P. Buonpensiero

A novel treatment of cystic fibrosis acting on-target: cysteamine plus epigallocatechin gallate for the autophagy-dependent rescue of class II-mutated CFTR

We previously reported that the combination of two safe proteostasis regulators, cysteamine and epigallocatechin gallate (EGCG), can be used to improve deficient expression of the cystic fibrosis transmembrane conductance regulator (CFTR) in patients homozygous for the CFTR Phe508del mutation. Here we provide the proof-of-concept that this combination treatment restored CFTR function and reduced lung inflammation (P<0.001) in Phe508del/Phe508del or Phe508del/null-Cftr (but not in Cftr-null mice), provided that such mice were autophagy-competent. Primary nasal cells from patients bearing different class II CFTR mutations, either in homozygous or compound heterozygous form, responded to the treatment in vitro. We assessed individual responses to cysteamine plus EGCG in a single-centre, open-label phase-2 trial. The combination treatment decreased sweat chloride from baseline, increased both CFTR protein and function in nasal cells, restored autophagy in such cells, decreased CXCL8 and TNF-α in the sputum, and tended to improve respiratory function. These positive effects were particularly strong in patients carrying Phe508del CFTR mutations in homozygosity or heterozygosity. However, a fraction of patients bearing other CFTR mutations failed to respond to therapy. Importantly, the same patients whose primary nasal brushed cells did not respond to cysteamine plus EGCG in vitro also exhibited deficient therapeutic responses in vivo. Altogether, these results suggest that the combination treatment of cysteamine plus EGCG acts ‘on-target’ because it can only rescue CFTR function when autophagy is functional (in mice) and improves CFTR function when a rescuable protein is expressed (in mice and men). These results should spur the further clinical development of the combination treatment.

Hyaluronic acid improves “pleasantness” and tolerability of nebulized hypertonic saline in a cohort of patients with cystic fibrosis

IntroductionInhaled hypertonic saline improves lung function and decreases pulmonary exacerbations in people with cystic fibrosis. However, side effects such as cough, narrowing of airways and saltiness cause intolerance of the therapy in 8% of patients. The aim of our study was to compare the effect of an inhaled solution of hyaluronic acid and hypertonic saline with hypertonic solution alone on safety and tolerability.MethodsA total of 20 patients with cystic fibrosis aged 6 years and over received a single treatment regimen of 7% hypertonic saline solution or hypertonic solution with 0.1% hyaluronate for 2 days nonconsecutively after a washout period in an open crossover study. Cough, throat irritation, and salty taste were evaluated by a modified ordinal score for assessing tolerability; “pleasantness” was evaluated by a five-level, Likert-type scale. Forced expiratory volume in 1 second was registered before and after the end of the saline inhalations.ResultsAll 20 patients (nine males, 11 females, mean age 13 years, range 8.9–17.7) completed the study. The inhaled solution of 0.1% hyaluronic acid and hypertonic saline significantly improved tolerability and pleasantness compared to hypertonic saline alone. No major adverse effects were observed. No difference was documented in pulmonary function tests between the two treatments.ConclusionHyaluronic acid combined with hypertonic saline solution may contribute to improved adherence to hypertonic saline therapy. Further clinical trials are needed to confirm our findings. Considering the extraordinary versatility of hyaluronic acid in biological reactions, perspective studies could define its applicability to halting progression of lung disease in cystic fibrosis.

