Preoperative frailty screening in elderly patients with non-small cell lung cancer surgery: an essential step for a good surgical outcome

INTRODUCTION

Non-small cell lung cancer (NSCLC) is a disease commonly diagnosed in the elderly, often in advanced stages. However, elderly patients with lung cancer can benefit from surgery, provided that postoperative risks are assessed appropriately before surgery. Frailty is a measure of age-related impaired functional status and a predictor of mortality and morbidity. However, its importance as a preoperative marker is not well defined.

AREAS COVERED

This systematic review discusses the importance of preoperative frailty screening in elderly patients with NSCLC. A literature search was performed on the MEDLINE database in June 2023, and relevant studies on frailty or preoperative assessment of NSCLC which were published between 2000 and 2023 were retained and discussed in this review.

EXPERT OPINION

Among the types of existing methods used to assess frailty those on the geriatric assessment seem to be the most appropriate; however, they are unable to fully capture the 'surgical' frailty; thus, other instruments should be developed and validated in NSCLC.

Navafenterol for chronic obstructive pulmonary disease therapy

INTRODUCTION

Chronic obstructive pulmonary disease (COPD) is a prevalent disease of the airways in which inhaled bronchodilators can be given as monotherapy or fixed dose combination, in order to better control disease symptoms and to reduce its morbidity. A novel bronchodilator approach is represented by bifunctional molecules such as navafenterol which exert dual synergic bronchodilator effects as a monotherapy. Navafenterol is currently investigated for COPD.

AREAS COVERED

this review summarizes the preclinical data regarding navafenterol synthesis and in vitro and in vivo testing. Clinical data coming from phase I and II studies are also discussed. Navafenterol was found to improve lung function, dyspnea and cough severity and was well tolerated, and its effect was comparable with that of fixed dose combinations in patients with moderate to severe COPD.

EXPERT OPINION

despite clinical evidence of efficacy for navafenterol is still limited the existing data prompts further clinical evaluation and also consideration of other inhalation approaches such as pressure metered dose inhalers (pMDIs) or nebulization. Other interesting approach would be combination with another bifunctional molecule such as ensifentrine.

COVID-19 vaccination in patients with multiple sclerosis receiving disease-modifying therapies: pragmatic issues

The SARS-COV-2 pandemic has been a global public health problem since 2019, with over 400 million reported cases, 6 million deaths, and significant economic and social damage. Overlapping SARS-CoV-2 infection in patients with chronic diseases, such as multiple sclerosis (MS), causes management problems, especially in patients treated with disease-modifying therapies. Studies investigating COVID-19 vaccination effectiveness have shown variability in postvaccination immune response that depends on the patient's background treatment, and special attention is required for anti-CD20 therapies. Existing data on the efficacy of COVID-19 vaccination in patients with MS undergoing disease-modifying treatment are summarized and critically evaluated in this article.

Inhaled interferons beta and SARS-COV2 infection: a preliminary therapeutic perspective

Introduction

SARS-COV2 infection represents a therapeutic challenge due to the limited number of effective therapies available and due to the fact that it is not clear which host response in terms of inflammation pattern is the most predictive for an optimal (and rapid) recovery. Interferon β pathway is impaired in SARS-COV2 infection and this is associated with a bigger disease burden. Exogenous inhaled interferon might be beneficial in this setting.

Areas covered

Nebulized interferon-β is currently investigated as a potential therapy for SARS-COV2 because the available data from a phase II study demonstrate that this medication is able to accelerate the recovery from disease.

Expert opinion

Further clinical studies are needed in order to better document the efficacy of this therapy especially in severe forms of COVID-19, the optimal duration of therapy and if such a medication is appropriate for domiciliary use. Also combined regimens with antivirals or with compounds which are able to enhance the endogenous production of interferon might be of promise.

Marine-Derived Compounds for the Potential Treatment of Glucocorticoid Resistance in Severe Asthma

One of the challenges to the management of severe asthma is the poor therapeutic response to treatment with glucocorticosteroids. Compounds derived from marine sources have received increasing interest in recent years due to their prominent biologically active properties for biomedical applications, as well as their sustainability and safety for drug development. Based on the pathobiological features associated with glucocorticoid resistance in severe asthma, many studies have already described many glucocorticoid resistance mechanisms as potential therapeutic targets. On the other hand, in the last decade, many studies described the potentially anti-inflammatory effects of marine-derived biologically active compounds. Analyzing the underlying anti-inflammatory mechanisms of action for these marine-derived biologically active compounds, we observed some of the targeted pathogenic molecular mechanisms similar to those described in glucocorticoid (GC) resistant asthma. This article gathers the marine-derived compounds targeting pathogenic molecular mechanism involved in GC resistant asthma and provides a basis for the development of effective marine-derived drugs.

