Immunologic mast cell-mediated responses and histamine release are attenuated by heparin

Mast cell-neural interactions contribute to pain and itch

Mast cells are best recognized for their role in allergy and anaphylaxis, but increasing evidence supports their role in neurogenic inflammation leading to pain and itch. Mast cells act as a "power house" by releasing algogenic and pruritogenic mediators, which initiate a reciprocal communication with specific nociceptors on sensory nerve fibers. Consequently, nerve fibers release inflammatory and vasoactive neuropeptides, which in turn activate mast cells in a feedback mechanism, thus promoting a vicious cycle of mast cell and nociceptor activation leading to neurogenic inflammation and pain/pruritus. Mechanisms underlying mast cell differentiation, activation, and intercellular interactions with inflammatory, vascular, and neural systems are deeply influenced by their microenvironment, imparting enormous heterogeneity and complexity in understanding their contribution to pain and pruritus. Neurogenic inflammation is central to both pain and pruritus, but specific mediators released by mast cells to promote this process may vary depending upon their location, stimuli, underlying pathology, gender, and species. Therefore, in this review, we present the contribution of mast cells in pathological conditions, including distressing pruritus exacerbated by psychologic stress and experienced by the majority of patients with psoriasis and atopic dermatitis and in different pain syndromes due to mastocytosis, sickle cell disease, and cancer.

Chondroitin sulfate inhibits secretion of TNF and CXCL8 from human mast cells stimulated by IL-33

Glycosaminoglycans (GAGs) are linear, highly negatively charged carbohydrate chains present in connective tissues. Chondroitin sulfate (CS) and heparin (Hep) are also found in the numerous secretory granules of mast cells (MC), tissue immune cells involved in allergic and inflammatory reactions. CS and Hep may inhibit secretion of histamine from rat connective tissue MC, but their effect on human MC remains unknown. Human LAD2 MC were pre-incubated with CS, Hep, or dermatan sulfate (DS) before being stimulated by either the peptide substance P (SP, 2 μM) or the cytokine IL-33 (10 ng/mL). Preincubation with CS had no effect on MC degranulation stimulated by SP, but inhibited TNF (60%) and CXCL8 (45%) secretion from LAD2 cells stimulated by IL-33. Fluorescein-conjugated CS (CS-F) was internalized by LAD2 cells only at 37 °C, but not 4 °C, indicating it occurred by endocytosis. DS and Hep inhibited IL-33-stimulated secretion of TNF and CXCL8 to a similar extent as CS. None of the GAGs tested inhibited IL-33-stimulated gene expression of either TNF or CXCL8. There was no effect of CS on ionomycin-stimulated calcium influx. There was also no effect of CS on surface expression of the IL-33 receptor, ST2. Neutralization of the hyaluronan receptor CD44 did not affect the internalization of CS-F. The findings in this article show that CS inhibits secretion of TNF and CXCL8 from human cultured MC stimulated by IL-33. CS could be formulated for systemic or topical treatment of allergic or inflammatory diseases, such as atopic dermatitis, cutaneous mastocytosis, and psoriasis. © 2018 BioFactors, 45(1):49-61, 2019.

Effects of Medium Molecular Weight Heparinyl Phenylalanine on Type I Hypersensitivity

BACKGROUND/AIM

We investigated the inhibitory action of medium molecular weight heparinyl phenylalanine (MHF) on type I hypersensitivity in comparison with medium molecular weight heparinyl arginine (MHR).

MATERIALS AND METHODS

MHF and MHR were synthesized from heparin (HE) to decrease the side-effect of HE based on its anticoagulant action and used in this study.

RESULTS

MHF demonstrated a significant inhibitory action on 48-h homologous passive cutaneous anaphylaxis in rats. Although MHF did not affect the death of mice injected with a lethal dose of histamine, it significantly prolonged the survival time of mice administered a lethal dose of compound 48/80. On the other hand, MHR did not inhibit type I hypersensitivity.

CONCLUSION

The inhibitory action of MHF on the type I allergic reaction was due to a reduction or delay in histamine release from mast cells. MHF may be a potent anti-allergic agent.

Inhaled Heparin: Therapeutic Efficacy and Recent Formulations

Heparin is well known for its anticoagulant and anti-inflammatory properties. Inhaled heparin regimens are increasingly being used to manage lung disease. It has been used to treat cystic fibrosis, thromboembolism, and pulmonary fibrosis, as well as bronchial asthma and asthma-induced airway hypersensitivity. Several preclinical studies attained some useful effects of heparin-administered, parenterally and through inhalation, treatment of lung disease. Besides, recent clinical trials suggest that inhaled heparin for lung diseases is beneficial and safe, but such data remain to be limited. In 2005, the orphan designation was granted by the European Commission for heparin sodium (inhalation use) for the treatment of cystic fibrosis. The positive results of heparin in the pulmonary route necessitate a focus on the preparation and evaluation of heparin in advanced drug delivery systems, namely nano/microparticles and liposomes. Through this pulmonary delivery, heparin is protected from enzymatic degradation within the airway. Heparin is thus passively targeted into the lungs, and long-lasting localized treatment is achieved. On the other hand, these systems have encountered several problems as follows: (1) polymers, such as poly-L-lactide-glycolic acid, poly (lactic acid), and chitosan, used to prepare heparin-loaded microparticle/nanoparticle (MP/NP) systems have not been granted approval for lung application by the FDA and (2) liposomal and NP formulation stability is the main problem of formulation design. We propose that additional in vitro and in vivo research is necessary to assess the clinical applicability of this treatment strategy. The present article discusses heparin treatments for lung diseases and the use of heparin and/or heparin-loaded drugs in advanced delivery systems through the pulmonary route.

Autologous serum and plasma skin test to predict 2-year outcome in chronic spontaneous urticaria

Background

Autologous serum skin test (ASST) and autologous plasma skin test (APST) are simple methods to diagnose autoimmune chronic urticaria. However, the association data of ASST or APST with disease severity and long-term outcome are still unclear.

Objective

The results of ASST and APST might be used to predict urticaria symptom severity and long-term outcomes among chronic spontaneous urticaria (CSU) patients.

Methods

We evaluated the prevalence of reactive ASST and APST in 128 CSU patients. The patients were characterized by 4 groups: negative, ASST positive, APST positive, and both ASST and APST positive. We observed remission rate among the CSU patients during 2 years.

Results

Forty-four of 128 CSU patients (34%) had negative autologous skin test. The CSU patients with positive ASST, positive APST, and both positive ASST and APST were 47 (37%), 6 (5%), and 31 (24%), respectively. No significant difference was found between the groups according to urticaria severity score (USS) and dermatology life quality index (DLQI). Mean wheal diameter of ASST showed positive correlation with DLQI. Also, mean wheal diameter of APST showed positive correlation with USS and DLQI. Both the positive ASST and APST groups had a high proportion of 4-fold dose of H1-antihistamine than the positive ASST (p = 0.03) and negative groups (p = 0.0009). The rate of remission over 2 years in the negative, positive ASST, positive APST, and both positive ASST and APST groups were 81.1%, 62.3%, 60%, and 46.1%, respectively. The urticaria remission rate in patients in the negative group was significantly higher compared with both positive ASST and APST groups (odds ratio, 5.0; 95% confidence interval, 1.61–15.44; p = 0.006).

