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BackgroundInhibition of the epithelial sodium channel (ENaC) in cystic fibrosis (CF) airways provides a mutation-agnostic approach that could improve mucociliary clearance in all CF patients. BI 1265162 is an ENaC inhibitor with demonstrated pre-clinical efficacy and safety already demonstrated in humans.ObjectiveWe present results from BALANCE-CFTM 1, a phase II, placebo-controlled, randomised, double-blind study of four dose levels of BI 1265162 versus placebo for 4 weeks on top of standard of care in adults and adolescents with CF.ResultsInitially, 28 randomised subjects (BI 1265162 200 µg twice daily n=14, placebo twice daily n=14) were assessed at an interim futility analysis. Compared with placebo, numerical changes of –0.8% (95% CI –6.6 to 4.9%) in percentage predicted forced expiratory volume in 1s (ppFEV1) and +2.1 units (95% CI –2.4 to 6.5 units) in lung clearance index (LCI) were observed in the active group, meeting a pre-defined stopping rule; accordingly, the study was terminated. Recruitment had continued during the interim analysis and pending results; 24 patients were added across three dose levels and placebo. The final results including these patients (+1.5% ppFEV1, 200 µg twice-daily dose versus placebo) were not supportive of relevant clinical effect. Furthermore, LCI change was not supportive, although interpretation was limited due to insufficient traces meeting quality criteria. A 9.4-point improvement in the Cystic Fibrosis Questionnaire – Revised Respiratory Domain was observed in the 200 µg twice daily dose group versus placebo. BI 1265162 up to 200 µg twice daily was safe and well-tolerated. Pharmacokinetics were similar to those in healthy volunteers.ConclusionBI 1265162 was safe, but did not demonstrate a potential for clinical benefit. Development has been terminated.

Autoimmune pulmonary alveolar proteinosis (aPAP) is a rare lung disorder involving production of autoantibodies against endogenous granulocyte–macrophage colony-stimulating factor (GM-CSF). This study aimed to identify biomarkers that could be used to monitor for aPAP, particularly in patients treated with anti-GM-CSF antibodies. This was an exploratory, prospective, observational, single-center study. Pre-specified biomarkers were evaluated between baseline and Day 120 in serum/plasma, whole blood, sputum and exhaled breath condensate from patients with aPAP, healthy volunteers, and patients with chronic obstructive pulmonary disease (COPD) and asthma (not treated with anti-GM-CSF and with no evidence of aPAP). Pulmonary function tests were also performed. Overall, 144 individuals were enrolled (aPAP: n = 34, healthy volunteers: n = 24, COPD: n = 40 and asthma: n = 46). Plasma GM-CSF levels were lower, and Krebs von den Lungen 6 and GM-CSF autoantibody ranges were higher, in patients with aPAP compared with other populations. Surfactant proteins-A and -D, lactate dehydrogenase and carcinoembryonic antigen ranges partially or completely overlapped across populations. Most plasma biomarkers showed high sensitivity and specificity for detection of aPAP; GM-CSF and GM-CSF autoantibody concentrations demonstrated equivalent sensitivity for differentiating aPAP. In addition to characteristic GM-CSF autoantibodies, assessment of plasma GM-CSF may identify individuals at risk of developing aPAP.Trial registration: EudraCT, 2012-003475-19. Registered 23 July 2012—https://eudract.ema.europa.eu/.

Inhibition of the epithelial sodium channel (ENaC) represents an important, mutation-agnostic therapeutic approach to restore airway surface liquid in patients with cystic fibrosis (CF). A phase II trial of the ENaC inhibitor BI 1265162, inhaled via the Respimat® Soft Mist™ inhaler, in patients aged ≥12 years with CF is being conducted to assess the efficacy and safety of BI 1265162, on top of standard CF treatment (www.clinicaltrials.gov identifier NCT04059094). BALANCE-CF™ 1 is a multinational, randomised, double-blind, placebo-controlled, parallel-group, dose-ranging trial consisting of 2 weeks’ screening, 4 weeks’ randomised treatment and 1 week follow-up. 98 patients, including ≥21 adolescents, will be randomised. First, 28 patients will be allocated to the highest dose of BI 1265162 (200 µg twice daily) or placebo in a 1:1 ratio. The remaining 70 patients will be allocated to one of five treatment arms (200 µg, 100 µg, 50 µg, 20 µg or placebo twice daily), with a final distribution ratio of 2:1:1:1:2. Recruitment and randomisation will begin with adult patients. An independent data monitoring committee will review safety data to advise on inclusion of adolescents and study continuation. A futility analysis will be conducted after 28 patients to prevent exposure of further patients in case of insufficient evidence of clinical efficacy. The design ensures that potential for effect is assessed ahead of wider enrolment, allowing investigation of a dose–response effect with minimal patient numbers. The results will increase understanding of efficacy, safety and optimal dosing of the inhaled ENaC inhibitor BI 1265162 in adults and adolescents with CF., BALANCE-CF™-1 is an innovative phase II trial in patients aged ≥12 years with CF to assess the efficacy and safety of the inhaled ENaC inhibitor BI 1265162 vs placebo. The results will increase understanding and support further investigation in phase III trials. https://bit.ly/2B8WOPe

