conjunction with a maintenance dose of methotrexate (M-MTX) on RA.

Methods

A Collagen-Induced Arthritis (CIA) mouse model was used to evaluate the anti-RA effects of LBT combined with M-MTX. Assessments included foot swelling, arthritis scoring, serum inflammatory factor analysis, and histopathological examination of the foot. These effects were compared with those of high-dose MTX (H-MTX). Network pharmacology was employed to construct a compound-target network for RA, based on drug composition, to predict its potential mechanism of action. Flow cytometry, Western Blot, and immunohistochemical analyses in animal models identified multiple inflammatory pathways targeted by LBT to augment the anti-RA effects of MTX.

Results

The study revealed that LBT combined with M-MTX significantly alleviated CIA-induced arthritis without adverse effects. The combination of LBT and M-MTX showed similar or superior efficacy in regulating macrophage polarization, NF-κB, MAPK signaling pathways, and in the suppression of TH-17 expression in proinflammatory cells. These findings suggest that LBT may exert a multi-pathway therapeutic effect in RA treatment. The predicted pharmacological targets and mechanisms align well with this hypothesis.

Conclusion

LBT, when combined with MTX, enhances the anti-RA effect by targeting multiple inflammatory pathways, demonstrating significant therapeutic potential.

[Diagnosis and treatment of asthma: a guideline for respiratory specialists 2023 - published by the German Respiratory Society (DGP) e. V.]

The management of asthma has fundamentally changed during the past decades. The present guideline for the diagnosis and treatment of asthma was developed for respiratory specialists who need detailed and evidence-based information on the new diagnostic and therapeutic options in asthma. The guideline shows the new role of biomarkers, especially blood eosinophils and fractional exhaled NO (FeNO), in diagnostic algorithms of asthma. Of note, this guideline is the first worldwide to announce symptom prevention and asthma remission as the ultimate goals of asthma treatment, which can be achieved by using individually tailored, disease-modifying anti-asthmatic drugs such as inhaled steroids, allergen immunotherapy or biologics. In addition, the central role of the treatment of comorbidities is emphasized. Finally, the document addresses several challenges in asthma management, including asthma treatment during pregnancy, treatment of severe asthma or the diagnosis and treatment of work-related asthma.

Risk of Chronic Obstructive Pulmonary Disease Exacerbation in Patients Who Use Methotrexate-A Nationwide Study of 58,580 Outpatients

Patients with severe chronic obstructive pulmonary disease (COPD) experience frequent acute exacerbations and require repeated courses of corticosteroid therapy, which may lead to adverse effects. Methotrexate (MTX) has anti-inflammatory properties. The objective of this study was to describe the risk of COPD exacerbation in patients exposed to MTX. In this nationwide cohort study of 58,580 COPD outpatients, we compared the risk of hospitalization-requiring COPD exacerbation or death within 180 days in MTX vs. non-MTX users in a propensity-score matched study population as well as an unmatched cohort, in which we adjusted for confounders. The use of MTX was associated with a reduction in risk of COPD exacerbation in the propensity-score matched population at 180 days follow-up (HR 0.66, CI 0.66-0.66, p < 0.001). Similar results were shown in our sensitivity analyses at 180-day follow-up on unmatched population and 365-day follow-up on matched and unmatched population (HR 0.76 CI 0.59-0.99, HR 0.81 CI 0.81-0.82 and HR 0.92 CI 0.76-1.11, respectively). MTX was associated with a lower risk of COPD exacerbation within the first six months after study entry. The finding seems biologically plausible and could potentially be a part of the management of COPD patients with many exacerbations.

Diagnosis and treatment of severe asthma: a phenotype-based approach

Severe asthma is a heterogeneous and often difficult to treat condition that results in a disproportionate cost to healthcare systems. Appropriate diagnosis and management of severe asthma is critical, as most asthma deaths have been retrospectively identified as having poorly recognised severe asthma. With multiple biologic agents becoming available, it is crucial to correctly phenotype patients in order to identify those that will respond to these high-cost treatments. We provide an overview of the assessment, phenotyping and management of severe asthma in primary and secondary care.

Diagnosis and treatment of severe asthma: a phenotype-based approach

Severe asthma is a heterogeneous and often difficult to treat condition that results in a disproportionate cost to healthcare systems. Appropriate diagnosis and management of severe asthma is critical, as most asthma deaths have been retrospectively identified as having poorly recognised severe asthma. With multiple biologic agents becoming available, it is crucial to correctly phenotype patients in order to identify those that will respond to these high-cost treatments. We provide an overview of the assessment, phenotyping and management of severe asthma in primary and secondary care.

