The effect of airway epithelium on smooth muscle contractility in bovine trachea.

In bovine tracheal smooth muscle the presence of airway epithelium significantly reduced the sensitivity and maximum contractile response to histamine, 5-hydroxytryptamine (5-HT) or acetylcholine. Muscle contraction induced by K+ and electrical field stimulation was of similar magnitude both in the presence or absence of adherent epithelium. The effect of epithelium on smooth muscle contractility was unaffected by pretreatment with indomethacin (10(-6) M) or mepacrine (5 X 10(-5) M). The relaxant response to isoprenaline was enhanced in the presence of epithelium, although this was significant only in the case of precontraction with 5-HT. It is concluded that the bronchial epithelium may produce a relaxant factor which is not a cyclooxygenase or lipoxygenase product. The production of this factor may be reduced or lost following epithelial damage and this may be important in the pathogenesis of bronchial hyperresponsiveness in asthma.

Nociceptin inhibits cough in the guinea-pig by activation of ORL(1) receptors.

We studied the central and peripheral antitussive effect of ORL(1) receptor activation with nociceptin/orphanin FQ in conscious guinea-pigs. In guinea-pig cough studies, nociceptin/orphanin FQ (10, 30, and 90 microg) given directly into the CNS by an intracerebroventricular (i.c.v.) route inhibited cough elicited by capsaicin exposure by approximately 23, 29 and 52%, respectively. The antitussive activity of nociceptin/orphanin FQ (90 microg, i.c.v.) was blocked by the selective ORL(1) antagonist [Phe(1)gamma(CH(2)-NH)Gly(2)]nociceptin-(1-13)-NH(2) (180 microg, i.c.v.) and J113397 (10 mg kg(-1), i.p.) but not by the opioid antagonist, naltrexone (3 mg kg(-1), i.p.). Furthermore, intravenous (i.v.) nociceptin/orphanin FQ (1.0 and 3.0 mg kg(-1)) also inhibited cough approximately by 25 and 42%, respectively. These findings indicate that selective ORL(1) agonists display the potential to inhibit cough by both a central and peripheral mechanism, and potentially represent a novel therapeutic approach for the treatment of cough.

Calcitonin gene-related peptide is localised to human airway nerves and potently constricts human airway smooth muscle.

In human airways synthetic human sequence calcitonin gene-related peptide (hCGRP), a novel peptide produced by alternative processing of mRNA from the calcitonin gene, caused concentration-dependent contraction of human bronchi (EC50 4.9 X 10(-9) M) and was significantly more potent than substance P or carbachol. The contractile response was unaffected by atropine (2 X 10(-6) M), propranolol (10(-6) M), indomethacin (10(-5) M), tetrodotoxin (3 X 10(-6) M), chlorpheniramine (10(-4) M), cimetidine (10(-5) M), or FPL55712 (10(-4) M) suggesting a direct effect of CGRP on airways smooth muscle. CGRP was detected in human airways by radioimmunoassay with highest concentrations in cartilaginous airways. CGRP was localised by immunocytochemistry to both nerves and ganglia in human airways. CGRP, is a potent constrictor of human airways and may have important effects on airway function and be implicated in the pathogenesis of bronchial hyper-responsiveness and asthma.

A comparison of double-strength beclomethasone dipropionate (84 microg) MDI with beclomethasone dipropionate (42 microg) MDI in the treatment of asthma.

STUDY OBJECTIVE: To compare the efficacy and safety of a double-strength formulation of beclomethasone dipropionate (BDP 84) metered-dose inhaler (MDI) with that of beclomethasone dipropionate (BDP 42) MDI in the treatment of chronic asthma. DESIGN: A 28-day, randomized, double-blind, double-dummy, placebo-controlled, multicenter study. SETTING: Outpatient. PATIENTS: A total of 423 patients aged 12 to 65 years (mean range, 34 to 36 years) with moderate asthma (FEV1, 50 to 80% of predicted) who required long-term inhaled corticosteroids were enrolled. INTERVENTIONS: Patients were randomized to receive BDP 84, two oral inhalations bid (336 microg/d), BDP 42, four oral inhalations bid (336 microg/d), or placebo. A fourth treatment arm administering BDP 84, eight oral inhalations bid (HD BDP 84; 1,344 microg/d) was also included to determine whether a dose-response relationship could be demonstrated. MEASUREMENTS: Spirometry, clinical observations. RESULTS: The three active treatments were significantly more effective (p < or = 0.01) than placebo at all time points in improving FEV1, the primary efficacy parameter; BDP 42 and BDP 84 were comparable to each other at every time point. Secondary pulmonary function tests (FVC, forced expiratory flow at 25 to 75% of FVC, and peak expiratory flow rate) showed similar results. All three active treatments were well tolerated. A dose response between 336 microg/d and 1,344 microg/d was demonstrated. CONCLUSION: In this well-controlled 28-day study, BDP 42 and BDP 84 were shown to be comparable in efficacy and safety on a microgram-for-microgram basis.

