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Karamchand S, Williams M, Naidoo P, Decloedt E, Allwood B. Post-tuberculous lung disease: should we be using Theophylline? J Thorac Dis 2021; 13:1230-1238. [PMID: 33717595 PMCID: PMC7947523 DOI: 10.21037/jtd-20-1298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Tuberculosis affects 10 million people and over 320,000 South Africans every year. A significant proportion of patients treated for tuberculosis develop post-tuberculous lung disease (PTBLD), a disease of chronic respiratory impairment for which there is a lack of affordable treatment options. PTBLD a heterogenous disorder that shares phenotypical features with chronic obstructive lung disease, bronchiectasis, lung fibrosis and destruction as well as pulmonary hypertension. There remains a paucity of proven pharmacotherapy for the management of PTBLD. Theophylline, a widely available and affordable medicine that has largely fell out of favour in high-income settings due to its toxicity and narrow therapeutic index, may be repositioned for the treatment of PTBLD. In this review, we unpack the potential role of theophylline in the management of PTBLD by reviewing the evidence for its bronchodilatory, anti-inflammatory and potential pleotrophic effects.
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Affiliation(s)
- Sumanth Karamchand
- Division of Pulmonology, Western Cape Department of Health, Tygerberg Hospital, Bellville, South Africa
| | - Morne Williams
- Division of Pulmonology, Western Cape Department of Health, Tygerberg Hospital, Bellville, South Africa
| | - Poobalan Naidoo
- Department of Informatics, School of Health Professions, Rutgers University, New Jersey, USA
| | - Eric Decloedt
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital, Bellville, South Africa
| | - Brian Allwood
- Division of Pulmonology, Western Cape Department of Health, Tygerberg Hospital, Bellville, South Africa
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2
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Devereux G, Cotton S, Fielding S, McMeekin N, Barnes PJ, Briggs A, Burns G, Chaudhuri R, Chrystyn H, Davies L, Soyza AD, Gompertz S, Haughney J, Innes K, Kaniewska J, Lee A, Morice A, Norrie J, Sullivan A, Wilson A, Price D. Low-dose oral theophylline combined with inhaled corticosteroids for people with chronic obstructive pulmonary disease and high risk of exacerbations: a RCT. Health Technol Assess 2020; 23:1-146. [PMID: 31343402 DOI: 10.3310/hta23370] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Despite widespread use of therapies such as inhaled corticosteroids (ICSs), people with chronic obstructive pulmonary disease (COPD) continue to suffer, have reduced life expectancy and utilise considerable NHS resources. Laboratory investigations have demonstrated that at low plasma concentrations (1-5 mg/l) theophylline markedly enhances the anti-inflammatory effects of corticosteroids in COPD. OBJECTIVE To determine the clinical effectiveness and cost-effectiveness of adding low-dose theophylline to a drug regimen containing ICSs in people with COPD at high risk of exacerbation. DESIGN A multicentre, pragmatic, double-blind, randomised, placebo-controlled clinical trial. SETTING The trial was conducted in 121 UK primary and secondary care sites. PARTICIPANTS People with COPD [i.e. who have a forced expiratory volume in 1 second (FEV1)/forced vital capacity (FVC) of < 0.7] currently on a drug regimen including ICSs with a history of two or more exacerbations treated with antibiotics and/or oral corticosteroids (OCSs) in the previous year. INTERVENTIONS Participants were randomised (1 : 1) to receive either low-dose theophylline or placebo for 1 year. The dose of theophylline (200 mg once or twice a day) was determined by ideal body weight and smoking status. PRIMARY OUTCOME The number of participant-reported exacerbations in the 1-year treatment period that were treated with antibiotics and/or OCSs. RESULTS A total of 1578 people were randomised (60% from primary care): 791 to theophylline and 787 to placebo. There were 11 post-randomisation exclusions. Trial medication was prescribed to 1567 participants: 788 in the theophylline arm and 779 in the placebo arm. Participants in the trial arms were well balanced in terms of characteristics. The mean age was 68.4 [standard deviation (SD) 8.4] years, 54% were male, 32% smoked and mean FEV1 was 51.7% (SD 20.0%) predicted. Primary outcome data were available for 98% of participants: 772 in the theophylline arm and 764 in the placebo arm. There were 1489 person-years of follow-up data. The mean number of exacerbations was 2.24 (SD 1.99) for participants allocated to theophylline and 2.23 (SD 1.97) for participants allocated to placebo [adjusted incidence rate ratio (IRR) 0.99, 95% confidence interval (CI) 0.91 to 1.08]. Low-dose theophylline had no significant effects on lung function (i.e. FEV1), incidence of pneumonia, mortality, breathlessness or measures of quality of life or disease impact. Hospital admissions due to COPD exacerbation were less frequent with low-dose theophylline (adjusted IRR 0.72, 95% CI 0.55 to 0.94). However, 39 of the 51 excess hospital admissions in the placebo group were accounted for by 10 participants having three or more exacerbations. There were no differences in the reporting of theophylline side effects between the theophylline and placebo arms. LIMITATIONS A higher than expected percentage of participants (26%) ceased trial medication; this was balanced between the theophylline and placebo arms and mitigated by over-recruitment (n = 154 additional participants were recruited) and the high rate of follow-up. The limitation of not using documented exacerbations is addressed by evidence that patient recall is highly reliable and the results of a small within-trial validation study. CONCLUSION For people with COPD at high risk of exacerbation, the addition of low-dose oral theophylline to a drug regimen that includes ICSs confers no overall clinical or health economic benefit. This result was evident from the intention-to-treat and per-protocol analyses. FUTURE WORK To promote consideration of the findings of this trial in national and international COPD guidelines. TRIAL REGISTRATION Current Controlled Trials ISRCTN27066620. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 37. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Graham Devereux
- Respiratory Medicine, Aberdeen Royal Infirmary, University of Aberdeen, Aberdeen, UK
| | - Seonaidh Cotton
- Centre for Healthcare Randomised Trials (CHaRT), University of Aberdeen, Aberdeen, UK
| | - Shona Fielding
- Medical Statistics Team, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Nicola McMeekin
- Institute of Health & Wellbeing, University of Glasgow, Glasgow, UK
| | - Peter J Barnes
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Andy Briggs
- Institute of Health & Wellbeing, University of Glasgow, Glasgow, UK
| | - Graham Burns
- Department of Respiratory Medicine, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Rekha Chaudhuri
- Gartnavel General Hospital, University of Glasgow, Glasgow, UK
| | | | - Lisa Davies
- Aintree Chest Centre, University Hospital Aintree, Liverpool, UK
| | | | | | - John Haughney
- Gartnavel General Hospital, University of Glasgow, Glasgow, UK
| | - Karen Innes
- Centre for Healthcare Randomised Trials (CHaRT), University of Aberdeen, Aberdeen, UK
| | - Joanna Kaniewska
- Centre for Healthcare Randomised Trials (CHaRT), University of Aberdeen, Aberdeen, UK
| | - Amanda Lee
- Medical Statistics Team, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Alyn Morice
- Cardiovascular and Respiratory Studies, Castle Hill Hospital, Cottingham, UK
| | - John Norrie
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | | | - Andrew Wilson
- Department of Medicine, Norwich Medical School, University of East Anglia, Norwich, UK
| | - David Price
- Respiratory Medicine, Aberdeen Royal Infirmary, University of Aberdeen, Aberdeen, UK.,Academic Primary Care, University of Aberdeen, Aberdeen, UK
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3
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Matera MG, Page CP, Calzetta L, Rogliani P, Cazzola M. Pharmacology and Therapeutics of Bronchodilators Revisited. Pharmacol Rev 2020; 72:218-252. [PMID: 31848208 DOI: 10.1124/pr.119.018150] [Citation(s) in RCA: 79] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Bronchodilators remain the cornerstone of the treatment of airway disorders such as asthma and chronic obstructive pulmonary disease (COPD). There is therefore considerable interest in understanding how to optimize the use of our existing classes of bronchodilator and in identifying novel classes of bronchodilator drugs. However, new classes of bronchodilator have proved challenging to develop because many of these have no better efficacy than existing classes of bronchodilator and often have unacceptable safety profiles. Recent research has shown that optimization of bronchodilation occurs when both arms of the autonomic nervous system are affected through antagonism of muscarinic receptors to reduce the influence of parasympathetic innervation of the lung and through stimulation of β 2-adrenoceptors (β 2-ARs) on airway smooth muscle with β 2-AR-selective agonists to mimic the sympathetic influence on the lung. This is currently achieved by use of fixed-dose combinations of inhaled long-acting β 2-adrenoceptor agonists (LABAs) and long-acting muscarinic acetylcholine receptor antagonists (LAMAs). Due to the distinct mechanisms of action of LAMAs and LABAs, the additive/synergistic effects of using these drug classes together has been extensively investigated. More recently, so-called "triple inhalers" containing fixed-dose combinations of both classes of bronchodilator (dual bronchodilation) and an inhaled corticosteroid in the same inhaler have been developed. Furthermore, a number of so-called "bifunctional drugs" having two different primary pharmacological actions in the same molecule are under development. This review discusses recent advancements in knowledge on bronchodilators and bifunctional drugs for the treatment of asthma and COPD. SIGNIFICANCE STATEMENT: Since our last review in 2012, there has been considerable research to identify novel classes of bronchodilator drugs, to further understand how to optimize the use of the existing classes of bronchodilator, and to better understand the role of bifunctional drugs in the treatment of asthma and chronic obstructive pulmonary disease.
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Affiliation(s)
- M G Matera
- Unit of Pharmacology, Department of Experimental Medicine, University of Campania "Luigi Vanvitelli," Naples, Italy (M.G.M.); Sackler Institute of Pulmonary Pharmacology, Institute of Pharmaceutical Science, King's College London, London, United Kingdom (C.P.P.); and Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome "Tor Vergata," Rome, Italy (L.C., P.R., M.C.)
| | - C P Page
- Unit of Pharmacology, Department of Experimental Medicine, University of Campania "Luigi Vanvitelli," Naples, Italy (M.G.M.); Sackler Institute of Pulmonary Pharmacology, Institute of Pharmaceutical Science, King's College London, London, United Kingdom (C.P.P.); and Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome "Tor Vergata," Rome, Italy (L.C., P.R., M.C.)
| | - L Calzetta
- Unit of Pharmacology, Department of Experimental Medicine, University of Campania "Luigi Vanvitelli," Naples, Italy (M.G.M.); Sackler Institute of Pulmonary Pharmacology, Institute of Pharmaceutical Science, King's College London, London, United Kingdom (C.P.P.); and Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome "Tor Vergata," Rome, Italy (L.C., P.R., M.C.)
| | - P Rogliani
- Unit of Pharmacology, Department of Experimental Medicine, University of Campania "Luigi Vanvitelli," Naples, Italy (M.G.M.); Sackler Institute of Pulmonary Pharmacology, Institute of Pharmaceutical Science, King's College London, London, United Kingdom (C.P.P.); and Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome "Tor Vergata," Rome, Italy (L.C., P.R., M.C.)
| | - M Cazzola
- Unit of Pharmacology, Department of Experimental Medicine, University of Campania "Luigi Vanvitelli," Naples, Italy (M.G.M.); Sackler Institute of Pulmonary Pharmacology, Institute of Pharmaceutical Science, King's College London, London, United Kingdom (C.P.P.); and Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome "Tor Vergata," Rome, Italy (L.C., P.R., M.C.)