Ursodeoxycholic acid treatment in patients with cystic fibrosis at risk for liver disease

BACKGROUND Meconium ileus has been detected as a risk factor for development of liver disease in cystic fibrosis, with influence on morbidity and mortality. AIMS To evaluate the effect of early treatment with ursodeoxycholic acid in patients with cystic fibrosis and meconium ileus to prevent chronic hepatic involvement and to explore the potential role of therapy on clinical outcomes. METHODS 26 cystic fibrosis patients with meconium ileus (16 M, mean age 8,4 years, range 3,5-9) were assigned to two groups: group 1 (14 patients) treated early with ursodeoxycholic acid (UDCAe); group 2 (12 patients) treated with ursodeoxycholic acid at the onset of cystic fibrosis liver disease (UDCAd). Anthropometric data, pulmonary function tests, pancreatic status, complications such as diabetes, hepatic involvement and Pseudomonas aeruginosa colonisation were compared among groups. RESULTS A higher prevalence of cystic fibrosis chronic liver disease was observed in the UDCAd group with a statistically significant difference at 9 years of age (p<0.05). Chronic infection by P. aeruginosa was found in 7% of UDCAe and 33% of UDCAd (p<0.05). No differences were observed in nutritional status and other complications. CONCLUSIONS Early treatment with ursodeoxycholic acid may be beneficial in patients at risk of developing cystic fibrosis chronic liver disease such as those with meconium ileus. Multicentre studies should be encouraged to confirm these data.

Randomized, single blind, controlled trial of inhaled glutathione vs placebo in patients with cystic fibrosis☆ , ☆☆

BACKGROUND In cystic fibrosis (CF) the defective CF transmembrane conductance regulator protein may be responsible for the impaired transport of glutathione (GSH), the first line defense of the lung against oxidative stress. The aim of this single-blind, randomized, placebo-controlled trial was to evaluate the effect of inhaled GSH in patients with CF. METHODS 54 adult and 51 pediatric patients were randomized to receive inhaled GSH or placebo twice daily for 12 months. RESULTS Twelve month treatment with inhaled GSH did not achieve our predetermined primary outcome measure of 15% improvement in FEV1%. Only in patients with moderate lung disease, 3, 6 and 9 months therapy with GSH resulted in a statistically significant increase of FEV1 values from the baseline. Moreover GSH therapy improved 6-minute walking test in pediatric population. GSH was well tolerated by all patients. CONCLUSIONS Inhaled GSH has slight positive effects in CF patients with moderate lung disease warranting further study. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT01450267; URL: www.clinicaltrialsgov.

51 Inhaled GSH tolerability in patients with cystic fibrosis (CF)

Objectives: Oxidative stress biomarkers as reactive oxygen species are induced by the sustained activation of neutrophils and other CF-derived defects in the lung of CF patients. Observed defects include an impaired glutathione (GSH) metabolism. Its supplementation may counterbalance the oxidative stress. A randomized, single blind controlled trial of inhaled GSH versus placebo (NCT01450267) is underway in order to evaluate the effect of GSH in cohort of CF patients. We report preliminary data on tolerability to GSH in a pediatric subset of enrolled patients. Methods: 48 CF patients (F 23, age M±DS 13.53 yrs), in regular follow up at the Regional Pediatric CF Center of Naples, were enrolled for RCT. The main inclusion criteria were: CF diagnosis by sweat test and/or two CF causing mutations, age of patients >6 yrs, FEV1% >40% of the predicted value, negative culture for Burkholderia cepacia. Spirometry was performed before and 10 and 60 minutes after GSH inhalation test (10mg/kg, maximum dosage 600mg/dose) in order to assess tolerability. Conclusions: No patients showed a decrease in FEV1% >15% after GSH inhalation as defined in the study design. A statistically significant increase was observed for FEF25−75% after 10 and 60 minutes from inhalation (FEF25−75 M±DS: T0 71.64±33.35 VS T10 76.37±36.73; p< 0.02 and T0 71.64±33.35 VS T60: 80.26±35.25; p< 0.0001) and for FEV1% after 60 minutes from inhalation (FEV1 M±DS: T0 97.90±21.03 VS T60 100.01±19.42; p< 0.01). No side effects were reported. On the basis of these preliminary results we are currently evaluating the efficacy of inhaled GSH on pulmonary function and inflammatory markers within a 12 months therapy.