Conclusion

ASST and APST results could predict remission rates among patients with CSU. Our results suggested investigating ASST and APST among CSU patients before starting treatment.

Non-anticoagulant derivatives of heparin for the management of asthma: distant dream or close reality?

INTRODUCTION

Approximately 300 million people worldwide are currently affected by asthma. Improvements in the understanding of the mechanisms involved in such inflammatory airway disorders has led to the recognition of new therapeutic approaches. Heparin, a widely used anticoagulant, has been shown to be beneficial in the management of asthma. It belongs to the family of highly sulphated polysaccharides referred to as glycosaminoglycans, containing a heterogeneous mixture of both anticoagulant and non-anticoagulant polysaccharides. Experimental findings have suggested that heparin has potential anti-asthmatic properties owing to the ability of its non-anticoagulant oligosaccharides to bind and modulate the activity of a wide range of biological molecules involved in the inflammatory process.

AREAS COVERED

This review focuses on the potential mechanisms of action and clinical application of heparin as an anti-inflammatory agent for the management of asthma.

EXPERT OPINION

Heparin may play a significant role in the management of asthma. However, these properties are often hindered by the presence of anticoagulant oligosaccharides, which possess a significant risk of bleeding. Therefore, its therapeutic potential must be explored using well-designed clinical studies that focus on identifying and isolating the anti-inflammatory oligosaccharides of heparin and further elucidating the structure and mechanisms of actions of these non-anticoagulant oligosaccharides.

A potential nanomedicine consisting of heparin-loaded polysaccharide nanocarriers for the treatment of asthma

A new nanomedicine consisting of chitosan/carboxymethyl-β-cyclodextrin loaded with unfractioned or low-molecular-weight heparin is described and its potential in asthma treatment is evaluated. The nanoparticles are prepared by ionotropic gelation showing a size that between 221 and 729 nm with a positive zeta potential. The drug association efficiency is higher than 70%. Developed nanosystems are stable in Hank's balanced salt solution at pH = 6.4, releasing the drug slowly. Ex vivo assays show that nanocarriers lead to an improvement of heparin preventing mast cell degranulation. These results agree with the effective cellular internalization of the fluorescently labeled nanocarriers, and suggest these nanomedicines as promising formulations for asthma treatment.

EAACI/GA(2)LEN task force consensus report: the autologous serum skin test in urticaria

Injection of autologous serum collected during disease activity from some patients with chronic spontaneous urticaria (CU) into clinically normal skin elicits an immediate weal and flare response. This observation provides a convincing demonstration of a circulating factor or factors that may be relevant to the understanding of the pathogenesis and management of the disease. This test has become known as the autologous serum skin test (ASST) and is now widely practised despite incomplete agreement about its value and meaning, the methodology and the definition of a positive response. It should be regarded as a test for autoreactivity rather than a specific test for autoimmune urticaria. It has only moderate specificity as a marker for functional autoantibodies against IgE or the high affinity IgE receptor (FcepsilonRI), detected by the basophil histamine release assay, but high negative predictive value for CU patients without them. It is usually negative in other patterns of CU, including those that are physically induced. Positive ASSTs have been reported in some subjects without CU, including those with multiple drug intolerance, patients with respiratory allergy and healthy controls, although the clinical implications of this are uncertain. It is essential that failsafe precautions are taken to ensure that the patient's own serum is used for skin testing and aseptic procedures are followed for sample preparation and handling. CU patients with a positive ASST (ASST(+)) are more likely to be associated with HLADR4, to have autoimmune thyroid disease, a more prolonged disease course and may be less responsive to H1-antihistamine treatment than those with a negative ASST (ASST(-)) although more evidence is needed to confirm these observations conclusively.

Activation of connective tissue-type and mucosal-type mast cells in compound 48/80-induced airway response

The pathology of non-immunological airway contraction is not well understood. To define the activation of different phenotypes of mast cells, a rat non-immunological asthmatic model was prepared. Airway contraction in rats was measured by an unrestrained whole-body plethysmographic system following a 10-min inhalation challenge with a 5% solution of compound 48/80. Histamine, leukotrein C(4) (LTC(4)) and tumor necrosis factor (TNF)-alpha levels in bronchoalveolar lavage fluid, as well as tissue histamine content were quantified. Mast cells and eosinophils were detected by histology. Both the early and late phase of airway responses were induced by inhalation of compound 48/80. Histamine and TNF-alpha levels increased significantly 30 min after challenge, but no increases were detected at either 8 or 24 h after challenge. A high LTC(4) level was detected in 30 min and 8 h after challenge. Tissue histamine content decreased at 30 min after challenge and returned to the unstimulated level by 8 h. Connective tissue mast cells in rat trachea showed a degranulation response. Along with the increase in numbers of mucosal mast cells, rat mast cell protease II at both mRNA and protein levels in the trachea epithelial layer was also increased significantly at 30 min after challenge. We conclude that compound 48/80 inhalation causes both the early and late phase of airway contraction in rats. Mast cell degranulation is responsible for the early phase of airway response, which subsequently triggers the late phase of airway response.

Effects of inhaled brevetoxins in allergic airways: toxin-allergen interactions and pharmacologic intervention

During a Florida red tide, brevetoxins produced by the dinoflagellate Karenia brevis become aerosolized and cause airway symptoms in humans, especially in those with pre-existing airway disease (e.g., asthma). To understand these toxin-induced airway effects, we used sheep with airway hypersensitivity to Ascaris suum antigen as a surrogate for asthmatic patients and studied changes in pulmonary airflow resistance (R(L) after inhalation challenge with lysed cultures of K. brevis (crude brevetoxins). Studies were done without and with clinically available drugs to determine which might prevent/reverse these effects. Crude brevetoxins (20 breaths at 100 pg/mL; n = 5) increased R(L) 128 +/- 6% (mean +/- SE) over baseline. This bronchoconstriction was significantly reduced (% inhibition) after pretreatment with the glucocorticosteroid budesonide (49%), the beta(2) adrenergic agent albuterol (71%), the anticholinergic agent atropine (58%), and the histamine H1-antagonist diphenhydramine (47%). The protection afforded by atropine and diphenhydramine suggests that both cholinergic (vagal) and H1-mediated pathways contribute to the bronchoconstriction. The response to cutaneous toxin injection was also histamine mediated. Thus, the airway and skin data support the hypothesis that toxin activates mast cells in vivo. Albuterol given immediately after toxin challenge rapidly reversed the bronchoconstriction. Toxin inhalation increased airway kinins, and the response to inhaled toxin was enhanced after allergen challenge. Both factors could contribute to the increased sensitivity of asthmatic patients to toxin exposure. We conclude that K. brevis aerosols are potent airway constrictors. Clinically available drugs may be used to prevent or provide therapeutic relief for affected individuals.