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4
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AlAjmi MF, Azhar A, Owais M, Rashid S, Hasan S, Hussain A, Rehman MT. Antiviral potential of some novel structural analogs of standard drugs repurposed for the treatment of COVID-19. J Biomol Struct Dyn 2020; 39:6676-6688. [DOI: 10.1080/07391102.2020.1799865] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Mohamed F. AlAjmi
- Department of Pharmacognosy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Asim Azhar
- Interdisciplinary Biotechnology Unit, Aligarh Muslim University, Aligarh, Uttar Pradesh, India
| | - Mohd Owais
- Interdisciplinary Biotechnology Unit, Aligarh Muslim University, Aligarh, Uttar Pradesh, India
| | - Summya Rashid
- Department of Pharmacology and Toxicology, College of Pharmacy Girls Section, Prince Sattam Bin AbdulAziz University, Al Kharj, Saudi Arabia
| | - Sadaf Hasan
- Department of Orthopaedic Surgery, New York University, School of Medicine, New York, NY, USA
| | - Afzal Hussain
- Department of Pharmacognosy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Md Tabish Rehman
- Department of Pharmacognosy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
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5
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Cazzola M, Matera MG. The effect of doxofylline in asthma and COPD. Respir Med 2020; 164:105904. [PMID: 32094104 DOI: 10.1016/j.rmed.2020.105904] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 02/17/2020] [Indexed: 10/25/2022]
Abstract
Theophylline is still one of the most widely prescribed drugs for the treatment of asthma and COPD in developing countries because the majority of asthma and COPD medicines are largely unavailable and also because it is a cheap option. In any case, its anti-inflammatory effects and capacity to reverse corticosteroid resistance deserve consideration, but it can induce numerous side effects and drug-drug interactions and frequently requires measurement of drug levels in plasma. In order to overcome the problems posed by theophylline, other xanthines have been developed. Doxofylline is a newer generation xanthine with both bronchodilating and anti-inflammatory activities and for this reason it has been called "novofylline". It differs substantially from theophylline at the pharmacological level. Clinical studies have shown substantial differences between doxofylline and theophylline. In particular, efficacy/safety profile of doxofylline is better than that of theophylline.
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Affiliation(s)
- Mario Cazzola
- Chair of Respiratory Medicine, Department of Experimental Medicine, University of Rome Tor Vergata, Italy.
| | - Maria Gabriella Matera
- Chair of Pharmacology, Department of Experimental Medicine, University of Campania, Naples, Italy
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6
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Gholizadeh-Ghaleh Aziz S, Pashaiasl M, Khodadadi K, Ocheje O. Application of nanomaterials in three-dimensional stem cell culture. J Cell Biochem 2019; 120:18550-18558. [PMID: 31364198 DOI: 10.1002/jcb.29133] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 03/02/2019] [Accepted: 03/15/2019] [Indexed: 11/10/2022]
Abstract
Petri dish cultured cells have for long provided scientists an aperture to understanding cell's behavior both in normal and disease states as well as in vitro and in vivo. But recent advances have brought to light how the architecture and composite nature of the immediate environment within which the cell is proliferated can profoundly influence its phenotypic features and functions, thus making obvious, limitations of the conventional two-dimensional cell culture despite it cost effectiveness. Fortunately, the transition to three-dimensional (3D) cell culture has occurred concurrently with expanded knowledge of nanoscience and materials, thereby lending significant impetus for innovative research. This review is focused on the application of nanoparticles in 3D stem cell breeding, recent trends and developments in medical sciences for improved drug delivery, and treatment approaches to some human diseases. We also reviewed prevailing challenges and concerns of nanotoxicity as it continues to impede and delay clinical applications as well the ongoing concerted and multidisciplinary efforts to overcome them.
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Affiliation(s)
| | - Maryam Pashaiasl
- Department of Molecular Medicine, School of Advanced Medical Science, Tabriz University of Medical Science, Tabriz, Iran.,Women's Reproductive Health Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.,Department of Anatomical Sciences, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Khodadad Khodadadi
- Department of Molecular Medicine, School of Advanced Medical Science, Tabriz University of Medical Science, Tabriz, Iran.,Murdoch Childrens Research Institute, Royal Children's Hospital, Melbourne, Australia
| | - Onuche Ocheje
- Department of Medical Biotechnology, School of Advanced Technologies in Medicine, Tehran University of Medical Sciences, Tehran, Iran
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7
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Lin CC, Chen WJ, Liaw SF, Lin MW, Lin SC. Effects of aminophylline on airway epithelial-mesenchymal transition in brown Norway rats after repeated allergen challenge. Exp Lung Res 2019; 45:42-53. [PMID: 31064232 DOI: 10.1080/01902148.2019.1610116] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Purpose: Chronic asthma is characterized by airway inflammation and remodeling. The aim of this study is to evaluate the effects of aminophylline on airway epithelial-mesenchymal transition (EMT). Materials and methods: Two experimental groups of brown Norway rats that were repeatedly challenged with aerosolized ovalbumin (OA) were given oral aminophylline (OA-aminophylline group) or saline only (OA-saline group). A third group was challenged by saline as a control. The rats were anesthetized and pulmonary function were performed. Immuno-histochemical staining of epithelial markers (zonula occludens-1 (ZO-1)) and mesenchymal markers (vimentin) in the airway were performed. The protein expressions of ZO-1, E-cadherin, vimentin, fibronectine, TGF-ß1, SMAD 2/3, JNK, and p38 MAPK were examined by western blot. Results: Aminophylline had beneficial effects on airway inflammation, and airway remodeling in the OA-aminophylline group compared to the OA-saline group. The OA-saline group had decreased ZO-1 but increased vimentin according to immuno-histochemical staining. The protein expression indicated decreases in ZO-1 and E-cadherin but increases in vimentin, fibronectine, TGF-ß1, SMAD 2/3, JNK, and p38 MAPK in comparison to the other two groups. The OA-aminophylline group had higher ZO-1 but lower vimentin in immuno-histochemical staining compared to the OA-saline group. The protein expression showed higher ZO-1 and E-cadherin but lower vimentin, fibronectine, TGF-ß1, SMAD 2/3, JNK, and p38 MAPK when compared to the OA-saline group. Conclusions: Ovalbumin increases airway remodeling and airway EMT. Aminophylline is effective in preventing airway remodeling and airway EMT in Brown Norway rats after repeated allergen challenge.
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Affiliation(s)
- Ching-Chi Lin
- a Division of Pulmonary Medicine, Department of Internal Medicine , Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation , New Taipei City , Taiwan
| | - Wei-Ji Chen
- b Division of Pulmonary Medicine, Department of Internal Medicine , Lukang Christian Hospital , Changhua , Taiwan
| | - Shwu-Fang Liaw
- c Department of Medical Research , Mackay Memorial Hospital , Taipei , Taiwan
| | - Mei-Wei Lin
- a Division of Pulmonary Medicine, Department of Internal Medicine , Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation , New Taipei City , Taiwan
| | - Shiuan-Chi Lin
- a Division of Pulmonary Medicine, Department of Internal Medicine , Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation , New Taipei City , Taiwan
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8
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Page C, Cazzola M. Bifunctional Drugs for the Treatment of Respiratory Diseases. Handb Exp Pharmacol 2017; 237:197-212. [PMID: 27787715 DOI: 10.1007/164_2016_69] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Over the last decade, there has been a steady increase in the use of fixed dose combinations for the treatment of a range of diseases, including cancer, AIDS, tuberculosis and other infectious diseases. It is now evident that patients with asthma or chronic obstructive pulmonary disease (COPD) can also benefit from the use of fixed dose combinations, including combinations of a long-acting β2-agonist (LABA) and an inhaled corticosteroid (ICS), and combinations of LABAs and long-acting muscarinic receptor antagonists (LAMAs). There are now also "triple inhaler" fixed dose combinations (containing a LABA, LAMA and ICS) under development and already being made available in clinical practice, with the first such triple combination having been approved in India. The use of combinations containing drugs with complementary pharmacological actions in the treatment of patients with asthma or COPD has led to the discovery and development of drugs having two different primary pharmacological actions in the same molecule that we have called "bifunctional drugs". In this review we have discussed the state of the art of bifunctional drugs that can be categorized as bifunctional bronchodilators, bifunctional bronchodilator/anti-inflammatory drugs, bifunctional anti-inflammatory drugs and bifunctional mucolytic and anti-inflammatory drugs.
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Affiliation(s)
- Clive Page
- Sackler Institute of Pulmonary Pharmacology, Institute of Pharmaceutical Science, King's College London, 150 Stamford Street, London, SE1 9NH, UK.
| | - Mario Cazzola
- Division of Respiratory Medicine and Research Unit of Respiratory Clinical Pharmacology, Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy
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9
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Shih YN, Chen YT, Chu H, Shih CJ, Ou SM, Hsu YT, Chen RC, Quraishi SA, Aisiku IP, Seethala RR, Frendl G, Hou PC. Association of pre-hospital theophylline use and mortality in chronic obstructive pulmonary disease patients with sepsis. Respir Med 2017; 125:33-38. [PMID: 28340860 DOI: 10.1016/j.rmed.2017.02.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Revised: 02/24/2017] [Accepted: 02/25/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Although theophylline has been shown to have anti-inflammatory effects, the therapeutic use of theophylline before sepsis is unknown. The aim of our study was to determine the effect of theophylline on COPD patients presenting with sepsis. METHODS This nationwide, population-based, propensity score-matched analysis used data from the linked administrative databases of Taiwan's National Health Insurance program. Patients with COPD who were hospitalized for sepsis between 2000 and 2011 were divided into theophylline users and non-users. The primary outcome was 30-day mortality. The secondary outcome was in-hospital death, intensive care unit admission, and need for mechanical ventilation. Cox proportional hazard model and conditional logistic regression were used to calculate the risk between groups. RESULTS A propensity score-matched cohort of 51,801 theophylline users and 51,801 non-users was included. Compared with non-users, the 30-day (HR 0.931, 95% CI 0.910-0.953), 180-day (HR 0.930, 95% CI 0.914-0.946), 365-day (HR 0.944, 95% CI 0.929-0.960) and overall mortality (HR 0.965, 95% CI 0.952-0.979) were all significantly lower in theophylline users. Additionally, the theophylline users also had lower risk of in-hospital death (OR 0.895, 95% CI 0.873-0.918) and need for mechanical ventilation (OR 0.972, 95% CI 0.949-0.997). CONCLUSIONS Theophylline use is associated with a lower risk of sepsis-related mortality in COPD patients. Pre-hospital theophylline use may be protective to COPD patients with sepsis.