Background Epithelial sodium channel (ENaC) is an important regulator of airway surface liquid volume; ENaC is hyperactivated in cystic fibrosis (CF). ENaC inhibition is a potential therapeutic target for CF. Here, we report in vitro and in vivo results for BI 1265162, an inhaled ENaC inhibitor currently in Phase II clinical development, administered via the Respimat® Soft Mist™ inhaler. Methods In vitro inhibition of sodium ion (Na+) transport by BI 1265162 was tested in mouse renal collecting duct cells (M1) and human bronchial epithelial cells (NCI-H441); inhibition of water transport was measured using M1 cells. In vivo inhibition of liquid absorption from rat airway epithelium and acceleration of mucociliary clearance (MCC) in sheep lungs were assessed. Fully differentiated normal and CF human epithelium was used to measure the effect of BI 1265162 with or without ivacaftor and lumacaftor on water transport and MCC. Results BI 1265162 dose-dependently inhibited Na+ transport and decreased water resorption in cell line models. BI 1265162 reduced liquid absorption in rat lungs and increased MCC in sheep. No effects on renal function were seen in the animal models. BI 1265162 alone and in combination with CF transmembrane conductance regulator (CFTR) modulators decreased water transport and increased MCC in both normal and CF airway human epithelial models and also increased the effects of CFTR modulators in CF epithelium to reach the effect size seen in healthy epithelium with ivacaftor/lumacaftor alone. Conclusion These results demonstrate the potential of BI 1265162 as a mutation agnostic, ENaC-inhibitor-based therapy for CF., ENaC inhibition is a potential strategy for a mutation-agnostic therapy in CF. In preclinical studies, BI 1265162 is a potent ENaC inhibitor, alone and in synergy with CFTR modulators, supporting Phase I clinical development. https://bit.ly/3mCeWE9

Methacholine challenges have been used in clinical trials to assess therapeutic effects and potential adverse reactions of interventions on pulmonary function in a sensitive population, such as in subjects with asthma. Here, we evaluate the variability of the methacholine challenge recovery model, and compare the results obtained for both incremental and bolus challenge methods.The extent, time course and variability of change in forced expiratory volume in 1 s (FEVA total of 19 subjects were included in the study. Both the mean FEVMaximum reduction in FEV

BI 1021958, a novel antagonist of the chemoattractant-receptor-homologous molecule (CRTH2), targets airway inflammation in asthma by inhibiting prostaglandin binding to CRTH2 receptors. Two phase 1 studies assessed BI 1021958 safety/tolerability and pharmacokinetics (PK)/pharmacodynamics (PD) following single doses in healthy men and multiple doses in men/women with well-controlled asthma. Studies 1 had 2 parts: a placebo-controlled, fixed-sequence, single-blind, single-rising-dose part (n = 56) and a randomized, 2-way crossover, open-label, repeated-dose part studying the food effect on PK/PD (n = 12). Study 2 was a placebo-controlled, single-center, double-blind multiple-rising-dose study (n = 84). Primary end points were safety/tolerability and PK/PD (both studies); secondary end points were eosinophil shape change (ESC; study 1) and dose proportionality/linearity following first dose and at steady state (study 2). BI 1021958 was adequately tolerated in both studies; adverse events were infrequent, generally mild to moderate, and occurred similarly in treatment groups. Maximum measured concentration (Cmax) was achieved in ≤2.5 hours in study 1 and ≤2.0 hours in study 2. BI 1021958 exposure increased proportionally with dose. In study 1, following a single 60-mg dose, AUC parameters and Cmax were 20% and 15% lower, respectively, after a high-fat meal compared with the fasted state. After ≥60-mg single doses (study 1) and >40-mg multiple doses (study 2), >95% ESC inhibition was observed for ≥24 hours. PK/PD was similar in healthy subjects and subjects with well-controlled asthma. Data support further investigation of CRTH2 antagonists for the treatment of asthma.

