Long-term outcomes of combination biologic therapy in uncontrolled severe asthma: a case study.

INTRODUCTION: Treatment with biologics has significantly reduced the social and economic burden of severe asthma. However, some patients may still feature a suboptimal control of their symptoms while on therapy. In this subset of asthmatic patients, a benefit from a dual biologic therapy has sporadically been reported in literature. Our aim is to add our experience to the limited body of evidence supporting combination biologic therapies. CASE STUDY: Here we present the case of a 68-year-old nonsmoker female, with an allergic and eosinophilic corticosteroid-dependent severe asthma. She displayed well controlled comorbidities and good adherence to the inhaled therapy. Omalizumab was started in 2008 with an initial remarkable clinical improvement. After nine years of biologic therapy, she reported a gradual worsening of her symptoms and exacerbations. Mepolizumab was then added in 2019. RESULTS: The addition of Mepolizumab resulted in a meaningful amelioration of her quality of life, asthma control, number of exacerbations and 6-minute-walking-distance at 3-year follow-up. The average Prednisone dosage was tapered from 25 mg to 20 mg daily. No adverse events were observed since the introduction of the second biologic. CONCLUSION: Our experience indicates that Mepolizumab may be beneficial and safe as an add-on biologic in a patient whose allergic and eosinophilic asthma remains uncontrolled despite treatment with an anti-IgE strategy. Further studies on a larger number of patients are required to demonstrate whether the positive outcomes published so far are replicable on a larger scale.

New insights into the regulation of TGF-ß/Smad and MPK signaling pathway gene expressions by nasal allergen and methacholine challenge test in asthma.

Background: Asthma is a heterogeneous chronic inflammatory disease of the bronchi, the course of which is significantly influenced by extrinsic factors (specific and non-specific). Methods: The aim of this study was to evaluate the effect of these factors represented by nasal allergen challenge (specific factors) and methacholine challenge test (non-specific) on changes in mRNA expression of genes encoding the TGF-ß (TGF-ß1 and TGF-ß3)‒Smad (mitogen-activated protein kinase 1/3 [MPK1/3], Smad1/3/6/7) signaling pathway in asthmatic patients. Results: Seventy-five subjects were included in the study, of whom 27 were applied an intranasal allergen provocation and 48 a methacholine provocation. There were 9 men and 18 women in the intranasal provocation group, and 17 men and 31 women in the methacholine test group. We found that both examined the types of challenges contributed to changes in the relative expression of genes of the TGF-ß (TGF-ß1 and TGF-ß3)‒Smad (MPK1/3, Smad1/3/6/7) signaling pathway in asthmatic patients. A decrease was noted for MAPK1, MAPK3, Smad3, Smad6, and Smad7 genes and an increase of up to 2.5 times for TGF-ß1 gene. Conclusions: Our experiment allows us to conclude that the change in the mRNA expression of the TGF-ß1-MPK1/3 and Smad3/6/7 genes occurs after an intranasal allergen and bronchial methacholine challenge.

The correlation of the BMP-4 and BMP-7 proteins of the TGFß-BMP-SMAD pathway in the response to a specific and non-specific trigger in asthma.

INTRODUCTION: Asthma is characterized by persistent inflammation, airway hypersensitivity and remodelling. Bone Morphogenetic Proteins belong to the Transforming Growth Factor Superfamily and have a similar signalling transduction pathway and common co-mediating protein. However, the BMPs role in the remodelling remains unclear; they appear to be involved in the airway inflammation and fibrogenesis process. MATERIAL AND METHODS: 60 patients with asthma and 48 healthy volunteers were recruited for the study. Blood samples were collected before, 1 hour, 24 and 48 hours after the allergen or the methacholine challenge test. Evaluation of BMP-4 and BMP-7 serum concentration and expression was performed using ELISA and real time PCR methods, respectively. RESULTS: Statistically significant differences in BMP-7 concentration between healthy controls and asthmatics before the chal-lenge were noted. We found two statistically significant correlations: between the basal BMP-4 concentration and the FEV1(L) raw value and FEV1/FVC(%) index. We did not observe significant changes in the gene expression of BMP-4 and BMP-7 in different time points. CONCLUSIONS: Observed differences in BMP-7 concentration between asthmatic and healthy groups and correlations between BMP-4 concentration and some lung function test values may indicate the role of the BMPs in the etiopathogenesis of asthma. The unique characteristic of our study is the evaluation of BMPs serum levels, not in the bronchial epithelium.