Frailty, a Dimension of Impaired Functional Status in Advanced COPD: Utility and Clinical Applicability

Background and Objectives: In advanced chronic obstructive pulmonary disease (COPD), functional status is significantly impaired mainly as a result of disease related respiratory symptoms such as dyspnea or as a result of fatigue, which is the extra-respiratory symptom the most prevalent in this setting. "Physical" frailty, considered to be an aging phenotype, has defining traits that can also be considered when studying impaired functional status, but little is known about this relationship in advanced COPD. This review discusses the relevance of this type of frailty in advanced COPD and evaluates it utility and its clinical applicability as a potential outcome measure in palliative care for COPD. Materials and Methods: A conceptual review on the functional status as an outcome measure of mortality and morbidity in COPD, and an update on the definition and traits of frailty. Results: Data on the prognostic role of frailty in COPD are rather limited, but individual data on traits of frailty demonstrating their relationship with mortality and morbidity in advanced COPD are available and supportive. Conclusions: Frailty assessment in COPD patients is becoming a relevant issue not only for its potential prognostic value for increased morbidity or for mortality, but also for its potential role as a measure of functional status in palliative care for advanced COPD.

Pharmacological strategies for smoking cessation in patients with chronic obstructive pulmonary disease: a pragmatic review

Introduction: Chronic obstructive pulmonary disease (COPD) is progressive inflammatory disease of the lungs in which smoking plays a significant pathogenic role. Smoking cessation is the only therapeutic intervention which was demonstrated to interfere with disease progression. Smoking cessation intervention can benefit from pharmacological therapies such as nicotine replacement therapies, bupropion, or varenicline which can be given individually or in combination, their effectiveness being demonstrated in various clinical trials enrolling COPD patients.Areas covered: The authors provide a pragmatic discussion of the clinical data of the main studies evaluating therapies for smoking cessation within COPD starting with the seminal Lung Health Study and continuing with more recent ones.Expert opinion: Smoking cessation is one of the most difficult therapeutic interventions in COPD, despite having the highest impact on disease progression and despite the demonstrated benefit of the discussed pharmacological therapies. Potential approaches to maximize its chance of success might be represented by prolonging the time of administration, combinational options, or sequential pharmacotherapy.

Pharmacotherapy options in pulmonary alveolar proteinosis

INTRODUCTION

Pulmonary alveolar proteinosis (PAP) is a heterogeneous group of rare diseases characterized by the abnormal production and impaired degradation of pulmonary surfactant as a result of malfunctioning of alveolar macrophages. This is due to the downstream dysregulation of the GM-CSF pathway, which can be caused by specific autoantibodies (autoimmune, aPAP formerly known as idiopathic iPAP), direct injury to alveolar macrophages (e.g. by toxic inhaled agents.), or by genetic defects (hereditary or congenital PAP). Few pharmacotherapy options are currently available to treat this disease.

AREA COVERED

The authors discuss the exogenous administration of GM-CSF, rituximab, and the potential role of cholesterol lowering medications in this review. The authors, furthermore, provide their opinion on the available pharmacotherapeutic options and give their future perspectives.

EXPERT OPINION

Inhaled GM-CSF remains the most commonly used therapy in patients with iPAP but other inhaled therapies such as PPARγ activators should be considered, especially in patients who are partially responsive or unresponsive to traditional treatments.

Investigational inhaled therapies for non-CF bronchiectasis

INTRODUCTION

Bronchiectasis not related to cystic fibrosis (non-CF bronchiectasis) are associated with a high unmet therapeutic need due to the lack of specifically authorized medications, especially via the inhalation route. In non-CF bronchiectasis chronic infection with Pseudomonas aeruginosa is common and favored by the persistent local inflammation and viscid sputum production. Therefore inhaled antibiotics, mucolytics or anti-inflammatory agents could represent appropriate therapeutic interventions in this setting.