Background: Chronic obstructive pulmonary disease (COPD) remains a major cause of morbidity and mortality. Present-day diagnostic criteria are largely based solely on spirometric criteria. Accumulating evidence has identified a substantial number of individuals without spirometric evidence of COPD who suffer from respiratory symptoms and/or increased morbidity and mortality. There is a clear need for an expanded definition of COPD that is linked to physiologic, structural (computed tomography [CT]) and clinical evidence of disease. Using data from the COPD Genetic Epidemiology study (COPDGene(®)), we hypothesized that an integrated approach that includes environmental exposure, clinical symptoms, chest CT imaging and spirometry better defines disease and captures the likelihood of progression of respiratory obstruction and mortality. Methods: Four key disease characteristics – environmental exposure (cigarette smoking), clinical symptoms (dyspnea and/or chronic bronchitis), chest CT imaging abnormalities (emphysema, gas trapping and/or airway wall thickening), and abnormal spirometry – were evaluated in a group of 8784 current and former smokers who were participants in COPDGene(®) Phase 1. Using these 4 disease characteristics, 8 categories of participants were identified and evaluated for odds of spirometric disease progression (FEV(1) > 350 ml loss over 5 years), and the hazard ratio for all-cause mortality was examined. Results: Using smokers without symptoms, CT imaging abnormalities or airflow obstruction as the reference population, individuals were classified as Possible COPD, Probable COPD and Definite COPD. Current Global initiative for obstructive Lung Disease (GOLD) criteria would diagnose 4062 (46%) of the 8784 study participants with COPD. The proposed COPDGene(®) 2019 diagnostic criteria would add an additional 3144 participants. Under the new criteria, 82% of the 8784 study participants would be diagnosed with Possible, Probable or Definite COPD. These COPD groups showed increased risk of disease progression and mortality. Mortality increased in patients as the number of their COPD characteristics increased, with a maximum hazard ratio for all cause-mortality of 5.18 (95% confidence interval [CI]: 4.15–6.48) in those with all 4 disease characteristics. Conclusions: A substantial portion of smokers with respiratory symptoms and imaging abnormalities do not manifest spirometric obstruction as defined by population normals. These individuals are at significant risk of death and spirometric disease progression. We propose to redefine the diagnosis of COPD through an integrated approach using environmental exposure, clinical symptoms, CT imaging and spirometric criteria. These expanded criteria offer the potential to stimulate both current and future interventions that could slow or halt disease progression in patients before disability or irreversible lung structural changes develop.

Background: Chronic obstructive pulmonary disease (COPD) remains a major cause of morbidity and mortality. Present-day diagnostic criteria are largely based solely on spirometric criteria. Accumulating evidence has identified a substantial number of individuals without spirometric evidence of COPD who suffer from respiratory symptoms and/or increased morbidity and mortality. There is a clear need for an expanded definition of COPD that is linked to physiologic, structural (computed tomography [CT]) and clinical evidence of disease. Using data from the COPD Genetic Epidemiology study (COPDGene®), we hypothesized that an integrated approach that includes environmental exposure, clinical symptoms, chest CT imaging and spirometry better defines disease and captures the likelihood of progression of respiratory obstruction and mortality. Methods: Four key disease characteristics – environmental exposure (cigarette smoking), clinical symptoms (dyspnea and/or chronic bronchitis), chest CT imaging abnormalities (emphysema, gas trapping and/or airway wall thickening), and abnormal spirometry – were evaluated in a group of 8784 current and former smokers who were participants in COPDGene® Phase 1. Using these 4 disease characteristics, 8 categories of participants were identified and evaluated for odds of spirometric disease progression (FEV1 > 350 ml loss over 5 years), and the hazard ratio for all-cause mortality was examined. Results: Using smokers without symptoms, CT imaging abnormalities or airflow obstruction as the reference population, individuals were classified as Possible COPD, Probable COPD and Definite COPD. Current Global initiative for obstructive Lung Disease (GOLD) criteria would diagnose 4062 (46%) of the 8784 study participants with COPD. The proposed COPDGene® 2019 diagnostic criteria would add an additional 3144 participants. Under the new criteria, 82% of the 8784 study participants would be diagnosed with Possible, Probable or Definite COPD. These COPD groups showed increased risk of disease progression and mortality. Mortality increased in patients as the number of their COPD characteristics increased, with a maximum hazard ratio for all cause-mortality of 5.18 (95% confidence interval [CI]: 4.15–6.48) in those with all 4 disease characteristics. Conclusions: A substantial portion of smokers with respiratory symptoms and imaging abnormalities do not manifest spirometric obstruction as defined by population normals. These individuals are at significant risk of death and spirometric disease progression. We propose to redefine the diagnosis of COPD through an integrated approach using environmental exposure, clinical symptoms, CT imaging and spirometric criteria. These expanded criteria offer the potential to stimulate both current and future interventions that could slow or halt disease progression in patients before disability or irreversible lung structural changes develop.

