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Bernstein ZJ, Shenoy A, Chen A, Heller NM, Spangler JB. Engineering the IL-4/IL-13 axis for targeted immune modulation. Immunol Rev 2023; 320:29-57. [PMID: 37283511 DOI: 10.1111/imr.13230] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 05/19/2023] [Indexed: 06/08/2023]
Abstract
The structurally and functionally related interleukin-4 (IL-4) and IL-13 cytokines play pivotal roles in shaping immune activity. The IL-4/IL-13 axis is best known for its critical role in T helper 2 (Th2) cell-mediated Type 2 inflammation, which protects the host from large multicellular pathogens, such as parasitic helminth worms, and regulates immune responses to allergens. In addition, IL-4 and IL-13 stimulate a wide range of innate and adaptive immune cells, as well as non-hematopoietic cells, to coordinate various functions, including immune regulation, antibody production, and fibrosis. Due to its importance for a broad spectrum of physiological activities, the IL-4/IL-13 network has been targeted through a variety of molecular engineering and synthetic biology approaches to modulate immune behavior and develop novel therapeutics. Here, we review ongoing efforts to manipulate the IL-4/IL-13 axis, including cytokine engineering strategies, formulation of fusion proteins, antagonist development, cell engineering approaches, and biosensor design. We discuss how these strategies have been employed to dissect IL-4 and IL-13 pathways, as well as to discover new immunotherapies targeting allergy, autoimmune diseases, and cancer. Looking ahead, emerging bioengineering tools promise to continue advancing fundamental understanding of IL-4/IL-13 biology and enabling researchers to exploit these insights to develop effective interventions.
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Affiliation(s)
- Zachary J Bernstein
- Translational Tissue Engineering Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Anjali Shenoy
- Translational Tissue Engineering Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Amy Chen
- Department of Molecular and Cellular Biology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Nicola M Heller
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA
- Division of Allergy and Clinical Immunology, Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA
- Department of Molecular Microbiology and Immunology, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Jamie B Spangler
- Translational Tissue Engineering Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Molecular Microbiology and Immunology, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Chemical & Biomolecular Engineering, Johns Hopkins University, Baltimore, Maryland, USA
- Bloomberg Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University, Baltimore, Maryland, USA
- Department of Oncology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Sidney Kimmel Cancer Center, The Johns Hopkins University, Baltimore, Maryland, USA
- Department of Ophthalmology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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Conner KP, Pastuskovas CV, Soto M, Thomas VA, Wagner M, Rock DA. Preclinical characterization of the ADME properties of a surrogate anti-IL-36R monoclonal antibody antagonist in mouse serum and tissues. MAbs 2021; 12:1746520. [PMID: 32310023 PMCID: PMC7188401 DOI: 10.1080/19420862.2020.1746520] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
The decision to pursue a monoclonal antibody (mAb) as a therapeutic for disease intervention requires the assessment of many factors, such as target-biology, including the total target burden and its accessibility at the intended site of action, as well as mAb-specific properties like binding affinity and the pharmacokinetics in serum and tissue. Interleukin-36 receptor (IL-36 R) is a member of the IL-1 family cytokine receptors and an attractive target to treat numerous epithelial-mediated inflammatory conditions, including psoriatic and rheumatoid arthritis, asthma, and chronic obstructive pulmonary disease. However, information concerning the expression profile of IL-36 R at the protein level is minimal, so the feasibility of developing a therapeutic mAb against this target is uncertain. Here, we present a characterization of the properties associated with absorption, distribution, metabolism, and excretion of a high-affinity IL-36 R-targeted surrogate rat (IgG2a) mAb antagonist in preclinical mouse models. The presence of IL-36 R in the periphery was confirmed unequivocally as the driver of non-linear pharmacokinetics in blood/serum, although a predominant site of tissue accumulation was not observed based upon the kinetics of radiotracer. Additionally, the contribution of IL-36 R-mediated catabolism of mAb in kidney was tested in a 5/6 nephrectomized mouse model where minimal effects on serum pharmacokinetics were observed, although analysis of functional mAb in urine suggests that target can influence the amount of mAb excreted. Our data highlight an interesting case of target-mediated drug disposition (TMDD) where low, yet broadly expressed levels of membrane-bound target result in a cumulative effect to drive TMDD behavior typical of a large, saturable target sink. The potential differences between our mouse model and IL-36 R target profile in humans are also presented.
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Affiliation(s)
- Kip P Conner
- Department Pharmacokinetics and Drug Metabolism, Amgen, South San Francisco, CA, USA
| | - Cinthia V Pastuskovas
- Department Pharmacokinetics and Drug Metabolism, Amgen, South San Francisco, CA, USA
| | - Marcus Soto
- Department Pharmacokinetics and Drug Metabolism, Amgen, Thousand Oaks, CA, USA
| | - Veena A Thomas
- Department Pharmacokinetics and Drug Metabolism, Amgen, South San Francisco, CA, USA
| | - Mylo Wagner
- Department Pharmacokinetics and Drug Metabolism, Amgen, Thousand Oaks, CA, USA
| | - Dan A Rock
- Department Pharmacokinetics and Drug Metabolism, Amgen, South San Francisco, CA, USA
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3
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Ahmed S, Handa A. Diagnostic value of bronchoprovocation challenge with adenosine monophosphate versus exercise testing in early diagnosis of asthma. Med J Armed Forces India 2020; 77:46-50. [PMID: 33487865 DOI: 10.1016/j.mjafi.2019.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 12/05/2019] [Indexed: 11/18/2022] Open
Abstract
Background Airway hyperresponsiveness (AHR) is a characteristic feature of bronchial asthma and is diagnosed using direct and indirect bronchoprovocation tests. The diagnosis of AHR is a challenge in symptomatic patients with a normal baseline prebronchodilator spirometry and postbronchodilator spirometry. Exercise-induced asthma or exercise-induced bronchoconstriction (EIB) is a distinct form of AHR. There is no single test that is sufficient to exclude AHR in symptomatic military personnel with normal spirometry. This study was conducted to compare the diagnostic value of indirect bronchoprovocation test using inhaled adenosine monophosphate (AMP) and exercise challenge test (ECT) in the diagnosis of EIB. Methods A crossover study was conducted with consecutive sampling of patients presenting with symptoms suggestive of asthma and with normal spirometry results who were subjected to both ECT and bronchoprovocation test using inhaled AMP on separate days. Results Forty participants were recruited (the mean age: 25 yrs, 100% male). The commonest presentation was breathlessness on exercise (55%). With exercise alone, 40% tested positive for AHR, while with AMP alone, the positivity increased to 53%, and the difference was statistically significant (p= 0.03). Exercise alone failed to detect 8 cases that tested positive for AHR by inhaled AMP challenge. Conclusion Indirect bronchoprovocation test using inhaled AMP may be used to diagnose AHR in conditions in which exercise challenge testing is not available or the patient is unable to complete ECT.