Effects of bemiparin on airway responses to antigen in sensitized Brown-Norway rats

Heparins have demonstrated activity in asthma. The effects of bemiparin, a low molecular weight heparin, were examined on antigen-induced responses in sensitized Brown-Norway rats. Inhaled bemiparin (1 mg/ml) reduced the acute bronchospasm produced by aerosol antigen, prevented airway hyperresponsiveness to 5-hydroxytryptamine postantigen exposure, and reduced the eosinophil count (from 0.205+/-0.062 to 0.054+/-0.016 x 10(6) cells/ml in antigen and antigen+bemiparin groups, respectively; P<0.05), eosinophil peroxidase activity, and proteins in the bronchoalveolar lavage fluid (BALF), as well as the transiently augmented mucin Muc5ac expression. Hyperresponsiveness to adenosine was not affected by bemiparin. In similar experiments, inhaled fondaparinux (1 mg/ml) did not affect the antigen-induced responses, while a low-anticoagulant low molecular weight heparin was effective. In conclusion, bemiparin showed beneficial effects in experimental asthma, probably unrelated to its anticoagulant activity, which extends the previous positive findings obtained with other heparins.

Heparin attenuates symptoms and mast cell degranulation induced by AMP nasal provocation

BACKGROUND

Previous studies have shown that inhaled heparin attenuated the airway responses to allergen, exercise, and AMP bronchial provocation, possibly through an inhibition of mast cell activation.

OBJECTIVE

The aim of this study was to provide the evidence of in vivo inhibition of human mast cell activation by heparin in a noninvasive model.

METHODS

Nine atopic and 6 nonatopic subjects received placebo and unfractionated heparin sodium (5000 IU/mL) 15 minutes before an AMP nasal provocation in a double-blind crossover study design. The nasal lavage was collected from these subjects before or 3, 5, 15, or 30 minutes after the AMP nasal challenge, and concentrations of histamine and tryptase in the nasal lavage were measured.

RESULTS

AMP nasal provocation produced considerable sneezing and induced a transient increase in histamine and tryptase release, with peak values achieved at 3 to 5 minutes after the challenge in all atopic subjects. Compared with placebo, inhaled heparin significantly attenuated the release of histamine and tryptase induced by AMP challenge (P=.012 and.004, respectively). Moreover, the AMP-induced sneezing was also inhibited by pretreatment with heparin (P=.016). In nonatopic subjects, AMP did not induce a significant increase in histamine and tryptase release on placebo-treated or heparin-treated days.

CONCLUSION

These data suggest that AMP nasal provocation and AMP bronchial provocation cause mast cell mediator release in a similar fashion. In addition, the data support the hypothesis that inhaled heparin plays a protective role against AMP provocation by inhibition of mast cell activation.

Heparin normalizes allergen-induced nitric oxide deficiency and airway hyperresponsiveness

It has been established that polycations cause airway hyperresponsiveness (AHR) to methacholine by inducing a deficiency of constitutive nitric oxide synthase (cNOS)-derived bronchodilating nitric oxide (NO). Since a deficiency of cNOS-derived NO also contributes to allergen-induced AHR after the early asthmatic reaction (EAR) and since this AHR is associated with the release of polycationic proteins from infiltrated eosinophils in the airways, we hypothesized that endogenous polycations underlie or at least contribute to the allergen-induced NO deficiency and AHR. Using a guinea-pig model of allergic asthma, we addressed this hypothesis by examining the effect of the polyanion heparin, acting as a polycation antagonist, on the responsiveness to methacholine of isolated perfused tracheae from unchallenged control animals and from animals 6 h after ovalbumin challenge, that is, after the EAR. A 2.0-fold AHR (P<0.001) to intraluminal administration of methacholine was observed in airways from allergen-challenged animals compared to control. Incubation of these airways with 250 U ml(-1) heparin completely normalized the observed hyperresponsiveness (P<0.001), whereas the responsiveness to methacholine of airways from unchallenged control animals was not affected. The effect of heparin on airways from allergen-challenged guinea-pigs was dose-dependently (0.1 and 1.0 mM) reversed by the NOS inhibitor L-NAME (P<0.01). These results indicate that endogenous (presumably eosinophil-derived) polycations are involved in allergen-induced NO deficiency and AHR after the EAR, probably by inhibition of l-arginine transport.

Nadroparine inhibits the hypersensitivity response in the conjunctiva

This study sought to investigate the effects of nadroparine on an in vivo experimental model of type I hypersensitivity response in the rat conjunctiva. Following drug application onto the eye, either before or after challenge with the mast cell degranulator, basic polyamine compound 48/80, the conjunctival histamine content and the nitrite levels in the conjunctival lavage fluid were quantified fluorometrically and spectrophotometrically, respectively. Instillation into the eye of nadroparine inhibited the C48/80-induced decreases in conjunctival histamine and the delayed increases in nitrite levels, without influencing basal mediator levels. Protamine did not induce histamine release and only partially reversed the effects of nadroparine post-challenge, yet it had no effect on the protective action of the drug when administered prior to degranulation. The results showed that nadroparine was equally effective in attenuating the effects of compound 48/80 in the eye when administered topically either before or after challenge.

Modulation of airway responsiveness by anionic and cationic polyelectrolyte substances

To elucidate the effects of anionic and cationic polyelectrolyte substance on bronchoconstriction, we examined the serial changes in respiratory resistance (Rrs) in ovalbumin-sensitized guinea pigs after antigen exposure with or without pre-inhalation of low-molecular-weight heparin, poly-L-glutamic acid, poly-L-lysine and dextran, and with or without oral intake of dalteparin. Both immediate and late responses after antigen exposure were significantly decreased after pretreatment with inhaled low-molecular-weight heparin and poly-L-glutamic acid compared with saline alone. The late response was significantly decreased after pretreatment with oral dalteparin. Both low-molecular-weight heparin and poly-L-glutamic acid significantly decreased the airway response to methacholine in sensitized guinea pigs. In sensitized guinea pigs, the airway response to methacholine was significantly increased after pretreatment with inhaled poly-L-lysine. Pretreatment with inhaled low-molecular-weight heparin before poly-L-lysine exposure significantly suppressed the airway hyperresponsiveness after inhaled poly-L-lysine. These findings indicated that the "cationic-anionic interaction" plays an important role in airway responsiveness.