Background Methacholine challenges have been used in clinical trials to assess therapeutic effects and potential adverse reactions of interventions on pulmonary function in a sensitive population, such as in subjects with asthma. Here, we evaluate the variability of the methacholine challenge recovery model, and compare the results obtained for both incremental and bolus challenge methods. Methods The extent, time course and variability of change in forced expiratory volume in 1 s (FEV1) following repeated methacholine challenges in subjects with mild asthma were investigated in an open-label, four-period, fixed-sequence, two-method, replicate crossover study. At Visits 1 and 2, subjects underwent an incremental challenge using doubling doses of methacholine until a ≥20% decrease in FEV1 was observed; at Visits 3 and 4, subjects underwent a bolus challenge, inhaling a single dose of methacholine calculated from the cumulative dose established during Visit 1. Results A total of 19 subjects were included in the study. Both the mean FEV1 area under the curve (FEV1 AUC0–tz) and mean maximum reductions in FEV1 (absolute and relative) 120 min post-challenge values were higher for the incremental challenges than the bolus challenges, with no reported difference between repetitions of the same methodology. FEV1 AUC0–tz decrease 120 min post challenge demonstrated an intra-subject coefficient of variation (CV) of 47.2% (incremental) and 78.3% (bolus), suggesting considerable between-visit variability. The mean absolute, and similarly relative, maximum reductions in FEV1 compared with post-diluent baseline values demonstrated lower intra-subject variability (incremental 21.16%, bolus 40.67%) than the FEV1 AUC0–tz-based endpoint. There was a trend towards faster recovery following the bolus challenge than with the incremental challenge. The provocative dose of methacholine inducing a ≥20% decrease in FEV1 resulted in a between-group mean difference of 27.20% in the incremental challenge periods, with a high intra-subject CV of 80.64%, demonstrating considerable variability. Conclusion Maximum reduction in FEV1 had the lowest variability. There was little difference between repetitions of the same methodology, as indicated by overlapping confidence intervals. There was a trend towards faster recovery following bolus challenge than with the incremental challenge. The results of this trial could be of value when designing future clinical trials using the methacholine challenge methodology.

Background: Segmental LPS challenge is used in studies which examine inflammation induced edema in the lung. Currently, bronchoalveolar lavage (BAL) is used to quantify the LPS-induced amount of inflammation. Objectives: MRI is investigated to quantify regional edema following endobronchial LPS challenge using a scoring system and a quantitative method. Methods: In 23 healthy smokers segments 4 or 5 of the right lung were challenged with LPS and of the left lung with saline as control. BAL was performed prior to challenge and 24h after. Seven days before and prior the BAL 24h post LPS challenge the volunteers underwent a lung MRI scan. Edema was quantified on the TIRM images (score) and T1 maps (volume over threshold [VOT]) before contrast agent (CA) administration. Results: The percentage of neutrophilic cells was higher in LPS challenged segments (58.5%) compared to baseline (0.75%;p

Chemokine receptors CXC receptor (CXCR) 1 and 2, and their ligands interleukin (IL)-8 and growth-related oncogene alpha (GRO alpha), are principal regulators of neutrophil activation and migration. To investigate the role of p38 mitogen activated protein kinase (MAPK) in the regulation of CXCR expression during an inflammatory response in vivo, 24 healthy volunteers received an intravenous injection with lipopolysaccharide (LPS) preceded (-3 hr) by a specific p38 MAPK inhibitor (BIRB 796 BS) at a high dose (600 mg) or a low dose (50 mg) or a placebo. The LPS-induced reduction of neutrophil CXCR 1 and 2 expression, as determined by fluorescence-activated cell sorter analysis, was inhibited in volunteers receiving the high dose of the p38 MAPK inhibitor. The kinase inhibitor also dose dependently diminished the LPS-induced rises in plasma IL-8 and GRO alpha levels. These results indicate a principal role for p38 MAPK in regulating factors essential for neutrophil activation and chemotaxis in vivo.

