Search

BackgroundThymic stromal lymphopoietin (TSLP) is a key upstream regulator driving allergic inflammatory responses. We evaluated the efficacy and safety of ecleralimab, a potent inhaled neutralising antibody fragment against human TSLP, using allergen inhalation challenge (AIC) in subjects with mild atopic asthma.MethodsThis was a 12-week, randomised, double-blind, placebo-controlled, parallel-design, multicentre allergen bronchoprovocation study conducted at 10 centres across Canada and Germany. Subjects aged 18–60 years with stable mild atopic asthma were randomised (1:1) to receive 4 mg once-daily inhaled ecleralimab or placebo. Primary end-points were the allergen-induced change in forced expiratory volume in 1 s (FEV1) during the late asthmatic response (LAR) measured by area under the curve (AUC3–7h) and maximum percentage decrease (LAR%) on day 84, and the safety of ecleralimab. Allergen-induced early asthmatic response (EAR), sputum eosinophils and fractional exhaled nitric oxide (FENO) were secondary and exploratory end-points.Results28 subjects were randomised to ecleralimab (n=15) or placebo (n=13). On day 84, ecleralimab significantly attenuated LAR AUC3–7hby 64% (p=0.008), LAR% by 48% (p=0.029), and allergen-induced sputum eosinophils by 64% at 7 h (p=0.011) and by 52% at 24 h (p=0.047) post-challenge. Ecleralimab also numerically reduced EAR AUC0–2h(p=0.097) and EAR% (p=0.105).FENOlevels were significantly reduced from baseline throughout the study (pConclusionEcleralimab significantly attenuated allergen-induced bronchoconstriction and airway inflammation, and was safe in subjects with mild atopic asthma.

Chronic obstructive pulmonary disease (COPD) patients with higher eosinophil counts are associated with increased clinical response to phosphodiesterase‐4‐inhibitors (PDE4i). However, the underlying inflammatory mechanisms associated with this increased response is not yet elucidated. This post hoc analysis focused on sputum gene expression in patients with chronic bronchitis who underwent 32‐day treatment with two doses of the inhaled PDE4i CHF6001 (tanimilast) or placebo on top of triple therapy. Biological characterization and treatment effects were assessed between patients with different sputum eosinophil levels (eosinophilhigh ≥ 3%; eosinophillow

Asthma worsening and symptom control are clinically important health outcomes in patients with severe eosinophilic asthma. This analysis of COMET evaluated whether stopping versus continuing long-term mepolizumab therapy impacted these outcomes. Patients with severe eosinophilic asthma with ≥3 years continuous mepolizumab treatment (via COLUMBA (NCT01691859) or COSMEX (NCT02135692) open-label studies) were eligible to enter COMET (NCT02555371), a randomised, double-blind, placebo-controlled study. Patients were randomised 1:1 to continue mepolizumab 100 mg subcutaneous every 4 weeks or to stop mepolizumab, plus standard of care asthma treatment. Patients could switch to open-label mepolizumab following an exacerbation. Health outcome endpoints included time to first asthma worsening (composite endpoint: rescue use, symptoms, awakening at night and morning peak expiratory flow (PEF)), patient and clinician assessed global rating of asthma severity and overall perception of response to therapy, and unscheduled healthcare resource utilisation. Patients who stopped mepolizumab showed increased risk of and shorter time to first asthma worsening compared with those who continued mepolizumab (hazard ratio (HR) 1.71; 95% CI 1.17–2.52; p=0.006), including reduced asthma control (increased risk of first worsening in rescue use (HR 1.36; 95% CI 1.00–1.84; p=0.047) and morning PEF (HR 1.77; 95% CI 1.21–2.59; p=0.003). There was a higher probability of any unscheduled healthcare resource use (HR 1.81; 95% CI 1.31–2.49; p, The COMET study investigated whether stopping long-term mepolizumab had an impact on health outcomes in patients with severe eosinophilic asthma; data suggest those who continue long-term mepolizumab treatment sustain clinically important improvements https://bit.ly/3A0bvwu

