Anti-inflammatory agents and allergen-induced beta2-receptor dysfunction in isolated human bronchi

Models to understand contractile function in the airways

Although the role of contractile function in the airways is controversial, there is general consensus on the importance of airway smooth muscle (ASM) as a therapeutic target for diseases characterized by airway obstruction, such as asthma or chronic obstructive pulmonary disease. Indeed, the use of bronchodilators to relax ASM is the most common and effective practice to treat airflow obstruction. Excessive pathologic bronchoconstriction may originate from primary alterations of ASM mechanical function and/or from the effects exerted on ASM function by disease processes, such as inflammation and remodeling. An in depth knowledge of the potentially multiple mechanisms that distinctively regulate primary and secondary alterations in ASM contractile function would be essential for the development of new therapeutic approaches aimed at preventing the occurrence or reducing the severity of bronchoconstriction. The present review discusses studies that have addressed the mechanisms of altered ASM contractile function in models of airway hyperresponsiveness. Although not comprehensively, in the present review, animal models of intrinsic airway hyperresponsiveness, normal ontogenesis, and allergic sensitization are analyzed in the attempt to summarize the current knowledge on regulatory mechanisms of ASM contractile function in health and disease. Studies in human ASM and the need for additional models to understand contractile function in the airways are also discussed.

Beta-Adrenergic Agonists

Inhaled β₂-adrenoceptor (β₂-AR) agonists are considered essential bronchodilator drugs in the treatment of bronchial asthma, both as symptoms-relievers and, in combination with inhaled corticosteroids, as disease-controllers. In this article, we first review the basic mechanisms by which the β₂-adrenergic system contributes to the control of airway smooth muscle tone. Then, we go on describing the structural characteristics of β₂-AR and the molecular basis of G-protein-coupled receptor signaling and mechanisms of its desensitization/ dysfunction. In particular, phosphorylation mediated by protein kinase A and β-adrenergic receptor kinase are examined in detail. Finally, we discuss the pivotal role of inhaled β₂-AR agonists in the treatment of asthma and the concerns about their safety that have been recently raised.

Airway smooth muscle as a model for new investigative drugs in asthma

Bronchial asthma as such exists because airway smooth muscle (ASM) contracts excessively in response to various stimuli. After several decades during which research was mainly focused on airway inflammation, increasing attention is now being paid to a possible abnormal behaviour of ASM. Thus, ASM is regarded as a major target for anti-asthma treatments. This review first describes the mechanisms of ASM contraction and airway hyperresponsiveness, through cellular, animal and human models. The developments of new drugs targeting extra and/or intracellular pathway of ASM contraction are discussed.

Getting to the heart of asthma: can "beta blockers" be useful to treat asthma?

beta(2)-adrenoceptor agonists are the mainstay for the acute symptomatic treatment of asthma and provide effective bronchoprotection to a wide range of bronchoconstrictor agents. However, over the past 4 decades there has been a continuing debate concerning whether regular chronic treatment with these drugs may be doing more harm than good. The FDA's recent decision to add black box warnings concerning the regular use of salmeterol- and formoterol-containing compounds, as well as their decision not to recommend agents containing long-acting beta(2)-adrenoceptor agonists as first-line therapy, seems to confirm the concerns regarding the regular use of the long-acting beta(2)-adrenoceptor agonists. A similar debate arose in the late 1980s concerning the use of beta-adrenoceptor agonists in the treatment of heart failure. In this disease, short-term use of beta agonists is associated with increased cardiac index and stroke volume, yet their long-term use is associated with increased morbidity and mortality. Moreover, certain beta blockers that are initially detrimental when used short term are now considered beneficial in the treatment of this disease when used chronically. Here, there is a parallel, as beta blockers are contraindicated in patients with asthma but the use of beta blockers chronically has never been evaluated. This begs the question of whether a similar paradigm shift is applicable in the treatment of asthma and whether under certain circumstances the long-term use of certain beta blockers may be useful in the treatment of this disease.