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Affiliation(s)
- Safia Ahmed
- Associate Professor (Medicine & Pumonology), Command Hospital (Air Force), Bengaluru, India
| | - Ajay Handa
- Professor and Consultant (Medicine &Pulmonology), Command Hospital (Air Force), Bengaluru, India
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García-Menaya JM, Cordobés-Durán C, García-Martín E, Agúndez JAG. Pharmacogenetic Factors Affecting Asthma Treatment Response. Potential Implications for Drug Therapy. Front Pharmacol 2019; 10:520. [PMID: 31178722 PMCID: PMC6537658 DOI: 10.3389/fphar.2019.00520] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2018] [Accepted: 04/25/2019] [Indexed: 12/27/2022] Open
Abstract
Asthma is a frequent disease, mainly characterized by airway inflammation, in which drug therapy is crucial in its management. The potential of pharmacogenomics testing in asthma therapy has been, to date, little explored. In this review, we discuss pharmacogenetic factors affecting asthma treatment, both related to drugs used as controller medications for regular maintenance, such as inhaled corticosteroids, anti-leukotriene agents, long-acting beta-agonists, and the new biologic agents used to treat severe persistent asthma. In addition, we discuss current pharmacogenomics knowledge for rescue medications provided to all patients for as-needed relief, such as short-acting beta-agonists. Evidence for genetic variations as a factor related to drugs response has been provided for the following genes and groups of drugs: Inhaled corticosteroids: FCER2; anti-leukotriene agents: ABCC1, and LTC4S; beta-agonists: ADRB2. However, the following genes require further studies confirming or rejecting association with the response to asthma therapy: ADCY9, ALOX5, ARG1, ARG2, CRHR1, CRHR2, CYP3A4, CYP3A5, CYSLTR1, CYSLTR2, GLCCI1, IL4RA, LTA4H, ORMDL3, SLCO2B1, SPATS2L, STIP1, T, TBX21, THRA, THRB, and VEGFA. Although only a minority of these genes are, at present, listed as associated with drugs used in asthma therapy, in the Clinical Pharmacogenomics Implementation Consortium gene-drug pair list, this review reveals that sufficient evidence to start testing the potential of clinical pharmacogenomics in asthma therapy already exists. This evidence supports the inclusion in pilot pharmacogenetics tests of at least four genes. Hopefully these tests, if proven useful, will increase the efficiency and the safety of asthma therapy.
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Affiliation(s)
| | | | - Elena García-Martín
- ARADyAL Instituto de Salud Carlos III, University Institute of Molecular Pathology Biomarkers, Universidad de Extremadura, Cáceres, Spain
| | - José A G Agúndez
- ARADyAL Instituto de Salud Carlos III, University Institute of Molecular Pathology Biomarkers, Universidad de Extremadura, Cáceres, Spain
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5
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Immune monitoring for precision medicine in allergy and asthma. Curr Opin Immunol 2017; 48:82-91. [PMID: 28889067 DOI: 10.1016/j.coi.2017.08.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Revised: 08/01/2017] [Accepted: 08/16/2017] [Indexed: 11/22/2022]
Abstract
'Precision Medicine' embodies the analyses of extensive data collected from patients and their environments to identify and apply patient-specific prophylactic strategies and medical treatments to improve clinical outcomes and healthcare cost-effectiveness. Many new methods have been developed for evaluating the activity of the human immune system. Such 'immune monitoring' approaches are now being used in studies of allergy and asthma in the hope of identifying better correlates of disease status, predictors of therapeutic outcomes, and potential side-effects of treatment. Together with analyses of family histories, genetic and other biometric data, and measurements of exposures to environmental and other risk factors for developing or exacerbating disease, immune monitoring approaches promise to enable 'Precision Medicine' for allergic diseases and asthma.
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6
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Becerra-Díaz M, Wills-Karp M, Heller NM. New perspectives on the regulation of type II inflammation in asthma. F1000Res 2017; 6:1014. [PMID: 28721208 PMCID: PMC5497827 DOI: 10.12688/f1000research.11198.1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/16/2017] [Indexed: 12/12/2022] Open
Abstract
Asthma is a chronic inflammatory disease of the lungs which has been thought to arise as a result of inappropriately directed T helper type-2 (Th2) immune responses of the lungs to otherwise innocuous inhaled antigens. Current asthma therapeutics are directed towards the amelioration of downstream consequences of type-2 immune responses (i.e. β-agonists) or broad-spectrum immunosuppression (i.e. corticosteroids). However, few approaches to date have been focused on the primary prevention of immune deviation. Advances in molecular phenotyping reveal heterogeneity within the asthmatic population with multiple endotypes whose varying expression depends on the interplay between numerous environmental factors and the inheritance of a broad range of susceptibility genes. The most common endotype is one described as “type-2-high” (i.e. high levels of interleukin [IL]-13, eosinophilia, and periostin). The identification of multiple endotypes has provided a potential explanation for the observations that therapies directed at typical Th2 cytokines (IL-4, IL-5, and IL-13) and their receptors have often fallen short when they were tested in a diverse group of asthmatic patients without first stratifying based on disease endotype or severity. However, despite the incorporation of endotype-dependent stratification schemes into clinical trial designs, variation in drug responses are still apparent, suggesting that additional genetic/environmental factors may be contributing to the diversity in drug efficacy. Herein, we will review recent advances in our understanding of the complex pathways involved in the initiation and regulation of type-2-mediated immune responses and their modulation by host factors (genetics, metabolic status, and the microbiome). Particular consideration will be given to how this knowledge could pave the way for further refinement of disease endotypes and/or the development of novel therapeutic strategies for the treatment of asthma
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Affiliation(s)
- Mireya Becerra-Díaz
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, 21205, USA
| | - Marsha Wills-Karp
- Department of Environmental Health and Engineering, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, 21205, USA
| | - Nicola M Heller
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, 21205, USA
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7
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Galli SJ. Toward precision medicine and health: Opportunities and challenges in allergic diseases. J Allergy Clin Immunol 2017; 137:1289-300. [PMID: 27155026 DOI: 10.1016/j.jaci.2016.03.006] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 03/14/2016] [Accepted: 03/14/2016] [Indexed: 10/21/2022]
Abstract
Precision medicine (also called personalized, stratified, or P4 medicine) can be defined as the tailoring of preventive measures and medical treatments to the characteristics of each patient to obtain the best clinical outcome for each person while ideally also enhancing the cost-effectiveness of such interventions for patients and society. Clearly, the best clinical outcome for allergic diseases is not to get them in the first place. To emphasize the importance of disease prevention, a critical component of precision medicine can be referred to as precision health, which is defined herein as the use of all available information pertaining to specific subjects (including family history, individual genetic and other biometric information, and exposures to risk factors for developing or exacerbating disease), as well as features of their environments, to sustain and enhance health and prevent the development of disease. In this article I will provide a personal perspective on how the precision health-precision medicine approach can be applied to the related goals of preventing the development of allergic disorders and providing the most effective diagnosis, disease monitoring, and care for those with these prevalent diseases. I will also mention some of the existing and potential challenges to achieving these ambitious goals.