The effects of heparin and related molecules on vascular permeability and neutrophil accumulation in rabbit skin

Unfractionated heparin (UH) has been shown to possess a wide range of properties which are potentially anti-inflammatory. Many of these studies, including effects of heparin on adhesion of inflammatory cells to endothelium, have been carried out in vitro. In the present study, we have used radioisotopic techniques to study the effect of UH, and related molecules, on in vivo inflammatory responses (plasma exudation (PE) and PMN accumulation) in rabbit skin induced by cationic proteins, mediators and antigen. Intradermal (i.d.) pretreatment with UH dose-dependently inhibited poly-L-lysine (PLL)-induced responses. The same treatment had no effect on antigen (extract of Alternaria tenuis, AT)-, formyl-methionyl-leucyl-phenylalanine (fMLP)- or leukotriene (LT) B(4)-induced responses, although i.d. dextran sulphate (DS) significantly inhibited responses to all of these mediators. High dose (10,000 u kg(-1)) intravenous UH significantly decreased cutaneous responses to fMLP and LTB(4). By comparison, the selectin inhibitor, fucoidin, and DS, were very effective inhibitors of these responses, and of responses to AT and PLL. In contrast to the weak effect in the in vivo studies, UH significantly inhibited in vitro homotypic aggregation of rabbit PMNs, showing that it can modify PMN function. Our data with i.d. UH confirm the important ability of this molecule to interact with and neutralize polycationic peptides in vivo, suggesting that this is a prime role of endogenous heparin. The lack of effect of exogenous heparin on acute inflammatory responses induced by allergen, suggests that cationic proteins are unlikely to be primary mediators of the allergen-induced PE or PMN accumulation.

Intranasal heparin reduces eosinophil recruitment after nasal allergen challenge in patients with allergic rhinitis

BACKGROUND

Recently, several studies have shown that heparin possesses various anti-inflammatory and antiallergic properties. It has been proposed that heparin might play an important role in limiting the inflammatory events associated with asthma and allergic rhinitis by neutralizing inflammatory mediators, such as eosinophil cationic protein and major basic protein, and by limiting eosinophil recruitment.

OBJECTIVE

To test the hypothesis that heparin can limit the extent and magnitude of eosinophilic inflammation, we examined the effect of inhaled intranasal heparin on nasal response to allergen challenge in 10 patients with allergic rhinitis.

METHODS

The capacity of heparin to reduce nasal response was studied by evaluating symptom score, eosinophil cationic protein concentration, and eosinophil counts in nasal lavage fluids 10, 60, and 360 minutes after allergen challenge.

RESULTS

Pretreatment with intranasal heparin produced a significant reduction in symptom score 10 minutes after allergen challenge and reduced the eosinophil influx at each time point after antigen challenge, statistical significance being reached 60 and 360 minutes after allergen challenge. Similarly, the amount of eosinophil cationic protein in the nasal wash was reduced at each time point; this reached statistical significance 360 minutes after allergic challenge.

CONCLUSION

Heparin was shown to provide protection with respect to nasal allergen challenge. The mechanism by which heparin produces its protective activity seems to be related to the neutralization of eosinophil cationic protein as well as to the reduction of eosinophil recruitment.

Chronic urticaria: novel clinical and serological aspects

BACKGROUND

Recently, distinct studies have shown that: (a) chronic idiopathic urticaria (CIU) is autoimmune in 30-50% of cases; (b) in patients with CIU the autologous serum skin test is inhibited by heparin; and (c) basophil histamine release induced in vitro by CIU sera maybe complement-dependent.

OBJECTIVE

To carry out a comprehensive clinical and serological study on CIU based upon these observations.

METHODS

Three hundred and six adults with CIU underwent intradermal (ID) test with autologous serum; 57 of them with autologous heparinized plasma as well. Sera from 121 patients (plasmas from 17) were employed to induce in vitro histamine release from basophils of normal donors. The effects of heating (56 degrees C, 60 min), filtration through membrane, and preincubation with heparin were evaluated as well.

RESULTS

Autologous serum and plasma induced a weal and flare reaction in 205 out of 306 (205/306; 67%) and in 8/57 (14%) patients, respectively. Positive plasma skin tests were observed only in patients showing strongly positive serum skin tests. Plasma did not elicit any skin reaction in 3/3 patients with dermatographism who showed a positive intradermal test with saline. Sera from 20/121 (16.5%) patients induced significant histamine release from basophils of normal donors. 19/20 sera were from patients with a positive intradermal test; thus, basophil histamine release assay was positive in 19/87 (21.8%) patients with a positive serum skin test. Heating at 56 degrees C x 1 h markedly reduced the histamine-releasing activity of both serum and plasma from in vitro reactors. Ultrafiltered fractions > 100 kDa of both sera tested retained the histamine-releasing activity, whereas fractions < 100 kDa were not able to induce any histamine release. Heparin dose-dependently inhibited histamine release induced by sera and plasma, and by basophil agonists such as anti-IgE, formyl-methionyl-leucyl-phenilalanine, and interleukin (IL)-3.

CONCLUSIONS

67% of our patients with CIU showed a positive autologous serum skin test. Sera from about 20% of those positive on autologous serum skin test induced histamine release from normal basophils in vitro probably as a consequence of the presence of functional autoantibodies. The marked difference between in vivo and in vitro findings could reflect the existence of a mast cell-specific histamine-releasing factor which does not release histamine from basophils of healthy blood donors. However, it might be also the result of in vivo priming of patients' cutaneous mast cells or of heterogeneity of basophil donors. At least in some cases complement seems essential for histamine-releasing activity of serum from patients with CIU. Heparin inhibits histamine release from both basophils (in vitro) and mast cells (in vivo), probably acting directly at a cellular level.

Tumor necrosis factor-dependent adhesions as a major protective mechanism early in septic peritonitis in mice

The occurrence of peritoneal adhesions in surgical patients is positively correlated with tumor necrosis factor (TNF) levels. In a model of septic peritonitis-cecal ligation and puncture-TNF neutralization prevented formation of peritoneal adhesions and increased mortality, most likely because localization of the septic focus was prevented. To discriminate between the coagulation-independent protective TNF effect and a potential protective procoagulant TNF effect, formation of peritoneal adhesions after CLP was inhibited with heparin, hirudin, or urokinase. Each treatment increased mortality and increased the number of bacteria in the peritoneal lavage fluid, kidney, and liver to various degrees. Under these experimental conditions, antibiotics prevented death. In coagulation-compromised mice, lethality was further enhanced by additional TNF neutralization. These findings demonstrate that peritoneal adhesions early in septic peritonitis are an important mechanism of innate immunity that prevents increased spread of bacteria and reduces mortality.

