Helen Bailey

A randomised controlled trial of small particle inhaled steroids in refractory eosinophilic asthma (SPIRA)

Background Some patients with refractory asthma have evidence of uncontrolled eosinophilic inflammation in the distal airways. While traditional formulations of inhaled steroids settle predominantly in the large airways, newer formulations with an extra-fine particle size have a more peripheral pattern of deposition. Specifically treating distal airway inflammation may improve asthma control. Methods 30 patients with refractory asthma despite high dose inhaled corticosteroids were identified as having persistent airway eosinophilia. Following 2 weeks of prednisolone 30 mg, patients demonstrating an improvement in asthma control were randomised to receive either ciclesonide 320 µg twice daily or placebo in addition to usual maintenance therapy for 8 weeks. The primary outcome measure was sputum eosinophil count at week 8. Alveolar nitric oxide was measured as a marker of distal airway inflammation. Results There was continued suppression of differential sputum eosinophil counts with ciclesonide (median 2.3%) but not placebo (median 4.5%) though the between-group difference was not significant. When patients who had changed their maintenance prednisolone dose during the trial were excluded the difference between groups was significant (1.4% vs 4.5%, p=0.028). Though alveolar nitric oxide decreased with ciclesonide the value did not reach statistical significance. Conclusions These data demonstrate that patients with ongoing eosinophilic inflammation are not truly refractory, and that suppression of airway eosinophilia may be maintained with additional inhaled corticosteroid. Further work is needed with a focus on patient-orientated outcome measures such as exacerbation rate, with additional tests of small airway function. Trial registration number NCT01171365. Protocol available at http://www.clinicaltrials.gov.

Evaluation of the PPAR-γ Agonist Pioglitazone in Mild Asthma: A Double-Blind Randomized Controlled Trial.

Background Peroxisome proliferator-activated receptor gamma (PPAR-γ) is a nuclear receptor that modulates inflammation in models of asthma. To determine whether pioglitazone improves measures of asthma control and airway inflammation, we performed a single-center randomized, double-blind, placebo-controlled, parallel-group trial. Methods Sixty-eight participants with mild asthma were randomized to 12 weeks pioglitazone (30 mg for 4 weeks, then 45 mg for 8 weeks) or placebo. The primary outcome was the adjusted mean forced expiratory volume in one second (FEV1) at 12 weeks. The secondary outcomes were mean peak expiratory flow (PEF), scores on the Juniper Asthma Control Questionnaire (ACQ) and Asthma Quality of Life Questionnaire (AQLQ), fractional exhaled nitric oxide (FeNO), bronchial hyperresponsiveness (PD20), induced sputum counts, and sputum supernatant interferon gamma-inducible protein-10 (IP-10), vascular endothelial growth factor (VEGF), monocyte chemotactic protein-1 (MCP-1), and eosinophil cationic protein (ECP) levels. Study recruitment was closed early after considering the European Medicines Agency’s reports of a potential increased risk of bladder cancer with pioglitazone treatment. Fifty-five cases were included in the full analysis (FA) and 52 in the per-protocol (PP) analysis. Results There was no difference in the adjusted FEV1 at 12 weeks (-0.014 L, 95% confidence interval [CI] -0.15 to 0.12, p = 0.84) or in any of the secondary outcomes in the FA. The PP analysis replicated the FA, with the exception of a lower evening PEF in the pioglitazone group (-21 L/min, 95% CI -39 to -4, p = 0.02). Conclusions We found no evidence that treatment with 12 weeks of pioglitazone improved asthma control or airway inflammation in mild asthma. Trial Registration ClinicalTrials.gov NCT01134835

The Effects of Azithromycin in Treatment-Resistant Cough: A Randomized, Double-Blind, Placebo-Controlled Trial

