The effects of sodium cromoglycate on lung irritant receptors and left ventricular cardiac receptors in the anaesthetized dog

Effect of disodium cromoglycate on airway mucus secretion during antigen-induced late asthmatic responses in a murine model of asthma

BACKGROUND

Disodium cromoglycate (DSCG) is known to inhibit both immediate and late asthmatic responses (IAR and LAR). However, its effect on mucus hypersecretion is unknown. Using a murine model of asthma, we aimed to determine whether mucus secretion increased during IAR and LAR. We also studied the potency of DSCG in inhibiting mucus secretion and on airway eosinophilia.

METHODS

Mice were subjected to initial intraperitoneal sensitization and airway challenge to ovalbumin (OVA) and then provoked by additional exposure to OVA. Some mice were pretreated with aerosolized DSCG (20 mg/ml) 1 h before the provocation with OVA. After serial measurements of enhanced pause (Penh), an indicator of airflow obstruction, serum samples and bronchoalveolar lavage fluids (BALF) were collected. Then, the lungs were excised and a morphometric analysis for mucus hypersecretion was performed.

RESULTS

A biphasic increase in Penh (IAR and LAR) was observed in sensitized animals after provocation with OVA. Airway eosinophilia was observed during both responses. Intraluminal mucus significantly increased during LAR, but not during IAR. DSCG significantly attenuated both IAR and LAR, and significantly inhibited the increase in intraluminal mucus during LAR, but had no effect on eosinophilia in BALF.

CONCLUSION

Our results suggest that airway hypersecretion may be involved as a component of airflow obstruction during LAR, and that this is unlikely during IAR. DSCG may be effective in reducing excessive airway mucus caused by exposure to allergens.

Species differences in bradykinin receptor-mediated responses of the airways

1. Bradykinin (BK) is a nine amino acid peptide (Arg-Pro-Pro-Gly-Phe-Ser-Pro-Phe-Arg) formed from the plasma precursor kininogen during inflammation and tissue injury. The actions of BK are mediated by G protein-coupled cell surface receptors, designated B1 and B2. 2. BK has a plethora of effects in the airways including bronchoconstriction, bronchodilation, stimulation of cholinergic and sensory nerves, mucus secretion, cough and oedema resulting from promotion of microvascular leakage. These airway effects are mediated in the main by the B2 receptor subtype. 3. BK acts mainly indirectly, primarily through airway nerve activation, but also by the release of prostanoids, thromboxanes and nitric oxide (NO). 4. Airway responses to BK have been studied in detail in guinea-pigs, mice, sheep and rats. This review describes the effects of BK in these species and draws comparison with its effects in normal humans and patients with respiratory diseases. 5. Despite its many and varied effects in the airways of animals and man, the exact contribution of BK to airways disease remains unclear.

Neurogenic inflammation in the airways

Release of neuropeptides, including tachykinins and calcitonin gene-related peptide, from sensory nerves via an axon or local reflex may have inflammatory effects in the airways. This neurogenic inflammation may be initiated by activation of sensory nerves by inflammatory mediators and irritants. Neurogenic inflammation is well developed in rodents and may contribute to the inflammatory response to allergens, infections and irritants in animal models. However, the role of neurogenic inflammation in airway inflammatory diseases, such as asthma and COPD is still uncertain as there is little direct evidence for the involvement of sensory neuropeptides in human airways. Initial clinical studies using strategies to block neurogenic inflammation have not been encouraging, but it is important to study more severe forms of airway disease in more prolonged studies in the future to explore the role of neurogenic inflammation.

Modulation of sensory nerve function in the airways

Several clinical studies document a greater discrimination between asthmatic and healthy subjects in bronchial responsiveness to a range of stimuli such as cold air, distilled water and sodium metabisulphite, than to conventional bronchoconstrictor agonists including histamine and methacholine. One of the mechanisms thought to account for the bronchoconstriction induced by these agents is via reflex activation of the cholinergic pathway. An increase in sensory nerve (afferent) activity in asthma might account for the increased responsiveness to these agents. If so, a number of strategies are available to inhibit the function of afferent nerves which could lead to a suppression of bronchial hyperresponsiveness, including (1) inhibition of afferent activity, (2) inhibition of neuropeptide release and (3) antagonism of tachykinin receptors. As there are numerous reviews dealing with the latter, in this review Domenico Spina, Saloni Shah and Selena Harrison focus on the first two strategies.