Development of New Therapies for Severe Asthma

Persistent asthma has long been treated with inhaled corticosteroids (CSs), as the mainstay of therapy. However, their efficacy in patients with more severe disease is limited, which led to the incorporation of poor response to ICSs (and thereby use of high doses of ICS) into recent definitions of severe asthma. Several studies have suggested that severe asthma might consist of several different phenotypes, each with ongoing symptoms and health care utilization, despite the use of high doses of ICS, usually in combination with a second or third controller. Several new therapies have been approved for severe asthma. Long-acting muscarinic agents have recently been approved as an additional controller agent and appear to improve lung function, although their effect on symptoms and exacerbations is less. Although bronchial thermoplasty (BT) has emerged as a therapy for severe asthma, little is understood regarding the appropriate selection of these patients. Considerable data have emerged to support the presence of a group of patients with severe asthma who have ongoing Type 2 inflammation. These patients appear to respond to targeted biologic approaches which are at the current time mostly investigational. In contrast, few effective therapies for patients with less or no evidence for Type 2 inflammation have emerged. Many new and exciting therapies are at the forefront for severe asthma therapy and, in conjunction with precision medicine approaches to identify the group of patients likely to respond to these approaches, will change the way we think about treating severe asthma.

Neutrophilic inflammation in asthma: mechanisms and therapeutic considerations

INTRODUCTION

Neutrophilic airway inflammation represents a pathologically distinct form of asthma and frequently appears in symptomatic adulthood asthmatics. However, clinical impacts and mechanisms of the neutrophilic inflammation have not been thoroughly evaluated up to date. Areas covered: Currently, distinct clinical manifestations, triggers, and molecular mechanisms of the neutrophilic inflammation (namely Toll-like receptor, Th1, Th17, inflammasome) are under investigation in asthma. Furthermore, possible role of the neutrophilic inflammation is being investigated in respect to the airway remodeling. We searched the related literatures published during the past 10 years on the website of Pub Med under the title of asthma and neutrophilic inflammation in human. Expert commentary: Epidemiologic and experimental studies have revealed that the neutrophilic airway inflammation is induced by a wide variety of stimuli including ozone, particulate matters, cigarette smoke, occupational irritants, endotoxins, microbial infection and colonization, and aeroallergens. These triggers provoke diverse immune and inflammatory responses leading to progressive and sometimes irreversible airway obstruction. Clinically, neutrophilic airway inflammation is frequently associated with severe asthma and poor response to glucocorticoid therapy, indicating the need for other treatment strategies. Accordingly, therapeutics will be targeted against the main mediators behind the underlying molecular mechanisms of the neutrophilic inflammation.

Drug therapies in severe asthma - the era of stratified medicine

Difficult-to-treat asthma affects up to 20% of patients with asthma and is associated with significant healthcare cost. It is an umbrella term that defines a heterogeneous clinical problem including incorrect diagnosis, comorbid conditions and treatment non-adherence; when these are effectively addressed, good symptom control is frequently achieved. However, in 3-5% of adults with difficult-to-treat asthma, the problem is severe disease that is unresponsive to currently available treatments. Current treatment guidelines advise the 'stepwise' increase of corticosteroids, but it is now recognised that many aspects of asthma are not corticosteroid responsive, and that this 'one size fits all' approach does not deliver clinical benefit in many patients and can also lead to side effects. The future of management of severe asthma will involve optimisation with currently available treatments, particularly corticosteroids, including addressing non-adherence and defining an 'optimised' corticosteroid dose, allied with the use of 'add-on' target-specific novel treatments. This review examines the current status of novel treatments and research efforts to identify novel targets in the era of stratified medicines in severe asthma.

Methotrexate as an oral corticosteroid-sparing agent in severe asthma: the emergence of a responder asthma endotype

Background

Sustained use of oral corticosteroids is associated with significant side effects. It is therefore of interest to find a corticosteroid-sparing agent. In two meta-analyses, methotrexate resulted in a rather small reduction in the oral corticosteroid maintenance dose. We have used methotrexate as an oral corticosteroid-sparing agent in consecutive patients with severe bronchial asthma and find a need for a real-life observational study to evaluate the effect of methotrexate in clinical practice.

Methods

We analyzed the clinical data of 13 oral corticosteroid-dependent asthma patients with a mean prednisolone dose of 15 mg/day for up to 8 years. The diagnosis of asthma based on the clinical history, positive bronchodilator reversibility test, and variable airflow obstruction was secured by bronchial biopsies in all patients. We reviewed the literature and found 12 studies evaluating methotrexate as an oral corticosteroid-sparing agent in severe asthma and calculated the mean daily reduction in mg of prednisolone.