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Affiliation(s)
- Stephen Joseph Galli
- Department of Pathology, Stanford, Calif; Department of Microbiology & Immunology, Stanford, Calif; Sean N. Parker Center for Allergy and Asthma Research, Stanford, Calif; Stanford Center for Genomics and Personalized Medicine, Stanford, Calif.
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8
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Robinson MJ, Prout M, Mearns H, Kyle R, Camberis M, Forbes-Blom EE, Paul WE, Allen CDC, Le Gros G. IL-4 Haploinsufficiency Specifically Impairs IgE Responses against Allergens in Mice. THE JOURNAL OF IMMUNOLOGY 2017; 198:1815-1822. [PMID: 28115531 DOI: 10.4049/jimmunol.1601434] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Accepted: 12/28/2016] [Indexed: 01/26/2023]
Abstract
Polymorphisms in genes involved in IL-4 responses segregate with allergic disease risk and correlate with IgE levels in humans, and IL-4 promotes IgE and IgG1 Ab production against allergens in mice. We report that mice with only one intact Il4 gene copy are significantly impaired in their ability to make specific IgE responses against allergens, whereas IgG1 responses to allergens remain unaffected. Il4-hemizygosity also resulted in a modest but detectable drop in IL-4 production by CD4+ T cells isolated from lymph nodes and prevented IgE-dependent oral allergen-induced diarrhea. We conclude that a state of haploinsufficiency for the Il4 gene locus is specifically relevant for IL-4-dependent IgE responses to allergens with the amount of IL-4 produced in the hemizygous condition falling close to the threshold required for switching to IgE production. These results may be relevant for how polymorphisms in genes affecting IL-4 responses influence the risk of IgE-mediated allergic disease in humans.
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Affiliation(s)
- Marcus J Robinson
- Malaghan Institute of Medical Research, Wellington 6242, New Zealand.,Cardiovascular Research Institute, University of California, San Francisco, San Francisco, CA 94143.,Sandler Asthma Basic Research Center, University of California, San Francisco, San Francisco, CA 94143
| | - Melanie Prout
- Malaghan Institute of Medical Research, Wellington 6242, New Zealand
| | - Helen Mearns
- Malaghan Institute of Medical Research, Wellington 6242, New Zealand
| | - Ryan Kyle
- Malaghan Institute of Medical Research, Wellington 6242, New Zealand
| | - Mali Camberis
- Malaghan Institute of Medical Research, Wellington 6242, New Zealand
| | | | - William E Paul
- Laboratories of Immunology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD 20892; and
| | - Christopher D C Allen
- Cardiovascular Research Institute, University of California, San Francisco, San Francisco, CA 94143.,Sandler Asthma Basic Research Center, University of California, San Francisco, San Francisco, CA 94143.,Department of Anatomy, University of California, San Francisco, San Francisco, CA 94143
| | - Graham Le Gros
- Malaghan Institute of Medical Research, Wellington 6242, New Zealand;
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De Ferrari L, Chiappori A, Bagnasco D, Riccio AM, Passalacqua G, Canonica GW. Molecular phenotyping and biomarker development: are we on our way towards targeted therapy for severe asthma? Expert Rev Respir Med 2015; 10:29-38. [PMID: 26566089 DOI: 10.1586/17476348.2016.1111763] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Although different phenotypes of severe asthma can be identified, all are characterized by common symptoms. Due to their heterogeneity, they exhibit differences in pathogenesis, etiology and clinical responses to therapeutic approaches. The identification of distinct molecular phenotypes to define severe asthmatic patients will allow us to better understand the pathophysiology of the disease and thus to more precisely target the treatment for each patient. To achieve this goal, a systematic search for new, reliable and stable biomarkers specific for each phenotype is essential. This review focuses on the current known molecular phenotypes of severe asthma and highlights the need for biomarkers that could (either alone or in combination) be predictive of the treatment outcome.
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Affiliation(s)
- Laura De Ferrari
- a Allergy and Respiratory Diseases, IRCCS San Martino-IST , University of Genoa , Genoa , Italy
| | - Alessandra Chiappori
- a Allergy and Respiratory Diseases, IRCCS San Martino-IST , University of Genoa , Genoa , Italy
| | - Diego Bagnasco
- a Allergy and Respiratory Diseases, IRCCS San Martino-IST , University of Genoa , Genoa , Italy
| | - Anna Maria Riccio
- a Allergy and Respiratory Diseases, IRCCS San Martino-IST , University of Genoa , Genoa , Italy
| | - Giovanni Passalacqua
- a Allergy and Respiratory Diseases, IRCCS San Martino-IST , University of Genoa , Genoa , Italy
| | - Giorgio Walter Canonica
- a Allergy and Respiratory Diseases, IRCCS San Martino-IST , University of Genoa , Genoa , Italy
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10
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Anti-interleukin 4 and 13 for asthma treatment in the era of endotypes. Curr Opin Allergy Clin Immunol 2015; 14:570-5. [PMID: 25159182 DOI: 10.1097/aci.0000000000000108] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE OF REVIEW To summarize recent advances in IL-4 and IL-13 blockade in the treatment of asthma. RECENT FINDINGS Historically, anticytokine therapies have historically been unsuccessful in the treatment of asthma because of the heterogeneity of its pathogenesis. Recent advances in our understanding of asthma pathophysiology and our increased ability to phenotype patients have led to the identification of asthmatic subsets (endotypes) that are most likely to respond to anticytokine therapy. Several new biologic therapies targeting IL-13 or both IL-4 and IL-13 signaling are currently in clinical trials and both types of therapies have demonstrated therapeutic benefit. SUMMARY Anti-IL-4/13 therapies, guided by knowledge of an individual's underlying pathophysiology, are a promising class of therapies for treatment of asthma.