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Affiliation(s)
- Yu-Ning Shih
- Division of Emergency Critical Care Medicine, Department of Emergency Medicine, Brigham and Women's Hospital, USA; Surgical ICU Translational Research (STAR) Center, Brigham and Women's Hospital, Boston, MA, USA; Department of Chest Medicine, Taipei City Hospital, Heping Fuyou Branch, School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC; Harvard Medical School, Boston, MA, USA
| | - Yung-Tai Chen
- Department of Nephrology, Taipei City Hospital, Heping Fuyou Branch, School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC; School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Hsi Chu
- Department of Chest Medicine, Taipei City Hospital, Heping Fuyou Branch, School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Chia-Jen Shih
- School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC; Department of Medicine, Taipei Veterans General Hospital, Yuanshan Branch, Yilan, Taiwan, ROC
| | - Shuo-Ming Ou
- School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC; Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Yen-Tao Hsu
- Department of Chest Medicine, Taipei City Hospital, Heping Fuyou Branch, School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Ran-Chou Chen
- School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC; Department of Radiology, Taipei City Hospital, Heping Fuyou Branch, Taipei, Taiwan, ROC
| | - Sadeq A Quraishi
- Department of Anesthesiology, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Imoigele P Aisiku
- Division of Emergency Critical Care Medicine, Department of Emergency Medicine, Brigham and Women's Hospital, USA; Harvard Medical School, Boston, MA, USA
| | - Raghu R Seethala
- Division of Emergency Critical Care Medicine, Department of Emergency Medicine, Brigham and Women's Hospital, USA; Surgical ICU Translational Research (STAR) Center, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Gyorgy Frendl
- Surgical ICU Translational Research (STAR) Center, Brigham and Women's Hospital, Boston, MA, USA; Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Peter C Hou
- Division of Emergency Critical Care Medicine, Department of Emergency Medicine, Brigham and Women's Hospital, USA; Surgical ICU Translational Research (STAR) Center, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
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Abstract
Theophylline is an orally acting xanthine that has been used since 1937 for the treatment of respiratory diseases including asthma and chronic obstructive pulmonary disease (COPD). However, in most treatment guidelines, xanthines have now been consigned to third-line therapy because of their narrow therapeutic window and propensity for drug-drug interactions. However, lower than conventional doses of theophylline considered to be bronchodilator are now known to have anti-inflammatory actions of relevance to the treatment of respiratory disease. The molecular mechanism(s) of action of theophylline are not well understood, but several potential targets have been suggested including non-selective inhibition of phosphodiesterases (PDE), inhibition of phosphoinositide 3-kinase, adenosine receptor antagonism and increased activity of certain histone deacetylases. Although theophylline has a narrow therapeutic window, other xanthines are in clinical use that are claimed to have a better tolerability such as doxofylline and bamifylline. Nonetheless, xanthines still play an important role in the treatment of asthma and COPD as they can show clinical benefit in patients who are refractory to glucocorticosteroid therapy, and withdrawal of xanthines from patients causes worsening of disease, even in patients taking concomitant glucocorticosteroids.More recently the orally active selective PDE4 inhibitor, roflumilast, has been introduced into clinical practice for the treatment of severe COPD on top of gold standard treatment. This drug has been shown to improve lung function in patients with severe COPD and to reduce exacerbations, but is dose limited by a range side effect, particularly gastrointestinal side effects.
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Affiliation(s)
- D Spina
- The Sackler Institute of Pulmonary Pharmacology, Institute of Pharmaceutical Science, King's College London, Franklin Wilkins Building, London, SE1 9NH, UK
| | - C P Page
- The Sackler Institute of Pulmonary Pharmacology, Institute of Pharmaceutical Science, King's College London, Franklin Wilkins Building, London, SE1 9NH, UK.
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11
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Kwon JW, Song WJ, Kim MH, Lim KH, Yang MS, Jung JW, Lee J, Suh DI, Shin YS, Kim SH, Kim SH, Lee BJ, Cho SH. The KAAACI Standardization Committee Report on the procedure and application of fractional exhaled nitric oxide measurement. ALLERGY ASTHMA & RESPIRATORY DISEASE 2017. [DOI: 10.4168/aard.2017.5.4.185] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Jae-Woo Kwon
- Department of Internal Medicine, Kangwon National University School of Medicine, Chuncheon, Korea
| | - Woo-Jung Song
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Min-Hye Kim
- Department of Internal Medicine, Ewha Womans University School of Medicine, Seoul, Korea
| | - Kyung-Hwan Lim
- Department of Internal Medicine, Armed Forces Capital Hospital, Seongnam, Korea
| | - Min-Suk Yang
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Department of Internal Medicine, Seoul Metropolitan Government - Seoul National University Boramae Medical Center, Seoul, Korea
| | - Jae-Woo Jung
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Jeongmin Lee
- Department of Pediatrics, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Dong In Suh
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Yoo Seob Shin
- Department of Allergy and Clinical Immunology, Ajou University School of Medicine, Suwon, Korea
| | - Sae-Hoon Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Sang-Heon Kim
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Byung-Jae Lee
- Division of Allergy, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sang-Heon Cho
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
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12
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George L, Brightling CE. Eosinophilic airway inflammation: role in asthma and chronic obstructive pulmonary disease. Ther Adv Chronic Dis 2016; 7:34-51. [PMID: 26770668 DOI: 10.1177/2040622315609251] [Citation(s) in RCA: 198] [Impact Index Per Article: 24.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
The chronic lung diseases, asthma and chronic obstructive pulmonary disease (COPD), are common affecting over 500 million people worldwide and causing substantial morbidity and mortality. Asthma is typically associated with Th2-mediated eosinophilic airway inflammation, in contrast to neutrophilic inflammation observed commonly in COPD. However, there is increasing evidence that the eosinophil might play an important role in 10-40% of patients with COPD. Consistently in both asthma and COPD a sputum eosinophilia is associated with a good response to corticosteroid therapy and tailored strategies aimed to normalize sputum eosinophils reduce exacerbation frequency and severity. Advances in our understanding of the multistep paradigm of eosinophil recruitment to the airway, and the consequence of eosinophilic inflammation, has led to the development of new therapies to target these molecular pathways. In this article we discuss the mechanisms of eosinophilic trafficking, the tools to assess eosinophilic airway inflammation in asthma and COPD during stable disease and exacerbations and review current and novel anti-eosinophilic treatments.
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Affiliation(s)
- Leena George
- Institute for Lung Health, NIHR Respiratory Biomedical Research Unit, Department of Infection, Immunity and Inflammation, University of Leicester and University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Christopher E Brightling
- Institute for Lung Health, Clinical Science Wing, University Hospital of Leicester, Leicester LE3 9QP, UK
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13
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Albertson TE, Schivo M, Gidwani N, Kenyon NJ, Sutter ME, Chan AL, Louie S. Pharmacotherapy of critical asthma syndrome: current and emerging therapies. Clin Rev Allergy Immunol 2015; 48:7-30. [PMID: 24178860 DOI: 10.1007/s12016-013-8393-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
The critical asthma syndrome (CAS) encompasses the most severe, persistent, refractory asthma patients for the clinician to manage. Personalized pharmacotherapy is necessary to prevent the next acute severe asthma exacerbation, not just the control of symptoms. The 2007 National Asthma Education and Prevention Program Expert Panel 3 provides guidelines for the treatment of uncontrolled asthma. The patient's response to recommended pharmacotherapy is highly variable which risks poor asthma control leading to frequent exacerbations that can deteriorate into CAS. Controlling asthma symptoms and preventing acute exacerbations may be two separate clinical activities with their own unique demands. Clinicians must be prepared to use the entire spectrum of asthma medications available but must concurrently be aware of potential drug toxicities some of which can paradoxically worsen asthma control. Medications normally prescribed for COPD can potentially be useful in the CAS patient, particularly those with asthma-COPD overlap syndrome. Immunomodulation with drugs like omalizumab in IgE-mediated asthma syndromes is one important approach. New and emerging drugs address unique aspects of airway inflammation and biology but at a significant financial cost. The pharmacology and toxicities of the agents that may be used in the treatment of CAS to control asthma symptoms and prevent severe exacerbations are reviewed.
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Affiliation(s)
- T E Albertson
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, School of Medicine, University of California, Davis, Sacramento, CA, 95817, USA,
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Zhao H, Li R, Lv Y, Dong H, Yao L, Wu Y, Xiao G, Cai S. Albuterol inhalation increases FeNO level in steroid-naive asthmatics but not COPD patients with reversibility. CLINICAL RESPIRATORY JOURNAL 2015; 11:328-336. [PMID: 26077165 DOI: 10.1111/crj.12340] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 12/26/2014] [Revised: 05/22/2015] [Accepted: 06/12/2015] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Fractional exhaled nitric oxide (FeNO) has been used as a marker of airway inflammation. Airway caliber is related to the level of FeNO in asthmatics. OBJECTIVES This study aimed to investigate whether airway obstruction could interfere with real FENO levels and if different FeNO changes after albuterol inhalation could assist in distinguishing asthma from chronic obstructive pulmonary disease (COPD). METHODS FeNO and spirometry measurements were performed before and after albuterol inhalation in the following three patient groups: 30 steroid-naive asthmatics, 25 asthmatics inhaling corticosteroids/long-acting β(2)-adrenergic agonists for at least 1 month and 20 COPD patients. Bronchodilator test (BDT) results were positive in all patients enrolled. The correlations among FeNO levels, pulmonary function and sputum eosinophil counts were analyzed. RESULTS FeNO increased significantly after albuterol inhalation in steroid-naive asthmatics but not in ICS-treated asthmatics or COPD patients. The FeNO levels demonstrated no significant correlation with spirometry results or sputum eosinophil counts before or after inhaling bronchodilator in all three groups. Both the levels of FeNO and changes in FENO after albuterol inhalation in steroid-naive asthma patients were higher than those in ICS-treated asthmatics and COPD patients (P < 0.001). The differences remained after proper adjustment for confounding factors (gender, age, smoking pack-years, ICS-treated and pulmonary function index). CONCLUSIONS Our results support the role of FeNO in differentiating asthmatics from COPD patients with positive BDT. FeNO detection after albuterol inhalation should be encouraged in steroid-naive asthma patients with airway obstruction.
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Affiliation(s)
- Haijin Zhao
- Department of Respiratory and Critical Care Medicine, Chronic Airways Diseases Laboratory, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Rui Li
- Department of Respiratory and Critical Care Medicine, Chronic Airways Diseases Laboratory, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Yanhua Lv
- Department of Respiratory and Critical Care Medicine, Chronic Airways Diseases Laboratory, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Hangming Dong
- Department of Respiratory and Critical Care Medicine, Chronic Airways Diseases Laboratory, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Lihong Yao
- Department of Respiratory and Critical Care Medicine, Chronic Airways Diseases Laboratory, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Yue Wu
- Department of Respiratory and Critical Care Medicine, Chronic Airways Diseases Laboratory, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Guanhua Xiao
- Department of Respiratory and Critical Care Medicine, Chronic Airways Diseases Laboratory, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Shaoxi Cai
- Department of Respiratory and Critical Care Medicine, Chronic Airways Diseases Laboratory, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
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Devereux G, Cotton S, Barnes P, Briggs A, Burns G, Chaudhuri R, Chrystyn H, Davies L, De Soyza A, Fielding S, Gompertz S, Haughney J, Lee AJ, McCormack K, McPherson G, Morice A, Norrie J, Sullivan A, Wilson A, Price D. Use of low-dose oral theophylline as an adjunct to inhaled corticosteroids in preventing exacerbations of chronic obstructive pulmonary disease: study protocol for a randomised controlled trial. Trials 2015; 16:267. [PMID: 26058585 PMCID: PMC4465017 DOI: 10.1186/s13063-015-0782-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Accepted: 05/27/2015] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) is associated with high morbidity, mortality, and health-care costs. An incomplete response to the anti-inflammatory effects of inhaled corticosteroids is present in COPD. Preclinical work indicates that 'low dose' theophylline improves steroid responsiveness. The Theophylline With Inhaled Corticosteroids (TWICS) trial investigates whether the addition of 'low dose' theophylline to inhaled corticosteroids has clinical and cost-effective benefits in COPD. METHOD/DESIGN TWICS is a randomised double-blind placebo-controlled trial conducted in primary and secondary care sites in the UK. The inclusion criteria are the following: an established predominant respiratory diagnosis of COPD (post-bronchodilator forced expiratory volume in first second/forced vital capacity [FEV1/FVC] of less than 0.7), age of at least 40 years, smoking history of at least 10 pack-years, current inhaled corticosteroid use, and history of at least two exacerbations requiring treatment with antibiotics or oral corticosteroids in the previous year. A computerised randomisation system will stratify 1424 participants by region and recruitment setting (primary and secondary) and then randomly assign with equal probability to intervention or control arms. Participants will receive either 'low dose' theophylline (Uniphyllin MR 200 mg tablets) or placebo for 52 weeks. Dosing is based on pharmacokinetic modelling to achieve a steady-state serum theophylline of 1-5 mg/l. A dose of theophylline MR 200 mg once daily (or placebo once daily) will be taken by participants who do not smoke or participants who smoke but have an ideal body weight (IBW) of not more than 60 kg. A dose of theophylline MR 200 mg twice daily (or placebo twice daily) will be taken by participants who smoke and have an IBW of more than 60 kg. Participants will be reviewed at recruitment and after 6 and 12 months. The primary outcome is the total number of participant-reported COPD exacerbations requiring oral corticosteroids or antibiotics during the 52-week treatment period. DISCUSSION The demonstration that 'low dose' theophylline increases the efficacy of inhaled corticosteroids in COPD by reducing the incidence of exacerbations is relevant not only to patients and clinicians but also to health-care providers, both in the UK and globally. TRIAL REGISTRATION Current Controlled Trials ISRCTN27066620 was registered on Sept. 19, 2013, and the first subject was randomly assigned on Feb. 6, 2014.