VIP and PHM and their role in nonadrenergic inhibitory responses in isolated human airways.

There is increasing evidence in many species that vasoactive intestinal peptide (VIP) may be a neurotransmitter in nonadrenergic inhibitory nerves. We have studied the effect of electrical field stimulation (EFS), exogenous VIP, and isoproterenol (Iso) on human airways in vitro. We have also studied a related peptide, peptide histidine methionine (PHM), which coexists with VIP in human airway nerves, and in separate experiments studied fragments of the VIP amino acid sequence (VIP1-10 and VIP16-28) for agonist and antagonist activity. Human airways were obtained at thoracotomy and studied in an organ bath. In bronchi EFS gave an inhibitory response that was unaltered by 10(-6) M propranolol but was blocked by tetrodotoxin, whereas in bronchioles there was little or no nonadrenergic inhibitory response. VIP, PHM, and Iso all caused dose-dependent relaxation of bronchi, VIP and PHM being approximately 50-fold more potent than Iso. VIP, but not Iso, mimicked the time course of nonadrenergic inhibitory nerve stimulation. In contrast bronchioles relaxed to Iso but not to VIP or PHM. Neither propranolol nor indomethacin altered the relaxant effects of VIP or PHM, suggesting a direct effect of these peptides on airway smooth muscle. Neither of the VIP fragments showed either agonist or antagonist activity. We conclude that VIP and PHM are more potent bronchodilators of human bronchi than Iso and that the association between the relaxant effects of these peptides and nonadrenergic inhibitory responses suggests that they may be possible neurotransmitters of nonadrenergic inhibitory nerves in human airways.

Ventilatory effects of substance P, vasoactive intestinal peptide, and nitroprusside in humans.

Animal studies suggest that the neuropeptides, substance P and vasoactive intestinal peptide (VIP), may influence carotid body chemoreceptor activity and that substance P may take part in the carotid body response to hypoxia. The effects of these peptides on resting ventilation and on ventilatory responses to hypoxia and to hypercapnia have been investigated in six normal humans. Infusions of substance P (1 pmol.kg-1.min-1) and of VIP (6 pmol.kg-1.min-1) were compared with placebo and with nitroprusside (5 micrograms.kg-1.min-1) as a control for the hypotensive action of the peptides. Both peptides caused significantly less hypotension than nitroprusside. Substance P and nitroprusside caused significantly greater increases in ventilation and in the hypoxic ventilatory response than VIP. No changes were seen in hypercapnic sensitivity. The stimulation of ventilation and the differential effects on ventilatory chemosensitivity that accompanied hypotension are consistent either with stimulation of carotid body chemoreceptor activity or with an interaction with peripheral chemoreceptor input to the respiratory center, as is seen in animals. The similar cardiovascular but different ventilatory effects of the peptides suggest that substance P may also stimulate the carotid body in a manner independent of the effect of hypotension. This is consistent with a role of substance P in the hypoxic ventilatory response in humans.

Breakdown of phosphoinositides in airway smooth muscle: lack of influence of anti-asthmatic drugs.

Hydrolysis of membrane inositol phospholipids during agonist-induced contraction in bronchial smooth muscle leads to formation of inositol phosphates. Inositol phosphates are associated with intracellular Ca++ mobilization, which in smooth muscle leads to contraction. We have investigated the effects of inhibitors of the contraction, theophylline, isoproterenol (isoprenaline), and verapamil, on contraction due to carbachol and histamine in bovine airway smooth muscle, and on the formation of inositol phosphates in the same preparation. Since phospholipase C and A2 are involved in the formation of inositol phosphates, we have also studied the effect of inhibitors of phospholipases, dexamethasone and mepacrine, on the accumulation of inositol phosphates. Theophylline, isoproterenol and verapamil elicited a concentration-dependent relaxation of pre-contracted smooth muscle, with the following order of potency: Isoproterenol greater than verapamil greater than theophylline. The relaxant effect was more effective on histamine than on carbachol-induced contraction and depended on the initial airway tone. However, neither theophylline, isoproterenol or verapamil, nor dexamethasone or mepacrine changed the basal level of inositol phosphates or affected the rise due to agonists. We conclude that the smooth muscle effects of theophylline, isoproterenol, verapamil, dexamethasone and mepacrine are not mediated by interference with membrane phosphoinositide breakdown.

