Leukotriene antagonists and inhibitors as modulators of IgE-mediated reactions

Leukotrienes as mediators of asthma

This review describes the aspects of leukotriene (LT) pharmacology and biology that are relevant to their important role in asthma. The biosynthesis and metabolism, including transcellular metabolism, of LTB4 and the cysteinyl-LTs (i.e. LTC4, LTD4 and LTE4) are described, and their transport is briefly outlined. The existence, distribution and pharmacological characterization of the receptors (BLT, CysLT1, CysLT2), as well as the transduction mechanisms triggered, are discussed in detail. We also describe their effects on airway smooth muscle tone, hyperresponsiveness and proliferation, on vascular tone and permeability, on mucus secretion, on neural fibers and inflammatory cell functions. Finally, the evidence supporting their role as asthma mediators is reviewed, including the effects of anti LT drugs (both biosynthesis inhibitors and receptor antagonists) in experimental and clinical asthma.

5-Lipoxygenase metabolites inhibit bone formation in vitro

The leukotrienes and peptido-leukotrienes are 5-lipoxygenase (5-LO) metabolites of arachidonic acid that appear to have unique effects on bone, distinct from those of the prostaglandins. Application of exogenous leukotrienes in vitro and in vivo results in increased osteoclast formation and bone resorption. While 5-LO metabolites of arachidonic acid clearly stimulate osteoclastic bone resorption, little is known concerning their effects on osteoblastic bone formation. We examined the effects of the 5-LO metabolites 5-HETE, the leukotriene LTB4 and, as representative of the peptido-leukotrienes, LTD4 on the formation of mineralized nodules of fetal rat calvarial cells in the presence of dexamethasone and recombinant human bone morphogenetic protein-2 (rhBMP-2). We also examined the effects of these 5-LO metabolites on alkaline phosphatase activity and cell proliferation in these cultures and the effects of 5-HETE and LTB4 on cultured explants of neonatal murine calvariae. We found that the bone-forming capacity of osteoblasts was impaired when cells were cultured in the presence of 5-LO metabolites. These data indicate that metabolites of the 5-LO pathway are negative regulators of bone formation. The continued presence of these metabolites in the bone environment might account, in part, for the bone loss associated with chronic inflammatory conditions.

Leukotriene activity modulation in asthma

Leukotrienes constitute a class of inflammatory mediators synthesised from arachidonic acid, a product of cell membrane metabolism. Synthesis occurs in the 5-lipoxygenase enzyme pathway, which produces several species of leukotrienes, each with characteristic biological activities. With regard to asthma, the leukotrienes are particularly important because of their ability to directly and potently mediate bronchoconstriction; in addition, they specifically stimulate the secretion of mucus into the airways and the extravasation of fluids and proteins into the airway tissues, both of which contribute to airway obstruction. A number of antileukotriene agents have been developed with the goal of modulating the inflammatory process in various disease states. These agents fall into 2 general classes: leukotriene receptor antagonists and leukotriene synthesis inhibitors. Results of antileukotriene agents in preclinical and clinical trials indicate that antileukotriene agents attenuate the response to challenges with inhaled leukotrienes, cold air, exercise, aspirin and allergen; in addition, they have shown efficacy in clinical asthma and have not been associated with serious adverse effects. Although results to date indicate that these medications are well tolerated and effective in the treatment of asthma, the recent approval by the FDA of 2 antileukotriene agents will give physicians further insight into how patients with asthma respond to them.

Leukotrienes in the pathogenesis of asthma

Asthma is a chronic inflammatory disease that is associated with widespread but variable airflow obstruction. The mechanisms that lead to airflow obstruction in asthma are bronchoconstriction, mucosal edema, increased secretion of mucus, and an inflammatory-cell infiltrate that is rich in eosinophils. Leukotrienes (LTs) B4, C4, D4, and E4 have been shown experimentally to play a role in each of these inflammatory mechanisms and to mimic the pathologic changes seen in asthma. Inhaled LTC4 and LTD4 are the most potent bronchoconstrictors yet studied in human subjects. LTC4 and LTD4 also may cause migration of inflammatory cells into the asthmatic airway. LTs are derived from the 5-lipoxygenase (5-LO) pathway of arachidonic acid metabolism, and increased production of LTs has been demonstrated in patients who have asthma. Leukotriene receptor antagonists and specific inhibitors of the 5-LO pathway hold great promise as new therapies to treat asthma. Because LTC4, LTD4, and LTE4 appear to interact with a common LTD4 receptor, selective LTD4 receptor antagonists (eg, pranlukast [SB205312/ONO-1078], zafirlukast [ICI 204,219], MK-571, and MK-679), as well as zileuton (A-64077, a direct inhibitor of 5-LO) have been developed as antiasthma agents. Clinical and experimental studies have demonstrated the efficacy of these compounds in reducing not only the symptoms of asthma, but use of beta 2-agonists and bronchoconstriction induced by exposure to allergens, exercise, aspirin, and cold air.