Chondroitin sulphate inhibits connective tissue mast cells

1. Mast cells derive from the bone marrow and are responsible for the development of allergic and possibly inflammatory reactions. Mast cells are stimulated by immunoglobulin E (IgE) and specific antigen, but also by a number of neuropeptides such as neurotensin (NT), somatostatin or substance P (SP), to secrete numerous pro-inflammatory molecules that include histamine, cytokines and proteolytic enzymes. 2. Chondroitin sulphate, a major constituent of connective tissues and of mast cell secretory granules, had a dose-dependent inhibitory effect on rat peritoneal mast cell release of histamine induced by the mast cell secretagogue compound 48/80 (48/80). This inhibition was stronger than that of the clinically available mast cell 'stabilizer' disodium cromoglycate (cromolyn). Inhibition by chondroitin sulphate increased with the length of preincubation and persisted after the drug was washed off, while the effect of cromolyn was limited by rapid tachyphylaxis. 3. Immunologic stimulation of histamine secretion from rat connective tissue mast cells (CTMC) was also inhibited, but this effect was weaker in umbilical cord-derived human mast cells and was absent in rat basophilic leukemia (RBL) cells which are considered homologous to mucosal mast cells (MMC). Oligo- and monosaccharides were not as effective as the polysaccharides. 4. Inhibition, documented by light and electron microscopy, involved a decrease of intracellular calcium ion levels shown by confocal microscopy and image analysis. Autoradiography at the ultrastructural level showed that chondroitin sulphate was mostly associated with plasma and perigranular membranes. 5. Chondroitin sulphate appears to be a potent mast cell inhibitor of allergic and nonimmune stimulation with potential clinical implications.

Heparin inhibits eicosanoid metabolism and hyperventilation-induced bronchoconstriction in dogs

Inhalation of heparin, an anticoagulant, attenuates exercise- induced asthma (EIA) in human subjects. The purpose of this study was to determine if heparin inhibits hyperventilation-induced bronchoconstriction (HIB) in a canine model of EIA, and if its mode of action involves the inhibition of eicosanoid mediator production and release. We used a wedged bronchoscope technique to measure baseline peripheral airway resistance (Rp). We then performed either a 2-min or 5-min dry air challenge (DAC) by temporarily increasing from 200 to 2,000 ml/min the flow of 5% CO(2) in air used to ventilate a wedged sublobar segment. We compared HIB before and 60 min after aerosol treatment with either bacteriostatic water (BW) or heparin. We found that (1) heparin had no effect on baseline Rp, (2) BW did not alter the response to DAC, and (3) heparin reduced HIB by approximately 50-60%. On the basis of bronchoalveolar lavage fluid (BALF) cell analysis, heparin and BW caused acute infiltration of macrophages and eosinophils, and heparin increased the number of erythrocytes recovered immediately after DAC. Despite these acute inflammatory effects initiated prior to DAC, BALF mediator analyses revealed that pretreatment with heparin either attenuated or abolished hyperventilation-induced leukotriene, prostaglandin, and thromboxane release. Thus, our data provide direct evidence that inhaled heparin inhibits eicosanoid mediator production and release caused by hyperventilation with dry air, and significantly attenuates HIB.

Effects of inhaled low molecular weight heparin on airway allergic inflammation in aerosol-ovalbumin-sensitized guinea pigs

Low molecular weigh, heparin (LMWH) possesses multiple nonanticoagulant properties. In the present study, we observed its anti-airway allergic inflammatory effects by bronchoalveolar lavage in guinea pigs. Guinea pigs were sensitized by repeatedly inhaling aerosolized ovalbumin. LMWH (400 u/l, 800 u/l), dexamethasone (1.2 mg/1) or vehicle (normal saline) was inhaled for 7 days. Then the animals were sacrificed under anesthesia and then lavaged with ice-cold Hank's buffer immediately; bronchoalveolar lavage fluid (BALF) was prepared 24 h after the animals were challenged by antigen exposure. The effects of LMWH on total cell counts, absolute eosinophil counts and cell catalogues in BALF were studied; effects on the activity of eosinophil peroxidase (EPO) and the contents of histamine and eosinophil cationic protein (ECP) in BALF supernatant were detected. Our results showed that compared with the vehicle group, LMWH at 400 u/l and 800 u/1 could significantly reduce total cell counts, absolute eosinophil counts and percentage of eosinophils in BALF (P<0.05 and P<0.01, respectively); LMWH at 800 u/l markedly inhibited the activity of EPO in BALF supernatant (P<0.05); LMWH at 400 u/l and 800 u/l remarkably reduced the content of histamine in BALF supernatant (P<0.05 and P<0.01, respectively), LMWH at 800 u/l decreased the content of ECP (P<0.05) significantly. It suggested that LMWH exerted anti-airway allergic inflammatory action by inhibiting infiltration of inflammatory cells and reducing release of inflammatory mediators, as well as antagonizing their activities, and that LMWH could be developed as a potential anti-bronchial asthmatic drug.

Prevention of exercise-induced bronchoconstriction by inhaled low-molecular-weight heparin

Because many biological actions of heparin including the antiallergic activity are molecular weight dependent, we hypothesized that low-molecular-weight heparin (LMWH) may have greater potency in attenuating exercise-induced bronchoconstriction (EIB). Therefore, in the present investigation we studied the effects of inhaled LMWH, enoxaparin, and unfractionated heparin on EIB in subjects with asthma. Thirteen asthmatic subjects performed a standardized exercise challenge on a treadmill to document the presence of EIB. The workload was increased until 85% of predicted maximal heart rate was achieved, and the exercise was sustained at that workload for 10 min. EIB was assessed by measuring FEV(1) before and immediately after the exercise. On five different experiment days the subjects were pretreated with 4 ml of aerosolized heparin (80,000 units = 7.5 mg/kg), placebo, or 3 different doses of enoxaparin (0.5 mg/kg, 1 mg/kg, 2 mg/kg) in a double-blind, randomized, crossover design, and exercise challenge was performed 45 min later. Bronchial provocation with methacholine was also performed in five subjects on two additional days after pretreatment with either placebo or inhaled enoxaparin (2 mg/kg), and venous blood was obtained for analysis of plasma antifactor Xa. Postexercise, the maximal decreases in FEV(1) (mean +/- SE) were 30 +/- 4% and 29 +/- 5% on control and placebo days. The exercise-induced decreases in FEV(1) were inhibited by 31% with heparin (DeltaFEV(1) = 20 +/- 4%); and by 28%, 38%, and 48% by enoxaparin at doses of 0.5 mg/kg (DeltaFEV(1) = 21 +/- 5%), 1 mg/kg (DeltaFEV(1) = 18 +/- 5%), and 2 mg/kg (DeltaFEV(1) = 15 +/- 3%), respectively (p < 0.05). The inhibitory effect of 0.5 mg/kg dose of enoxaparin was comparable to heparin (7.5 mg/kg), whereas 2 mg/ kg dose of enoxaparin was the most potent. Inhaled enoxaparin failed to modify the bronchoconstrictor response to methacholine, and did not change the plasma antifactor Xa activity. These data demonstrate that inhaled enoxaparin prevents EIB in a dose-dependent manner; and its antiasthmatic activity is independent of its effect on plasma antifactor Xa activity.

Inhibitory effect of heparin on skin reactivity to autologous serum in chronic idiopathic urticaria

BACKGROUND

Most patients with chronic idiopathic urticaria (CIU) show cutaneous reactivity to intradermal injection of autologous serum. In some cases this reactivity is associated with the presence of autoantibodies directed against IgE or IgE receptors expressed on mast cells, whereas in others no autoimmune mechanisms can be documented.