Effect of vagotomy on airway hyperreactivity to endogenously released neurotransmitters at 18-24 h after inhaled antigen

Airway reactivity was examined in anaesthetized guinea-pigs 18-24 h after inhalation challenge of ovalbumin-sensitized animals with ovalbumin. Bronchoconstrictor responses were measured from the increases in pulmonary inflation pressure. The study was undertaken to examine whether ovalbumin challenge induced airway hyperreactivity to neurotransmitters released endogenously by vagal nerve stimulation. Stimulation parameters were selected to cause release of either acetylcholine (0.3 ms pulse width for 3 s, 20 V, 2-40 Hz), both acetylcholine and neuropeptide (5 ms pulse width for 15 s, 20 V, 0.5-8 Hz) or neuropeptide only, using the latter parameters in the presence of atropine. The vagi were paired for stimulation and in some experiments were cut central to the stimulation point. Frequency-response curves for acetylcholine- and neuropeptide-mediated bronchoconstrictor responses to vagal stimulation when the nerves were intact revealed no airway hyperreactivity after ovalbumin challenge. The presence of atropine failed to reveal airway hyperreactivity. However, when the vagi were cut, the frequency-response curves were displaced to the left after ovalbumin challenge compared with saline challenged animals, indicating airway hyperreactivity. This airway hyperreactivity was significant after atropine and suggests an increase in sensitivity to endogenously released neuropeptides rather than acetylcholine. It also indicates that the airway hyperreactivity is dependent on removal of the afferent vagal pathways. Frequency-response curves for cholinergic stimulation (0.3 ms) with intact vagi revealed no airway hyperreactivity after antigen challenge. Comparisons of exogenously administered 5-hydroxytryptamine (5-HT, 300 ng/100 g i.v.) and a single vagal stimulation of 0.3 ms pulse width (cholinergic) revealed no airway hyperreactivity to either stimulus after ovalbumin challenge. However if the vagi were cut, airway hyperreactivity was observed, again suggesting that removal of afferent pathways is important for revealing airway hyperreactivity in the anaesthetized guinea-pig. Ovalbumin challenge caused significant increases in the bronchoconstrictor responses to a single dose of capsaicin (50 microg/100 g i.v.) or dose-response curves to bradykinin. Since these agents release neuropeptides from sensory C-fibres, this is further support for a raised sensitivity to endogenously released neuropeptides.

Inhaled sodium cromoglycate in angiotensin-converting enzyme inhibitor cough

Cough is a frequent side-effect of angiotensin-converting enzyme (ACE) inhibitors. We examined the effects of inhaled sodium cromoglycate in 10 patients with ACE-inhibitor cough in a double-blind crossover study. After a 2-week run-in, patients were randomised to either 2 weeks' inhaled sodium cromoglycate or placebo followed by a further 2 weeks on the other treatment. Patients kept a cough diary during each study period. Cough severity was recorded on a scale from 0 to 12. At the end of each study period the cough threshold to inhaled capsaicin was measured. 9 patients reported a reduction in cough after sodium cromoglycate. Median (range) daily cough scores during run-in and placebo periods were 3.6 (1.9-6.4) and 4.1 (0.6-8.1), respectively (p > 0.05). Median daily cough score after sodium cromoglycate was 1.8 (0.4-3; p < 0.01). There was a significant relation between initial cough severity and benefit from sodium cromoglycate; and cough-reflex sensitivity to inhaled capsaicin was significantly reduced. Inhaled sodium cromoglycate is an effective treatment for ACE-inhibitor cough. Its effect may be due to suppression of afferent vagal activity.