Goals of asthma management. A step-care approach

The past 15 years have seen a rise in mortality and morbidity resulting from asthma, despite a concurrent rise in general knowledge about the disease. The step-care strategy recognized these changes in its approach to asthma management; however, this approach should be used only with attempts to control environmental allergens. Step-care therapy requires that patients be categorized by the severity of illness. Step-one therapy is used for mild, infrequent symptoms and involves treatment based primarily on inhaled bronchodilators. Step-two therapy is instituted in all asthmatics except the mildest cases; it involves treatment by inhaled corticosteroids, cromolyn, or nedocromil. Step-three treatment targets cases of severe asthma through the use of oral corticosteroids. In all phases of treatment, however, it should be remembered that patient education is of critical importance. Education improves patient compliance and is critical to the successful treatment of asthma.

Regulation of leukotriene biosynthesis

Leukotrienes are products of arachidonic acid metabolism derived through the action of the 5-lipoxygenase enzyme pathway. Leukotriene B4 has been implicated as a mediator of inflammation through induction of leukocyte and lymphocyte activation. The cysteinyl leukotrienes are important mediators of immediate hypersensitivity reactions and initiate smooth muscle contraction. Regulation of the production of leukotrienes can be achieved either through the action of direct 5-lipoxygenase inhibitors or indirect leukotriene biosynthesis inhibitors which bind to 5-lipoxygenase activating protein. Leukotriene C4 synthase and leukotriene A4 hydrolase represent alternative enzymic targets within the biosynthetic cascade. Leukotriene receptor antagonists also have important therapeutic possibilities and in particular, leukotriene D4 receptor antagonists have shown utility in the treatment of human bronchial asthma.

Leukotriene B4 formation upon halothane-induced lipid peroxidation in liver membrane fractions under low O2 concentrations in vitro

Lipid peroxidation was induced in rat liver membrane fractions in vitro upon NADPH-dependent metabolic activation of the anesthetic agent halothane at low O2 concentrations. Halothane-induced lipid peroxidation was dependent on time, concentration of halothane, and the calculated O2 concentrations present in the system. Lipid peroxidation was inducible at increasing O2 concentrations up to 12 microM, decreased at higher O2 concentrations up to 48 microM, and was not detectable at normoxic conditions. Leukotriene B4 (LTB4) was identified as a product arising upon lipid peroxidation by reverse-phase high-pressure liquid chromatography combined with a radioimmunoassay. LTB4 formation was maximal under conditions of maximal lipid peroxidation at a calculated O2 concentration of 12 microM. Even at high concentrations, the 5-lipoxygenase inhibitors MK886 (10 microM), ZD2138 (20 microM), and ZM230487 (20 microM) were not inhibitory in halothane-induced lipid peroxidation nor in the associated formation of LTB4. Synthetic LTB4 was transformed into its 20-hydroxy derivative by omega-oxidation in an O2-concentration-dependent manner, being considerably reduced at the low O2 concentrations that maximally promoted lipid peroxidation. The collective evidence of these data raises the possibility that exposure to halothane might lead to peroxidation-associated net synthesis of LTB4 through 5-lipoxygenase-independent escape routes in liver tissue under physiologically or pathophysiologically low O2 concentrations.

Leukotrienes as a target in asthma therapy

Asthma is a chronic inflammatory condition characterised by bronchial hyper-responsiveness and reversible airways obstruction. Research has demonstrated that these effects are mediated by a wide range of compounds. In the last decade leukotrienes have been identified as products of arachidonic acid metabolism. Their effects mimic the pathological changes seen in asthma both in vitro and in vivo. Further research has demonstrated increased production of leukotrienes both during episodes of asthma and in patients with stable asthma. The demonstration that leukotrienes have proinflammatory biological properties relevant to the pathogenesis of asthma has stimulated the development of many potential therapeutic compounds to block these actions. Early studies in laboratory-induced asthma in human volunteers have shown the efficacy of some of these compounds. They have been shown to attenuate the bronchoconstriction caused by allergen challenge, exercise, aspirin and exposure to cold air. Most encouraging of all have been recent placebo-controlled studies in clinical asthma where significant improvements in terms of spirometry, symptoms and beta 2-agonist use have been demonstrated. Leukotriene receptor antagonists and synthesis inhibitors are the first mediator antagonists to have been shown to be effective in treating clinical asthma and as such represent one of the most interesting new classes of antiasthma drugs in development at present.