OBJECTIVES

The aims of this study were to compare the cutaneous reactivity to serum and plasma samples in a series of patients with active CIU and to address the mechanisms of the inhibitory effect exerted by heparin on the cutaneous responsiveness to the histamine-releasing factors (HRFs) present in CIU serum.

METHODS

Fourteen patients with CIU were injected intradermally with autologous serum, plasma (anticoagulated by either heparin or EDTA), or serum samples to which heparin had been added. The effects of heparin injection on cutaneous responsiveness to allergens was tested in 5 atopic patients. Moreover, in a set of experiments sera were also adsorbed with Sepharose-conjugated heparin.

RESULTS

All the patients had positive cutaneous reactions to autologous serum injection. When heparinized plasma was injected, negative reactions were observed in 12 of 14 patients, and a sizable reduction in the wheal-and-flare reactions was recorded in the remaining 2. Compared with results obtained with serum, no substantial change was observed in 6 of 8 patients injected with EDTA-anticoagulated plasma. When heparin was added to serum, abrogation of skin reactivity was seen; nonetheless, no change in the cutaneous response to allergens was associated with locally administered heparin in 5 atopic patients with no history of CIU. Finally, adsorption of CIU sera with solid-phase heparin abrogated the ability to induce cutaneous reactions in 5 of 7 patients, whereas in the remaining 2 a sizable reduction was observed.

CONCLUSIONS

These data indicate that heparin is able to profoundly inhibit the cutaneous response to HRFs present in the sera of patients with CIU. Although the precise level of action of this heparin-mediated effect is unclear from present data, preliminary evidence seems to indicate that heparin could directly interfere with HRFs present in CIU sera.

Heparin in inflammation: potential therapeutic applications beyond anticoagulation

In this chapter we have described anti-inflammatory functions of heparin distinct from its traditional anticoagulant activity. We have presented in vivo data showing heparin's beneficial effects in various preclinical models of inflammatory disease as well as discussed some clinical studies showing that the anti-inflammatory activities of heparin may translate into therapeutic uses. In vivo models that use low-anticoagulant heparins indicate that the anticoagulant activity can be distinguished from heparin's anti-inflammatory properties. In certain cases such as hypovolemic shock, the efficacy of a low-anticoagulant heparin derivative (GM1892) exceeds heparin. Data also suggest that nonconventional delivery of heparin, specifically via inhalation, has therapeutic potential in improving drug pharmacokinetics (as determined by measuring blood coagulation parameters) and in reducing the persistent concerns of systemic hemorrhagic complications. Results from larger clinical trials with heparin and LMW heparins are eagerly anticipated and will allow us to assess our predictions on the effectiveness of this drug class to treat a variety of human inflammatory diseases.

Molecular-weight-dependent effects of nonanticoagulant heparins on allergic airway responses

We have hypothesized that antiallergic activity of inhaled heparin is molecular weight dependent and mediated by "nonanticoagulant fractions" (NAF-heparin). Therefore, we studied comparative effects of high-, medium-, and ultralow-molecular-weight (HMW, MMW, and ULMW, respectively) NAF-heparins on acute bronchoconstrictor response (ABR) and airway hyperresponsiveness (AHR) in allergic sheep. Specific lung resistance was measured in 23 allergic sheep, before and immediately after challenge with Ascaris suum antigen, without and after pretreatment with inhaled NAF-heparins. Airway responsiveness was estimated before and 2 h postantigen as the cumulative provocating dose of carbachol in breath units, which increased specific lung resistance by 400%. NAF-heparins attenuated ABR and AHR in a molecular-weight-dependent fashion. HMW NAF-heparin (n = 8) was the least effective agent: it attenuated ABR [inhibitory dose causing 50% protection (ID50) = 4 mg/kg] but had no effect on AHR. MMW NAF-heparin (n = 8) showed intermediate efficacy (ABR ID50 = 0.8 mg/kg, AHR ID50 = 1.4 mg/kg), whereas ULMW NAF-heparin (n = 7) was the most effective agent (ABR ID50 = 0.4 mg/kg, AHR ID50 = 0.2 mg/kg). ULMW NAF-heparin was 3.5 times more potent in attenuating antigen-induced AHR when administered "after" antigen challenge and failed to inhibit the bronchoconstrictor response to carbachol and histamine. In 15 additional sheep, segmental antigen challenge caused a marked increase in histamine in bronchoalveolar lavage fluid that was not prevented by any of the inhaled NAF-heparins. These data indicate that antiallergic activity of inhaled heparin is independent of its anticoagulant action and resides in the <2,500 ULMW chains. The antiallergic activity of NAF-heparins is mediated by an unknown biological action and may have therapeutic potential.

Actions of heparin that may affect the malignant process

BACKGROUND

Heparin has many actions that may affect the malignant process, especially metastasis.

METHODS

The author conducted an extensive review of the available medical literature about heparin activity that may apply to important factors involved in the malignant process.

RESULTS

Thrombin is generated by tumors, and the resultant fibrin formation impedes natural killer cell activity. Microthrombi arrest tumor cells in capillaries. Heparin prevents the formation of thrombin and neutralizes its activity. Angiogenesis has an important role in metastasis; heparin minimizes angiogenesis via the inhibition of vascular endothelial growth factor, tissue factor, and platelet activating factor. It decreases tumor cell adhesion to vascular endothelium as it inhibits selectin and chemokine actions, and it also decreases the replication and activity of some oncogenic viruses. Matrix metalloproteinases, serine proteases, and heparanases have an important role in metastasis. Heparin decreases their activation and limits their effects. It competitively inhibits tumor cell attachment to heparan sulfate proteoglycans. It blocks the oncogenic action of ornithine decarboxylase and enhances the antineoplastic effect of transforming growth factor-beta. Heparin inhibits activator protein-1, which is the nuclear target of many oncogenic signal transduction pathways, and it potently inhibits casein kinase II, which has carcinogenic activity. Platelet-derived growth factor, which has oncogenic effects, is also inhibited by heparin, as are reverse transcriptase, telomerase, and topoisomerase prooncogenic actions.

CONCLUSIONS

These various heparin actions justify clinical investigation of its possible beneficial effect on malignant disease.