AREAS COVERED

This review herein discusses the inhaled therapies currently under investigation for non-CF bronchiectasis and their potential therapeutic positioning in exacerbation versus stable state.

EXPERT OPINION

Inhaled antipseudomonal antibiotics are of promising efficacy, but further efforts should also be made to detect bactericidal approaches against Burkholderia cepacia complex, and to interfere chronic inflammation topically.

Benralizumab as a potential treatment of asthma

INTRODUCTION

Current anti-inflammatory asthma therapies including inhaled corticosteroids and leukotriene modifiers, are not always able to appropriately control the disease and other approaches are needed. These therapies specific target IgE (omalizumab) or IL-5 (mepolizumab). However, there is research underway investigating interleukin-based monoclonal antibodies such as benralizumab, an anti-IL-5R monoclonal antibody which is currently in phase III clinical development. Areas covered: This review summarizes the existing preclinical and clinical data of benralizumab. Data reviewed includes benralizumab's efficacy and safety data. The author also provides their expert opinion on this potential therapeutic and provide their perspectives for its future development. Expert opinion: Benralizumab was able to interfere significantly with disease-related morbidity and in particular with hospitalizations due to asthma exacerbation rates in a subset of patients with higher systemic eosinophil burden and higher doses of inhaled corticosteroids. The sustained inhibitory effect on eosinophilic inflammation might be an advantage which can be translated in less frequent dosing. Further attempts should be made to better define the asthma endotype in which such an antibody would be the most efficacious.

Lebrikizumab for the treatment of asthma

INTRODUCTION

In asthma, most commonly, 'conventional' anti-inflammatory medications represented by inhaled corticosteroids and leukotriene inhibitors are effective. In some patients however additional inhibition of the airways inflammation is necessary. Such compounds might be molecules inhibiting specifically certain inflammation pathways and lebrikizumab an anti IL-13 molecule might represent a relevant example as a potential asthma therapy.

AREAS COVERED

Discussion of the rationale for the use of lebrikizumab in asthma. Analysis of the related preclinical and clinical data on lebrikizumab in asthma.

EXPERT OPINION

Lebrikizumab demonstrated efficacy in an asthma subset characterized by high serum periostin levels and by heavy eosinophilic inflammation. Phase III data are necessary in order to better position this therapy in asthma including as a potential personalized approach.

Palliative care outcome measures in COPD patients: a conceptual review

In chronic obstructive pulmonary disease (COPD), palliative care is appropriate in very advanced stages based on recognition of its need when conventional therapy is no longer able to control symptoms, disease morbidity, or to improve/maintain an acceptable quality of life. Palliative care aims to improve quality of life, or, if applied specifically at the end-of-life, to ensure comfortable care. In COPD palliative care effectiveness of interventions should be quantified with outcome measures able to better capture the holistic nature of approaches and not only the specific features of disease. These should include: physical outcomes, psychological outcomes, social outcomes, spiritual outcomes. Such measures are discussed in this review along with arguments supporting their use.

Impact of fatigue in patients with chronic obstructive pulmonary disease: results from an exploratory study

INTRODUCTION

Fatigue, which is also present in the healthy population, is a common but understudied symptom in chronic obstructive pulmonary disease (COPD). We hypothesized that clinically significant fatigue is also frequent in COPD and can be associated with an increased disease burden.

METHODS

An exploratory analysis derived from an ongoing cross-sectional study was carried out to evaluate levels of fatigue and impact on health-related quality of life/health status in patients with COPD (COPD group; n = 20) and healthy subjects (control group; n = 5). Health-related quality of life was measured using the Short Form Health Survey 36 (SF-36), health status with the Clinical COPD Questionnaire (CCQ), and airways obstruction with postbronchodilator forced expiratory volume in 1 s (FEV1 %predicted). Fatigue was measured with the vitality score of the SF-36, its clinical significance being defined by values of 50 or less. Fatigue was also measured using the Functional Assessment of Chronic Illness Therapy scale for fatigue (FACIT-F).