The prostaglandin D2 (PGD2) receptor, CRTH2, plays a role in allergic airway inflammation. The efficacy of BI 671800, a CRTH2 antagonist, was assessed in 2 separate trials in patients with asthma, in either the absence or the presence of inhaled corticosteroid (ICS) therapy. In this study, BI 671800 (50, 200 or 400 mg) and fluticasone propionate (220 μg) all given twice daily (bid) were compared with bid placebo in symptomatic controller-naïve adults with asthma (Trial 1), and BI 671800 400 mg bid compared with montelukast 10 mg once daily (qd), and matching placebo bid, in patients with asthma receiving inhaled fluticasone (88 μg bid) (Trial 2). The primary endpoint in both trials was change from baseline in trough forced expiratory volume in 1 s (FEV1) percent predicted. After 6 weeks' treatment, adjusted mean treatment differences (SE) for the primary endpoint compared with placebo in Trial 1 were 3.08% (1.65%), 3.59% (1.60%) and 3.98% (1.64%) for BI 671800 50, 200 and 400 mg bid, respectively, and 8.62% (1.68%) for fluticasone 220 μg bid (p = 0.0311, p = 0.0126, p = 0.0078 and p

BACKGROUND: The inflammatory response in patients with seasonal allergic rhinitis (SAR) is partly mediated by the prostaglandin D2 receptor chemoattractant receptor homologous molecule on TH2 cells (CRTH2). OBJECTIVE: We sought to investigate the efficacy and safety of the oral CRTH2 antagonist BI 671800 (50, 200, and 400 mg twice daily), fluticasone propionate nasal spray (200 mg once daily), or oral montelukast (10 mg once daily) administered for 2 weeks in patients with SAR. METHODS: In this randomized, double-blind, placebo-controlled, partial-crossover study, participants aged 18 to 65 years with a positive skin prick test to Dactylis glomerata pollen were exposed to out-of-season allergen in the environmental challenge chamber for 6 hours. The primary efficacy variable was the total nasal symptom score assessed as the area under the curve (AUC)0-6h. RESULTS: In total, 146 patients (63.7% male; mean age, 36.1 years) were randomized. The adjusted mean total nasal symptom score AUC0-6h was significantly reduced versus placebo with 200 mg of BI 671800 (absolute difference, -0.85; percentage difference, -17%; P = .0026), montelukast (absolute difference, -0.74; percentage difference, -15%; P = .0115), and fluticasone propionate (absolute difference, -1.64; percentage difference, -33%; P < .0001). Compared with placebo, BI 671800 significantly reduced nasal eosinophil values (P < .05 for all doses), significantly inhibited nasal inflammatory cytokine levels (IL-4 and eotaxin, P < .05; 200 mg twice daily), and induced a dose-related reduction in ex vivo prostaglandin D2-mediated eosinophil shape change. CONCLUSION: Two hundred milligrams of BI 671800 twice daily demonstrated efficacy in treating SAR symptoms induced by environmental challenge chamber allergen exposure and had a favorable safety profile.

Background Immunocompromised children are at risk for disseminated varicella infections. Standard management involves hospitalization and intravenous acyclovir for 7 to 10 days. This approach is expensive, is inconvenient and may not be necessary. We undertook a pilot study to assess the safety and efficacy of an alternative approach that utilized a combination of intravenous (i.v.) followed by oral (p.o) acyclovir in a cohort of immunocompromised children. Methods The cohort consisted of 26 immunocompromised children between the ages of 1.5 and 12.7 years (mean, 6.3). Therapy was commenced with i.v. acyclovir (1500 mg/m2/day in 3 divided doses). Concurrent management included holding or reducing immunosuppressive therapy (by 50%) and administering varicella-zoster immunoglobulin in 69% (11 of 16) of cases where exposure to chickenpox was recognized. Patients were eligible to switch to p.o therapy after receiving a minimum of 48 h of i.v. acyclovir therapy provided they were afebrile; had no new lesions for 24 h; had no internal organ involvement and were able to tolerate oral medications. Patients were observed in hospital for a further 24 h and then discharged provided they remained well. Oral acyclovir was continued for a total of 7 to 10 days (i.v. plus p.o). Results Of the 26 patients 25 were successfully switched from i.v. to p.o after 4.1 +/- 1.2 days (mean +/- SD) (range, 2.3 to 6) Children had fever for a mean of 2.0 +/- 1.6 days (range, 0 to 5) and developed new lesions for 2.9 +/- 0.7 days (range, 2 to 4). All 25 patients switched to p.o therapy had resolution of their disease and no patient required resumption of i.v. therapy. Conclusions The sequential use of i.v. followed by p.o acyclovir is feasible in the treatment of varicella in immunocompromised children and results in a reduction in duration of intravenous therapy and hospitalization.