The effect of topical sodium cromoglycate on intranasal histamine challenge in allergic rhinitis

Topical sodium cromoglycate is used to treat allergic diseases of the upper and lower airways. To investigate its mechanisms of action, intranasal histamine challenge was used in nine subjects with perennial allergic rhinitis. After a preliminary day where subjects' reactivity thresholds (D100) for histamine were determined, intranasal sodium cromoglycate was administered in a double-blind, placebo-controlled fashion. Graded (D100/3, D100, D100X3), sequential challenges were performed on days 1 and 21 of each course, and responses measured by changes in nasal airway resistance, sneezes, secretion volume and secretion content: total protein, lysozyme and mucin. After a single dose of sodium cromoglycate, there was no change in resistance, but secretion volumes fell significantly (3.12 ml/5 min c.i. 2.83-3.4; placebo 3.61, c.i. 3.32-3.90: P = 0.026). After a 3-week-course, there was a significant fall in resistance (4.29 cm H2O/l/s, c.i. 3.85-4.72; placebo 5.45, c.i. 5.01-5.88: P < 0.0001). No change in other parameters was observed. Thus, in perennial allergic rhinitis, intranasal sodium cromoglycate has both short- and long-term effects on nasal reactivity to histamine challenge. Acutely, there is a reduction in nasal lavage fluid volume which may be the result of reduced irritant receptor activity. After a 3-week course, there is a reduction in nasal resistance responses, a possible anti-inflammatory effect.

Neurogenic inflammation and asthma

The release of neurotransmitters may exacerbate the inflammatory response. Such neurogenic inflammation has been documented in a number of inflammatory diseases. Neurogenic inflammation due to release of neuropeptides from sensory nerves has been demonstrated in airways of several species, particularly rodents, and may contribute to the inflammatory response in asthmatic airways. Tachykinins (substance P and neurokinin A) released from airway sensory nerves may cause bronchoconstriction, vasodilatation, plasma exudation, and mucus secretion, whereas another sensory neuropeptide, calcitonin generelated peptide, may contribute to hyperemia of inflammation. Airway epithelial damage in asthma exposes sensory nerves which may become sensitized by inflammatory products (including prostaglandins and cytokines) so that neuropeptides are released via a local reflex trigger such as bradykinin, resulting in exaggerated inflammation. The effects of tachykinins may be amplified further by loss of the major degrading enzyme, neutral endopeptidase, from epithelial cells. Direct evidence for neurogenic inflammation in asthma is still awaited, however. Several strategies for reducing neurogenic inflammation are possible, particularly inhibition of neuropeptide release from sensory nerves by stimulating prejunctional receptors such as mu-opioid receptors.

Neuropeptides and asthma

Many neuropeptides have recently been identified in human and animal airways. These peptides have potent effects on airway caliber, blood vessels, and secretions, raising the possibility that they may be involved in airway diseases such as asthma. Vasoactive intestinal peptide and peptide histidine methionine are potent bronchodilators and may be neurotransmitters of nonadrenergic bronchodilator nerves. In asthma, if these peptides are broken down more rapidly by enzymes from inflammatory cells, this might contribute to exaggerated bronchial responsiveness. Neuropeptides that are found in sensory nerves, such as substance P, neurokinin A, and calcitonin gene-related peptide, have inflammatory effects and might also contribute to the pathology of asthma if released from sensory nerve endings by an axon reflex. These findings may have important therapeutic implications for the future.

Histamine receptors in the lung

Histamine, which has long been implicated as a mediator of allergic airway disease, has multiple effects on airways which are mediated by at least three histamine receptors. H1-receptors mediate bronchoconstriction, vasoconstriction and dilatation, microvascular leak and activation of sensory nerves. H2-receptors mediate vasodilatation in some species and mucus secretion. H3-receptors mediate vasodilatation in some species and mucus secretion. H3-receptors modulate cholinergic neurotransmission, the release of neuropeptides from sensory nerves and allergen-induced bronchoconstriction.

Modulation of neurogenic inflammation: novel approaches to inflammatory disease

Neurogenic inflammation, which involves the release of neuropeptides from capsaicin-sensitive sensory nerves, may contribute to inflammatory diseases of the airways, joints, bladder, skin, eye and gut. Peter Barnes and colleagues review some of the therapeutic strategies that can be used to inhibit this neurogenic inflammation, with particular reference to the respiratory tract.