RESULTS

Vitality scores were significantly worse in the COPD group (45.60 versus 76.25; p = 0.004). FACIT-F scores were significantly lower in the COPD group versus the control group (74.5 versus 95.0; p = 0.03). Clinically significant fatigue was detected in 60% of the COPD group, and was associated with a worse FEV1 %predicted (47.71 versus 65.82%; p = 0.016), worse symptoms burden (CCQ symptoms score 3.75 versus 2.43; p = 0.019), and worse overall health status (CCQ total score 3.30 versus 2.11; p = 0.011). Its link with systemic inflammation remains to be clarified further.

CONCLUSIONS

Clinically significant fatigue is common among patients with COPD and is associated with an increased disease burden. It should therefore be integrated as a measure of disease prognosis and control in patients with COPD.

Efficacy of indacaterol as a single therapy versus salmeterol/fluticasone therapy in patients with milder chronic obstructive pulmonary disease

INTRODUCTION

In non-exacerbation chronic obstructive pulmonary disease (COPD) with mild lung function impairment, single bronchodilator therapy might be as effective as combined inhaled corticosteroid/bronchodilator therapy, whereas the risk of pneumonia associated with the latter would be practically absent.

AREAS COVERED

We performed an analysis of a recent study evaluating the efficacy and safety of inhaled indacaterol versus inhaled salmeterol/fluticasone in COPD patients.

EXPERT OPINION

Both therapies were found to exert comparable effects on lung function, symptom severity and health status.

Measuring fatigue as a symptom in COPD: From descriptors and questionnaires to the importance of the problem

Fatigue is a symptom commonly diagnosed in cancers and in many other chronic debilitating diseases and is one of the main therapeutic targets for various pharmacologic and non-pharmacologic interventions. However, in chronic obstructive pulmonary disease (COPD), this symptom, which can be considered as the main extrapulmonary clinical feature of the disease, can impact significantly on the health-related quality of life of the patients. The aims of this review are to discuss the issues related to fatigue assessment in COPD and to highlight the importance of this symptom in this setting based on the data retrieved from articles published between 1987 through August 2014 available on MEDLINE database. Fatigue can be measured by various scales or questionnaires that are designed for generic purposes or for COPD-related purposes but is still underdiagnosed and undertreated. This is due to the fact that its clinical and prognostic relevance are not appropriately acknowledged. The early identification of fatigue clinical descriptors from patients' reports could help with better management of this symptom.

Targeting 5-lipoxygenase-activating protein in asthma and chronic obstructive pulmonary disease

INTRODUCTION

In asthma and chronic obstructive pulmonary disease (COPD), there is an unmet therapeutic need for the anti-inflammatory therapies, and the identification of therapeutic targets and potent corresponding therapies is necessary. Although inhaled corticosteroids and leukotriene modifiers are most effective in asthma they are still not always capable of appropriately controlling the disease. In COPD, the therapeutic gap is even larger because inhaled corticosteroids and other anti-inflammatory therapies are not beneficial in all disease subsets.

AREAS COVERED

The role of the 5-lipoxygenase-activating protein (FLAP) in generating proinflammatory molecules such as leukotrienes is discussed, highlighting, in particular, its potential as a therapeutic target in asthma and COPD. The preclinical data on FLAP inhibitors are discussed. The clinical data on the FLAP inhibitors investigated so far for these diseases are analyzed.

EXPERT OPINION

FLAP inhibitors have emerged during the past decade as a promising therapeutic class in asthma and COPD, but there exists only a limited amount of data supporting their efficacy in these diseases. This might be due to the fact that the development of some of the molecules discussed was abandoned. Such therapies might be of particular interest in COPD and in asthma-COPD overlap syndrome.

Asthma and pregnancy: therapeutic challenges

PURPOSE

Asthma in pregnancy represents a complex therapeutic challenge as it can have unfavourable consequences on both the mother and the fetus. Pregnancy can have a variable impact on asthma, and there is no general rule to predict in whom is going to be better, stable or worse. On the other hand, asthma can increase the risks of fetal malformations, low birth weight or premature birth.

METHODS AND RESULTS

The review of the literature regarding the asthma pathogenic maternal and fetal effects and the current therapeutic recommendations.

CONCLUSIONS

A multidisciplinary team is needed to appropriately follow up a pregnant woman with asthma and this should involve a pulmonary disease physician, a neonatologist, an obstetrician and, if necessary, an allergolocist. Most of the medications used in asthma outside pregnancy can safely be used during it. An appropriate management according to existing guidelines can minimize both maternal and fetal risks.