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Affiliation(s)
- Graham Devereux
- Respiratory Medicine, Chest Clinic C, Aberdeen Royal Infirmary, University of Aberdeen, Aberdeen, AB25 2ZN, UK.
| | - Seonaidh Cotton
- Centre for Healthcare Randomised Trials (CHaRT), University of Aberdeen, Aberdeen, AB25 2ZN, UK.
| | - Peter Barnes
- Imperial College, National Heart & Lung Institute, Dovehouse Street, London, SW3 6LY, UK.
| | - Andrew Briggs
- Institute of Health & Wellbeing, University of Glasgow, 1 Lilybank Gardens, Glasgow, G12 8RZ, UK.
| | - Graham Burns
- Department of Respiratory Medicine, Royal Victoria Infirmary, Newcastle Upon Tyne, NE1 4LP, UK.
| | - Rekha Chaudhuri
- Gartnavel General Hospital, University of Glasgow, Glasgow, G12 0YN, UK.
| | - Henry Chrystyn
- Division of Pharmacy & Pharmaceutical Sciences, University of Huddersfield, Huddersfield, HD1 3DH, UK.
| | - Lisa Davies
- Aintree Chest Centre, University Hospital Aintree, Liverpool, L9 7AL, UK.
| | - Anthony De Soyza
- Medical School, University of Newcastle, Newcastle Upon Tyne, NE2 4HH, UK.
| | - Shona Fielding
- Medical Statistics Team, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, AB25 2ZD, UK.
| | - Simon Gompertz
- Queen Elizabeth Hospital Birmingham, Birmingham, B15 2WB, UK.
| | - John Haughney
- Centre of Academic Primary Care, University of Aberdeen, Aberdeen, AB25 2ZD, UK.
| | - Amanda J Lee
- Medical Statistics Team, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, AB25 2ZD, UK.
| | - Kirsty McCormack
- Centre for Healthcare Randomised Trials (CHaRT), University of Aberdeen, Aberdeen, AB25 2ZN, UK.
| | - Gladys McPherson
- Centre for Healthcare Randomised Trials (CHaRT), University of Aberdeen, Aberdeen, AB25 2ZN, UK.
| | - Alyn Morice
- Cardiovascular and Respiratory Studies, Castle Hill Hospital, Hull, HU16 5JQ, UK.
| | - John Norrie
- Centre for Healthcare Randomised Trials (CHaRT), University of Aberdeen, Aberdeen, AB25 2ZN, UK.
| | - Anita Sullivan
- Queen Elizabeth Hospital Birmingham, Birmingham, B15 2WB, UK.
| | - Andrew Wilson
- Department of Medicine, Norwich Medical School, University of East Anglia, Norwich, NR4 7TJ, UK.
| | - David Price
- Centre of Academic Primary Care, University of Aberdeen, Aberdeen, AB25 2ZD, UK.
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16
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Salama RO, Young PM, Traini D. Concurrent oral and inhalation drug delivery using a dual formulation system: the use of oral theophylline carrier with combined inhalable budesonide and terbutaline. Drug Deliv Transl Res 2015; 4:256-67. [PMID: 25786880 DOI: 10.1007/s13346-013-0137-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
A novel approach to concurrently deliver oral and inhaled drugs as a single formulation is presented. A triple therapy containing theophylline (THEO; orally delivered) with budesonide (BUD) and terbutaline (TERB; as single and co-spray-dried inhaled powders) was prepared as an ordered mix, with THEO acting as a carrier. The aerosolisation performance of THEO formulations containing BUD and TERB alone, physical mix and co-spray-dried powder was evaluated using a next-generation impactor (NGI). Physicochemical properties were investigated using electron microscopy, laser diffraction, dynamic vapour sorption and thermal analysis. NGI analysis indicated that >99 % of the THEO powder was >4.46 μm, with >90 % dissolved within 5 min. Particle size analysis showed TEB and BUD samples were of a suitable size for inhalation. Thermal and moisture analysis suggested powders to be stable at room temperature up to 70 % RH. Aerosol studies indicated a different performance of BUD and TERB depending on the mixing procedure. The co-spray-dried formulation showed the highest performance, with a fine particle fraction (≤4.46 μm) of BUD and TERB of 34.39 ± 3.56 and 33.61 ± 5.67 %, respectively. Such observations suggest that this multicomponent drug delivery system could be developed to concomitantly deliver oral and inhaled drugs, an approach that, to date, does not exist. Ultimately, this technology potentially reduces the requirement for multiple therapies and increases patient compliance.
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Affiliation(s)
- Rania O Salama
- Respiratory Technology, Woolcock Institute of Medical Research, 431 Glebe Point Road, Glebe, NSW, 2037, Australia
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17
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Fractional Exhaled Nitric Oxide: Indications and Interpretation. DIAGNOSTIC TESTS IN PEDIATRIC PULMONOLOGY 2015. [DOI: 10.1007/978-1-4939-1801-0_14] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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18
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Watanabe K, Shinkai M, Shinoda M, Hara Y, Yamaguchi N, Rubin BK, Ishigatsubo Y, Kaneko T. Measurement of eNO with portable analyser might improve the management of persistent cough at primary care practice in Japan. CLINICAL RESPIRATORY JOURNAL 2014; 10:380-8. [PMID: 25307553 DOI: 10.1111/crj.12228] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Revised: 07/23/2014] [Accepted: 09/29/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND AIMS There are some controversial reports that investigated the usefulness of exhaled nitric oxide (eNO) to predict the efficacy of inhaled corticosteroids (ICS) in chronic cough patients. Therefore, we retrospectively analysed the usefulness of eNO measurement with portable analyser to predict the requirement of ICS therapy in persistent cough (defined as lasting for 3 weeks or more) patients in Japan and investigated whether it might improve the management of persistent cough at primary care practice. METHODS We retrospectively reviewed the clinical records of adult patients who had been referred to our hospital for persistent cough from 1 June 2009 to 30 April 2011. RESULTS Forty-two patients had the requirement of ICS (group S) and 35 patients had no requirement of ICS (group N). Forty-three per cent of the patients who required ICS had not received ICS, and 29% of the patients who did not required ICS had received ICS. In the steroid-naive patients without current smoking, mean eNO level was significantly higher in group S [60.6 ± 14.1 parts per billion (ppb) vs 22.2 ± 2.3 ppb, P = 0.001] and the sensitivity and the specificity of eNO for predicting the requirement of ICS were 78.6% and 80.0%, respectively. The rate of the patients who received inappropriate treatment about ICS tended to be reduced from 41% to 21% if the eNO was used to predict the requirement of ICS with cut-off value of eNO 26.5 ppb (P = 0.118). CONCLUSION Measurement of eNO could be one of the management tools for persistent cough at primary care practice.
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Affiliation(s)
- Keisuke Watanabe
- Respiratory Disease Center, Yokohama City University Medical Center, Yokohama, Japan
| | - Masaharu Shinkai
- Respiratory Disease Center, Yokohama City University Medical Center, Yokohama, Japan
| | - Masahiro Shinoda
- Respiratory Disease Center, Yokohama City University Medical Center, Yokohama, Japan
| | - Yu Hara
- Respiratory Disease Center, Yokohama City University Medical Center, Yokohama, Japan
| | - Nobuhiro Yamaguchi
- Respiratory Disease Center, Yokohama City University Medical Center, Yokohama, Japan
| | - Bruce K Rubin
- Department of Pediatrics, Virginia Commonwealth University, Richmond, VA, USA
| | - Yoshiaki Ishigatsubo
- Department of Internal Medicine and Clinical Immunology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Takeshi Kaneko
- Department of Pulmonology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
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Felton JM, Lucas CD, Rossi AG, Dransfield I. Eosinophils in the lung - modulating apoptosis and efferocytosis in airway inflammation. Front Immunol 2014; 5:302. [PMID: 25071763 PMCID: PMC4076794 DOI: 10.3389/fimmu.2014.00302] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Accepted: 06/15/2014] [Indexed: 01/09/2023] Open
Abstract
Due to the key role of the lung in efficient transfer of oxygen in exchange for carbon dioxide, a controlled inflammatory response is essential for restoration of tissue homeostasis following airway exposure to bacterial pathogens or environmental toxins. Unregulated or prolonged inflammatory responses in the lungs can lead to tissue damage, disrupting normal tissue architecture, and consequently compromising efficient gaseous exchange. Failure to resolve inflammation underlies the development and/or progression of a number of inflammatory lung diseases including asthma. Eosinophils, granulocytic cells of the innate immune system, are primarily involved in defense against parasitic infections. However, the propagation of the allergic inflammatory response in chronic asthma is thought to involve excessive recruitment and impaired apoptosis of eosinophils together with defective phagocytic clearance of apoptotic cells (efferocytosis). In terms of therapeutic approaches for the treatment of asthma, the widespread use of glucocorticoids is associated with a number of adverse health consequences after long-term use, while some patients suffer from steroid-resistant disease. A new approach for therapeutic intervention would be to promote the resolution of inflammation via modulation of eosinophil apoptosis and the phagocytic clearance of apoptotic cells. This review focuses on the mechanisms underpinning eosinophil-mediated lung damage, currently available treatments and therapeutic targets that might in future be harnessed to facilitate inflammation resolution by the manipulation of cell survival and clearance pathways.
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Affiliation(s)
- Jennifer M. Felton
- MRC Centre for Inflammation Research, Queen’s Medical Research Institute, The University of Edinburgh, Edinburgh, UK
| | - Christopher D. Lucas
- MRC Centre for Inflammation Research, Queen’s Medical Research Institute, The University of Edinburgh, Edinburgh, UK
| | - Adriano G. Rossi
- MRC Centre for Inflammation Research, Queen’s Medical Research Institute, The University of Edinburgh, Edinburgh, UK
| | - Ian Dransfield
- MRC Centre for Inflammation Research, Queen’s Medical Research Institute, The University of Edinburgh, Edinburgh, UK
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20
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Mitochondria in the center of human eosinophil apoptosis and survival. Int J Mol Sci 2014; 15:3952-69. [PMID: 24603536 PMCID: PMC3975377 DOI: 10.3390/ijms15033952] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Revised: 02/20/2014] [Accepted: 02/26/2014] [Indexed: 12/13/2022] Open
Abstract
Eosinophils are abundantly present in most phenotypes of asthma and they contribute to the maintenance and exacerbations of the disease. Regulators of eosinophil longevity play critical roles in determining whether eosinophils accumulate into the airways of asthmatics. Several cytokines enhance eosinophil survival promoting eosinophilic airway inflammation while for example glucocorticoids, the most important anti-inflammatory drugs used to treat asthma, promote the intrinsic pathway of eosinophil apoptosis and by this mechanism contribute to the resolution of eosinophilic airway inflammation. Mitochondria seem to play central roles in both intrinsic mitochondrion-centered and extrinsic receptor-mediated pathways of apoptosis in eosinophils. Mitochondria may also be important for survival signalling. In addition to glucocorticoids, another important agent that regulates human eosinophil longevity via mitochondrial route is nitric oxide, which is present in increased amounts in the airways of asthmatics. Nitric oxide seems to be able to trigger both survival and apoptosis in eosinophils. This review discusses the current evidence of the mechanisms of induced eosinophil apoptosis and survival focusing on the role of mitochondria and clinically relevant stimulants, such as glucocorticoids and nitric oxide.