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11
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IL-4 and IL-13 signaling in allergic airway disease. Cytokine 2015; 75:68-78. [PMID: 26070934 DOI: 10.1016/j.cyto.2015.05.014] [Citation(s) in RCA: 309] [Impact Index Per Article: 34.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Accepted: 05/15/2015] [Indexed: 12/12/2022]
Abstract
Aberrant production of the prototypical type 2 cytokines, interleukin (IL)-4 and IL-13 has long been associated with the pathogenesis of allergic disorders. Despite tremendous scientific inquiry, the similarities in their structure, and receptor usage have made it difficult to ascertain the distinct role that these two look-alike cytokines play in the onset and perpetuation of allergic inflammation. However, recent discoveries of differences in receptor distribution, utilization/assembly and affinity between IL-4 and IL-13, along with the discovery of unique innate lymphoid 2 cells (ILC2) which preferentially produce IL-13, not IL-4, are beginning to shed light on these mysteries. The purpose of this chapter is to review our current understanding of the distinct roles that IL-4 and IL-13 play in allergic inflammatory states and the utility of their modulation as potential therapeutic strategies for the treatment of allergic disorders.
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12
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Asthma phenotypes and the use of biologic medications in asthma and allergic disease: the next steps toward personalized care. J Allergy Clin Immunol 2015; 135:299-310; quiz 311. [PMID: 25662302 DOI: 10.1016/j.jaci.2014.12.1871] [Citation(s) in RCA: 263] [Impact Index Per Article: 29.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Revised: 12/10/2014] [Accepted: 12/11/2014] [Indexed: 11/21/2022]
Abstract
Traditionally, asthma and allergic diseases have been defined by broad definitions and treated with nonspecific medications, including corticosteroids and bronchodilators. There is an increasing appreciation of heterogeneity within asthma and allergic diseases based primarily on recent cluster analyses, molecular phenotyping, biomarkers, and differential responses to targeted and nontargeted therapies. These pioneering studies have led to successful therapeutic trials of molecularly targeted therapies in defined phenotypes. This review analyzed randomized double-blind, placebo-controlled trials of molecularly targeted therapies in defined allergic disease and asthma phenotypes. IgE was the first successful biological target used in patients with allergic disease and asthma. This review shows that therapies targeting the canonical type 2 cytokines IL-4, IL-5, and IL-13 have shown consistent efficacy, especially in asthmatic patients with evidence of TH2/type 2 inflammation ("type 2 high"). As of yet, there are no successful trials of targeted therapies in asthmatic patients without evidence for type 2 inflammation. We conclude that further refinement of type 2 therapies to specific type 2 phenotypes and novel approaches for patients without type 2 inflammation are needed for asthma and allergic disease treatment.
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13
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Thomsen SF. Genetics of asthma: an introduction for the clinician. Eur Clin Respir J 2015; 2:24643. [PMID: 26557257 PMCID: PMC4629762 DOI: 10.3402/ecrj.v2.24643] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2014] [Revised: 10/14/2014] [Accepted: 12/04/2014] [Indexed: 12/21/2022] Open
Abstract
Asthma runs in families, and children of asthmatic parents are at increased risk of asthma. Prediction of disease risk is pivotal for the clinician when counselling atopic families. However, this is not always an easy task bearing in mind the vast and ever-increasing knowledge about asthma genetics. The advent of new genotyping technologies has made it possible to sequence in great detail the human genome for asthma-associated variants, and accordingly, recent decades have witnessed an explosion in the number of rare and common variants associated with disease risk. This review presents an overview of methods and advances in asthma genetics in an attempt to help the clinician keep track of the most important knowledge in the field.
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Affiliation(s)
- Simon F Thomsen
- Department of Dermatology, Bispebjerg Hospital, Copenhagen NV, Denmark
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14
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Radonjic-Hoesli S, Valent P, Klion AD, Wechsler ME, Simon HU. Novel targeted therapies for eosinophil-associated diseases and allergy. Annu Rev Pharmacol Toxicol 2014; 55:633-56. [PMID: 25340931 DOI: 10.1146/annurev-pharmtox-010814-124407] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Eosinophil-associated diseases often present with life-threatening manifestations and/or chronic organ damage. Currently available therapeutic options are limited to a few drugs that often have to be prescribed on a lifelong basis to keep eosinophil counts under control. In the past 10 years, treatment options and outcomes in patients with clonal eosinophilic and other eosinophilic disorders have improved substantially. Several new targeted therapies have emerged, addressing different aspects of eosinophil expansion and inflammation. In this review, we discuss available and currently tested agents as well as new strategies and drug targets relevant to both primary and secondary eosinophilic diseases, including allergic disorders.