Background The long-term efficacy and safety of mepolizumab for treatment of severe eosinophilic asthma are well established. Here, we examine the clinical impact of stopping mepolizumab after long-term use. Methods COMET (NCT02555371) was a randomised, double-blind, placebo-controlled, parallel-group, multicentre study. Patients who had completed COLUMBA (NCT01691859) or COSMEX (NCT02135692) and received continuous mepolizumab treatment for ≥3 years were randomised 1:1 to stop (switch to placebo) or continue subcutaneous mepolizumab 100 mg every 4 weeks for 52 weeks. Primary end-point: time to first clinically significant exacerbation; secondary end-points: time to first exacerbation requiring hospitalisation/emergency department visit, time to decrease in asthma control (≥0.5-point increase in Asthma Control Questionnaire-5 score from COMET baseline) and blood eosinophil count ratio to COMET baseline. Safety was assessed. Results Patients stopping (n=151) versus continuing (n=144) mepolizumab had significantly shorter times to first clinically significant exacerbation (hazard ratio 1.61, 95% CI 1.17–2.22; p=0.004) and decrease in asthma control (hazard ratio 1.52, 95% CI 1.13–2.02; p=0.005), and higher blood eosinophil counts at week 52 (270 versus 40 cells·µL−1; ratio (stopping versus continuing) 6.19, 95% CI 4.89–7.83; p, This randomised study demonstrates increased exacerbation risk and a decrease in asthma control in patients with severe eosinophilic asthma who stop mepolizumab treatment after long-term use, when compared with those who continue treatment. https://bit.ly/3fsxGV2

Introduction: CSJ117 is a potent neutralizing antibody fragment against human Thymic stromal lymphopoietin (TSLP), formulated as a PulmoSol™ engineered powder in hard capsules for delivery to the lungs via dry powder inhaler. Methods: In this double-blind, placebo-controlled study, 28 mild, atopic asthmatics meeting elibility criteria were randomized to receive 4mg CSJ117 (n = 15) or placebo (n = 13) inhaled daily for 12 weeks. Allergen inhalation challenge (AIC) was conducted at screening, day 42 and day 84. The primary efficacy variable was the late asthmatic response (LAR), measured 3 to 7 hours after AIC at day 84. Other outcomes included the early asthmatic response (EAR) measured within 2 hours after AIC, fractional exhaled nitric oxide (FeNO) level, and sputum eosinophils. Data were analyzed using repeated measures ANCOVA (β=10%) and one-sided tests (α=10%). Results: CSJ117 attenuated allergen-induced LAR and EAR at day 84. The time-adjusted AUC percentage decrease and the maximum decrease in FEV1 from pre-AIC were lower in the CSJ117 group compared to placebo (4.20% vs 11.38%, p = 0.008, and 9.28% vs 17.70%, P=0.029, during LAR; 12.83% vs 17.09%, P = 0.097, and 25.48% vs 30.90%, P = 0.105, during EAR). CSJ117 significantly attenuated the allergen-induced increase in % sputum eosinophils after AIC on day 84. CSJ117 significantly reduced FeNO before AIC at Day 83, but not the allergen-induced change. Conclusion: CSJ117 reduced allergen-induced bronchoconstriction and sputum eosinophilia, and pre challenge FeNO levels. These findings demonstrate CSJ117’s ability to attenuate airway inflammation in allergic asthmatics and support further studies as an inhaled anti-TSLP.

