Anne Pietinalho

Delivery Devices for Inhaled Asthma Medication

This review deals with results of comparative clinical studies where 2 or more delivery devices have been used, the lung deposition of the drug has been measured or is known and the clinical efficacy has been documented. With optimal inhalation technique the lung deposition of inhalation devices is approximately as follows: pressurised metered dose inhalers (pMDIs) 10 to 15% [salbutamol (albuterol) around 20%]; pMDI + spacer 20 to 30%; Rotahaler®, Diskhaler® and Inhalator Ingelheim® around 10%; Easyhaler® 20 to 25%; and Turbuhaler® 20 to 35% of the metered dose depending on the substance. These differences in deposition figures have been reflected in the results of most single-dose crossover studies with bronchodilator substances. A pMDI is clinically more effective than Rotahaler® and Diskhaler®. Turbuhaler® is more effective than a pMDI. In single-dose studies where expected differences based on deposition values have been undetected, all responses have probably been on the top of the dose-response curves. Studies with a cumulative-dose design have not usually reflected known differences in deposition values between bronchodilator devices. This discrepancy between single-dose crossover studies and cumulative-dose studies seems to be the result of different doses and amounts of drug administered at different time points (especially the first dose) in the cumulative-dose studies. Studies with repeated doses over weeks and months do not reflect differences in deposition values between bronchodilator devices, since short-acting bronchodilators, irrespective of the delivery system, do not affect the level of airway function in the morning. There are only 2 studies comparing the efficacy of a long-acting bronchodilator given via 2 different devices. Anti-inflammatory medication is impossible to evaluate without using long screening periods, when the lowest required maintenance dosage of the inhaled corticosteroid has to be individually defined. Comparative studies are meaningless without knowing that patients are neither under- nor over-treated when entering the study. Thereafter, comparisons can be made in studies with a duration of several months. Very few studies fulfil these criteria. However, the results of these types of studies do reflect differences in deposition values between delivery devices. Studies reported so far show that the budesonide Turbuhaler® is clinically approximately twice as effective as a budesonide pMDI or a beclomethasone pMDI with spacer. The results of short-term studies seem to indicate that fluticasone is twice as effective as beclomethasone, irrespective of pMDI or Diskhaler® delivery system. So far no well-designed double-blind studies have been performed comparing the budesonide Turbuhaler® with fluticasone via pMDI or Diskhaler®. No deposition data are available for fluticasone (in pMDI, Diskhaler® or Diskus®/Accuhaler®), or for the most recent device introductions such as the Diskus®/Accuhaler® with any substance. The Easyhaler® (available with salbutamol or beclomethasone) has good deposition values, but has not been compared clinically with Turbuhaler®, Diskhaler® or Diskus®/Accuhaler®. Even when used properly, delivery devices may deposit very different amounts of drug into the lungs. Also, pMDIs may have different deposition properties. Recent studies with bronchodilators and corticosteroids have shown that there is a good correlation between the amount of drug deposited in the lungs and the level of clinical efficacy.

HLA-DRB1 allele frequencies and C4 copy number variation in Finnish sarcoidosis patients and associations with disease prognosis.

Sarcoidosis is a multiorgan immune-mediated disease of unknown etiology with varying clinical pictures. We studied 3 genes in the major histocompatibility complex region (HLA-DRB1 and complement C4A and C4B) in patients with resolved disease after a 2-year follow-up (n = 90) and in patients whose disease was still active at that time point (n = 98) and compared them with controls (n = 150). Our primary aim was to detect genetic differences between the patient groups. We observed that the susceptibility allele for sarcoidosis was HLA-DRB1*15:01 (p = 0.011; odds ratio [OR] = 1.67) and the protective allele was HLA-DRB1*01:01 (p = 0.001; OR = 0.43). HLA-DRB1*03:01 was associated with resolving disease when compared with the persistent group (p = 0.011; OR = 2.22). The probability of having resolving disease was even greater if the patient had HLA-DRB1*03:01 and did not have extrapulmonary lesions (p = 0.001; OR = 3.39). By evaluating amino acid variants of the HLA-DRB1 gene, we determined that specific amino acids in pockets 4, 7, and 9 were associated with the prognosis of sarcoidosis. Our results support the importance of HLA-DRB1 as a predisposing gene for sarcoidosis. Particularly, HLA-DRB1*03:01 and polymorphisms of DRB1 pocket residues were associated with a favorable prognosis. Thus, accurate categorization of disease phenotype and HLA-DRB1 sequencing offer a basis for disease course estimation of sarcoidosis.