Synergistic antiallergic activity of combined histamine H1- and cysteinyl leukotriene1-receptor blockade in human bronchus.

Mast cell histamine (HA) and cysteinyl leukotrienes (CysLT) account for most of the early phase bronchospasm in asthma. However, activation of the smooth muscle CysLT1-receptor plays a major role in asthmatic bronchospasms. CysLT-receptor antagonists or CysLT-synthesis inhibitors are efficacious in asthma but do not completely abolish asthmatic bronchospasms. A recent clinical study showed that combined antagonists loratadine (H1) and zafirlukast (CysLT1) were more effective against allergic bronchospasms than either drug alone. We examined the combined efficacy of H1- and CysLT1-receptor antagonists in allergic human bronchus. The H1- and CysLT1-receptor antagonists chlorpheniramine (CTM; 1 microM) and MK-571 (0.03 microM), were tested alone and in combination, against anti-human IgE antibody (Ab)-induced contractions of passively sensitized isolated human bronchus. Ab-induced allergic contractions were reduced 15% and 36% by CTM (1 microM) and MK-571 (0.03 microM), respectively. Combined CTM (1 microM) and MK-571 (0.03 microM) significantly inhibited the Ab response by 87%. Mechanistic investigations in isolated human bronchus and cultured human cord blood mast cells suggest that H1- and CysLT-receptor interactions likely occur at the airway smooth muscle level. CTM and MK-571 synergistically inhibited human allergic bronchospasm in the present in vitro model. The mechanism underlying this synergistic activity requires further investigation.

Dose-ranging study of a new steroid for asthma: mometasone furoate dry powder inhaler.

A new formulation of mometasone furoate (MF) for administration by dry powder inhaler (DPI) was evaluated for the treatment of asthma. A 12-week, double-blind, placebo-controlled dose-ranging study compared the efficacy and safety of three doses of MF DPI (100, 200 and 400 mcg b.i.d) with beclomethasone dipropionate (BDP) 168 mcg b.i.d. administered by metered dose inhaler in 365 adult or adolescent patients being treated with inhaled glucocorticoids. The mean change from baseline to endpoint (last treatment visit) for forced expiratory volume in 1 sec (FEV1) was the primary efficacy variable. Secondary efficacy variables included other objective measures of pulmonary function [forced vital capacity (FVC), forced expiratory flow 25-75% (FEV25-75%.) and peak expiratory flow rate (PEFR)] as well as subjective measures of therapeutic response (patients' daily evaluation of asthma symptoms and physicians' evaluation). At endpoint, all four active treatments were significantly more effective than placebo (P < 0.01) in improving FEV1 (MF DPI 5 to 7%, BDP 3%, placebo -6.6%) and all other measures of pulmonary function (FVC: MF DPI 4 to 5%, BDP 2%, placebo -4.7%; FEF25-75%: MF DPI 6 to 18%, BDP 7.5%, placebo -9.5%; PEFR (AM): MF DPI 5 to 10%, BDP 5.7%, placebo -7%). A consistent trend was observed for better improvement in patients treated with MF DPI 200 mcg b.i.d. than with MF DPI 100 mcg b.i.d., with no apparent additional benefit of MF DPI 400 mcg b.i.d. Results for the MF DPI 100 mcg b.i.d. and BDP 168 mcg b.i.d. treatment groups were similar. Patients' and physicians' subjective evaluations of symptoms found similar improvement in the MF DPI 200 and 400 mcg b.i.d. treatment groups, which were slightly better than that in the MF DPI 100 mcg b.i.d. group. Symptoms tended to worsen in the placebo group. MF DPI was well tolerated at all dose levels and the most frequently reported treatment-related adverse effects were headache, pharyngitis and oral candidiasis. No evidence of HPA-axis suppression was detected in any treatment group. In summary, all doses of MF DPI were well tolerated and significantly improved lung function and MF DPI 400 mcg (200 mcg b.i.d.) was the optimal dose in this study of patients with moderate persistent asthma.