BACKGROUND Chronic cough is a common clinical problem worldwide. Although many patients have underlying precipitating conditions such as asthma, gastroesophageal reflux, or rhinitis, many remain symptomatic despite treating these conditions. New approaches are needed for the treatment of this group of patients. METHODS We conducted a randomized, double-blind, placebo-controlled trial to determine whether 250 g of azithromycin three times a week for 8 weeks would affect the Leicester Cough Questionnaire (LCQ) score in 44 patients with treatment-resistant cough. Cough severity on a visual analog scale and bronchial exhaled nitric oxide were measured as secondary outcomes. RESULTS There was a clinically important improvement in LCQ score with azithromycin (mean change, 2.4; 95% CI, 0.5 to 4.2) but not placebo (mean change, 0.7; 95% CI, -0.6 to 1.9), but the between-group difference was not statistically significant (P = .12). There were no significant between-group differences for any of the secondary outcome measures. Looking at subgroups of responders, there was a large and significant improvement in LCQ score in patients with chronic cough and a concurrent diagnosis of asthma who were treated with azithromycin (mean, 6.19; 95% CI, 4.06 to 8.32). CONCLUSIONS Treatment with low-dose azithromycin for 8 weeks did not significantly improve LCQ score compared with placebo. The use of macrolides for treatment-resistant cough cannot be recommended from this study, but they may have a place in the treatment of chronic cough associated with asthma; this is worthy of further investigation. TRIAL REGISTRY WHO International Clinical Trials Registry; No.: ISRCTN75749391. URL: http://apps.who.int.

Exhaled nitric oxide and inhaled corticosteroid dose reduction in asthma: a cohort study

To the Editor: Inhaled corticosteroids (ICS) reduce airway inflammation; however, guidelines recommend titrating ICS dose based on symptoms [1], which are not closely associated with airway inflammation [2]. Once symptoms are controlled for ≥3 months, ICS reduction is recommended [3] but step-down is often not implemented. Studies suggest that the majority of patients treated with ICS can have their therapy stepped down, although there is no clear evidence on how best to achieve this [4]. We assessed whether exhaled nitric oxide fraction ( F eNO) measurements could predict a loss of symptom control or exacerbation following a reduction in ICS dose in a cohort study of people with well-controlled asthma recruited from primary care. All participants had a recorded asthma diagnosis, were aged 18–75 years, and had received at least one ICS prescription in the last year. The study was restricted to nonsmokers ( 1.5 at visit 1 (indicating poor control) were excluded. Participants were seen at the same time of day on four occasions: days 0, 14, 21 and 110. At each visit, ACQ-5, F eNO (Flex Flow; Aerocrine, Solna, Sweden) and spirometry were performed. Symptoms were assessed using the ACQ-5 [6]. Airway inflammation was measured using F eNO at 50 mL·s−1; participants were blinded to their measurements. Differential …

P106 Tissue factor pathway inhibitor (TFPI) is cleaved by multiple proteases in COPD lungs to affect circulating TFPI levels

Background Tissue factor pathway inhibitor (TFPI) attenuates intravascular coagulation, a function limited by its proteolysis. Airway inflammation in COPD is associated with protease activity and intravascular thrombotic events, yet the link between proteolysis of TFPI in the airways and intravascular thrombosis in COPD is unexplored. Aims To explore the presence and processing of TFPI in COPD airways and its relationship to plasma TFPI levels. Methods COPD sputum and blood were collected at exacerbation and when stable. In vitro cleavage of TFPI was explored by incubation with proteases and Western blotting. TFPI presence and cleavage in sputum was detected by Western blotting. To determine the main protease/s involved in TFPI cleavage, sputum was spiked with recombinant TFPI in the presence of protease inhibitors, followed by Western blotting. Results TFPI was cleaved in vitro by Matrix Metalloproteinase (MMP)-12, Neutrophil Elastase (NE) and urokinase-type plasminogen activator (uPA) to <20. Conclusion TFPI is cleaved by NE in COPD airways, leading to lower circulating levels. Further studies are needed to determine if lower circulating TFPI levels lead to increased intravascular thrombotic events in COPD.