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Scheerens H, Arron JR, Zheng Y, Putnam WS, Erickson RW, Choy DF, Harris JM, Lee J, Jarjour NN, Matthews JG. The effects of lebrikizumab in patients with mild asthma following whole lung allergen challenge. Clin Exp Allergy 2014; 44:38-46. [PMID: 24131304 PMCID: PMC4204278 DOI: 10.1111/cea.12220] [Citation(s) in RCA: 95] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2012] [Revised: 10/07/2013] [Accepted: 10/10/2013] [Indexed: 12/03/2022]
Abstract
Background Interleukin 13 (IL13) is a T-helper type 2 (Th2) cytokine associated with inflammation and pathology in allergic diseases such as bronchial asthma. We have shown that treatment with lebrikizumab, an anti-IL13 monoclonal antibody, significantly improves prebronchodilator forced expiratory volume in 1 s (FEV1) in a subset of subjects with uncontrolled asthma. Objective To evaluate efficacy and safety of lebrikizumab in subjects with mild asthma who underwent bronchial allergen challenge. Methods Twenty-nine subjects were randomized 1: 1–5 mg/kg lebrikizumab (n = 13) or placebo (n = 16) administered subcutaneously every 4 weeks over 12 weeks, a total of four doses. Primary efficacy outcome was late asthmatic response (LAR) at Week 13, defined as area under the curve of FEV1 measured 2–8 h following inhaled allergen challenge. Serum biomarkers were measured to verify IL13 pathway inhibition and identify patients with an increased response to lebrikizumab. Results At Week 13, the LAR in lebrikizumab subjects was reduced by 48% compared with placebo subjects, although this was not statistically significant (95% confidence interval, −19%, 90%). Exploratory analysis indicated that lebrikizumab-treated subjects with elevated baseline levels of peripheral blood eosinophils, serum IgE, or periostin exhibited a greater reduction in LAR compared with subjects with lower baseline levels of these biomarkers. Lebrikizumab exerted systemic effects on markers of Th2 inflammation, reducing serum immunoglobulin E (IgE), chemokine ligands 13 and 17 by approximately 25% (P < 0.01). Lebrikizumab was well tolerated. Conclusion and Clinical Relevance Lebrikizumab reduced the LAR in subjects with mild asthma. Clinical trial number NCT00781443.
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Pharmacogenetics and the development of personalized approaches for combination therapy in asthma. Curr Allergy Asthma Rep 2014; 13:443-52. [PMID: 23912588 DOI: 10.1007/s11882-013-0372-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Asthma is a common, chronic disease of the airways that is treated with a combination of different therapies. The combination of LABA and ICS therapy results in a synergistic interaction that is efficacious in improving asthma symptom control; however, genetic variation has the potential to alter therapeutic efficacy. Both agents mediate complex molecular pathways consisting of gene variation that has been investigated with the analysis of candidate genes in the β2-adrenergic receptor and glucocorticoid pathway. These pharmacogenetic studies have been limited to retrospective analyses of clinical trial cohorts and a small number of prospective, genotype-stratified trials. More recently, genome-wide association studies in combination with replication in additional cohorts and in vitro cell-based models have been used to identify novel pathway-related pharmacogenetic variations. This review of the pharmacogenetics of the β2-adrenergic receptor and glucocorticoid pathways highlights the genotypic effects of variation in multiple genes from interacting pathways which may contribute to differential responses to inhaled beta agonists and glucocorticoids. As our understanding of these genetic mechanisms improves, panels of biomarkers may be developed to determine which combination therapies are the most effective with the least risk to an individual asthma patient. Before we can usher in an era of personalized medicine for asthma, it is first important to improve our ability to analyze large volumes of genetic data in large clinical trial cohorts using a combination of study designs, analytical methods, and in vitro functional studies.
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Romeo MJ, Agrawal R, Pomés A, Woodfolk JA. A molecular perspective on TH2-promoting cytokine receptors in patients with allergic disease. J Allergy Clin Immunol 2013; 133:952-60. [PMID: 24084078 DOI: 10.1016/j.jaci.2013.08.006] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2013] [Revised: 08/12/2013] [Accepted: 08/13/2013] [Indexed: 12/17/2022]
Abstract
The cytokines IL-4, IL-13, and thymic stromal lymphopoietin play a key role in allergic disease by virtue of their ability to initiate, maintain, and augment TH2 responses. These molecules mediate their effects through type 1 cytokine receptors, which bind cytokines with a characteristic structure. Receptors are expressed on a broad array of immune cell types and are integral to complex cytokine networks operating in health and disease. TH2-promoting cytokines bind different configurations of receptors. Receptor subunits can exist in surface-bound or soluble forms, as well as in isolation or in partnership with other subunits. Sharing of receptor subunits among different cytokine receptor complexes adds to the intricate landscape. This article describes the characteristics of receptors for IL-4, IL-13, and thymic stromal lymphopoietin and their respective ligands from a structure-function perspective. We detail the mechanisms of receptor complex assembly, the interrelated nature of these receptors, and the effect on allergic inflammation. The ability for novel and atypical types of receptors to modulate inflammatory processes is also discussed. We highlight current and emerging treatments that target TH2-promoting receptor complexes. Understanding the molecular features of these receptors provides insight into different disease phenotypes and the variable clinical outcomes arising from targeted therapies. These considerations can be used to inform future directions for research and creative strategies for treating individual patients.
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Affiliation(s)
- Martin J Romeo
- Asthma and Allergic Diseases Center, University of Virginia, Charlottesville, Va
| | - Rachana Agrawal
- Asthma and Allergic Diseases Center, University of Virginia, Charlottesville, Va
| | - Anna Pomés
- Indoor Biotechnologies Inc, Charlottesville, Va
| | - Judith A Woodfolk
- Asthma and Allergic Diseases Center, University of Virginia, Charlottesville, Va.
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Tapia LI, Ampuero S, Palomino MA, Luchsinger V, Aguilar N, Ayarza E, Mamani R, Larrañaga C. Respiratory syncytial virus infection and recurrent wheezing in Chilean infants: a genetic background? INFECTION GENETICS AND EVOLUTION 2013; 16:54-61. [PMID: 23333336 DOI: 10.1016/j.meegid.2012.12.030] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2012] [Revised: 12/17/2012] [Accepted: 12/26/2012] [Indexed: 11/18/2022]
Abstract
UNLABELLED Respiratory syncytial virus (RSV) infection has been associated to recurrent wheezing, but pathogenic mechanisms are unclear. Interleukin-4/Interleukin-13 (IL-4/IL-13) pathway is involved in both conditions. A common host genetic susceptibility may exist in patients whom RSV will trigger severe illness and those who develop recurrent wheezing. OBJECTIVE To assess, by a candidate-gene approach, whether genetic polymorphisms in IL-4/IL-13 pathway are associated with RSV infection severity and its outcome in Chilean children. A cohort of 118 RSV-infected infants was analyzed and followed for one year. Severity of acute infection and later recurrent wheezing were characterized. Alleles and genotypes frequencies were determined for two SNP in each of the genes IL-4, IL-13 and IL-4Rα. Association tests and interaction analyses were performed. Enrollment included 60 moderate and 58 severe cases. Two SNP were found associated to severity during acute infection in IL-4Rα gene (Gln551Arg, Ile50Val). The follow up was completed in 71% of patients (84/118). Later recurrent wheezing was 54% in severe group, versus 31% in moderate cases (p=0.035). In relation to outcome, allele Ile50 in IL-4Rα was more frequent in patients with moderate disease and no wheezing outcome. A common protector genotype is proposed for Chilean children: IL-4Rα Ile/Ile. CONCLUSION Genetic variations in the host are associated to infection severity and outcome. A common genetic background might be influencing both pathologies.