Role of IL-15 in the modulation of TGF-ß1-mediated inflammation in asthma.

Transforming growth factor (TGF)-ß1 has an essential role in bronchitis and the induction of bronchial remodelling, which are critical processes in the pathogenesis of asthma. However, the role of interleukin (IL)-15 in asthma inflammation remains unclear. The aim of the present study was to evaluate the effect of TGF-ß1 mRNA expression on IL-15 mRNA expression in asthmatic patients and to assess the role of IL-15 in the clinical course of asthma. The study included 221 participants, comprising 130 patients with asthma and 91 healthy volunteers. The participants were subjected to testing using spirometry, as well as the Asthma Control Test™ and Borg Scale. The expression of TGF-ß1 and IL-15 mRNA was analyzed in blood samples using reverse transcription-quantitative polymerase chain reaction. Statistical analysis indicated that IL-15 and TGF-ß1 mRNA expression each differed significantly between the patient and control groups (P=0.0016 and P=0.033, respectively). A significant correlation was identified between IL-15 expression and TGF-ß1 expression (R=0.41, P=0.0005). No correlation was observed between IL-15 expression and the degree of asthma severity, the results of spirometric examination or the frequency of asthma exacerbations. Further analysis revealed that IL-15 expression was elevated following the administration of inhaled glucocorticosteroids (iGCs; P=0.024), and reduced following methylxanthine treatment (P<0.001). The occurrence of dyspnoea differed between the study and control groups, and this was not found to be associated with IL-15 expression. Since IL-15 expression was correlated with TGF-ß1 expression among asthmatic patients, and IL-15 expression was elevated following iGC administration, the results of the study suggest that IL-15 activity might be associated with the pathogenesis of asthma.

Selected bone morphogenetic proteins - the possibility of their use in the diagnostics and therapy of severe asthma.

Asthma is a chronic heterogeneous illness of the lower airway with an inflammatory basis, developing from hyperresponsiveness and bronchial obstruction. One of the more unfavourable processes occurring in the airway are the long-term changes of the respiratory tract known as remodelling, resulting in complete irreversible obstruction. Bone morphogenetic protein (BMP) is a member of the Transforming Growth Factor beta (TGF-b) superfamily, which regulates processes in embryonic and post-embryonic development. The role played by BMP is regulation of degradation and remodelling of the extracellular matrix, which is one of the elements involved in the reconstruction of the structure of the bronchi in severe asthma. This paper presents the antagonistic properties of BMP against TGF-b, anti-inflammatory and counteracting fibrosis in the respiratory tract. The current state of knowledge indicates that this group of cytokines are potential new markers of remodelling in severe asthma, and further studies on their therapeutic value are necessary.

The role of the TGF-SMAD signalling pathway in the etiopathogenesis of severe asthma.

Asthma is a chronic inflammatory heterogeneous disease of the lower respiratory tract characterised by the occurrence of bronchial hyper-responsiveness and paroxysmal, changeable bronchial obstruction. Transforming growth factor-beta (TGF-b) is one of the cytokines involved in mediating airway inflammation and remodelling. The level of TGF-b1 gene expression correlates with severity of symptoms. Alterations in the main SMAD signal transmission, overexpression of TGF-b genes and changes in the transcriptome cause excessive secretion of TGF-b and its increased expression in target cells, which clinically induces a moderate-severe or severe course of asthma as well as an earlier and faster disease progression. Knowledge of these processes allows clinicians to assess immune responses in patients, which affects adequate disease control and prevention of remodelling.