Immune therapies for malignant mesothelioma

Malignant mesothelioma (MM) is a rare disease which can develop in pleura, pericardium or peritoneum and in which the therapies available have limited efficacy and are associated with various side effects. Therefore, there is a need for more targeted and more effective therapies which are able to halt the disease progression. Among them immune therapies actively or passively directed against various structures of the MM cells seem to be particularly promising given their inhibitory potential demonstrated in both experimental and early clinical studies. Mesothelin in particular seem to be not only a biomarker of disease activity but also a therapeutic target. This review discusses the immune therapies currently investigated for MM.

Hospitalizations for chronic obstructive pulmonary disease exacerbations and their impact on disease and subsequent morbidity and mortality

In chronic obstructive pulmonary disease (COPD), progressive airflow limitation is a risk factor for development of disease exacerbations, which, when severe, may require hospitalization. In the discussed study, a large cohort of patients hospitalized for their first COPD exacerbation were analyzed in terms of subsequent hospitalizations and mortality risk. COPD hospitalizations were found to be a risk factor for subsequent COPD-related hospitalizations, to increase their incidence and to increase the disease-related mortality risk. Male gender was also identified as a risk factor for a higher COPD-related morbidity and mortality. Hospitalizations for COPD exacerbation should be considered as additional criterion for disease severity in tailoring the disease management.

Discontinued drugs for pulmonary, allergy, gastrointestinal, arthritis (2012)

INTRODUCTION

Various compounds are developed to interfere with pathogenic pathways involved in inflammation processes. Some of them are able to enter the clinical development for different diseases with a common pathogenic denominator such as, for example, rheumatoid arthritis and chronic obstructive pulmonary disease (COPD), based on the preclinical evidence, but not all these molecules prove to be efficacious while tested in different phases of clinical development.

AREAS COVERED

This review discusses about the drugs that were discontinued from further development for pulmonary, allergy, gastrointestinal and arthritis diseases

EXPERT OPINION

Most of the drugs discontinued during 2012 were compounds with anti-inflammatory activity which were mostly designed to treat arthritis/rheumatoid arthritis. Some of these molecules were also intended for COPD. Many of them failed the late phases of the clinical development.

Evaluation of inhaled tiotropium in asthma, uncontrolled with standard combination therapy

INTRODUCTION

In uncontrolled asthma, the suboptimally inhibited airways inflammation is the main pathogenic event. Addition of other medications to the regular regimen might be able to improve disease control by enhancing bronchodilation and/or by reducing the bronchial inflammation. Tiotropium is currently under evaluation as a potential such therapy.

AREAS COVERED

The long-term efficacy and safety of tiotropium was recently evaluated in two studies in patients with poorly controlled asthma under inhaled corticosteroids + long-acting β2 agonists. Tiotropium was able to improve lung function and the effect was sustained, reduced the exacerbations risk (and in particular severe exacerbations risk), but had a marginal effect on symptoms and on quality of life.

EXPERT OPINION

In asthma, inhaled tiotropium is able to increase the bronchodilation, and might also be able to exert an anti-inflammatory effect.

Update on models of pulmonary fibrosis therapy for preclinical drug research

BACKGROUND

Idiopathic pulmonary fibrosis (IPF) is a disease with high morbidity and mortality for which current medications are not effective. Therefore, identification of potential therapies is of paramount importance. The preclinical evaluation of novel compounds in animal models represents a critical step in drug development.

OBJECTIVE

To describe features and limitations of common animal models of pulmonary fibrosis and discuss relevant preclinical and clinical data on novel potential IPF therapies.

METHODS

Review of the existing literature on such models with a special focus on the bleomycin model and its usefulness for the IPF preclinical drug testing.

CONCLUSIONS

The model of bleomycin-induced pulmonary fibrosis has the advantages of being well established, reproducible and both time- and cost-efficient. However, it has major limitations as it only mimics some features of human IPF. Most importantly, it is initiated by acute lung injury and is at least partially reversible, which is strikingly different from IPF. The failure in establishing effective IPF therapies despite strong efforts in the last decade is partly attributable to our uncritical trust in the models of lung fibrosis and the false belief that they truly reflect what is going on in human disease.