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21
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Theophylline inhibits the cough reflex through a novel mechanism of action. J Allergy Clin Immunol 2014; 133:1588-98. [PMID: 24406072 PMCID: PMC4048545 DOI: 10.1016/j.jaci.2013.11.017] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2013] [Revised: 11/08/2013] [Accepted: 11/19/2013] [Indexed: 01/25/2023]
Abstract
Background Theophylline has been used in the treatment of asthma and chronic obstructive pulmonary disease for more than 80 years. In addition to bronchodilator and anti-inflammatory activity, clinical studies have suggested that theophylline acts as an antitussive agent. Cough is the most frequent reason for consultation with a family doctor, and treatment options are limited. Determining how theophylline inhibits cough might lead to the development of optimized compounds. Objective We sought to investigate the inhibitory activity of theophylline on vagal sensory nerve activity and the cough reflex. Methods Using a range of techniques, we investigated the effect of theophylline on human and guinea pig vagal sensory nerve activity in vitro and on the cough reflex in guinea pig challenge models. Results Theophylline was antitussive in a guinea pig model, inhibited activation of single C-fiber afferents in vivo and depolarization of human and guinea pig vagus in vitro, and inhibited calcium influx in airway-specific neurons in vitro. A sequence of pharmacological studies on the isolated vagus and patch clamp and single-channel inside-out experiments showed that the effect of theophylline was due to an increase in the open probability of calcium-activated potassium channels. Finally, we demonstrated the antitussive activity of theophylline in a cigarette smoke exposure model that exhibited enhanced tussive responses to capsaicin. Conclusion Theophylline inhibits capsaicin-induced cough under both normal and “disease” conditions by decreasing the excitability of sensory nerves through activation of small- and intermediate-conductance calcium-activated potassium channels. These findings could lead to the development of optimized antitussive compounds with a reduced side effect potential.
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Abstract
During inspiration and expiration, gases traverse the conducting airways as they are transported between the environment and the alveolar region of the lungs. The term "conducting" airways is used broadly as the airway tree is thought largely to provide a conduit for the respiratory gases, oxygen and carbon dioxide. However, despite a significantly smaller surface area, and thicker barrier separating the gas phase from the blood when compared to the alveolar region, the airway tree can participate in gas exchange under special conditions such as high water solubility, high chemical reactivity, or production of the gas within the airway wall tissue. While these conditions do not apply to the respiratory gases, other gases demonstrate substantial exchange of the airways and are of particular importance to the inflammatory response of the lungs, the medical-legal field, occupational health, metabolic disorders, or protection of the delicate alveolar membrane. Given the significant structural differences between the airways and the alveolar region, the physical determinants that control airway gas exchange are unique and require different models (both experimental and mathematical) to explore. Our improved physiological understanding of airway gas exchange combined with improved analytical methods to detect trace compounds in the exhaled breath provides future opportunities to develop new exhaled biomarkers that are characteristic of pulmonary and systemic conditions.
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Affiliation(s)
- Steven C George
- Department of Biomedical Engineering, University of California, Irvine, California, USA.
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23
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Abstract
Theophylline (dimethylxanthine) has been used to treat airway diseases for more than 80 years. It was originally used as a bronchodilator, but the relatively high doses required are associated with frequent side effects, so its use declined as inhaled β2-agonists became more widely used. More recently it has been shown to have antiinflammatory effects in asthma and chronic obstructive pulmonary disease (COPD) at lower concentrations. The molecular mechanism of bronchodilatation is inhibition of phosphodiesterase (PDE)3, but the antiinflammatory effect may be due to inhibition of PDE4 and histone deacetylase-2 activation, resulting in switching off of activated inflammatory genes. Through this mechanism, theophylline also reverses corticosteroid resistance, and this may be of particular value in severe asthma and COPD, wherein histone deacetylase-2 activity is reduced. Theophylline is given systemically (orally as slow-release preparations for chronic treatment and intravenously for acute exacerbations of asthma). Efficacy is related to blood concentrations, which are determined mainly by hepatic metabolism, which may be increased or decreased in several diseases and by concomitant drug therapy. Theophylline is now usually used as an add-on therapy in patients with asthma not well controlled on inhaled corticosteroids with or without long-acting β2-agonists and in patients with COPD with severe disease not controlled by bronchodilator therapy. Side effects are related to plasma concentrations and include nausea, vomiting, and headaches due to PDE inhibition and at higher concentrations to cardiac arrhythmias and seizures due to adenosine A1-receptor antagonism. In the future, low-dose theophylline may be useful in reversing corticosteroid resistance in COPD and severe asthma.
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Affiliation(s)
- Peter J Barnes
- 1 National Heart and Lung Institute, Imperial College, London, United Kingdom
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Ilmarinen P, Kankaanranta H. Eosinophil apoptosis as a therapeutic target in allergic asthma. Basic Clin Pharmacol Toxicol 2013; 114:109-17. [PMID: 24148899 DOI: 10.1111/bcpt.12163] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2013] [Accepted: 10/17/2013] [Indexed: 01/21/2023]
Abstract
Asthma is a chronic inflammatory disease of the airways manifesting in many different phenotypes. Allergic asthma, comprising approximately half of patients with asthma, is characterized by the accumulation of eosinophils into the lungs. Eosinophils release factors that damage the surrounding cells and participate in the maintenance and exacerbation of inflammation. In the absence of any inflammatory survival-prolonging factors, eosinophils die by apoptosis in few days but in inflamed airways, eosinophil survival is thought to be prolonged due to the surrounding pro-inflammatory factors such as IL-5, IL-3 and GM-CSF. Resolution of eosinophilic inflammation is an important goal in the treatment of allergic asthma. Apoptosis is a physiological and non-inflammatory way to eliminate these harmful cells, and development of drugs targeting eosinophil apoptosis is one possible strategy for the therapy of allergic asthma. Importance of this strategy is supported by the fact that promotion of eosinophil apoptosis is a property of many anti-asthmatic agents such as glucocorticoids, the current main anti-inflammatory therapy of asthma, theophylline and leukotriene modifiers. β2 agonists have been shown to modulate eosinophil longevity by increasing survival. Also, anti-IL-5 antibody mesolizumab has shown efficacy in reducing asthma exacerbations in patients with severe eosinophilic asthma. Many potential future anti-asthmatic agents, such as Siglec-8 activating antibody and novel humanized anti-IL-5 antibody MEDI-563, have the property of inducing eosinophil apoptosis. This MiniReview aims to present eosinophil apoptosis as a therapeutic target in the treatment of allergic asthma. We summarize the effects and mechanisms of current and potential future anti-asthmatic drugs on eosinophil apoptosis and additionally, discuss the potential factors that promote eosinophil longevity in the lungs.
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Affiliation(s)
- Pinja Ilmarinen
- The Immunopharmacology Research Group, University of Tampere School of Medicine and Tampere University Hospital, Tampere, Finland
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25
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Hahn YS. Measurements of fractional exhaled nitric oxide in pediatric asthma. KOREAN JOURNAL OF PEDIATRICS 2013; 56:424-30. [PMID: 24244210 PMCID: PMC3827490 DOI: 10.3345/kjp.2013.56.10.424] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/17/2013] [Accepted: 08/27/2013] [Indexed: 01/19/2023]
Abstract
Exhaled nitric oxide (NO) has been extensively investigated as a noninvasive marker of airway inflammation in asthma. The increased NO expression induced by inflammatory mediators in airways can be monitored easily in exhaled air from asthmatic children. Based on the relationship between the increased NO expression and eosinophilic airway inflammation, fractional exhaled nitric oxide (FeNO) measurements become an important adjunct for the evaluation of asthma. In addition, the availability of portable devices makes it possible to measure FeNO more easily and frequently in the routine pediatric practice. Despite various confounding factors affecting its levels, FeNO can be applicable in diagnosing asthma, monitoring treatment response, evaluating asthma control, and predicting asthma exacerbations. Thus, although pulmonary function tests are the standard tools for objective measurements of asthmatic control, FeNO can broaden the way of asthma monitoring and supplement standard clinical asthma care guidelines.
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Affiliation(s)
- Youn-Soo Hahn
- Department of Pediatrics, Chungbuk National University College of Medicine, Cheongju, Korea
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Biomarker surrogates do not accurately predict sputum eosinophil and neutrophil percentages in asthmatic subjects. J Allergy Clin Immunol 2013; 132:72-80. [PMID: 23706399 DOI: 10.1016/j.jaci.2013.03.044] [Citation(s) in RCA: 187] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2012] [Revised: 03/05/2013] [Accepted: 03/13/2013] [Indexed: 01/21/2023]
Abstract
BACKGROUND Sputum eosinophil percentages are a strong predictor of airway inflammation and exacerbations and aid asthma management, whereas sputum neutrophil percentages indicate a different severe asthma phenotype that is potentially less responsive to TH2-targeted therapy. Variables, such as blood eosinophil counts, total IgE levels, fraction of exhaled nitric oxide (Feno) levels, or FEV1 percent predicted, might predict airway eosinophil percentages, whereas age, FEV1 percent predicted, or blood neutrophil counts might predict sputum neutrophil percentages. Availability and ease of measurement are useful characteristics, but accuracy in predicting airway eosinophil and neutrophil percentages either individually or combined is not established. OBJECTIVES We sought to determine whether blood eosinophil counts, Feno levels, and IgE levels accurately predict sputum eosinophil percentages and whether age, FEV1 percent predicted, and blood neutrophil counts accurately predict sputum neutrophil percentages. METHODS Subjects in the Wake Forest Severe Asthma Research Program (n = 328) were characterized by blood and sputum cell counts, health care use, lung function, Feno levels, and IgE levels. Multiple analytic techniques were used. RESULTS Despite significant association with sputum eosinophil percentages, blood eosinophil counts, Feno levels, and total IgE levels did not accurately predict sputum eosinophil percentages, and combinations of these variables did not improve prediction. Age, FEV1 percent predicted, and blood neutrophil counts were similarly unsatisfactory for the prediction of sputum neutrophil percentages. Factor analysis and stepwise selection found Feno levels, IgE levels, and FEV1 percent predicted, but not blood eosinophil counts, correctly predicted 69% of sputum eosinophil percentages of less than 2% or 2% and greater. Likewise, age, asthma duration, and blood neutrophil counts correctly predicted 64% of sputum neutrophil percentages of less than 40% or 40% and greater. A model to predict both sputum eosinophil and neutrophil percentages accurately assigned only 41% of samples. CONCLUSION Despite statistically significant associations, Feno levels, IgE levels, blood eosinophil and neutrophil counts, FEV1 percent predicted, and age are poor surrogates, both separately and combined, for accurately predicting sputum eosinophil and neutrophil percentages.
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Abstract
The principal aims of asthma management in childhood are to obtain symptom control that allows individuals to engage in unrestricted physical activities and to normalize lung function. These aims should be achieved using the fewest possible medications. Ensuring a correct diagnosis is the first priority. The mainstay of asthma management remains pharmacotherapy. Various treatment options are discussed. Asthma monitoring includes the regular assessment of asthma severity and asthma control, which then informs decisions regarding the stepping up or stepping down of therapy. Delivery systems and devices for inhaled therapy are discussed, as are the factors influencing adherence to prescribed treatment. The role of the pediatric health care provider is to establish a functional partnership with the child and their family in order to minimize the impact of asthma symptoms and exacerbations during childhood.