A case is presented of cardiac glycoside poisoning in a 1-year-old patient from the plant Nerium oleander (common oleander). The patient had bradycardia, vomiting, altered level of consciousness, and no history of ingestion. Antibody-based digoxin assays may cross-react with other cardiac glycosides nonquantitatively. Chromatographic techniques can be used in the specific diagnosis.

Neonates and older infants are a diverse group of children, quite different from their older counterparts. Adverse drug reactions may have profound immediate, delayed, and long-term implications for their neurologic and somatic development. The intrauterine, neonatal, and infancy periods are the only stages in life in which one is exposed to and affected by drugs administered to another person, the mother. In addition, because of the fragility of the neonate and the complexity of their illnesses, their pharmacotherapy is frequently complicated with misadventure and adverse drug reactions that are unavoidable or difficult to assess. Because of their differences in morphology and disease process and treatments, infants and children experience a different range of adverse drug reactions. These reactions are not necessarily predictable from the adult experience. Despite the advances made in the field of pediatric adverse drug reactions and the lessons learned through the misfortunes involving children, children continue to suffer. Sixty years after the Elixir of Sulfanilamide-Massengill disaster, children continue to be given medications with diethylene glycol in developing countries. Pediatricians, pharmacologists, and others must continue to be vigilant and active in preventing, monitoring, and treating adverse drug reactions in children. Learning from mistakes of the past will improve the health of children by preventing mistakes in the future.

P38 mitogen-activated protein kinase (MAPK) is an important component of intracellular signaling cascades that initiate various inflammatory cellular responses. To determine the role of p38 MAPK in the procoagulant response to lipopolysaccharide (LPS), 24 healthy subjects were exposed to an intravenous dose of LPS (4 ng/kg), preceded 3 hours earlier by orally administered 600 or 50 mg BIRB 796 BS (a specific p38 MAPK inhibitor), or placebo. The 600-mg dose of BIRB 796 BS strongly inhibited LPS-induced coagulation activation, as measured by plasma concentrations of the prothrombin fragment F1 + 2. BIRB 796 BS also dose dependently attenuated the activation and subsequent inhibition of the fibrinolytic system (plasma tissue-type plasminogen activator, plasmin-α2-antiplasmin complexes, and plasminogen activator inhibitor type 1) and endothelial cell activation (plasma soluble E-selectin and von Willebrand factor). Activation of p38 MAPK plays an important role in the procoagulant and endothelial cell response after in vivo exposure to LPS.

Inherited defects in detoxification of reactive metabolites of drugs predispose patients to "hypersensitivity" reactions. Covalent interaction of metabolites with cell macromolecules leads to cytotoxic and immunologic outcomes, manifested clinically by multisystem syndromes with variable organ involvement. Hypothyroidism developed in 5 of 202 patients (age range, 1 to 81 years) we investigated for hypersensitivity reactions to anticonvulsants or sulfonamides shortly after their reaction. None had previous personal or family histories of autoimmune disease. All had low thyroxine levels, elevated levels of thyroid stimulating hormone, and autoantibodies including antimicrosomal antibodies. Patients were 2 to 18 years of age at presentation, and two were male. All returned to a euthyroid state within a year of presentation, and all remain well. The demographics, clinical presentation, and course of the patients is atypical of idiopathic lymphocytic thyroiditis. We investigated the pathogenesis of thyroid toxicity using the hydroxylamine metabolite of sulfamethoxazole as a model. The hydroxyalmine was toxic to thyroid cells in vitro, which did or did not express thyroid peroxidase activity, whereas the parent sulfonamide was toxic only to cells with active thyroid peroxidase. The purified enzyme converted sulfamethoxazole to the hydroxylamine. Formation of reactive drug metabolites by thyroid peroxidase in a host who is genetically unable to detoxify the metabolites may lead directly to cytotoxicity. Covalent binding to macromolecules, including thyroid peroxidase, also may lead to expression of neoantigens and formation of autoantibodies. Patients who have sustained hypersensitivity reactions to drugs should be investigated for possible involvement of the thyroid.