Tuberculosis in renal failure: a high incidence in patients born in the Third World.

We report 11 cases of tuberculosis among patients with chronic renal failure being treated in our unit. All were born outside the United Kingdom, and represent 25% of the non-europid patients in the unit. This is about a seventy-fold increased incidence of tuberculosis in this group. Diagnosis is difficult and mortality high if the diagnosis is delayed. Culture of tissue biopsies is the most reliable investigation and chemotherapy should be commenced promptly or a therapeutic trial considered in doubtful cases. Chemoprophylaxis may be beneficial in patients from these ethnic groups or in any uremic patient with evidence of old tuberculosis. Three patients with advanced disease died despite antibiotic treatment, but in the remainder, triple therapy with normal doses of rifampicin, isoniazid and pyrazinamide proved safe and effective.

Budd-Chiari syndrome and alpha-1 antitrypsin deficiency.

A 44 year old man with Budd-Chiari syndrome and heterozygous PiMZ alpha-1 antitrypsin deficiency is reported. This association has not been reported before and its significance remains to be established.

Is choice of drug delivery as important as choice of drug in childhood asthma?

Inhalation of aerosols from a metered dose inhaler is a rational, convenient and well-liked method of administration of anti-asthmatic medication in adults but, in children, this method may be neither practical nor desirable. A number of devices such as spacers and dry powder inhalers have been developed and are particularly useful where children are too young to coordinate inspiration with actuation of the aerosol canister. In infants, administration of drug suspensions or solutions from a jet nebuliser via a face mask, or syrups by mouth, may be the only means of delivering anti-asthmatic medication.

Beyond the histamine receptor: effect of antihistamines on mast cells.

Many antihistamines exhibit inhibition of mediator release from mast cells and basophils, in in vitro studies in addition to H1 antagonism. The underlying mechanism is unclear but is unrelated to H1-receptor antagonism. Clinical studies of antihistamins in antigen challenge and seasonal allergy demonstrate reduction of mast cell mediators in nasal lavage. It is not known what mechanism(s) underly these observations, although the concentrations required in in vitro studies suggests that a direct effect on mast cells is unlikely. Furthermore, the therapeutic contribution of this effect is difficult to assess because of concomitant clinically significant H1 antagonism. This and other potential anti-allergic effects may enhance the therapeutic benefit of antihistamines and long-term studies are underway to explore this possibility.

Airway smooth muscle and disease workshop: epithelial mediators.

The bronchial epithelium has a number of mechanical functions including mucociliary clearance and protection against noxious agents. However, there is increasing evidence that it is a metabolically active tissue that may modulate the function of the underlying smooth muscle by metabolism and regulation of mediators and the production of relaxant, constrictor, or chemotactic factors. It is therefore possible that the epithelial abnormalities observed in asthmatics may lead, via several different mechanisms, to increased bronchial hyperresponsiveness (figure 2), which is a fundamental feature of asthma. However, it may not be necessary to invoke structural damage to explain derangement of epithelial function. It is possible that functional biochemical abnormalities may be present in epithelial cells, thereby producing bronchial hyperresponsiveness in the absence of histologic abnormalities. Further studies with bronchial epithelium, similar to those with vascular endothelium, are needed to clarify its role in the pathogenesis of asthma.

The effect of inhaled nifedipine on bronchial reactivity to histamine in man.

We have administered nifedipine by aerosol to six patients with mild asthma to determine whether local administration of a potent calcium channel blocker has any effect on resting airway tone or histamine reactivity. Subjects had their responsiveness to histamine measured and then received either nifedipine, 10 mg in 40% ethanol, or diluent alone in a randomized, double-blind fashion. Specific airway conductance, blood pressure, and heart rate did not change after either inhalation. Histamine reactivity was significantly reduced after the nifedipine aerosol, the geometric mean provocative concentration causing a 35% fall in specific airway conductance, rising from 5.0 to 10.9 mg/ml of histamine (p less than 0.05). In individuals this protective effect was variable but overall was no greater than that observed after sublingual nifedipine. Plasma nifedipine concentrations were measured in two subjects after administration of the aerosol and confirmed that inhaled nifedipine is absorbed across the bronchial mucosa.