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Affiliation(s)
- André Schultz
- School of Paediatrics and Child Health, University of Western Australia, Perth, Australia
- Department of Respiratory Medicine, Princess Margaret Hospital for Children, Perth, Australia
- Department of Paediatric and Adolescent Medicine, Princess Margaret Hospital for Children, Perth, Australia
| | - Andrew C. Martin
- School of Paediatrics and Child Health, University of Western Australia, Perth, Australia
- Department of Paediatric and Adolescent Medicine, Princess Margaret Hospital for Children, Perth, Australia
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Ludviksdottir D, Diamant Z, Alving K, Bjermer L, Malinovschi A. Clinical aspects of using exhaled NO in asthma diagnosis and management. CLINICAL RESPIRATORY JOURNAL 2012; 6:193-207. [DOI: 10.1111/crj.12001] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
| | | | - Kjell Alving
- Department of Women's and Children's Health; Uppsala University; Uppsala; Sweden
| | - Leif Bjermer
- Department of Respiratory Diseases and Allergology; Skane University; Lund; Sweden
| | - Andrei Malinovschi
- Department of Medical Sciences: Clinical Physiology; Uppsala University; Uppsala; Sweden
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Comparative monitoring of oral theophylline treatment in blood serum, saliva, and nasal mucus. Ther Drug Monit 2012; 34:217-21. [PMID: 22377744 DOI: 10.1097/ftd.0b013e3182492a20] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Theophylline, used in the treatment for various pulmonary pathologies, is usually given orally with drug levels measured primarily in blood serum and occasionally in saliva. Although theophylline treatment is now not commonly used it has been effective to correct smell loss (hyposmia). This is important because 21 million people in the United States exhibit hyposmia and oral theophylline has corrected hyposmia in about 50% of these patients. This result suggests that oral theophylline may result in the drug not only appearing in the serum but also in nasal mucus, thereby playing a role in correcting hyposmia. No prior report of theophylline in nasal mucus has been made and no comparison of levels in nasal mucus, blood serum, or saliva has been previously reported. PURPOSE The aim was to determine, after oral theophylline treatment, if it is present in nasal mucus and, if present, to compare the levels with those in serum and saliva. METHODS Oral theophylline was given to 23 hyposmic patients at daily doses of 200, 300, 400, 600, and 800 mg for periods of 2-10 months. During each period, blood serum, saliva, and nasal mucus were collected and theophylline measured in each fluid. RESULTS Theophylline was found in nasal mucus and in saliva and blood serum at each drug dose in each patient to whom it was given. The mean level of theophylline in nasal mucus was 74% that of serum; mean level in saliva was 67% of serum; mean level in nasal mucus was 111% that in saliva. CONCLUSIONS Theophylline is present in nasal mucus after oral administration. Levels in nasal mucus reflect blood and saliva levels in a consistent manner and offer a simple convenient noninvasive method to monitor theophylline doses of the oral drug.
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Royce SG, Ververis K, Karagiannis TC. Controversies Surrounding the Potential Use of Histone Deacetylase Inhibitors for the Treatment of Asthma. ACTA ACUST UNITED AC 2012. [DOI: 10.5402/2012/452307] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Management of asthma with long-acting β2-adrenergic receptor agonists and corticosteroids is exceptionally effective for the majority of asthma patients. However, corticosteroid insensitivity or resistance remains a significant clinical problem for a significant proportion of patients, requiring the investigation of new potential therapeutics for asthma. Histone deacetylase inhibitors represent a different class of compounds that have been evaluated for their potential antiasthmatic effects. Although accumulating evidence is indicating beneficial effects in rodent models of allergic airways disease, the potential use of histone deacetylase inhibitors in asthma remains controversial given their mechanisms of action. The aim of this paper is to provide an overview of histone deacetylases and pharmacological modifiers of these enzymes. The discussion represents a balanced account of the emerging evidence indicating the beneficial effects of histone deacetylase inhibitors in inflammatory lung diseases. The potential problems associated with the use of this class of compounds in asthma are also carefully considered.
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Affiliation(s)
- Simon G. Royce
- Allergy and Immune Disorders, Murdoch Children’s Research Institute, Parkville, VIC, Australia
- Department of Pathology, The University of Melbourne, Parkville, VIC, Australia
| | - Katherine Ververis
- Department of Pathology, The University of Melbourne, Parkville, VIC, Australia
- Epigenomic Medicine, Baker IDI Heart and Diabetes Institute, The Alfred Medical Research and Education Precinct, Melbourne, VIC, Australia
| | - Tom C. Karagiannis
- Department of Pathology, The University of Melbourne, Parkville, VIC, Australia
- Epigenomic Medicine, Baker IDI Heart and Diabetes Institute, The Alfred Medical Research and Education Precinct, Melbourne, VIC, Australia
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Abstract
OBJECTIVE The aim of this article is to provide an overview of the classical histone deacetylase (HDAC) enzymes and HDAC inhibitors. The discussion is focused on the potential anti-asthmatic effects of this group of compounds. METHODS Medline was used with the search terms, "asthma and HDAC," "asthma and Trichostatin A," "asthma and valproic acid," "allergic airways disease and HDAC," "allergic airways disease and Trichostatin A," and "allergic airways disease and valproic acid." Manuscripts from the past decade were accessed. Historical literature dating from the 1960s was accessed for the use of anti-epileptics in the treatment of asthma. RESULTS Preliminary clinical trials with anti-epileptic drugs including the well-known HDAC inhibitor, valproic acid, have shown long-lasting anti-asthmatic effects providing the basis for the evaluation of this class of compounds in asthma. Studies using the prototypical HDAC inhibitor, Trichostatin A, in well-established murine models of allergic airways disease have also indicated beneficial effects. CONCLUSION Although the precise mechanisms are still controversial, inhibition of airway hyperresponsiveness and agonist-induced contraction as well as anti-inflammatory effects have been described for HDAC inhibitors in asthma.
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Affiliation(s)
- Simon G Royce
- Allergy and Immune Disorders, Murdoch Children's Research Institute, Parkville, Victoria, Australia
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Kim YJ, Kim JY, Yoon JY, Kyung SY, Lee SP, Jeong SH, Moon C, Park JW. Protective effect of aminophylline against cigarette smoke extract-induced apoptosis in human lung fibroblasts (MRC-5 cells). Basic Clin Pharmacol Toxicol 2011; 109:17-22. [PMID: 21223510 DOI: 10.1111/j.1742-7843.2011.00673.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Cigarette smoking is the principal cause of chronic obstructive pulmonary disease (COPD), especially emphysema, which is characterized by alveolar wall destruction and airspace enlargement. Apoptosis of lung structural cells is involved in the pathogenesis of COPD. Xanthine derivatives (aminophylline or theophylline) have been used for the treatment of COPD as a bronchodilator. But the effects of xanthine derivatives on apoptosis of the lung structural cells remain poorly understood, even though it is known that theophylline protects against ultraviolet irradiation-induced cell death in corneal epithelial cells. This study was designed to determine whether aminophylline would protect against cigarette smoke extract (CSE)-induced apoptosis in lung fibroblasts. We demonstrated that aminophylline protected against apoptosis of MRC-5 cells at a relatively lower therapeutic range (10 μg/ml), resulting in a significant increase in cell viability occurring at 20% concentration after 8-hr exposure. Annexin staining decreased from 68 ± 4% of the control to 12 ± 2% of aminophylline (10 μg/ml) pre-treatment after 20% CSE exposure for 12 hr (p < 0.05). Aminophylline decreased caspase 3 and 8 activities and nuclear condensation or fragmentation in MRC-5 cells after exposure to 20% CSE for 12 hr compared with control and high levels of aminophylline (>50 μg/ml) pre-treatment. These findings suggest that aminophylline protected apoptosis of MRC-5 cells through the inactivation of caspases 3 and 8 and could be an effective agent to reduce cigarette smoking-induced lung structural cell apoptosis.
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Affiliation(s)
- Yu J Kim
- Department of Pulmonary and Critical Care Medicine, Gachon University Gil Hospital, Incheon, Korea
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Wang Y, Lin K, Wang C, Liao X. Addition of theophylline or increasing the dose of inhaled corticosteroid in symptomatic asthma: a meta-analysis of randomized controlled trials. Yonsei Med J 2011; 52:268-75. [PMID: 21319345 PMCID: PMC3051221 DOI: 10.3349/ymj.2011.52.2.268] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
PURPOSE Low-dose theophylline has anti-inflammatory effects. The aim of this study was to evaluate the effects of adding theophylline compared with increasing the dose of inhaled corticosteroid (ICS) on symptomatic asthma. MATERIALS AND METHODS The associated literature was acquired through deliberate searching and selected based on the established inclusion criteria for publications. The extracted data were further analyzed by a meta-analysis. RESULTS Four randomized, controlled, parallel studies were selected. Addition of theophylline produced a greater increase of forced expiratory volume in one second as %predicted (FEV₁pred) by 2.49% [95% confidence interval (CI) 1.99-3.00; z = 9.70; p < 0.001], compared with increasing the dose of ICS. There was no difference between the two treatments in terms of peak expiratory flow (PEF). CONCLUSION Addition of theophylline to ICS has similar therapeutic effects on improving lung function as increasing the dose of ICS in the treatment of symptomatic asthma.
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Affiliation(s)
- Yan Wang
- Institute of Respiratory Diseases, Xinqiao Hospital, Third Military Medical University, Chongqing, China
| | - Kexiong Lin
- Institute of Respiratory Diseases, Xinqiao Hospital, Third Military Medical University, Chongqing, China
| | - Changzheng Wang
- Institute of Respiratory Diseases, Xinqiao Hospital, Third Military Medical University, Chongqing, China
| | - Xiuqing Liao
- Department of Respiratory Diseases, Fuling Central Hospital, Fuling District, Chongqing, China
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Tenor H, Hatzelmann A, Beume R, Lahu G, Zech K, Bethke TD. Pharmacology, clinical efficacy, and tolerability of phosphodiesterase-4 inhibitors: impact of human pharmacokinetics. Handb Exp Pharmacol 2011:85-119. [PMID: 21695636 DOI: 10.1007/978-3-642-17969-3_3] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Since more than two decades anti-inflammatory effects of inhibitors of phosphodiesterase-4 have been described in numerous cellular and animal studies and were finally confirmed in clinical trials. The path from an early, pioneering study with Ro20-1724 showing reduction of psoriatric plaque size in 1979 to modern PDE4 inhibitors such as oral apremilast in development for psoriasis, the inhaled PDE4 inhibitor GSK256066 in development for asthma and COPD and finally roflumilast, the first PDE4 inhibitor approved and currently marketed as an oral, once-daily remedy for severe COPD was marked by large progress in chemical optimization based on improved understanding of PDE4 biology and drug-like properties determining the appropriate pharmacokinetic profile. In this chapter aspects of the pharmacology and clinical efficacy of PDE4 inhibitors, which have been in clinical development over the years are summarized with specific emphasis on their clinical pharmacokinetic properties.