VOLUME 109, NUMBER 1 I ~ Q Safety, Pharmacokinetics, and Pharmacodynamics of Single ~ I U Doses of an Oral p38 MAP Kinase Inhibitor (BIRB 796 BS) in Healthy Human Males a Placebo-Controlled, Randomised Study, Double Blinded at Each Dose Level Abhya Gupta*, Chan-Loi Yong§, Jeffrey B Madwed§, Hildegard Staehle*, Chester C Wood§ *Boehringer-Ingelheim Pharmaceuticals, Biberach an der Rissl Germany §Boehringer-Ingelheim Pharmaceuticals, Ridgefield, CT This was a Phase l, randomised, placebo-controlled (2:6 ratio per dose group), double-blind, single escalating dose (1, 4, 15, 50, 100, 200, 400, 600 mg) study to assess safety, tolerability, pharmacokinetics and pharmacodynamics of an orally available p38 MAPK inhibitor in a polyethylene glycol 400 (PEG) solution. Safety was determined by laboratory measurements and clinical examination. Kinetics was assessed by determining plasma concentrations of drug. Dynamics (including kinetic modeling) was assessed by measuring LPS-induced production of TNF-c~ ex vivo and expression of Mac1 and L-selectin cell surface markers. Sixty-four healthy males (mean age 30 yrs, mean weight 79 kg, mean BM123.9) participated. There were no significant changes in ECGs, vital signs or physical examination. There was a mild, reversible, clinically non-significant rise in GGT at the 400 and 600 mg doses. There was also a minor, reversible, increase in total bilirubin associated with the vehicle (15 ml PEG 400). The pharmacokinetic assessment showed good systemic exposure to the drug with a mean Tma x occurring 0.75 to 1.75 hours. Mean C~nax was 2,196 ng/ml at the 600 mg dose and elimination half-fife was 6.7 to 9.9 hours throughout the dose range. Dose proportionality was observed for AUC up to 600 mg dose. An Ema x model best described the effects of the drug on LPS-induced production of TNF-o~ and on the activation state of human whole blood PMN demonstrating a good relationship between the effects and plasma concentrations. The ex vivo ECs0 for inhibiting 1) LPS-induced TNF-ma x production was 1,228 ng/ml and 2) Mac-1/L-selectin ratio was 91.5 ng/ml with TNF-c~ stimulation and 238 ng/ml with fMLP stimulation. The results indicate that this orally available p38 MAPK inhibitor is well tolerated at single doses up to 600 mg with a good pharmacokinetic profile and a favorable pharmacodynamic effect. 1 5 9 Urticaria and Angi°edema in Renal Ca nc e r P a t i e n t s W i t h I L 2 Treated Theodore Francis Logan*, Giovanni Stripoli§, Macy Levine¥ *Indiana University, Indianapolis, IN §Universita'degli Study di Bail, Facolta' di Medicine e Chirugia, Bail, Italy YUniversity of Pittsburgh, Pittsburgh, PA Interleukin-2 (IL-2) therapy has produced significant improvement in a proportion of patients with metastatic renal cell carcinoma. Dermatological side effects have been common and urticaria reportedly occurs in 2% of patients treated with IL-2. However, we have been able to locate only three patients in the literature with hives occurring in association with Interleukin-2 treatment. We have identified patients with urticaria occurring in the setting of IL-2 therapy at a single institution. We report five patients with metastatic renal cell carcinoma treated with systemic IL-2 who developed urticaria and/or angiodema in association with IL-2. The patients were treated with systemic IL-2 either with high intravenous dose (1 pt), low-intermediate intravenous dose (3 pts), or subcutaneous injection (1 pt). The hives tended to occur at the end of the treatment course. Formal skin tests with IL-2 were negative in two patients. Urticaria did not worsen or consistently occur with repeated courses of IL-2 and anaphylaxis was not observed in any patient. Four of the five patients had previously had urticaria unrelated to IL-2 therapy. One patient also experienced angioedema. In conclusion, in this small series, urticaria tended to occur at the end of an IL-2 treatment course and did not appear to be associated with allergic or anaphylactic reactions. It may occur more frequently in patients with a prior history of hives. These observations suggest that urticaria in the setting of IL-2 therapy does not occur on an allergic or immunologic basis. ~ N Heat Shock Protein 90 Catalyses Activation of the Prekallikl 1 I JlIJI Kininogen Complex in the Absence of Factor XII