Cysteinyl-leukotrienes in the regulation of beta2-adrenoceptor function: an in vitro model of asthma

Background

The response to β₂-adrenoceptor agonists is reduced in asthmatic airways. This desensitization may be in part due to inflammatory mediators and may involve cysteinyl-leukotrienes (cysteinyl-LTs). Cysteinyl-LTs are pivotal inflammatory mediators that play important roles in the pathophysiology of asthma, allergic rhinitis, and other inflammatory conditions. We tested the hypothesis that leukotriene D₄ (LTD₄) and allergen challenge cause β₂-adrenoceptor desensitization through the activation of protein kinase C (PKC).

Methods

The isoproterenol-induced cAMP accumulation was evaluated in human airway smooth muscle cell cultures challenged with exogenous LTD₄ or the PKC activator phorbol-12-myristate-13-acetate with or without pretreatments with the PKC inhibitor GF109203X or the CysLT₁R antagonist montelukast. The relaxant response to salbutamol was studied in passively sensitized human bronchial rings challenged with allergen in physiological salt solution (PSS) alone, or in the presence of either montelukast or GF109203X.

Results

In cell cultures, both LTD₄ and phorbol-12-myristate-13-acetate caused significant reductions of maximal isoproterenol-induced cAMP accumulation, which were fully prevented by montelukast and GF109203X, respectively. More importantly, GF109203X also prevented the attenuating effect of LTD₄ on isoproterenol-induced cAMP accumulation. In bronchial rings, both montelukast and GF109203X prevented the rightward displacement of the concentration-response curves to salbutamol induced by allergen challenge.

Conclusion

LTD₄ induces β₂-adrenoceptor desensitization in human airway smooth muscle cells, which is mediated through the activation of PKC. Allergen exposure of sensitized human bronchi may also cause a β₂-adrenoceptor desensitization through the involvement of the CysLT₁R-PKC pathway.

Association between bronchodilating response to short-acting beta-agonist and non-synonymous single-nucleotide polymorphisms of beta-adrenoceptor gene

BACKGROUND

With beta-agonists being the most widely used agents in the treatment of asthma, in vitro studies reported that beta(2)-adrenergic receptor (ADRB2) polymorphisms are associated with agonist-promoted down-regulation.

OBJECTIVE

The present population-based study aimed to evaluate the association between bronchodilating response to inhaled short-acting beta-agonist and two non-synonymous single-nucleotide polymorphisms (SNPs) of ADRB2 (ADRB2-16 and ADRB2-27).

METHODS

Two hundred and nine children with reduction in forced expiratory volume in 1 s of more than 20% on methacholine bronchial challenge underwent bronchodilating response testing 5 min after the inhalation of 200 mug of albuterol. Of these 209, 195 gave peripheral blood for genotyping of ADRB2 polymorphisms.

RESULTS

The bronchodilating response was significantly higher in subjects with the homozygous Arg16 than in those with the homozygous Gly16. It was further demonstrated that haplotype pairs of the homozygous Arg16Gln27 and of the heterozygous Arg16Gln27/Gly16Glu27 showed the highest bronchodilating responses, and the haplotype pairs of the homozygous Gly16Gln27 the lowest response. As a whole, the bronchodilating response was more positively associated with the combined quantity of Arg16 and Glu27 polymorphisms than with that of Arg16 alone.

CONCLUSION

Non-synonymous SNPs of ADRB2 at codons 16 and 27 is significantly associated with bronchodilating response to inhaled short acting beta-agonists.

A model of allergen-driven human airway contraction: beta2 pathway dysfunction without cytokine involvement

BACKGROUND

In our previous in vitro model, allergen incubation of passively sensitized human airways reduced the response to salbutamol. However, whether cytokines play a role in this model is still unknown.

OBJECTIVE

To investigate interleukin 1beta and tumor necrosis factor a expression in allergen-challenged human airways.