Neuropeptides as modulators of airway function

Many neuropeptides have recently been identified in human and animal airways. These peptides, which may coexist with classical transmitters, have potent effects on airway calibre, blood vessels and secretions, raising the possibility that they may be involved in airway diseases such as asthma. Vasoactive intestinal peptide and peptide histidine methionine have potent relaxant effects on both vascular and bronchial smooth muscle, and may be neurotransmitters of non-cholinergic vasodilatation and non-adrenergic bronchodilation. Several neuropeptides which are found in sensory nerves, such as substance P, neurokinin A and calcitonin gene-related peptide, have both direct inflammatory effects and influence inflammatory cells, and might also contribute to the pathology of asthma if released from sensory nerve endings by an axon reflex.

A new approach to the treatment of asthma

Asthma is a chronic inflammatory condition. The previous emphasis on bronchodilator therapy, which does not treat the underlying inflammation, may be misplaced. Earlier introduction of antiinflammatory agents, such as corticosteroids or cromolyn sodium, is strongly recommended. Effective suppression of airway inflammation reduces the need for bronchodilator therapy and may reduce the morbidity and, perhaps, mortality of asthma.

Effects of nedocromil sodium on airway microvascular leakage and neural reflexes

Microvascular leakage and neurogenic mechanisms may be important components of the inflammatory response in asthmatic airways. We have examined the effects of nedocromil sodium on these responses. In guinea-pig airway, microvascular leakage induced by allergen was significantly inhibited by prior treatment with nedocromil sodium (100 micrograms/kg IV), but this had no effect on histamine-induced leakage and reduced PAF-induced leakage only at a dosage of 5 mg/kg. This suggests that nedocromil sodium acts mainly by preventing the release of inflammatory mediators. Both sulphur dioxide (SO2) and bradykinin cause bronchoconstriction in asthmatic patients, which is likely to be due to a neural mechanism since SO2 activates C-fibre sensory nerve endings in airways. Inhaled nedocromil sodium is effective in inhibiting both SO2- and bradykinin-induced bronchoconstriction, and furthermore reduces the sensation of dyspnoea, indicating a possible action on sensory nerve endings in airways.

Effect of nedocromil sodium on sulphur dioxide induced bronchoconstriction

Nedocromil sodium is a pyranoquinoline derivative that has been developed for the treatment of asthma. We report the results of a double blind randomised study of the effect of two doses of nedocromil sodium (2 and 4 mg) and matched placebo, delivered by metered dose pressurised aerosol, on bronchoconstriction induced by sulphur dioxide in six asthmatic subjects. Nedocromil sodium had no effect on baseline lung function. The magnitude of sulphur dioxide induced bronchoconstriction monitored by partial forced expiratory flow at 30% of reference vital capacity was significantly inhibited by nedocromil sodium 4 mg (p less than 0.05) but not by 2 mg. The maximum changes after placebo and after nedocromil 2 mg and 4 mg were -44.7, -32.7, and -11.8 l min-1. The area under the curve monitoring the effect over 6 minutes was significantly inhibited by both doses to the same extent, the mean changes after placebo and after nedocromil 2 mg and 4 mg being -349.3, -31.2, and 44.6 l. Dyspnoea was monitored by visual analogue scale and showed a significant reduction over 6 minutes with both doses of nedocromil. After placebo and after nedocromil 2 mg and 4 mg the mean maximum changes were 31.5, 13.7, and 15.7 mm, and the mean changes in area under the visual analogue scale-time curve were 289, 194, and 151 mm.min respectively.

Asthma as an axon reflex

In asthma, damage to airway epithelium, possibly caused by eosinophil products, exposes C-fibre afferent nerve endings. Stimulation of these endings by inflammatory mediators such as bradykinin may result in an axon (local) reflex with antidromic conduction down afferent nerve collaterals and release of sensory neuropeptides such as substance P, neurokinin A, and calcitonin gene-related peptide. These peptides are potent inducers of airway smooth muscle contraction, bronchial oedema, extravasation of plasma, mucus hypersecretion, and possibly inflammatory cell infiltration and secretion. Thus, axon reflexes could account for at least some of the pathophysiology of asthma and this concept might lead to new strategies for treatment.