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Affiliation(s)
- Hermann Tenor
- Nycomed GmbH, Byk Gulden Strasse 2, 78467 Konstanz, Germany,
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Ezeamuzie CI, Shihab PK. Interactions between theophylline and salbutamol on cytokine release in human monocytes. J Pharmacol Exp Ther 2010; 334:302-9. [PMID: 20388727 DOI: 10.1124/jpet.109.163238] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The combination of beta(2)-adrenoceptor agonists (beta(2)-agonists) with inhaled steroids has become the standard treatment for mild to moderate asthma. Theophylline has also been combined successfully with inhaled steroids. However, the possible interaction between theophylline and beta(2)-agonists, with regard to their anti-inflammatory effects, has not been clarified. The aim of this study was to investigate the in vitro interaction between theophylline and salbutamol on cytokine generation from human monocytes and compare it with a similar interaction between dexamethasone and salbutamol. Purified monocytes from normal donors were pretreated with the drugs (alone or in combination) and stimulated with lipopolysaccharide for 24 h. Released tumor necrosis factor-alpha (TNF-alpha) and interleukin-6 (IL-6), and their corresponding mRNA expressions, were determined and analyzed. Salbutamol (>or= 0.1 microM) significantly inhibited the release of TNF-alpha, but also significantly enhanced that of IL-6. In contrast, theophylline (50 microM) and dexamethasone (0.1 microM) strongly inhibited the generation of both cytokines. It is noteworthy that when the drugs were used in combination the effects of theophylline and salbutamol were additive in inhibiting TNF-alpha release, but theophylline blocked the IL-6-enhancing effect of salbutamol. A similar effect was seen when dexamethasone was combined with salbutamol. These results show that beta(2)-agonists have opposing effects on the generation of TNF-alpha and IL-6, but that when they were combined with clinically relevant concentrations of theophylline, theophylline, like dexamethasone, was capable of augmenting the anti-inflammatory effects of the beta(2)-agonists while at the same time preventing their proinflammatory effect. Thus, theophylline may have a potentially useful steroid-sparing effect.
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Affiliation(s)
- Charles I Ezeamuzie
- Department of Pharmacology and Toxicology, Faculty of Medicine, Kuwait University, Safat, Kuwait.
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Abstract
Theophylline (3-methyxanthine) has been used to treat airway diseases for over 70 years. It was originally used as a bronchodilator but the relatively high doses required are associated with frequent side effects, so its use declined as inhaled β₂-agonists became more widely used. More recently it has been shown to have anti-inflammatory effects in asthma and COPD at lower concentrations. The molecular mechanism of bronchodilatation is inhibition of phosphodiesterase(PDE)3 and PDE4, but the anti-inflammatory effect may be due to histone deacetylase (HDAC) activation, resulting in switching off of activated inflammatory genes. Through this mechanism theophylline also reverses corticosteroid resistance and this may be of particular value in severe asthma and COPD where HDAC2 activity is markedly reduced. Theophylline is given systemically (orally as slow-release preparations for chronic treatment and intravenously for acute exacerbations of asthma) and blood concentrations are determined mainly by hepatic metabolism, which may be increased or decreased in several diseases and by concomitant drug therapy. Theophylline is now usually used as an add-on therapy in asthma patients not well controlled on inhaled corticosteroids and in COPD patients with severe disease not controlled by bronchodilator therapy. Side effects are related to plasma concentrations and include nausea, vomiting and headaches due to PDE inhibition and at higher concentrations to cardiac arrhythmias and seizures due to adenosine A₁-receptor antagonism.
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Affiliation(s)
- Peter J Barnes
- National Heart and Lung Institute, Imperial College, London, UK.
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Swai H, Semete B, Kalombo L, Chelule P, Kisich K, Sievers B. Nanomedicine for respiratory diseases. WILEY INTERDISCIPLINARY REVIEWS-NANOMEDICINE AND NANOBIOTECHNOLOGY 2010; 1:255-63. [PMID: 20049795 DOI: 10.1002/wnan.33] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Treatment of respiratory diseases and infections has proved to be a challenging task, with the incidence of these ailments increasing worldwide. Nanotechnology-based drug and gene delivery systems offer a possible solution to some of the shortfalls of the current treatment regimen. Nanobased drug delivery systems have revolutionised the field of pharmacotherapy by presenting the ability to alter the pharmacokinetics of the conventional drugs to extend the drug retention time, reduce the toxicity and increase the half-life of the drugs. Delivery of exogenous genes to the airway epithelium in vivo has been limited by several physiological barriers, resulting in the low success rate of these systems. With the advent of nanotechnology, DNA compacted with cationic polymers to produce nanoparticles has exhibited a significant increase in the transfection efficiencies. With nanoparticulate drug/gene delivery systems, specific cells can be targeted by functionalising the polymeric nanoparticles with ligands that allow the particles to dock at a specific site of the cell. In addition, polymeric systems allow for the cargo to be released in a controlled and stimuli-responsive manner. The advantages that nanoparticulate delivery systems present in the treatment of respiratory diseases and infections are summarised in this review.
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Affiliation(s)
- Hulda Swai
- Council for Scientific and Industrial Research Polymers & Bioceramics, Pretoria, South Africa.
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Antus B, Barta I, Horvath I, Csiszer E. Relationship between exhaled nitric oxide and treatment response in COPD patients with exacerbations. Respirology 2010; 15:472-7. [PMID: 20210889 DOI: 10.1111/j.1440-1843.2010.01711.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND AND OBJECTIVE Fractional exhaled nitric oxide (FENO) has been implicated as a pulmonary biomarker in various respiratory diseases, including COPD. In this longitudinal study, the benefit of measuring FENO in a routine clinical setting was assessed in COPD patients hospitalized with an exacerbation of the disease. METHODS FENO, lung function and blood gases were measured in 58 COPD patients at hospital admission due to an exacerbation, and at discharge following treatment with corticosteroids and bronchodilators. RESULTS FENO levels were significantly decreased at discharge, compared with those at admission (geometric mean 25.3 ppb (95% CI: 21.2-30.1) vs 19.7 ppb (95% CI: 17.2-22.6); P = 0.002). There was a significant positive correlation between FENO concentrations at admission and the increase in FEV(1) after treatment (r = 0.441, P < 0.001), and a significant inverse correlation between FENO values at admission and the mean length of hospital stay (r = -0.297, P = 0.016). Using receiver operating characteristic curve analysis, the optimum cut point for FENO as a predictor for significant increase in FEV(1) was 26.8 ppb (sensitivity: 74%, specificity: 75%). There were no correlations between FENO levels and absolute values for lung function variables at admission or discharge. CONCLUSIONS These data suggest that FENO levels determined at hospital admission may predict the overall response to treatment in COPD patients with acute exacerbations.
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Affiliation(s)
- Balazs Antus
- Department of Pathophysiology, National Koranyi Institute for TB and Pulmonology, Budapest, Hungary.
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Stick S, Franklin P. NO more dogma. Nitric oxide marker in asthma. Am J Respir Crit Care Med 2009; 179:87-8. [PMID: 19119148 DOI: 10.1164/rccm.200810-1604ed] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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40
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Puckett JL, George SC. Partitioned exhaled nitric oxide to non-invasively assess asthma. Respir Physiol Neurobiol 2008; 163:166-77. [PMID: 18718562 DOI: 10.1016/j.resp.2008.07.020] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2008] [Revised: 07/17/2008] [Accepted: 07/23/2008] [Indexed: 01/02/2023]
Abstract
Asthma is a chronic inflammatory disease of the lungs, characterized by airway hyperresponsiveness. Chronic repetitive bouts of acute inflammation lead to airway wall remodeling and possibly the sequelae of fixed airflow obstruction. Nitric oxide (NO) is a reactive molecule synthesized by NO synthases (NOS). NOS are expressed by cells within the airway wall and functionally, two NOS isoforms exist: constitutive and inducible. In asthma, the inducible isoform is over expressed, leading to increased production of NO, which diffuses into the airway lumen, where it can be detected in the exhaled breath. The exhaled NO signal can be partitioned into airway and alveolar components by measuring exhaled NO at multiple flows and applying mathematical models of pulmonary NO dynamics. The airway NO flux and alveolar NO concentration can be elevated in adults and children with asthma and have been correlated with markers of airway inflammation and airflow obstruction in cross-sectional studies. Longitudinal studies which specifically address the clinical potential of partitioning exhaled NO for diagnosis, managing therapy, and predicting exacerbation are needed.
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Affiliation(s)
- James L Puckett
- Department of Biomedical Engineering, University of California, Irvine, Irvine, CA 92697, United States
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Abstract
Asthma is an inflammatory disease of the airways, for which many therapeutic options are available. Guidelines for the management of asthma suggest a stepwise approach to pharmacotherapy based on assessment of asthma severity and control. However, the assessment of asthma control presently relies on surrogate measures, such as the frequency of symptoms or the frequency of use of short-acting beta2-adrenergic agonists. There is no simple, noninvasive technique for the assessment of severity of actual airway inflammation in asthma. The collection and analysis of nitric oxide (NO) levels in exhaled breath has recently become feasible in humans. Based on increased exhaled NO (eNO) levels in patients with asthma, eNO analysis has been proposed as a novel, noninvasive approach to the assessment and monitoring of airway inflammation, and as a basis for adjustments in asthma therapy. In the present paper, the relationship of elevated eNO levels in asthma with inflammatory, physiological and clinical markers of asthma in adults was reviewed. Use of eNO is a promising tool for diagnosing asthma, for monitoring asthma control and for guiding optimal anti-inflammatory asthma therapy. However, because of many unresolved questions, eNO cannot be recommended at present for routine clinical management of adults with asthma.
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Lim KG, Mottram C. The use of fraction of exhaled nitric oxide in pulmonary practice. Chest 2008; 133:1232-42. [PMID: 18460522 DOI: 10.1378/chest.07-1712] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
The measurement of the fractional concentration of exhaled nitric oxide (FeNO) is a convenient, noninvasive, point-of-service office test for airway inflammation. The first half of this practice management review presents the methodological, interpretative, and clinical applications of FeNO. The second half discusses practical management issues, including current and future technology, equipment specifications, US Food and Drug Administration regulations, cost, current procedural terminology coding, and reimbursement. The measurement of FeNO is helpful in the diagnosis of asthma. It is predictive of a response to inhaled corticosteroids (ICSs). Monitoring FeNO is useful in maintaining asthma control by allowing the assessment of adherence to medication and dose titration of ICSs. An elevated level of FeNO is predictive of asthma relapse following corticosteroid withdrawal especially in children. The advances in technology, ease of use, and clinical utility will lead to greater availability, acceptance, and routine application in the care of asthma.
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Affiliation(s)
- Kaiser G Lim
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic Foundation, Rochester, MN, USA.
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Franklin PJ, Stick SM. The value of FeNO measurement in asthma management: the motion against FeNO to help manage childhood asthma--reality bites. Paediatr Respir Rev 2008; 9:122-6. [PMID: 18513672 DOI: 10.1016/j.prrv.2007.12.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Since exhaled nitric oxide (FeNO) was first demonstrated to be raised in asthmatic patients in the early 1990s, there has been a strong interest in its potential role in the diagnosis and management of asthma. This culminated in 2003 when the US Food and Drug Administration cleared the NIOX nitric oxide analyser for clinical application in patients with asthma. The interest in FeNO is based on the assumptions that FeNO is a marker of asthma and asthma control, and that it reflects eosinophilic airway inflammation. However, the literature remains unconvincing and inconclusive. Furthermore, studies which have management algorithms that include FeNO as a guide to asthma treatment have failed to observe any improvement in asthma control compared with the use of standard asthma guidelines. At present, the cost of including FeNO in management guidelines far outweighs any potential benefits.