Results

Oral corticosteroids could be reduced in 8/13 patients, 61.5% (mean reduction 9.0 mg/day), and stopped in six of these patients. Five patients had no reduction and remained oral corticosteroid-dependent. Patients with the highest oral corticosteroid doses experienced the greatest reductions. Two patients stopped methotrexate due to side effects. FEV1 remained unaffected by methotrexate treatment and corticosteroid reduction.

Conclusions

Methotrexate has significant oral corticosteroid-sparing effect while maintaining an unaltered asthma control and spirometry. Methotrexate seems an effective oral corticosteroid-sparing agent in a significant proportion of patients with severe asthma. The specific asthma phenotype/endotype that responds needs further study.

Defining severe asthma - an approach to find new therapies

Asthma is a chronic inflammatory disease that has reached epidemic proportions worldwide. It is treatable in the majority of patients, but there is no cure. Moreover, a proportion of patients suffer from severe, difficult-to-control disease with daily symptoms and high morbidity, making it imperative that we continue to improve our understanding of the underlying mechanisms of this disease. Severe asthma is a heterogeneous condition. A systematic approach to identify specific asthma phenotypes, including clinical characteristics and inflammatory processes, is the first step toward individualized, logical therapy. This review focuses on the need to characterize severe asthma phenotypes and on novel, targeted molecular treatment options currently under development.

Difficult-to-treat asthma in childhood

Asthma continues to be one of the greatest burdens to healthcare resources throughout the developed world. In most cases, good symptom control can be achieved with low-dose inhaled corticosteroids, and can be cared for in the primary and secondary healthcare systems. However, there is a group in whom control is not achieved despite high-dose inhaled corticosteroids and maximal add-on therapies; these are children with problematic severe asthma that should be referred to a specialist team for further investigation and management. In this review we aimed to provide an evidence-based guide for pediatricians providing care for children with asthma in secondary healthcare settings. The review focuses on a proposed investigation and management strategy for children aged between 6 and 16 years with problematic severe asthma, and is supported as far as possible by evidence from the literature. We first address recent advances in nomenclature and then discuss our proposed course of investigation and management of these children. Distinction of children with true, severe, therapy-resistant asthma from those with asthma that is difficult to treat because of unaddressed underlying modifiable factors is critical and is discussed in detail.

Clinical management and outcome of refractory asthma in the UK from the British Thoracic Society Difficult Asthma Registry

Refractory asthma represents a significant unmet clinical need. Data from a national online registry audited clinical outcome in 349 adults with refractory asthma from four UK specialist centres in the British Thoracic Society Difficult Asthma Network. At follow-up, lung function improved, with a reduction in important healthcare outcomes, specifically hospital admission, unscheduled healthcare visits and rescue courses of oral steroids. The most frequent therapeutic intervention was maintenance oral corticosteroids and most steroid sparing agents (apart from omalizumab) demonstrated minimal steroid sparing benefit. A significant unmet clinical need remains in this group, specifically a requirement for therapies which reduce systemic steroid exposure.

Optimal management of severe/refractory asthma

Asthma is a chronic inflammatory disease of the airways, affecting approximately 300 million people worldwide. Asthma results in airway hyperresponsiveness, leading to paroxysmal symptoms of wheeze, cough, shortness of breath, and chest tightness. When these symptoms remain uncontrolled, despite treatment with high doses of inhaled and ingested corticosteroids, asthmatic patients are predisposed to greater morbidity and require more health care support. Treating patients with severe asthma can be difficult and often poses a challenge to physicians when providing ongoing management. This clinical review aims to discuss the definition, prevalence and evaluation of severe asthmatics, and provides a review of the existing pharmacologic and non-pharmacologic treatment options.

An integrative review of systematic reviews related to the management of breathlessness in respiratory illnesses

BACKGROUND

Breathlessness is a debilitating and distressing symptom in a wide variety of diseases and still a difficult symptom to manage. An integrative review of systematic reviews of non-pharmacological and pharmacological interventions for breathlessness in non-malignant disease was undertaken to identify the current state of clinical understanding of the management of breathlessness and highlight promising interventions that merit further investigation.

METHODS

Systematic reviews were identified via electronic databases between July 2007 and September 2009. Reviews were included within the study if they reported research on adult participants using either a measure of breathlessness or some other measure of respiratory symptoms.