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Affiliation(s)
- Lorena I Tapia
- Programa de Virología, Instituto de Ciencias Biomédicas, Facultad de Medicina, Universidad de Chile, Chile.
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Arron JR, Scheerens H, Matthews JG. Redefining approaches to asthma: developing targeted biologic therapies. ADVANCES IN PHARMACOLOGY (SAN DIEGO, CALIF.) 2013; 66:1-49. [PMID: 23433454 DOI: 10.1016/b978-0-12-404717-4.00001-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Asthma is a chronic respiratory disorder canonically associated with type 2 airway inflammation as characterized by elevated levels of eosinophils, immunoglobulin E, and cytokines including interleukin (IL) 4, IL5, IL9, and IL13 and tumor necrosis factor (TNF) α. However, mounting evidence has shown that considerable heterogeneity exists in human asthma in terms of the nature and intensity of airway inflammation. While many asthma patients achieve acceptable control of symptoms with standard-of-care therapies such as β₂-adrenergic agonists and inhaled corticosteroids, a minority remains symptomatic despite maximal standard-of-care therapy and constitutes a significant unmet medical need. A growing number of investigational therapeutics under clinical development for asthma are biologic therapies that specifically target mediators of type 2 airway inflammation. In this chapter, we consider the biological functions of therapeutic targets in asthma and data from clinical trials of biologic agents directed against these targets. We discuss recent clinical trial results in terms of four key components of drug development: target selection, molecule selection, outcome selection, and patient selection, with particular attention paid to the emerging role of biomarkers in clinical development for asthma.
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Ingram JL, Kraft M. IL-13 in asthma and allergic disease: asthma phenotypes and targeted therapies. J Allergy Clin Immunol 2012; 130:829-42; quiz 843-4. [PMID: 22951057 DOI: 10.1016/j.jaci.2012.06.034] [Citation(s) in RCA: 195] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2012] [Revised: 06/25/2012] [Accepted: 06/29/2012] [Indexed: 02/07/2023]
Abstract
Decades of research in animal models have provided abundant evidence to show that IL-13 is a key T(H)2 cytokine that directs many of the important features of airway inflammation and remodeling in patients with allergic asthma. Several promising focused therapies for asthma that target the IL-13/IL-4/signal transducer and activator of transcription 6 pathway are in development, including anti-IL-13 mAbs and IL-4 receptor antagonists. The efficacy of these new potential asthma therapies depends on the responsiveness of patients. However, an understanding of how IL-13-directed therapies might benefit asthmatic patients is confounded by the complex heterogeneity of the disease. Recent efforts to classify subphenotypes of asthma have focused on sputum cellular inflammation profiles, as well as cluster analyses of clinical variables and molecular and genetic signatures. Researchers and clinicians can now evaluate biomarkers of T(H)2-driven airway inflammation in asthmatic patients, such as serum IgE levels, sputum eosinophil counts, fraction of exhaled nitric oxide levels, and serum periostin levels, to aid decision making in clinical trials and drug development and to identify subsets of patients who might benefit from therapies. Although it is unlikely that these therapies will benefit all asthmatic patients with this heterogeneous disease, advances in understanding asthma subphenotypes in relation to clinical variables and T(H)2 cytokine responses offer the opportunity to improve the efficacy and safety of proposed therapies for asthma.
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Affiliation(s)
- Jennifer L Ingram
- Division of Pulmonary, Allergy and Critical Care Medicine, Duke University Medical Center, Durham, NC 27710, USA.
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Portelli M, Sayers I. Genetic basis for personalized medicine in asthma. Expert Rev Respir Med 2012; 6:223-36. [PMID: 22455494 DOI: 10.1586/ers.12.9] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
There is heterogeneity in patient responses to current asthma medications. Significant progress has been made identifying genetic polymorphisms that influence the efficacy and potential for adverse effects to asthma drugs, including; β(2)-adrenergic receptor agonists, corticosteroids and leukotriene modifiers. Pharmacogenetics holds great promise to maximise clinical outcomes and minimize adverse effects. Asthma is heterogeneous with respect to clinical presentation and inflammatory mechanisms underlying the disease, which is likely to contribute to variable results in clinical trials targeting specific inflammatory mediators. Genome-wide association studies have begun to identify genes underlying asthma (e.g., IL1RL1), which represent future therapeutic targets. In this article, we review and update the pharmacogenetics of current asthma therapies and discuss the genetics underlying selected Phase II and future targets.
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Affiliation(s)
- Michael Portelli
- Division of Therapeutics and Molecular Medicine, Nottingham Respiratory Biomedical Research Unit, University of Nottingham, Nottingham, UK
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Grünig G, Corry DB, Reibman J, Wills-Karp M. Interleukin 13 and the evolution of asthma therapy. AMERICAN JOURNAL OF CLINICAL AND EXPERIMENTAL IMMUNOLOGY 2012; 1:20-27. [PMID: 23607082 PMCID: PMC3630076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Received: 01/23/2012] [Accepted: 03/05/2012] [Indexed: 06/02/2023]
Abstract
This is a concise review on Interleukin (IL)-13 and the evolution of asthma therapy, from discovery of the molecule, the identification of its pathogenic role in animal models of asthma, to the development of clinically successful neutralizing agents. The translational path from basic research to clinical application was not sequential as expected but random with respect to the tools (molecular & cell biology, animal models, human studies) used and to the application of academic versus industry research. The experiences with the development of neutralizing anti-IL-13 reagents emphasize the need for inclusion of a biomarker assay in the clinical trials that both identifies individuals that actually have aberrant expression of the pathway of interest and allows determining whether the target of interest is neutralized.