Inhibition of antigen-induced airway hyperresponsiveness by ultralow molecular-weight heparin

Unfractionated heparin (UF-heparin) has been shown to prevent antigen-induced airway hyperresponsiveness (AHR), but it is ineffective when administered after the antigen challenge. We hypothesized that the failure of UF-heparin to modify postantigen AHR might depend on molecular weight. We therefore studied the effects of UF-heparin and three low-molecular-weight heparin fractions (medium-molecular-weight heparin [MMWH]; low-molecular-weight heparin [LMWH]; and ultralow-molecular-weight heparin [ULMWH]) on antigen-induced AHR and histamine release in bronchoalveolar lavage fluid (BALF). Specific lung resistance (SRL) was measured in 20 allergic sheep before, immediately after, and up to 2 h after challenge with Ascaris suum antigen. Airway responsiveness was expressed as the cumulative provocative dose of carbachol, in breath units, that increased SRL by 400% (PD400). PD400 was determined before and 2 h after antigen, both without and after treatment with aerosolized UF-heparin (1,000 U/kg) and various heparin fractions (0.04 mg/kg to 5 mg/kg) administered after the antigen challenge. Inhaled UF-heparin (n = 4), MMWH (n = 4), and LMWH (n = 6) failed to modify postantigen AHR when administered after the challenge. Only ULMWH (n = 6) inhibited postantigen AHR in a dose-dependent manner (percent protection ranged from 31% to 139%). In eight additional sheep, histamine in BALF was measured with a radioimmunoassay (RIA) before and after the segmental antigen challenge, without and after pretreatment with inhaled UF-heparin, LMWH, or ULMWH. Inhaled UF-heparin and LMWH inhibited antigen-induced histamine release as measured in BALF by 81% and 75%, respectively; whereas ULMWH was ineffective in this respect. We conclude that: (1) modification of antigen-induced AHR by fractionated heparins is molecular-weight dependent; and (2) only ULMWH attenuates AHR when administered after antigen challenge, via an unknown mast-cell-independent action.

Cortical granule exocytosis is triggered by different thresholds of calcium during fertilisation in sea urchin eggs

In sea urchin eggs, fertilisation is followed by a calcium wave, cortical granule exocytosis and fertilisation envelope elevation. Both the calcium wave and cortical granule exocytosis sweep across the egg in a wave initiated at the point of sperm entry. Using differential interference contrast (DIC) microscopy combined with laser scanning confocal microscopy, populations of cortical granules undergoing calcium-induced exocytosis were observed in living urchin eggs. Calcium imaging using the indicator Calcium Green-dextran was combined with an image subtraction technique for visual isolation of individual exocytotic events. Relative fluorescence levels of the calcium indicator during the fertilisation wave were compared with cortical fusion events. In localised regions of the egg, there is a 6s delay between the detection of calcium release and fusion of cortical granules. The rate of calcium accumulation was altered experimentally to ask whether this delay was necessary to achieve a threshold concentration of calcium to trigger fusion, or was a time-dependent activation of the cortical granule fusion apparatus after the 'triggering' event. Calcium release rate was attenuated by blocking inositol 1,4,5-triphospate (InsP3)-gated channels with heparin. Heparin extended the time necessary to achieve a minimum concentration of calcium at the sites of cortical granule exocytosis. The data are consistent with the conclusion that much of the delay observed normally is necessary to reach threshold concentration of calcium. Cortical granules then fuse with the plasma membrane. Further, once the minimum threshold calcium concentration is reached, cortical granule fusion with the plasma membrane occurs in a pattern suggesting that cortical granules are non-uniform in their calcium sensitivity threshold.

Inhibition of allergic airway responses by inhaled low-molecular-weight heparins: molecular-weight dependence

Inhaled heparin prevents antigen-induced bronchoconstriction and inhibits anti-immunoglobulin E-mediated mast cell degranulation. We hypothesized that the antiallergic action of heparin may be molecular weight dependent. Therefore, we studied the effects of three different low-molecular-weight fractions of heparin [medium-, low-, and ultralow-molecular-weight heparin (MMWH, LMWH, ULMWH, respectively)] on the antigen-induced acute bronchoconstrictor response (ABR) and airway hyperresponsiveness (AHR) in allergic sheep. Specific lung resistance was measured in 22 sheep before and after airway challenge with Ascaris suum antigen, without and after pretreatment with inhaled fractionated heparins at doses of 0.31-5.0 mg/kg. Airway responsiveness was estimated before and 2 h postantigen as the cumulative provocating dose of carbachol in breath units that increased specific lung resistance by 400%. All fractionated heparins caused a dose-dependent inhibition of ABR and AHR. ULMWH was the most effective fraction, with the inhibitory dose causing 50% protection (ID50) against ABR of 0.5 mg/kg, whereas ID50 values of LMWH and MMWH were 1.25 and 1.8 mg/kg, respectively. ULMWH was also the most effective fraction in attenuating AHR; the ID50 values for ULMWH, LMWH, and MMWH were 0.5, 2.5, and 4.7 mg/kg, respectively. These data suggest that 1) fractionated low-molecular-weight heparins attenuate antigen-induced ABR and AHR; 2) there is an inverse relationship between the antiallergic activity of heparin fractions and molecular weight; and 3) ULMWH is the most effective fraction preventing allergic bronchoconstriction and airway hyperresponsiveness.

Heparin inhibits leukocyte rolling in pial vessels and attenuates inflammatory changes in a rat model of experimental bacterial meningitis

Heparin is a natural proteoglycan that was first described in 1916. In addition to its well characterized effect on blood coagulation, it is becoming clear that heparin also modulates inflammatory processes on several levels, including the interference with leukocyte-endothelium interaction. Anecdotal observations suggest a better clinical outcome of heparin-treated patients with bacterial meningitis. The authors demonstrate that heparin, a glycosaminoglycan, inhibits significantly in the early phase of experimental pneumococcal meningitis the increase of 1) regional cerebral blood flow (125 +/- 18 versus 247 +/- 42%), 2) intracranial pressure (4.5 +/- 2.0 versus 12.1 +/- 2.2 mm Hg), 3) brain edema (brain water content: 78.23 +/- 0.33 versus 79.49 +/- 0.46%), and 4) influx of leukocytes (571 +/- 397 versus 2400 +/- 875 cells/microL) to the cerebrospinal fluid compared with untreated rats. To elucidate the possible mechanism of this observation, the authors investigated for the first time leukocyte rolling in an inflammatory model in brain venules by confocal laser scanning microscopy in vivo. Heparin significantly attenuates leukocyte rolling at 2, 3, and 4 hours (2.8 +/- 1.3 versus 7.9 +/- 3.2/100 microm/min), as well as leukocyte sticking at 4 hours (2.1 +/- 0.4 versus 3.5 +/- 1.0/100 microm/min) after meningitis induction compared with untreated animals. The authors conclude that heparin can modulate acute central nervous system inflammation and, in particular, leukocyte-endothelium interaction, a key process in the cascade of injury in bacterial meningitis. They propose to evaluate further the potential of heparin in central nervous system inflammation in basic and clinical studies.