Monoclonal antibodies for asthma and chronic obstructive pulmonary disease

INTRODUCTION

In asthma and chronic obstructive pulmonary disease (COPD), the inflammation in the airways cannot always be controlled with conventional therapies, such as inhaled corticosteroids. Addition of more specific anti-inflammatory therapies, such as monoclonal antibodies, against inflammation pathways might improve the disease outcome.

AREAS COVERED

This review individually discusses the major inflammation pathways and their potential blocking monoclonal antibodies in asthma and COPD.

EXPERT OPINION

The current use of omalizumab in asthma provides a good example on the potential therapeutic role of monoclonal antibodies in both asthma and COPD. There are many other monoclonal antibodies which are currently investigated as possible therapies in these diseases. The identification of the disease subsets in which such antibodies might exert the maximum benefit opens the door for personalized medicine and for targeted biological therapy in asthma and COPD.

Targeting PDGF pathway in pulmonary arterial hypertension

INTRODUCTION

Pulmonary arterial hypertension (PAH) encompasses a rare potentially lethal group of diseases characterized by vasoconstriction, in situ thrombosis and vascular remodeling. Most of the existing therapies including endothelin receptor antagonists, prostacyclin and derivatives, or phsophodiesterase-5 inhibitors tackle mainly the endothelial dysfunction, leaving the remodeling suboptimally inhibited. This explains the disease progression that occurs even with combined therapies and the need for other therapies able to adequately inhibit the vascular remodeling.

AREAS COVERED

Platelet-derived growth factor (PDGF) signaling pathway was demonstrated to be involved in the vascular remodeling in PAH, and therefore, it might be a desirable therapeutic target in this setting. This review discusses the pathogenic role of this pathway in PAH and its potential inhibitory approaches, focusing on imatinib as well as on the existing preclinical data on this compound.

EXPERT OPINION

Preclinical studies demonstrated that PDGF inhibition with receptor antagonists such as imatinib reduces vascular remodeling. Therefore, PDGF might represent a plausible therapeutic target in this disease. However, compounds able to block this pathway via different mechanisms might also become potential PAH therapies.

Targeting RhoA/ROCK pathway in pulmonary arterial hypertension

INTRODUCTION

Pulmonary arterial hypertension (PAH) is a rare disease with a complex pathogenesis. It is often associated with an increased vascular resistance, whilst in the more advanced stages there is a remodelling of the vascular walls. PAH has an intricate involvement of various signaling pathways, including the ras homolog family member A (RhoA)-Rho kinase (ROCK) axis. Currently, available therapies are not always able to significantly slow PAH progression. Therefore, newer approaches are needed.

AREAS COVERED

In this review, areas covered include the role of the RhoA/ROCK in PAH pathogenesis and the plausibility of its therapeutic targeting. Furthermore, various inhibitory compounds are discussed, including Fasudil and SB-772077-B.

EXPERT OPINION

Currently, specific RhoA/ROCK inhibition is the most promising therapeutic approach for PAH. Research has shown that it suppresses both the components of this axis and the upstream upregulating mediators. An inhaled RhoA/ROCK inhibitor may be a successful future therapy; however, further clinical trials are needed to support this approach.

Aclidinium bromide in experimental asthma

Underlying inflammation in asthma increases the activity of the cholinergic nervous system, contributing to bronchoconstriction/airway hyper-responsiveness (AHR) and mucus hypersecretion. Inhaled anticholinergics with shorter duration of action were initially used and then discontinued when other bronchodilators became available. Previous preclinical and clinical studies have demonstrated that tiotropium bromide, a long-acting anticholinergic currently approved for chronic obstructive pulmonary disease, might be an effective therapy in asthma. Aclidinium bromide is an inhaled compound in the same class as tiotropium, which is currently being investigated in chronic obstructive pulmonary disease and asthma. In the evaluated study, it was found to reduce AHR and eosinophilic airway inflammation in an acute model of asthma.

New therapeutic options in the management of COPD - focus on roflumilast

In chronic obstructive pulmonary disease (COPD) the inflammation occurring in the airways and in other lung tissues is complex and is orchestrated by various mediators including the isoenzyme 4 of the phosphodiesterases family (PDE4), which contributes to bronchoconstriction and inflammation. Various PDE4 inhibitors have been evaluated as potential therapies in asthma or COPD but among these only roflumilast have been authorized in Europe to be used in patients with severe COPD as an add-on to the bronchodilator therapy. This review discusses the existing preclinical and clinical data supporting the use of roflumilast for this therapeutic indication and tackles some of the pending issues related to PDE4 in general and to roflumilast in particular.