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Affiliation(s)
- Gabriele Grünig
- Departments of Environmental Medicine and Medicine, NYU Langone Medical Center, Tuxedo, NY 10987
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Abstract
INTRODUCTION Current drug treatments for asthma relieve bronchospasm and airway inflammation but do not offer a cure, and symptoms return when treatment is stopped. Asthma management guidelines emphasize the importance of effective asthma treatment to achieve and maintain asthma control. However, despite widely available and effective treatments, achieving asthma control is still an unmet need for many patients. AREAS COVERED Remarkable efforts have been made to identify the characteristic features of difficult-to-control (usually severe) asthma that are different from those described for mild-to-moderate asthma, setting the stage for the development of new and even individualized therapies. The most fascinating options of the new asthma treatments are biologic therapies, in particular monoclonal antibodies. In addition, some novel once-daily combinations of long-acting β(2)-agonist and inhaled corticosteroids are under development. EXPERT OPINION Asthma is a complex syndrome made up of a number of disease variants or asthma phenotypes, with different underlying pathophysiology. As different drugs target different pathways, it is necessary to determine the individual profile of pathophysiological abnormalities for each patient. Several cytokines have been implicated in the inflammatory cascades leading to the different asthma phenotypes, and the most relevant ones are discussed. The challenge in treating asthma resides precisely in its heterogeneity.
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Affiliation(s)
- Santiago Quirce
- Department of Allergy, Hospital La Paz Institute for Health Research (IdiPAZ), Madrid, Spain.
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Abstract
Although asthma has been considered as a single disease for years, recent studies have increasingly focused on its heterogeneity. The characterization of this heterogeneity has promoted the concept that asthma consists of multiple phenotypes or consistent groupings of characteristics. Asthma phenotypes were initially focused on combinations of clinical characteristics, but they are now evolving to link biology to phenotype, often through a statistically based process. Ongoing studies of large-scale, molecularly and genetically focused and extensively clinically characterized cohorts of asthma should enhance our ability to molecularly understand these phenotypes and lead to more targeted and personalized approaches to asthma therapy.
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Holgate ST. Trials and tribulations in identifying new biologic treatments for asthma. Trends Immunol 2012; 33:238-46. [PMID: 22436378 DOI: 10.1016/j.it.2012.02.003] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2011] [Revised: 01/29/2012] [Accepted: 02/13/2012] [Indexed: 12/14/2022]
Abstract
Drugs used to treat asthma have a long history, beginning with the bronchodilators and evolving into compounds that suppress airway inflammation. Guidelines for treatment of asthma are largely based on disease severity and control, rather than underlying mechanisms. However, identification of biomarkers in the causal pathways of asthma is enabling responders to be differentiated from nonresponders. Initial efforts have focused on biomarkers of the T helper (Th)2 pathway because this is a target of novel therapeutics. A concerted effort is now needed to substratify asthma beyond Th2 pathways, and using appropriate biomarkers, to target only those patients likely to respond to a specific biologic. To achieve this goal, a different type of relationship is needed between academia and industry, and also within industry, to promote collaboration in the precompetitive space.
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Affiliation(s)
- Stephen T Holgate
- Inflammation, Infection and Immunity Division, Sir Henry Wellcome Laboratories, Mail Point 810, Level F, South Block, Southampton General Hospital, Southampton SO16 6YD, UK.
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Slager RE, Otulana BA, Hawkins GA, Yen YP, Peters SP, Wenzel SE, Meyers DA, Bleecker ER. IL-4 receptor polymorphisms predict reduction in asthma exacerbations during response to an anti-IL-4 receptor α antagonist. J Allergy Clin Immunol 2012; 130:516-22.e4. [PMID: 22541248 DOI: 10.1016/j.jaci.2012.03.030] [Citation(s) in RCA: 118] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2011] [Revised: 03/19/2012] [Accepted: 03/27/2012] [Indexed: 11/26/2022]
Abstract
BACKGROUND This is the first large pharmacogenetic investigation of the inflammatory IL-4/IL-13 pathway in patients with moderate-to-severe asthma. We analyzed genomic DNA from participants in a 12-week placebo-controlled efficacy trial of pitrakinra (1, 3, or 10 mg twice daily), a novel IL-4/IL-13 pathway antagonist (Clinicaltrials.govNCT00801853). OBJECTIVES The primary hypothesis for this analysis is that amino acid changes in the 3' end of the IL-4 receptor α gene (IL4RA) or closely proximal variants would predict reductions in asthma exacerbations for subjects randomized to pitrakinra therapy. METHODS Nineteen IL4RA single nucleotide polymorphisms (SNPs) were tested in 407 non-Hispanic white subjects for association with the primary clinical end point of asthma exacerbations and changes in secondary end points for asthma symptom scores. RESULTS The most consistent pharmacogenetic associations were observed for the correlated tagging SNPs rs8832 and rs1029489 in the IL4RA 3' untranslated and proximal regions, respectively. Subjects homozygous for the rs8832 common G allele randomized to pitrakinra (placebo group nonsignificant) had decreased asthma exacerbations and decreased nocturnal awakenings and activities limited by asthma. There was also a significant pitrakinra dose-response relationship (placebo/1 mg/3 mg/10 mg) for exacerbations in subjects homozygous for the common allele in rs1029489 (P = .005) and rs8832 (P= .009) and the intronic SNPs rs3024585, rs3024622, and rs4787956 (P = .03). CONCLUSION This study demonstrates a significant pharmacogenetic interaction between anti-IL-4 receptor α therapy and IL4RA gene variation, identifying an asthma subgroup that is more responsive to therapy with this antagonist.