METHODS

Nonasthmatic airways (n = 13) were passively sensitized by overnight atopic serum incubation and then challenged with allergen for 1 hour (n = 9). After repeated washouts, airways were immersed in physiologic salt solution for 6 hours and finally in formaldehyde for immunohistochemical studies. The effect of co-incubation in anti-interleukin 1beta and anti-tumor necrosis factor a specific neutralizing antibodies on salbutamol response was also studied (n = 4).

RESULTS

No differences were found among control, sensitized, and challenged rings in the number of inflammatory cells. The percentage of basement membrane covered by epithelium was similar in the different conditions. There was a higher percentage of degranulating to total mast cells in allergen-challenged rings than in sensitized rings (P < .001). A significant correlation was observed between allergen-induced contraction and mast cell degranulation (r = 0.88; P < .001). The sensitization procedure was validated by paired allergen-induced contractions. No expression of the 2 cytokines was detectable up to 6 hours after allergen challenge, and specific neutralizing antibodies did not attenuate the impaired response to salbutamol in allergen-challenged rings.

CONCLUSION

These data suggest that in our in vitro model of allergic inflammation, beta2 pathway dysfunction can occur without cytokine involvement, thus supporting previous results that suggest a role for leukotrienes.

Second-Generation Antihistamines

Antihistamines are useful medications for the treatment of a variety of allergic disorders. Second-generation antihistamines avidly and selectively bind to peripheral histamine H1 receptors and, consequently, provide gratifying relief of histamine-mediated symptoms in a majority of atopic patients. This tight receptor specificity additionally leads to few effects on other neuronal or hormonal systems, with the result that adverse effects associated with these medications, with the exception of noticeable sedation in about 10% of cetirizine-treated patients, resemble those of placebo overall. Similarly, serious adverse drug reactions and interactions are uncommon with these medicines. Therapeutic interchange to one of the available second-generation antihistamines is a reasonable approach to limiting an institutional formulary, and adoption of such a policy has proven capable of creating substantial cost savings. Differences in overall efficacy and safety between available second-generation antihistamines, when administered in equivalent dosages, are not large. However, among the antihistamines presently available, fexofenadine may offer the best overall balance of effectiveness and safety, and this agent is an appropriate selection for initial or switch therapy for most patients with mild or moderate allergic symptoms. Cetirizine is the most potent antihistamine available and has been subjected to more clinical study than any other. This agent is appropriate for patients proven unresponsive to other antihistamines and for those with the most severe symptoms who might benefit from antihistamine treatment of the highest potency that can be dose-titrated up to maximal intensity.

Do inflammatory mediators influence the contribution of airway smooth muscle contraction to airway hyperresponsiveness in asthma?

It is now accepted that a host of cytokines, chemokines, growth factors, and other inflammatory mediators contributes to the development of nonspecific airway hyperresponsiveness in asthma. Yet, relatively little is known about how inflammatory mediators might promote airway structural remodeling or about the molecular mechanisms by which they might exaggerate smooth muscle shortening as observed in asthmatic airways. Taking a deep inspiration, which provides relief of bronchodilation in normal subjects, is less effective in asthmatic subjects, and some have speculated that this deficiency stems directly from an abnormality of airway smooth muscle and results in airway hyperresponsiveness to constrictor agonists. Here, we consider some of the mechanisms by which inflammatory mediators might acutely or chronically induce changes in the contractile apparatus that in turn might contribute to hyperresponsive airways in asthma.