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Affiliation(s)
- Peter J Franklin
- Centre for Asthma, Allergy and Respiratory Research, University of Western Australia, Perth, Western Australia
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Antus B, Horváth I. Exhaled nitric oxide and carbon monoxide in respiratory diseases. J Breath Res 2007; 1:024002. [PMID: 21383433 DOI: 10.1088/1752-7155/1/2/024002] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Breath tests have gained increasing interest in recent years mainly driven by the unmet clinical need to monitor airway diseases and to obtain information on unravelled aspects of respiratory disorders. A prototype of such measurement reaching clinical significance besides its use as a research tool is the measurement of exhaled nitric oxide (NO). It took hardly more than a decade after the discovery that exhaled breath contains NO for this measurement to be approved for clinical practice to monitor anti-inflammatory treatment in asthma. Recent studies demonstrate that using exhaled NO measurement to guide anti-inflammatory treatment in asthma may help clinical decision making. A similarly small molecule present in exhaled breath is carbon monoxide, which is not only a biomarker of cigarette smoking but has also been suggested to reflect ongoing oxidative stress/antioxidant defense. The scope of this review is the exciting field of exhaled monoxides. Since several other biomarkers have also been studied in the exhaled breath this review will provide a brief introduction to them.
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Affiliation(s)
- Balázs Antus
- Department of Pathophysiology, National Koranyi Institute for Pulmonology, Budapest, Hungary
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van den Berge M, Hylkema MN, Versluis M, Postma DS. Role of adenosine receptors in the treatment of asthma and chronic obstructive pulmonary disease: recent developments. Drugs R D 2007; 8:13-23. [PMID: 17249846 DOI: 10.2165/00126839-200708010-00002] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Adenosine is a naturally occurring purine nucleoside with a ubiquitous presence in human tissue, where it plays a key role in many biological processes such as energy generation and protein metabolism. It has been shown that adenosine induces bronchoconstriction in asthmatic and chronic obstructive pulmonary disease (COPD) patients, but not in normal airways. Four different G-protein-coupled adenosine receptors have been described, namely adenosine A(1), A(2A), A(2B) and A(3) receptors. The main mechanism of adenosine-induced bronchoconstriction appears to involve the release of inflammatory mediators from mast cells via activation of the A(2B) receptor. However, adenosine can also act on A(1), A(2A) and A(3) receptors. In recent years there has been an increasing interest in the role of adenosine receptors in asthma and COPD, since it is now clear that they play an important role in the pathophysiology of asthma and COPD. Adenosine receptors are involved in the production and release of a variety of mediators from inflammatory and structural cells. A therapeutic potential for adenosine receptor modulation has even been anticipated. This review focuses on the role of adenosine and adenosine receptors in the treatment of asthma and COPD.
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Affiliation(s)
- Maarten van den Berge
- Department of Pulmonology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
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Kikuchi I, Kikuchi S, Kobayashi T, Takaku Y, Hagiwara K, Kanazawa M, Nagata M. Theophylline attenuates the neutrophil-dependent augmentation of eosinophil trans-basement membrane migration. Int Arch Allergy Immunol 2007; 143 Suppl 1:44-9. [PMID: 17541276 DOI: 10.1159/000101404] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Recent evidence suggests that both neutrophilic and eosinophilic inflammation persist in the airways of patients with severe asthma. Neutrophils can secrete a variety of mediators which may augment the migration of eosinophils. We have reported that activated neutrophils augment the trans-basement membrane migration (TBM) of eosinophils in vitro. Theophylline has been shown to modulate some functions of both neutrophils and eosinophils. The objective of this study was to evaluate whether theophylline modulates the neutrophil-dependent augmentation of eosinophil TBM. METHODS Eosinophils and neutrophils were isolated from peripheral blood collected from healthy donors and were then preincubated with either 0.1 mM theophylline or the medium control. The TBM of eosinophils in response to IL-8 was evaluated in the presence or absence of neutrophils by using the chambers with a Matrigel-coated Transwell insert. The generation of O(2)(-) was evaluated by the cytochrome c reduction assay. RESULTS As previously reported, IL-8-stimulated neutrophils significantly augmented the TBM of eosinophils. Theophylline significantly attenuated the neutrophil-dependent augmentation of eosinophil TBM (p < 0.001) and did not directly modify the TBM of neutrophils in response to IL-8 or LTB4. Similarly, the LTB4-induced TBM of eosinophils was not modified by theophylline. Finally, theophylline attenuated the superoxide anion generation from IL-8-stimulated neutrophils on the Matrigel-coated plates. CONCLUSIONS Our results show that theophylline can attenuate the neutrophil-dependent augmentation of eosinophil TBM. This effect is possibly attributable to the suppression of neutrophil activation provoked by the combination of basement membrane and IL-8.
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Affiliation(s)
- Izumi Kikuchi
- Department of Respiratory Medicine, Saitama Medical University, Saitama, Japan
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Gill M, Graff GR, Adler AJ, Dweik RA. Validation study of fractional exhaled nitric oxide measurements using a handheld monitoring device. J Asthma 2007; 43:731-4. [PMID: 17169823 DOI: 10.1080/02770900601031045] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
We tested reproducibility of exhaled nitric oxide (FE(NO)) and inter-operator handling when measured with a handheld device, NIOX MINO. We enrolled 20 volunteers using a priori goals of acceptable reproducibility to be mean within-subject standard deviation less than 3 parts per billion (ppb) for FE(NO) measurements less than 30 ppb, and mean coefficient of variation less than 10% for FE(NO) measurements more than 30 ppb. Seventeen subjects with measurements less than 30 ppb displayed a mean standard deviation of 1.15, and 3 subjects with FE(NO) more than 30 ppb had a mean coefficient of variation of 2.4%. We conclude that NIOX MINO demonstrates excellent reproducibility for all ranges of FE(NO).
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Affiliation(s)
- Michelle Gill
- The Department of Emergency Medicine, Loma Linda University School of Medicine, 11234 Anderson Street, Loma Linda, CA 92354, USA.
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Makino S, Adachi M, Ohta K, Kihara N, Nakajima S, Nishima S, Fukuda T, Miyamoto T. A prospective survey on safety of sustained-release theophylline in treatment of asthma and COPD. Allergol Int 2006; 55:395-402. [PMID: 17130682 DOI: 10.2332/allergolint.55.395] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2005] [Accepted: 04/26/2006] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Theophylline is a useful drug for the treatment of asthma. The Asthma Prevention and Management Guidelines (JGL) recommend use of sustained-release theophylline products as controllers and of injectable aminophylline products as relievers. The Global Initiative for Asthma: Global Strategy for Asthma Management and Prevention, the NHLB/WHP Workshop Report 1995 (GINA, 1995) and guidelines in Western countries recommend sustained-release theophylline, but not as positively as in the JGL. The aim of this survey was to determine the occurrence of serious adverse reactions. METHODS The survey was conducted in 66 institutions staffed by physicians certified by the Japanese Society of Allergology (JSA). The target diseases were asthma and COPD including chronic bronchitis and pulmonary emphysema, which are indications for use of sustained-release theophylline products in Japan. RESULTS 3,921 patients were included in the safety evaluation. No serious adverse reactions were observed among the patients in this survey, although 54 patients (1.38%) exhibited non-serious adverse reactions. The incidence of adverse reactions was found to be high in patients who had begun use of sustained-release theophylline products at the time of registration in this survey, and in patients who were concomitantly taking macrolide antibiotics. CONCLUSIONS The present survey demonstrates that sustained-release theophylline is safe, as long as used appropriately, although adverse reactions tend to develop early after initiation of administration.
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Affiliation(s)
- Sohei Makino
- Internal Medicine, Jobu Hospital for Respiratory Disease, Maebashi, Gunma, Japan.
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Effect of theophylline on endogenous hydrogen sulfide production in patients with COPD. Pulm Pharmacol Ther 2006; 21:40-6. [PMID: 17196413 DOI: 10.1016/j.pupt.2006.11.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2006] [Revised: 10/22/2006] [Accepted: 11/10/2006] [Indexed: 02/08/2023]
Abstract
BACKGROUND Airway inflammation plays a role in the pathogenesis of chronic obstructive pulmonary disease (COPD). Endogenous hydrogen sulfide (H2S) is involved in the physiological and pathophysiological process in systemic inflammation and may be involved in the pathogenesis of airway inflammation and airflow obstruction in COPD. The non-selective phosphodiesterase inhibitor theophylline has bronchodilator/anti-inflammatory properties and is widely used in the treatment of airways diseases. It is not fully understood whether endogenous H2S mediates the mechanism of theophylline anti-inflammatory effect. METHODS The effect of short-term theophylline treatment on airway inflammation and endogenous H2S production was prospectively studied in thirty-seven patients with stable COPD. Patients were randomly divided into theophylline-treatment group (nineteen patients, orally given sustained theophylline tablets for 1 month, 0.2g, q 12h) and control group (eighteen patients, not given any theophylline). Symptom score, lung function, total and differential cell counts in sputum, serum H2S and nitric oxide (NOx) levels, sputum and serum IL-8 levels were measured at baseline and 1 month later. RESULTS No significant difference was found in symptom scores, lung function and other investigated experimental parameters at baseline between treatment and control groups, and between baseline and a month follow-up in control patients. Symptom scores were significantly lowered only in the treated patients after treatment, compared with those before (P<0.01). The proportion of neutrophils in sputum was significantly decreased (P<0.05) while that of macrophages was markedly increased (P<0.01) in the treated patients after treatment, compared with that before. No significant change was found in serum H2S and NOx levels, serum and sputum IL-8 levels before and after experiment in treatment group. Serum H2S level correlated positively with percentage of predicted FEV1 (r=0.465, P=0.005), and with proportion of sputum macrophages (r=0.349, P=0.05), but negatively with proportion of sputum neutrophils (r=-0.351, P=0.049) in all patients at baseline. CONCLUSIONS Short-term theophylline treatment improved symptoms and decreased sputum neutrophils in COPD, while serum H2S levels were not affected in our study population. Large samples will be needed to illustrate the effect of long-term theophylline treatment on inflammatory mediators and H2S generation in COPD.
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Clinical trial of low-dose theophylline and montelukast in patients with poorly controlled asthma. Am J Respir Crit Care Med 2006; 175:235-42. [PMID: 16998094 DOI: 10.1164/rccm.200603-416oc] [Citation(s) in RCA: 95] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Asthma treatment guidelines recommend addition of controller medications for patients with poorly controlled asthma. We compared the effectiveness of once-daily oral controller therapy with either an antileukotriene receptor antagonist (montelukast) or low-dose theophylline added to existing medications in patients with poorly controlled asthma. METHODS We conducted a randomized, double-masked, placebo-controlled trial in 489 participants with poorly controlled asthma randomly assigned to placebo, theophylline (300 mg/d), or montelukast (10 mg/d). Participants were monitored for 24 wk to measure the rate of episodes of poor asthma control (EPACs) defined by decreased peak flow, increased beta-agonist use, increased oral corticosteroid use, or unscheduled health care visits. OBSERVATIONS There was no significant difference in EPAC rates (events/person/yr) compared with placebo: low-dose theophylline, 4.9 (95% confidence interval [CI], 3.6-6.7; not significant); montelukast, 4.0 (95% CI, 3.0-5.4; not significant); and placebo, 4.9 (95% CI, 3.8-6.4). Both montelukast and theophylline caused small improvements in prebronchodilator FEV(1) of borderline significance. Nausea was more common with theophylline only during the first 4 wk of treatment. Neither treatment improved asthma symptoms or quality of life. However, in patients not receiving inhaled corticosteroids, addition of low-dose theophylline significantly (p < 0.002) improved asthma control and symptoms as well as lung function. CONCLUSIONS Neither montelukast nor low-dose theophylline lowered the EPAC rate of poor asthma control in patients with poorly controlled asthma despite improved lung function. For patients not using inhaled corticosteroids, low-dose theophylline improved asthma symptom control more than montelukast or placebo, and provides a safe and low-cost alternative asthma treatment.
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