Effects of inhaled platelet activating factor on pulmonary function and bronchial responsiveness in man.

Platelet activating factor (PAF), a phospholipid inflammatory mediator, was given as an aerosol to eight normal subjects. PAF caused a dose-dependent bronchoconstriction in all subjects. This did not correlate well with responsiveness to methacholine. Some subjects showed tachyphylaxis to PAF-induced bronchoconstriction. No subject had a late bronchoconstriction response. Transient facial flushing and an increase in heart rate (mean 7 beats/min) occurred but there was no consistent change in blood pressure. Lyso-PAF, the inactive precursor and major metabolite of PAF, had no effect on pulmonary or cardiovascular responses. Six of the subjects took part in a double-blind, randomised, placebo-controlled, crossover study in which bronchial responsiveness to methacholine was measured over the 3 days after administration of PAF or lyso-PAF. PAF had a greater effect in raising responsiveness (p less than 0.01). Its maximum effect occurred at 3 days and returned to baseline in 1 to 4 weeks. PAF may contribute to the pathogenesis of bronchial hyperresponsiveness, which is the most characteristic abnormality in asthma.

Platelet activating factor: effects on bronchomotor tone and bronchial responsiveness in human beings.

Platelet-activating factor (PAF) is a newly discovered lipid mediator of inflammation. When inhaled by normal volunteers, it induces bronchoconstriction associated with facial flushing and with a transient fall in circulating neutrophils. Of greater interest is its ability to induce prolonged increases in bronchial responsiveness to methacholine. These observations support an important role for PAF in asthama; the availability of specific PAF antagonists will allow us to test this hypothesis.

Bradykinin-induced bronchoconstriction in humans. Mode of action.

The effect of bradykinin was studied by inhalation in normal and asthmatic human subjects, as well as on human bronchial smooth muscle in vitro. Bradykinin caused cough and retrosternal discomfort in all subjects and bronchoconstriction in asthmatic subjects. Bradykinin was approximately 10 times more potent than histamine and methacholine, and there was a significant correlation between the subjects' sensitivity to histamine and bradykinin. Bradykinin-induced bronchoconstriction was prolonged when compared with that of histamine and the C-fiber stimulant capsaicin. This bronchoconstriction was subject to tachyphylaxis, which was also associated with desensitization of the subjects to inhaled histamine. The provocative dose causing a 35% fall in specific airway conductance (PD35) was unaffected by aspirin (1 g orally). However, ipratropium bromide (0.25 mg by nebulizer) significantly inhibited the effect of bradykinin, the PD35 being 0.8 mumol (range, 0.16 to 3.4) and 0.15 mumol (range, 0.047 to 1.15) after active dose and placebo, respectively (p less than 0.05). Likewise, cromolyn sodium (40 mg dry powder) also significantly reduced response to bradykinin, with a PD35 of 0.04 mumol (range, 0.13 to 0.31) after placebo and 0.39 mumol (range, 0.05 to 4.45) after SCG (p less than 0.05). Bradykinin only weakly constricted human bronchial smooth muscle in vitro. Bradykinin at 10(-4) caused only 21.5 +/- 5.5% of the maximal carbamylcholine contraction in 11 of 18 airways. Captopril did not enhance the effect of bradykinin. Bradykinin is a potent bronchoconstrictor of human airways in vivo, acting in part through cholinergic mechanisms but not because of the formation of prostaglandins.

Cardiovascular profile of loratadine.

The extremely low reporting rate of cardiovascular adverse events for loratadine, the possible preferential use of loratadine in patients with pre-existing cardiovascular disorders, and the impressive lack of cardiovascular effects at extremely high concentrations in clinical and preclinical studies demonstrate the very safe cardiovascular profile of loratadine.

Th2 cytokines and asthma. The role of interleukin-5 in allergic eosinophilic disease.

Interleukin-5 is produced by a number of cell types, and is responsible for the maturation and release of eosinophils in the bone marrow. In humans, interleukin-5 is a very selective cytokine as a result of the restricted expression of the interleukin-5 receptor on eosinophils and basophils. Eosinophils are a prominent feature in the pulmonary inflammation that is associated with allergic airway diseases, suggesting that inhibition of interleukin-5 is a viable treatment. The present review addresses the data that relate interleukin-5 to pulmonary inflammation and function in animal models, and the use of neutralizing anti-interleukin-5 monoclonal antibodies for the treatment of asthma in humans.