S129 A two species proteomics approach to determine MMP-12 substrates in COPD

Background Genetic variability in MMP-12 is associated with COPD; the matrix Metalloproteinase (MMP)-12 knockout (KO) mouse is resistant to emphysema despite cigarette smoke exposure, strongly implicating MMP-12 in COPD pathogenesis. However, the complete MMP-12 substrate profile (degradome) in COPD remains unknown. Terminal amine isobaric labelling of substrates (TAILS) is a novel proteomic technique allowing identification of a protease degradome on an organism-wide scale. Identification of the MMP-12 degradome will lead to novel drugs, desperately needed in COPD. Objectives To identify the MMP-12 degradome in COPD by comparing cigarette smoke exposed MMP-12 KO and wildtype (WT) controls by TAILS and validating these targets against the human COPD sputum proteome during exacerbations and stable disease. Methods C57BL/6J MMP-12 KO and WT mice (n = 4) were exposed to cigarette smoke and airways sampled by bronchoalveolar lavage (BAL). BAL fluid was analysed by TAILS, high performance liquid chromatography (HPLC) and tandem mass spectrometry (MS/MS). Matched COPD exacerbation and stable disease sputum samples (n = 9) were analysed by TAILS, HPLC and MS/MS. Results The following new MMP-12 targets in the COPD mouse model were identified: alpha-2-HS glycoprotein, anti-thrombin III, clusterin, complement C3, complement C4b, complement factor H-related protein-1, hemopexin, serotransferrin and serum albumin, alpha-2-macroglobulin, beta-1, 4-galactosyltransferase 2, transmembrane protease 7, DEP domain-containing mTOR-interacting protein, kininogen-1, tumour necrosis factor ligand superfamily member 11. Of these, alpha-2-HS-glycoprotein, anti-thrombin III, complement factors C3 and C4B, hemopexin and serum albumin were identified in both exacerbation and stable COPD human sputum. Furthermore, 1,116 peptides were identified in COPD exacerbation and stable disease sputum, grouped into the following categories: cell adhesion/migration, complement system, acute phase response, extracellular matrix structure/function, anti-microbicidal activity, cytoskeletal function/remodelling, carbohydrate metabolism, oxidoreductase activity, cell death regulation/DNA synthesis/repair, immune response, protease activity, protease inhibition and ATP synthesis/function. Conclusion This study identifies the MMP-12 degradome in COPD and provides the most comprehensive analysis of the proteome of COPD sputum at exacerbation and stable disease. It suggests a role for MMP-12 in complement regulation and haemostasis in COPD. Thus an important peptide library has been unravelled, providing an ideal tool in developing drugs and understanding COPD pathogenesis.

S27 The effects of statin therapy on inflammatory markers in patients with copd: a double blind randomised controlled trial

Background Systemic and airway inflammation are recognised in COPDand reducing inflammation has been postulated to alter disease course1. Statins have pleiotropic effects including anti-inflammatory properties2. A study in asthma showed that statins reduced sputum macrophage levels3. We hypothesised that statins would reduce systemic (hs-CRP) and airway (exhaled nitric oxide: FeNO, sputum neutrophils and macrophages) inflammation in patients with COPD. Methods Clinically stable patients with confirmed COPD were recruited and randomised to either simvastatin 20mg od (active) or placebo for 6 weeks in a double blinded parallel group randomised controlled trial. Circulating hs-CRP and fasting lipids were measured in all subjects’ pre- and post- treatment. 5-flow FeNO and induced sputum were performed in consenting patients where possible pre- and post-treatment. Primary analysis compared the six week change in each inflammatory marker between active and placebo groups. Results Patients were matched for age, sex, smoking and lung function; active: n = 33, placebo: n = 37. Compliance was good and the active group achieved total cholesterol reduction: between arms mean (95% CI): -1.1 (-1.3, -0.8)mmol/L, p < 0.001. Baseline median (IQR) hs-CRP was 3.09 (1.3–7.4)mg/l but there was no significant change after treatment between active and placebo: between arms mean (95% CI) 0.5(-3.2, 4.1)mg/l. Baseline sputum samples were obtained in n = 27 and 22/27 had neutrophilic sputum. Paired samples were obtained in 20 patients: active n = 8 and placebo n = 12 with no significant difference in change between treatment arms for sputum neutrophils or macrophages. FeNO was measured in 36 patients: active n = 17, placebo n = 19 with no significant difference in change between arms. Conclusions In this pilot RCT, despite significant lipid lowering, there was no demonstrable systemic or airway anti-inflammatory effect over 6 weeks with simvastatin 20mg od in patients with COPD. Baseline results showed a majority had neutrophilic sputum however only a small proportion had airway inflammation evaluation. Trial reference: NCT01151306 Supported by NIHR RfPB grant References Sin, DD, et al. AJRCCM 2004;170:760–765 Walsh, G. M Expert Review of Respiratory Medicine 2008;2(3):329–335 Hothersall, EJ, et al., Thorax 2008;63(12):1070–5