Tiotropium in the treatment of asthma

Existing asthma therapies are not always able to achieve disease control. The addition of tiotropium bromide to inhaled corticosteroids might be effective in improving disease outcome. This paper discusses the results of a study evaluating the effects of tiotropium bromide added to inhaled corticosteroids when compared to other regimens in patients with uncontrolled asthma. The addition of tiotropium to the current inhaled corticosteroid dose is comparable to the addition of salmeterol: both are more effective in achieving disease control versus doubling the inhaled corticosteroid dose. It is well worth investigating the effects of tiotropium in asthma that is not adequately controlled with higher doses of inhaled corticosteroids.

Crizotinib for EML4-ALK positive lung adenocarcinoma: a hope for the advanced disease? Evaluation of Kwak EL, Bang YJ, Camidge DR, et al. Anaplastic lymphoma kinase inhibition in non-small-cell lung cancer. N Engl J Med 2010;363(18):1693-703

INTRODUCTION

In lung adenocarcinoma, certain mutations such as echinoderm microtubule-associated protein-like 4-anaplastic lymphoma kinase (ALK) are associated with lower sensitivity to chemotherapy, when used conventionally as the first-line therapy in the advanced stage of the disease.

AREAS COVERED

This paper discusses the clinical and therapeutic importance of ALK mutations in NSCLC and the early clinical results of a Phase I study assessing crizotinib in patients with ALK mutations.

EXPERT OPINION

Abnormal ALK is evolving as an important therapeutic target in patients with more aggressive lung adenocarcinoma. Further clinical studies are needed in order to assess if crizotinib, an ALK inhibitor, is able to increase the efficacy of the conventional chemotherapy in this disease subset.

Novel therapies for hypereosinophilic syndromes

BACKGROUND

Conventional therapies (corticosteroids, cytotoxic agents or interferon-a) or newer compounds such imatinib are used specifically in subsets of hypereosinophilic syndromes (HES). However other therapies are still needed in this condition.

OBJECTIVE

To review the novel therapies for HES discussing their advantages and shortcomings.

METHODS AND RESULTS

Preclinical and clinical data on novel tyrosine kinase inhibitors, anti-IL -5 antibodies or anti-CD52 antibodies (alemtuzumab) are analysed. The former might represent appropriate options in case of imatinib resistance; the efficacy of anti-IL-5 monoclonal antibodies therapy is limited by the occurrence of rebound eosinophilia and alemtuzumab might be a promising anti-eosinophil therapy for all HES subsets.

CONCLUSION

Some of the novel therapies might become appropriate therapeutic options for HES.

Tiotropium therapy and mortality risk in COPD patients: the most severe, the most protected? Evaluation of Celli B, Decramer M, Kesten S, et al. Mortality in the 4-year trial of tiotropium (UPLIFT) in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2009; 180(10): 948-55

IMPORTANCE OF THE FIELD

Tiotropium bromidum is an inhaled long acting anticholinergic used as first line monotherapy in stable COPD due to its beneficial effects on the lung function, respiratory symptoms, quality of life or disease morbidity. However there is limited data on its effects on mortality.

AREAS COVERED IN THIS REVIEW

The results of the UPLIFT (Understanding Potential Long-Term Impacts on Function with Tiotropium) study evaluating the effects of 4 year therapy with tiotropium on above mentioned outcomes including mortality.

WHAT THE READER WILL GAIN

Tiotropium demonstrated an uniform beneficial effect on mortality risk reduction but subset analyses yielded relevant results as well.

TAKE HOME MESSAGE

On long-term basis tiotropium therapy can reduce mortality rate overall and can exert such protective effects in various subsets such as patients with very severe COPD.