Sodium cromoglycate and atropine block the fall in FEV1 but not the cough induced by hypotonic mist

In a group of patients with mild asthma the inhalation of mist derived from ultrasonically nebulised distilled water caused an increase in cough and a fall in FEV1. Double blind administration for five minutes of sodium cromoglycate (from an original solution containing 30 mg/ml) or atropine (2 mg/ml) by inhalation from a Minineb nebuliser, 30 minutes before the mist challenge, caused a significant reduction in the fall in FEV1 (p less than 0.05), but not in cough, by comparison with the protection afforded by placebo (saline). In a second study the fall in FEV1 caused by the inhalation of distilled water was not significantly different from that seen in response to hypotonic sodium chloride (1.7 g/l, 58 mmol/l), but both produced a significantly greater fall than did a similar mist containing sodium cromoglycate at an original concentration of 10 mg/ml (58 mmol/l). The results show that both atropine and sodium cromoglycate can block the fall in FEV1 due to mist and that protection by sodium cromoglycate is immediate. These results suggest that sodium cromoglycate blocks the nervous reflexes concerned in the response to mist, probably in the afferent limb of the reflex.

Lack of cross-tolerance between disodium cromoglycate and veratrum alkaloids

We sought to determine if the hypotension and bradycardia caused by disodium cromoglycate (DSC) and veratrine sulfate were due to an action upon a common receptor. Tolerance rapidly developed to the hypotensive and bradycardic action of 10 micrograms/kg iv DSC in anesthetized dogs. Veratrine sulfate 30 micrograms/kg iv given after tolerance had developed to DSC gave falls in blood pressure and heart rate identical to those produced by the alkaloid before DSC tolerance had set in. Thus, no cross-tolerance between DSC and veratrine was observed. This result excludes the possibility of a common site of action for DSC and veratrine.

Evidence for an effect of sodium cromoglycate on sensory nerves in man

Sodium cromoglycate was given by both intravenous injection and local intra-arterial infusion to healthy volunteers. Intravenous injection of a dose of 4 mg in four subjects caused a statistically significant rise in blood pressure and pulse rate associated with a feeling of warmth in the perineum and blush areas of the face and chest. Brachial artery infusion of sodium cromoglycate at doses of 100-1000 microgram/min caused a feeling of warmth in the limb during 26 out of 30 infusions and this sensation was subject to tachyphylaxis. During eight infusions in which there was a sensation of warmth there was no change in local blood flow as measured by strain-gauge plethysmography. In a further six studies involving 12 infusions of sodium cromoglycate the feeling of warmth was not accompanied by a rise in local skin temperature. The results suggest that sodium cromoglycate may stimulate afferent nerves in man.

Protective effect of drugs on bronchoconstriction induced by sulphur dioxide

The response to inhaled sulphur dioxide in eight normal, seven atopic, and 22 asthmatic subjects was studied by measuring thoracic gas volume and airway resistance in a whole-body plethysmograph. The fall in specific airway conductance in relation to the concentration of sulphur dioxide inhaled (0-20 ppm) was determined in all three groups. The specific airway conductance fell significantly in the atopic and asthmatic subjects but not in the normal group. In a double-blind study prior inhalation of disodium cromoglycate caused a significant reduction in the response to sulphur dioxide inhalation in atopic and asthmatic subjects. Prior treatment with inhaled ipratropium bromide blocked the response in the atopic subjects, but the effect was variable in the patients with asthma. Previous treatment with inhaled clemastine also reduced the response in patients with asthma, without causing a change in baseline specific conductance. We conclude that non-allergic bronchial hyperreactivity was increased in the atopic and the asthmatic subjects and that mediator release, in addition to a vagal reflex, has a role in such bronchoconstriction.

Effects of salbutamol, ipratropium bromide and disodium cromoglycate on breathlessness induced by exercise in normal subjects

1 Healthy volunteers undertook submaximal graded exercise while objective measurements of cardio-respiratory function were made and breathlessness was assessed with serial visual analogue scales. 2 A useful and consistent relationship existed between breathlessness and ventilation for individual subjects. 3 Drugs were examined in this system to test whether they modified the relationship between ventilation and breathlessness such that less breathlessness occurred for a given level of ventilation. 4 Salbutamol, ipratropium bromide and disodium cromoglycate given by inhalation did not reduce breathlessness in healthy subjects during exercise.