RESULTS

In total 219 systematic reviews were identified and 153 included within the final review, of these 59 addressed non-pharmacological interventions and 94 addressed pharmacological interventions. The reviews covered in excess of 2000 trials. The majority of systematic reviews were conducted on interventions for asthma and COPD, and mainly focussed upon a small number of pharmacological interventions such as corticosteroids and bronchodilators, including beta-agonists. In contrast, other conditions involving breathlessness have received little or no attention and studies continue to focus upon pharmacological approaches. Moreover, although there are a number of non-pharmacological studies that have shown some promise, particularly for COPD, their conclusions are limited by a lack of good quality evidence from RCTs, small sample sizes and limited replication.

CONCLUSIONS

More research should focus in the future on the management of breathlessness in respiratory diseases other than asthma and COPD. In addition, pharmacological treatments do not completely manage breathlessness and have an added burden of side effects. It is therefore important to focus more research on promising non-pharmacological interventions.

Recommendation for optimal management of severe refractory asthma

Patients whose asthma is not adequately controlled despite treatment with a combination of high dose inhaled corticosteroids and long-acting bronchodilators pose a major clinical challenge and an important health care problem. Patients with severe refractory disease often require regular oral corticosteroid use with an increased risk of steroid-related adverse events. Alternatively, immunomodulatory and biologic therapies may be considered, but they show wide variation in efficacy across studies thus limiting their generalizability. Managing asthma that is refractory to standard treatment requires a systematic approach to evaluate adherence, ensure a correct diagnosis, and identify coexisting disorders and trigger factors. In future, phenotyping of patients with severe refractory asthma will also become an important element of this systematic approach, because it could be of help in guiding and tailoring treatments. Here, we propose a pragmatic management approach in diagnosing and treating this challenging subset of asthmatic patients.

Methotrexate for primary biliary cirrhosis

BACKGROUND

Methotrexate has been used to treat patients with primary biliary cirrhosis as it possesses immunosuppressive properties. The previously prepared version of this review from 2005 showed that methotrexate seemed to significantly increase mortality in patients with primary biliary cirrhosis. Since that last review version, follow-up data of the included trials have been published.

OBJECTIVES

To assess the beneficial and harmful effects of methotrexate for patients with primary biliary cirrhosis.

SEARCH STRATEGY

Randomised clinical trials were identified by searching The Cochrane Hepato-Biliary Group Controlled Trials Register, The Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, and EMBASE (from their inception until September 2009). Reference lists were also read through. Authors of trials were contacted.

SELECTION CRITERIA

We searched to include randomised clinical trials comparing methotrexate with placebo, no intervention, or another drug irrespective of blinding, language, year of publication, or publication status.

DATA COLLECTION AND ANALYSIS

Our primary outcomes were mortality, and mortality or liver transplantation combined. Dichotomous outcomes were reported as relative risks (RR) and hazard ratios (HR) if applicable. Continuous outcomes were reported as mean differences (MD).

MAIN RESULTS

Five trials were included. Four trials with 370 patients compared methotrexate with placebo or no intervention (three trials added an equal dose of ursodeoxycholic acid to the intervention groups). The bias risk of these trials was high. We did not find statistically significant effects of methotrexate on mortality (RR 1.32, 95% CI 0.66 to 2.64), mortality or liver transplantation combined, pruritus, fatigue, liver complications, liver biochemistry, liver histology, or adverse events. The pruritus score (MD - 0.17, 95% CI - 0.25 to - 0.09) was significantly lower in patients receiving methotrexate. The prothrombin time was significantly worsened in patients receiving methotrexate (MD 1.60 s, 95% CI 1.18 to 2.02). One trial with 85 patients compared methotrexate with colchicine. The trial had low risk of bias. Methotrexate, when compared to colchicine, did not significantly effect mortality, fatigue, liver biopsy, or adverse events. Methotrexate significantly benefited pruritus score (MD - 0.68, 95% CI - 1.11 to - 0.25), serum alkaline phosphatases (MD - 0.41 U/l, 95% CI - 0.70 to - 0.12), and plasma immunoglobulin M (MD - 0.47 mg/dl, 95% CI - 0.74 to - 0.20) compared with colchicine. Other outcomes showed no statistical difference.

AUTHORS' CONCLUSIONS

Methotrexate had no statistically significant effect on mortality in patients with primary biliary cirrhosis nor the need for liver transplantation. Although methotrexate may benefit other outcomes (pruritus score, serum alkaline phosphatase, immunoglobulin M levels), there is no sufficient evidence to support methotrexate for patients with primary biliary cirrhosis.