Major histocompatibility complex class II and BTNL2 associations in sarcoidosis

To the Editor: Sarcoidosis is a multiple organ immune-mediated disease of unknown aetiology. Identified genetic risk factors within the major histocompatibility complex (MHC), such as butyrophilin-like ( BTNL)2 , human leukocyte antigen ( HLA)-DRB1*03 and HLA-DRB1*15 , and protective factors, such as HLA-DRB1*01 , are found in many populations [1, 2]. The vast majority of sarcoidosis patients have a favourable prognosis, but approximately 20% develop a chronic, disabling disease [3]. Chronic beryllium disease (CBD) and chronic sarcoidosis share similarities as granulomatous diseases and they are pathologically indistinguishable from each other. CBD has been associated with HLA-DPB1*02:01 , especially with a glutamic acid residue at position 69 (Glu69) [4]. A functional splice-site polymorphism rs2076530 within the BTNL2 gene has been suggested to predispose to sarcoidosis [5]. However, previous studies have shown conflicting results as to whether HLA-DPB1 also predisposes to sarcoidosis, and whether the BTNL2 association is a result of linkage disequilibrium with HLA-DRB1 [6, 7]. The main objective of this study was to evaluate the HLA-DPB1 polymorphisms and the BTNL2 splice-site variant in Finnish patients suffering from sarcoidosis followed-up for 5–15 years and clinically categorised into subgroups based on disease prognosis. In addition, we constructed haplotypes containing MHC class II genes ( HLA-DRB1 and - DPB1 ) and rs2076530, and studied the influence of MHC markers and their combinations on disease susceptibility. We examined a total of 188 patients with verified pulmonary sarcoidosis. The patients were divided into those with a disease resolved within 2 years (n = 90) and those with persisting activity at …

SNP Variants in Major Histocompatibility Complex Are Associated with Sarcoidosis Susceptibility—A Joint Analysis in Four European Populations

Sarcoidosis is a multiorgan inflammatory disorder with heritability estimates up to 66%. Previous studies have shown the major histocompatibility complex (MHC) region to be associated with sarcoidosis, suggesting a functional role for antigen-presenting molecules and immune mediators in the disease pathogenesis. To detect variants predisposing to sarcoidosis and to identify genetic differences between patient subgroups, we studied four genes in the MHC Class III region (LTA, TNF, AGER, BTNL2) and HLA-DRA with tag-SNPs and their relation to HLA-DRB1 alleles. We present results from a joint analysis of four study populations (Finnish, Swedish, Dutch, and Czech). Patients with sarcoidosis (n = 805) were further subdivided based on the disease activity and the presence of Löfgren’s syndrome. In a joint analysis, seven SNPs were associated with non-Löfgren sarcoidosis (NL; the strongest association with rs3177928, P = 1.79E−07, OR = 1.9) and eight with Löfgren’s syndrome [Löfgren syndrome (LS); the strongest association with rs3129843, P = 3.44E−12, OR = 3.4] when compared with healthy controls (n = 870). Five SNPs were associated with sarcoidosis disease course (the strongest association with rs3177928, P = 0.003, OR = 1.9). The high linkage disequilibrium (LD) between SNPs and an HLA-DRB1 challenged the result interpretation. When the SNPs and HLA-DRB1 alleles were analyzed together, independent association was observed for four SNPs in the HLA-DRA/BTNL2 region: rs3135365 (NL; P = 0.015), rs3177928 (NL; P < 0.001), rs6937545 (LS; P = 0.012), and rs5007259 (disease activity; P = 0.002). These SNPs act as expression quantitative trait loci (eQTL) for HLA-DRB1 and/or HLA-DRB5. In conclusion, we found novel SNPs in BTNL2 and HLA-DRA regions associating with sarcoidosis. Our finding further establishes that polymorphisms in the HLA-DRA and BTNL2 have a role in sarcoidosis susceptibility. This multi-population study demonstrates that at least a part of these associations are HLA-DRB1 independent (e.g., not due to LD) and shared across ancestral origins. The variants that were independent of HLA-DRB1 associations acted as eQTL for HLA-DRB1 and/or -DRB5, suggesting a role in regulating gene expression.

Proteomic changes of alveolar lining fluid in illnesses associated with exposure to inhaled non-infectious microbial particles.

Background Hyperresponsiveness to inhaled non-infectious microbial particles (NIMPs) has been associated with illnesses in the airways. Hypersensitivity pneumonitis (HP) is considered to be the prototype for these NIMPs-related diseases; however, there is no consensus on the definitions or diagnostic criteria for HP and the spectrum of related illnesses. Methods and Findings In order to identify the possible diagnostic markers for illnesses associated with NIMPs in alveolar lining fluid, we performed a proteomic analysis using a two-dimensional difference gel electrophoresis on bronchoalveolar lavage (BAL) fluid from patients with exposure to NIMPs in the context of damp building-related illness (DBRI) or conditions on the borderline to acute HP, designated here as agricultural type of microbial exposure (AME). Samples from patients with HP and sarcoidosis (SARC) were included for reference. Results were compared to results of healthy subjects (CTR). Western blot was used for validation of potential marker proteins from BAL fluid and plasma. Protein expression patterns suggest a close similarity between AME and HP, while DBRI was similar to CTR. However, in DBRI the levels of the inflammation associated molecules galectin-3 and alpha-1-antitrypsin were increased. A novel finding emerging from this study was the increases of semenogelin levels in BAL fluid from patients with AME, HP and SARC. Histone 4 levels were increased in AME, HP and SARC. Elevated plasma levels of histone 2B were detected in HP and SARC, suggesting it to be a potential blood indicator for inflammatory diseases of the lungs. Conclusions In this study, the proteomic changes in bronchoalveolar lavage of DBRI patients were distinct from other NIMP exposure associated lung diseases, while changes in AME overlapped those observed for HP patient samples. Some of the proteins identified in this study, semenogelin and histone 4, could function as diagnostic markers for differential diagnosis between DBRI and HP-like conditions.