Cytokine antagonists for the treatment of asthma: progress to date

Asthma is a disease of the airways in which several cytokines such as interleukin (IL)-4, IL-5, IL-13 and tumor necrosis factor-alpha (TNFalpha) play a major role in the development and progression of inflammation, airway hyperresponsiveness, mucus production, and airway remodeling. The conventional anti-inflammatory therapies, represented by inhaled corticosteroids and antileukotrienes, are not always able to provide optimal disease control and it is therefore hoped that cytokine antagonists could achieve this goal in such situations. Anticytokine therapies have been tested in preclinical studies and some have entered clinical trials. Anti-IL-4 therapies have been tested in animal models of allergy-related asthma, but because of unclear efficacy their development was discontinued. However, IL-4/IL-13 dual antagonists and IL-13-specific blocking agents are more promising, as they exhibit more sustained anti-inflammatory effects. IL-5 antagonists have been found to be of limited efficacy in clinical studies but might be useful in conditions characterized by severe hypereosinophilia, and in which asthma is one of the disease manifestations. Unlike other chronic inflammatory conditions, such as rheumatoid arthritis, the use of anti-TNFalpha therapies in asthma might be limited by the unfavorable risk/benefit ratio associated with long-term use. The identification of so-called asthma TNFalpha phenotypes and perhaps the use of a less aggressive treatment regimen might address this important aspect. Other cytokine antagonists (for example for IL-9 or IL-25) are currently being evaluated in the asthma setting, and could open new therapeutic perspectives based on their efficacy and safety.

[Evaluation of therapeutic effect in chronic obstructive pulmonary disease (COPD) by assessment of quality of life: methodological considerations]

Health status represents a tool frequently used for assessment of therapeutic impact of different therapeutic methods in various diseases including chronic obstructive pulmonary disease (COPD). We review the methodology of health status assessment performed with generic and disease or symptoms specific questionnaires Definition of quality of life-related terms, analysis of data from various studies on COPD using health status as an outcome measure was performed. Health status is widely used in studies assessing efficacy of both pharmacological and non-pharmacological therapeutic methods in COPD. In COPD health status can be measured with several generic or specific questionnaires and can be an appropriate efficacy endpoint in therapeutic trials.

Effects of montelukast-desloratadine combination on early and late asthma responses Davis BE, Illamperuma C, Gauvreau GM, et al. Single-dose desloratadine and montelukast and allergen-induced late airway responses. Eur Respir J 2009;33(6):1302-308

BACKGROUND

In asthma, montelukast is given on regular basis to reduce eosinophilic airway inflammation. Addition of the antihistaminic desloratadine can amplify the early and late anti-inflammatory activities of montelukast in patients with asthma.

OBJECTIVE

To assess the efficacy data of preventive single-dose desloratadine, montelukast and combination therapy in asthma subjects challenged with inhaled allergens.

METHODS/RESULTS

Analysis of data from a placebo-controlled, cross-over study in which combination preventive therapy was demonstrated to be superior in reducing both early and late allergen-induced inflammatory response when compared with placebo and each component.

CONCLUSION

Although such combination therapy might be effective in preventing the inflammatory flare following the transient allergen exposure, further studies are needed to better define such therapy in terms of duration, doses and therapeutic indications.

Ciclesonide therapy in asthma: a potential effect on small airway inflammation?

BACKGROUND

In asthma small airways inflammation often persists despite inhaled corticosteroids therapy.

OBJECTIVE

To discuss the effects of ciclesonide, a newer inhaled corticosteroid on small airways inflammation and the reliability of some biomarkers of small airways inflammation in asthma.

METHODS AND RESULTS

Evaluation of a study assessing the short-term effects of ciclesonide on small airways inflammation in patients with mild to moderate asthma.

CONCLUSIONS

Ciclesonide could have beneficial effects on small airways inflammation and some of the outcome measures used as efficacy endpoints could represent possible biomarkers of small airways involvement in obstructive chronic respiratory diseases.

Fudosteine effects on mucin production

BACKGROUND

Many chronic respiratory conditions are associated with mucin hypersecretion induced by underlying inflammation.

OBJECTIVE

To analyse the results of a preclinical study assessing the pathogenic mechanisms of mucin hyperproduction and the consequent in vivo and in vitro effects of fudosteine, a mucoactive agent.

METHODS/RESULTS

Both LPS and TNF-alpha increased MUC5AC mucin production in vivo and in vitro, respectively, and fudosteine was found to reduce it by partially interfering with the kinase-mediated inflammation pathway that activates the MUC5AC gene.

CONCLUSIONS

Further preclinical testing in animal models with chronic airways inflammation is necessary.