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Affiliation(s)
- Rebecca E Slager
- Center for Genomics and Personalized Medicine Research, Wake Forest School of Medicine, Winston-Salem, NC 27157, USA
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Bossley CJ, Fleming L, Gupta A, Regamey N, Frith J, Oates T, Tsartsali L, Lloyd CM, Bush A, Saglani S. Pediatric severe asthma is characterized by eosinophilia and remodeling without T(H)2 cytokines. J Allergy Clin Immunol 2012; 129:974-82.e13. [PMID: 22385633 PMCID: PMC3381727 DOI: 10.1016/j.jaci.2012.01.059] [Citation(s) in RCA: 225] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2011] [Revised: 01/17/2012] [Accepted: 01/23/2012] [Indexed: 11/18/2022]
Abstract
BACKGROUND The pathology of pediatric severe therapy-resistant asthma (STRA) is little understood. OBJECTIVES We hypothesized that STRA in children is characterized by airway eosinophilia and mast cell inflammation and is driven by the T(H)2 cytokines IL-4, IL-5, and IL-13. METHODS Sixty-nine children (mean age, 11.8 years; interquartile range, 5.6-17.3 years; patients with STRA, n = 53; control subjects, n = 16) underwent fiberoptic bronchoscopy, bronchoalveolar lavage (BAL), and endobronchial biopsy. Airway inflammation, remodeling, and BAL fluid and biopsy specimen T(H)2 cytokines were quantified. Children with STRA also underwent symptom assessment (Asthma Control Test), spirometry, exhaled nitric oxide and induced sputum evaluation. RESULTS Children with STRA had significantly increased BAL fluid and biopsy specimen eosinophil counts compared with those found in control subjects (BAL fluid, P < .001; biopsy specimen, P < .01); within the STRA group, there was marked between-patient variability in eosinophilia. Submucosal mast cell, neutrophil, and lymphocyte counts were similar in both groups. Reticular basement membrane thickness and airway smooth muscle were increased in patients with STRA compared with those found in control subjects (P < .0001 and P < .001, respectively). There was no increase in BAL fluid IL-4, IL-5, or IL-13 levels in patients with STRA compared with control subjects, and these cytokines were rarely detected in induced sputum. Biopsy IL-5(+) and IL-13(+) cell counts were also not higher in patients with STRA compared with those seen in control subjects. The subgroup (n = 15) of children with STRA with detectable BAL fluid T(H)2 cytokines had significantly lower lung function than those with undetectable BAL fluid T(H)2 cytokines. CONCLUSIONS STRA in children was characterized by remodeling and variable airway eosinophil counts. However, unlike in adults, there was no neutrophilia, and despite the wide range in eosinophil counts, the T(H)2 mediators that are thought to drive allergic asthma were mostly absent.
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Affiliation(s)
- Cara J. Bossley
- Respiratory Paediatrics, the Royal Brompton and Harefield NHS Trust, Sydney Street, London
- Leukocyte Biology Section, National Heart & Lung Institute, Imperial College London
| | - Louise Fleming
- Respiratory Paediatrics, the Royal Brompton and Harefield NHS Trust, Sydney Street, London
- Leukocyte Biology Section, National Heart & Lung Institute, Imperial College London
| | - Atul Gupta
- Respiratory Paediatrics, the Royal Brompton and Harefield NHS Trust, Sydney Street, London
- Leukocyte Biology Section, National Heart & Lung Institute, Imperial College London
| | - Nicolas Regamey
- Division of Paediatric Respiratory Medicine, Department of Paediatrics, Inselspital and University of Bern
| | - Jennifer Frith
- Respiratory Paediatrics, the Royal Brompton and Harefield NHS Trust, Sydney Street, London
| | - Timothy Oates
- Leukocyte Biology Section, National Heart & Lung Institute, Imperial College London
| | - Lemonia Tsartsali
- Respiratory Paediatrics, the Royal Brompton and Harefield NHS Trust, Sydney Street, London
| | - Clare M. Lloyd
- Leukocyte Biology Section, National Heart & Lung Institute, Imperial College London
| | - Andrew Bush
- Respiratory Paediatrics, the Royal Brompton and Harefield NHS Trust, Sydney Street, London
| | - Sejal Saglani
- Leukocyte Biology Section, National Heart & Lung Institute, Imperial College London
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Pathophysiology of asthma: what has our current understanding taught us about new therapeutic approaches? J Allergy Clin Immunol 2011; 128:495-505. [PMID: 21807404 DOI: 10.1016/j.jaci.2011.06.052] [Citation(s) in RCA: 101] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2011] [Accepted: 06/16/2011] [Indexed: 12/14/2022]
Abstract
Current asthma therapy is based on the use of adrenergic bronchodilator and anti-inflammatory drugs the specificity, efficacy, duration of action, and safety of which have been derived through classical pharmacology and medicinal chemistry. That asthma is a T(H)2-type inflammatory disorder frequently associated with atopy and allergic comorbidities has led to a concentrated effort to find treatments that act selectively on this pathway. A systematic literature review was undertaken, as well as a review of the Web site Clinicaltrials.gov for ongoing trials. Targets have included T cells themselves and their associated cytokines, chemokines, and receptors mostly targeted with biological agents. With the exception of anti-human IgE, none of these have met the expectations predicted from animal models and human in vitro tests. For most of these new therapies, only a very small subpopulation appears to respond. A case is made for a different approach to drug discovery based on acquiring a greater understanding of asthma stratification, the relevant pathways involved, and the development of appropriate diagnostic tests enabling the targeting of selective treatments to those asthmatic phenotypes most likely to respond. The recognition that asthma is more than allergy mandates improved predictive animal models and an appreciation that many of the environmental insults that initiate, consolidate, and exacerbate asthma operate through an epithelium functioning in a disorderly fashion. An integrated model that places the epithelium at the forefront of asthma pathogenesis suggests that greater emphasis should be placed on therapeutics that increase the airways' resistance against the inhaled environment rather than focusing only on suppression of inflammation.
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Meyers DA. Genetics of asthma and allergy: what have we learned? J Allergy Clin Immunol 2010; 126:439-46; quiz 447-8. [PMID: 20816180 PMCID: PMC2936265 DOI: 10.1016/j.jaci.2010.07.012] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2010] [Accepted: 07/13/2010] [Indexed: 01/22/2023]
Abstract
The overall purpose of this review is to present an update on genetic approaches to understanding the susceptibility and expression (severity) of common diseases, such as asthma and allergy. Five key questions are addressed in this review: (1) What phenotypes are being studied? Multiple disease phenotypes in carefully characterized patients are required. (2) Are the same genes that are important in disease susceptibility important in disease severity? (3) Are there racial differences in disease expression and genetic susceptibility? (4) Are the genes important in normal variation in lung function important in asthma severity? (5) Are the genes important in other common diseases, such as chronic inflammatory diseases or chronic obstructive pulmonary disease, important in asthma or allergy? In addition, a discussion of some of current areas of research is presented, including the issue that current genome-wide association study results do not account for a significant portion of trait variability, the potential role of rare variants and large genome-sequencing studies, and pharmacogenetics: is there a role for basing treatment decisions on the results of genetic testing? Finally, the potential usefulness of DNA, personalized medicine, is discussed.
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Affiliation(s)
- Deborah A Meyers
- Center for Genomics and Personalized Medicine Research, Wake Forest University School of Medicine, Winston-Salem, NC 27157, USA.
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