Asthma in childhood

Management decisions for pediatric asthma (in patients younger than 12 years of age) based on extrapolation from available evidence in adolescents and adults (age 12 years and older) is common but rarely appropriate. This article addresses the disparity in response between the two age groups, presents the available pediatric evidence, and highlights the important areas in which further research is required. Evidence-based recommendations for acute and interval management of pediatric asthma are provided.

New drugs targeting Th2 lymphocytes in asthma

Asthma represents a profound worldwide public health problem. The most effective anti-asthmatic drugs currently available include inhaled beta2-agonists and glucocorticoids and control asthma in about 90-95% of patients. The current asthma therapies are not cures and symptoms return soon after treatment is stopped even after long term therapy. Although glucocorticoids are highly effective in controlling the inflammatory process in asthma, they appear to have little effect on the lower airway remodelling processes that appear to play a role in the pathophysiology of asthma at currently prescribed doses. The development of novel drugs may allow resolution of these changes. In addition, severe glucocorticoid-dependent and resistant asthma presents a great clinical burden and reducing the side-effects of glucocorticoids using novel steroid-sparing agents is needed. Furthermore, the mechanisms involved in the persistence of inflammation are poorly understood and the reasons why some patients have severe life threatening asthma and others have very mild disease are still unknown. Drug development for asthma has been directed at improving currently available drugs and findings new compounds that usually target the Th2-driven airway inflammatory response. Considering the apparently central role of T lymphocytes in the pathogenesis of asthma, drugs targeting disease-inducing Th2 cells are promising therapeutic strategies. However, although animal models of asthma suggest that this is feasible, the translation of these types of studies for the treatment of human asthma remains poor due to the limitations of the models currently used. The myriad of new compounds that are in development directed to modulate Th2 cells recruitment and/or activation will clarify in the near future the relative importance of these cells and their mediators in the complex interactions with the other pro-inflammatory/anti-inflammatory cells and mediators responsible of the different asthmatic phenotypes. Some of these new Th2-oriented strategies may in the future not only control symptoms and modify the natural course of asthma, but also potentially prevent or cure the disease.

Current evidence for the management of ankylosing spondylitis: a systematic literature review for the ASAS/EULAR management recommendations in ankylosing spondylitis

OBJECTIVE

To assess available management strategies in ankylosing spondylitis (AS) using a systematic approach, as a part of the development of evidence based recommendations for the management of AS.

METHODS

A systematic search of Medline, Embase, CINAHL, PEDro, and the Cochrane Library was performed to identify relevant interventions for the management of AS. Evidence for each intervention was categorised by study type, and outcome data for efficacy, adverse effects, and cost effectiveness were abstracted. The effect size, rate ratio, number needed to treat, and incremental cost effectiveness ratio were calculated for each intervention where possible. Results from randomised controlled trials were pooled where appropriate.

RESULTS

Both pharmacological and non-pharmacological interventions considered to be of interest to clinicians involved in the management of AS were identified. Good evidence (level Ib) exists supporting the use of non-steroidal anti-inflammatory drugs (NSAIDs) and coxibs for symptomatic treatment. Non-pharmacological treatments are also supported for maintaining function in AS. The use of conventional antirheumatoid arthritis drugs is not well supported by high level research evidence. Tumour necrosis factor inhibitors (infliximab and etanercept) have level Ib evidence supporting large treatment effects for spinal pain and function in AS over at least 6 months. Level IV evidence supports surgical interventions in specific patients.

CONCLUSION

This extensive literature review forms the evidence base considered in the development of the new ASAS/EULAR recommendations for the management of AS.

Severe asthma

Severe asthma is a term that is commonly used to describe patients with refractory, brittle, near fatal, and difficult-to-control asthma. Patients with severe asthma typically experience persistent symptoms despite medical therapy, report decreased quality of life and suffer an accelerated loss of lung function. The role of genetics, environmental exposure, and infection in the development of more severe asthma is the focus of ongoing research. While pathologic changes in these patients are now believed to involve lung parenchyma, in addition to large and small airways, the independent contribution of each of these compartments to the severe asthma phenotype is not well defined. The clinical evaluation of severe asthma patients should include investigating conditions commonly associated with severe asthma, such as gastroesophageal reflux disease, vocal cord dysfunction, and rhinosinusitis. In addition, advanced imaging techniques, measurement of exhaled gas or sputum indices, and airway biopsy are tools that may aid in evaluating severe asthma patients in the near future. Management of patients with severe asthma requires a comprehensive approach that includes non-pharmacological and pharmacological measures. Combination antiinflammatory and long-acting bronchodilator therapy remains the mainstay of management.