Kusumam Joseph, Baby G Tholanikunnel, Allen P Kaplan Medical versity of South Carolina, Charleston, SC Bradykinin is the mediator of swelling in C 1 inhibitor deficiency as as the angioedema seen with ACE inhibitors and may contribut bronchial hyperreactivity. Formation of bradykinin occurs in the 1 phase and along cell surfaces requiring interaction of Factor prekallikrein and high molecular weight kininogen (HK). Recent data gest that activation of the kinin-forming cascade can occur on the surfa, endothelial cells, even in the absence of Factor XII (Motta et al, Blood 516-528, 1998). We sought to further define this Factor XII indepen mechanism of bradykinin generation by identifying the activating fa Endothelial cells were lysed and membrane and cytosol fractions were ed for their ability to activate prekallikrein. Activation proceeded on HK and zinc ion were included and both fractions were effective. We fractionated the cytosol by batch elution from SP sepharose, Q sepharose and affinity chromatography employing corn trypsin inhibitor (CTI) as ligand. The fractions with peak activity were subjected to SDS gel electrophoresis, ligand blot with biotinylated CTI, and positive bands were sequenced. Heat shock protein 90 (Hsp90) was identified as one of the major proteins that was isolated by the above purification procedure. We tested purified and recombinant (commercial sources) Hsp90 for bradykinin generating capability. A mixture of prekallikrein, HK, and increasing concentration of Hsp90 were incubated in Hepes buffer containing 50raM zinc and kallikrein activity was monitored. There was conversion of prekallikrein to kallikrein as the concentration of Hsp90 was increased and the activity requirements were identical to that of the cytosol. Activation of the prekallikrein-HK complex on the surface of endothelial cells was inhibited with polyclonal antibody to Hsp90. The activity is also inhibitable with antipain, com trypsin inhibitor, EDTA and dithiothreitol. Hsp90 is not known to possess enzymatic activity, however a prekaUikrein activator is created when Hsp90, HK and prekallikrein are incubated together with zinc. Although the active site for this conversion has not yet been identified, this represents the first demonstration of activation of the bradykinin forming cascade in the absence of Factor XII and may be important for bradykinin formation along cell surfaces. 61 The Synthetic Immune Response Modifier R-848 Induces Dendritic Cells to Mature and Synthesize e Diverse Range of Cytokines Via a Pathway Distinct From Lipopolysaccharide Mirjana Fogel, Julie A Long, Philip J Thompson, John W Upham Asthma & Allergy Research Institute, Perth, WA, Australia Dendritic cells (DC) are specialized antigen presenting cells (APC) that play a prominent role in the development of T cell immune responses to allergens, having a key influence over the differentiation of naive T cells into Th 1 or Th2 effectors. Consequently, there is considerable interest in the development of pharmacological agents that can alter dendritic cell (DC) function. Our aims were to compare the effects of the imidazoquinoline R848 (3M Pharmaceuticals) and LPS on the function of human monocyte derived DC obtained from healthy individuals. Both R-848 and LPS were able to induce DC maturation and synthesis of the key Thl polarising cytokine IL-12 p70 in a dose and time dependent manner. However, these two stimuli appeared to be acting on DC via distinct pathways. Whereas LPS was only able to induce IL-12 synthesis following priming of DC with IFNy, R-848 was able to induce IL12 synthesis without the need for priming with IFN~/. Additionally both R-848 and LPS+ IFNy stimulated DC to express ILl,x, IL-I[3, IL-1Ra and IL-6, mRNA as well as low levels of IL18 mRNA. DC stimulated by LPS alone, did not increase their expression of IL-12 or IL-18 mRNA. Furthermore, the regulatory cytokine TGF]3 markedly inhibited IL-12 synthesis by DC stimulated with LPS + IFNy, whereas TGFI3 had little effect on the ability of R-848 to induce IL-12 synthesis by DC. All these findings suggest that R-848 acts directly on DC to induce the secretion of Thl polarising cytokines, via a pathway distinct from LPS. This agent may therefore be clinically useful in circumstances where augmentation of Th 1 immunity is desirable.