Effect of pretreatment with heparin on pulmonary and cutaneous response

Although anticoagulant properties of glycosaminoglycan heparin are primary in medicine, a variety of other biological functions related to heparin have been suggested. Since heparin is a selective inhibitor of inositol triphosphate (IP3) receptors that are involved in release of calcium in mast cells and many other cells, it is possible that heparin may act as a natural anti-inflammatory molecule and modify these reactions. Therefore, the purpose of the present study was to determine the role of heparin in allergic inflammatory responses: the pulmonary reaction and the cutaneous response, in a double-blind, placebo-controlled, crossover randomized trial. To evaluate the effect of heparin on methacholine-induced bronchoconstriction, nebulized heparin (20,000 units) was administered to 12 asthmatics and nonspecific challenge was performed immediately thereafter. Measurements of Raw and SGaw were obtained before and 1 hr after nebulization of heparin. In 12 other allergic subjects, heparin (25 U/kg) was given intravenously 10 min before skin prick test. We demonstrated that pretreatment with heparin reduced skin test reactivity from 24.06 +/- 1.2 mm to 18.26 +/- 2.27 mm and increased the methacholine PC20 value from 1.69 +/- 0.48 mg/ml to 8.14 +/- 3.11 mg/ml (p < 0.05), but did not prevent an increase in Raw and/or a decrease in SGaw. Heparin modified the methacholine-induced bronchoconstrictor response, but this did not reflect a protective effect in airway resistance and specific conductance. These data suggest that anti-inflammatory effects of heparin are time-dependent and/or that heparin may have a transient inhibitory role in allergic reactions.

Is nitric oxide and heparin treatment justified in inflammatory bowel disease? An experimental study

Microcirculatory disturbances of the colon may contribute to the pathogenesis of inflammatory bowel disease. The aim of the study was to investigate the alterations of rectal blood perfusion in experimental colitis with reference to nitric oxide and heparin treatment. The study was carried out on 36 rats, divided into six groups: group I, control; group II, control + NG-nitro-L-arginine (L-NNA); group III, colitis without treatment; group IV, colitis + L-arginine; group V, colitis + L-NNA; group VI, colitis + heparin treatment. Experimental colitis was induced by 4% acetic acid enema, and 48 h after the enema, besides the measurement of rectal capillary blood flow by means of laser Doppler flowmetry, the serum interleukin-6 (IL-6) level and histopathological alterations within the rectal mucosa were examined. Experimental colitis resulted in a drop in rectal wall perfusion. L-Arginine and heparin treatment improved the microcirculatory values. The highest IL-6 level and the most advanced histopathological alterations were observed in the rats treated with L-NNA. L-Arginine treatment had no influence on IL-6 concentration, however it aggravated the inflammatory changes within the rectal mucosa. Heparin administration reduced the IL-6 values and also had a positive impact on the microscopic alterations within the rectal wall. It is concluded that heparin treatment has a beneficial effect on the microcirculatory disturbances and inflammatory changes observed in experimental colitis. The inhibition of nitric oxide-synthase aggravated the course of experimental colitis. L-Arginine administration improves the rectal blood flow but aggravates the histopathological alterations within the rectal wall.

Review article: refractory distal colitis -- explanations and options

Distal colitis refractory to standard therapy is a complex and challenging problem. Physiological differences between the right and left colon may be exploited for maximum therapeutic benefit. Over-reliance on oral therapy should be seen as one of the reasons for treatment failure and delivery systems should target therapy to the distribution of the disease in doses proven to be therapeutically beneficial. The clinician should also be cognizant of potential adverse effects of standard therapies, particularly colitis due to mesalazine, which may mimic worsening disease. Numerous endogenous and exogenous factors that may exacerbate the underlying inflammatory bowel disease are discussed. This review explores the potential mechanisms why distal colitis may be refractory to therapy and addresses newer therapies that, while still in the investigatory stages, offer hope for a widening armamentarium of therapeutic modalities.

Therapeutic uses of heparin beyond its traditional role as an anticoagulant

A number of physiological effects have been ascribed to heparin since its discovery almost 80 years ago, many of which are independent from its first-described and best- characterized activity as an anticoagulant. Heparin and heparan sulphate are believed to possess many biological activities that include the ability to modulate embryonic development, neurite outgrowth, tissue homeostasis, wound healing, metastasis, cell differentation, cell proliferation and inflammation. In this review, David Tyrell, Stephen Kilfeather and Clive Page examine some of the activities of heparin (and heparin derivatives) beyond its effects as an anticoagulant, and discuss the therapeutic potential of this old, but certainly not antiquated, drug.

Heparin inhalation for asthma

The study of inhaled heparin in asthma has resurfaced recently in the medical literature. Although the above mentioned investigations have helped us better understand the pathologic processes of asthma, the results are too scant and preliminary to enable us to recommend the use of inhaled heparin in acute or chronic asthma. If the antiinflammatory properties of inhaled heparin prove to be of clinical value in asthma, it would represent a considerable advantage over steroids, which cause immunosuppression and other significant adverse reactions. Future trials will need to address such issues as: (1) What is the asthma subpopulation in which heparin is likely to be beneficial? (2) What is the optimal dose for inhalation? (3) What are the long-term adverse effects of inhaled heparin? (4) What is the optimal timing of administration with regard to allergen exposure? (5) If proven useful, what is the ideal delivery mode? Additional well-designed human trials will be necessary before we can define the place of inhaled heparin in the therapy or prevention of asthma.

Preventing bronchoconstriction in exercise-induced asthma with inhaled heparin

BACKGROUND

We have previously reported that inhaled heparin prevents allergic bronchoconstriction in sheep and inhibits the anti-IgE-mediated release of histamine from mast cells in vitro. Since the release of such mediators has been implicated in exercise-induced asthma, we investigated whether inhaled heparin could also attenuate the bronchoconstrictor response in this disease.

METHODS

On five days we studied 12 subjects with a history of exercise-induced asthma. On day 1 they underwent a standardized exercise challenge on a treadmill to document the presence of exercise-induced asthma. Minute ventilation was estimated with a calibrated respiratory inductive plethysmograph. The workload was increased until the heart rate reached 85 percent of the predicted maximal value, and was sustained for 10 minutes. The magnitude of bronchoconstriction was assessed by measuring specific airway conductance before and after the exercise. On day 2 the partial-thromboplastin time was measured in plasma obtained before and after the subjects inhaled a nebulized solution of heparin (1000 U per kilogram of body weight). On days 3 through 5 the subjects were pretreated with 4 ml of inhaled heparin (1000 U per kilogram), cromolyn sodium (20 mg), or placebo according to a single-blind, randomized, crossover design and underwent exercise challenge 45 minutes later. To exclude the possibility that heparin had any direct effect on airway smooth muscle, bronchial provocation with histamine was induced in five subjects on two further days after pretreatment with either heparin or placebo.

RESULTS

Inhaled heparin and cromolyn sodium had no effect on specific airway conductance at base line, but did attenuate the exercise-induced decreases in this variable: the mean (+/- SE) maximal decrease five minutes after exercise was 9 +/- 5 percent after pretreatment with heparin, as compared with 22 +/- 5 percent after pretreatment with cromolyn and 35 +/- 2 percent after pretreatment with placebo. Heparin did not change the partial-thromboplastin time and did not modify the bronchoconstrictor response to histamine.

CONCLUSIONS

Inhaled heparin prevents exercise-induced asthma without influencing histamine-induced bronchoconstriction. This non-anticoagulant action of heparin is more likely to be related to a modulation of mediator release than to a direct effect on smooth muscle.