Beclomethasone rapidly ablates allergen-induced beta 2-adrenoceptor pathway dysfunction in human isolated bronchi

Bronchial rings from nonatopic humans were passively sensitized with serum from allergic subjects. Allergen challenge significantly reduced the relaxant effect of salbutamol on carbachol-induced contractions, suggesting beta(2)-adrenoceptor (beta(2)-AR) pathway dysfunction. Incubation of challenged rings for 3 h with 3 x 10(-6) M beclomethasone dipropionate (BDP) restored the relaxant effect, suggesting reversal of beta(2)-AR pathway dysfunction. Incubation with the G(s)alpha protein-stimulating cholera toxin attenuated contractile responses to carbachol significantly less in challenged than in unchallenged rings. Treatment of challenged rings with BDP resulted in an inhibitory effect of cholera toxin that was similar to the effect in unchallenged rings. G(s)alpha protein expression was not significantly altered by BDP, suggesting that the activity of G(s)alpha protein was increased. Relaxation of challenged rings by forskolin was not significantly affected by BDP, suggesting that beta(2)-AR pathway dysfunction was proximal to the adenylyl cyclase. In conclusion, short-term (3-h) treatment with BDP after allergen challenge ablated beta(2)-AR pathway dysfunction by increasing the activity of the G(s)alpha protein in human isolated bronchi.

Allergic inflammation and airway smooth muscle function

It is widely accepted that airway smooth muscle (ASM) contraction plays a key role in asthmatic attacks. Whether abnormalities of contractility or autonomic regulation exist in the asthmatic ASM is still debated. Studies based on isometric contraction failed to show differences in the force-generation capability between asthmatic and normal ASM. Recent studies in vitro have shown that sensitized ASM: (1) shortens more and more rapidly than normal ASM; and (2) develops a myogenic response to stretching. The increased velocity of shortening may compromise in vivo the ability of tidal cycling to reduce airway tone, which would result in an enhanced response to bronchoconstrictor stimuli. The myogenic response may result in a sustained bronchospasm after a deep inhalation, a maneuver that in normal individuals causes bronchodilatation. Although there is no evidence that neural or humoral abnormalities in the autonomic regulation of ASM tone are central to the pathogenesis of bronchial asthma, recent data suggest that ASM receptor dysfunction may develop secondary to airway allergic response. It has been shown that exposure of passively sensitized human bronchi to allergens in vitro causes M2- and beta2-receptor dysfunction. Impairment of pre-junctional M2-autoreceptors may result in an enhancement of neurally mediated bronchoconstrictor responses, whereas beta2-receptor dysfunction may reduce the sensitivity to bronchodilator treatment. Airway inflammation, which is a characteristic feature of bronchial asthma, may alter both the contractile properties and the autonomic regulation of ASM. These changes may contribute to the severity of asthma, as they may cause an, imbalance between factors favoring and opposing airway narrowing.

G(s) protein dysfunction in allergen-challenged human isolated passively sensitized bronchi

We studied the intracellular mechanisms of allergen-induced beta(2)-adrenoceptor dysfunction in human isolated passively sensitized bronchi. Sensitization was obtained by overnight incubation of bronchial rings with serum containing a high specific IgE level to Dermatophagoides but a low total IgE level. Allergen challenge was done by incubation with a Dermatophagoides mix. The G(s) protein stimulant cholera toxin (2 microg/ml) displaced the carbachol (CCh) concentration-response curves of control and sensitized but not of challenged rings to the right. Cholera toxin (10 microg/ml) displaced the concentration-response curves to CCh of control, sensitized, and challenged rings to the right, but this effect was less in challenged rings. The effects of the G(i) protein inhibitor pertussis toxin (250 ng/ml or 1 microg/ml) on salbutamol concentration-relaxation curves did not differ significantly between challenged and sensitized rings. The adenylyl cyclase activator forskolin and the Ca(2+)-activated K(+)-channel opener NS-1619 relaxed CCh-contracted bronchial rings without significant differences between control, sensitized, and challenged rings. Neither G(i) nor G(s) alpha-subunit expression differed between control, sensitized, and challenged tissues. We conclude that G(s) protein dysfunction may be a mechanism of allergen-induced beta(2)-adrenoceptor dysfunction in human isolated passively sensitized bronchi.