Aim: Prior studies have confirmed the fast and sustained bronchodilation with IND and GLY1, and improved lung function with MF2. Here we evaluated the effect of IND/GLY/MF fixed-dose combination via Breezhaler® vs Sal/Flu+Tio on symptoms and rescue medication use in uncontrolled asthma patients. Methods: ARGON(NCT03158311) was a 24 wk, Phase 3b, multicentre, randomised, partially-blinded, non-inferiority, active-controlled study in symptomatic (ACQ-7 ≥1.5) patients (≥18 yrs). This exploratory analysis evaluated the effect of IND/GLY/MF medium-dose (150/50/80µg) o.d. vs combination of Sal/Flu high-dose (50/500µg) b.i.d. + Tio 5µg o.d. on symptom scores and rescue medication use at Wk 24. Results: Reduction in total daily symptom scores (LSM treatment difference [Δ]: −0.103, p=0.119), percentage of nights without awakenings (Δ: 0.864, p=0.608) and reduction in rescue medication use (Δ: −0.134, p=0.081) with IND/GLY/MF medium-dose were comparable with Sal/Flu+Tio. Patients receiving IND/GLY/MF medium-dose had a higher percentage of days with no day-time symptoms (Δ: 4.453, p=0.016) and mornings with no symptoms (Δ: 4.976, p=0.012) vs Sal/Flu+Tio. Conclusion: IND/GLY/MF medium-dose o.d. delivered via a single inhaler was comparable in terms of symptom scores and rescue medication use, while resulting in better improvements in day-time symptoms and morning symptoms vs Sal/Flu high-dose b.i.d. + Tio o.d. delivered via two inhalers, at a reduced ICS dose. References:1.Rossi A. et al. Int J Chron Obstruct Pulmon Dis 2015;10:1383-92; 2.Kemp JP. et al. J Allergy Clin Immunol 2000;106:485-92

Background: The long-term efficacy and safety of mepolizumab in severe eosinophilic asthma (SEA) have been shown. Aims: To assess the impact of stopping versus continuing long-term mepolizumab on asthma worsening. Methods: COMET (NCT02555371) was a randomised, double-blind, placebo-controlled study. Patients had completed COLUMBA (NCT01691859) or COSMEX (NCT02135692), had continuous mepolizumab for ≥3 years (mean 46.6 months), and stayed on asthma controller therapy. Randomisation was 1:1 to stop (switch to placebo) or continue subcutaneous mepolizumab 100 mg for 52 weeks. Composite endpoint: time to first asthma worsening (defined in Table). Daily eDiary data were analysed using Kaplan–Meier estimates and a Cox proportional hazards model adjusted for covariates. Results: Treatment differences for those who stopped versus continued mepolizumab emerged by Week 4 (8 weeks post last open-label mepolizumab dose). For those who stopped mepolizumab, 51.7% reported asthma worsening by Week 52 versus 35.0% who continued mepolizumab (Table), leading to a significantly shorter time to first asthma worsening in those who stopped mepolizumab. Conclusion: Stopping mepolizumab in patients with SEA led to an increased risk of asthma worsening with a significantly shorter time to first asthma worsening versus those continuing long-term mepolizumab. Funding: GSK [201810/NCT02555371].

OBJECTIVE: To evaluate cardiovascular safety of two new inhaled fixed-dose combinations for treatment of asthma: (i) the inhaled corticosteroid/long-acting beta2-agonist (ICS/LABA) mometasone furoate/indacaterol acetate (MF/IND), (ii) the ICS/LABA/long-acting muscarinic antagonist (LAMA) MF/IND/glycopyrronium bromide (GLY).METHODS: Patient-level data were pooled from four randomized trials, including 52-week studies PALLADIUM (n = 2216) and IRIDIUM (n = 3092), 24-week study ARGON (n = 1426), and 12-week study QUARTZ (n = 802). Cardio-/cerebrovascular (CCV) event frequencies were examined in the following comparisons: (1) LABA effect: pooled-dose MF/IND vs. pooled-dose MF; (2) LAMA effect: pooled-dose MF/IND/GLY vs. pooled-dose MF/IND; (3) ICS-dose effects: (a) high-dose MF/IND vs. medium-dose MF/IND, (b) high-dose MF/IND/GLY vs. medium-dose MF/IND/GLY; (4) intra-class effects: (a) high-dose MF/IND vs. Fluticasone/Salmeterol (F/S), (b) high-dose MF/IND/GLY vs. F/S + Tiotropium (TIO). Risk estimates (percentage of patients with ≥1 CCV event) and risk differences (RDs) with 95% confidence intervals (CIs) were calculated for each comparison.RESULTS: The frequency of CCV events was low, without notable differences between comparison groups. Risk estimates and corresponding RDs (95% CIs) were as follows: (1) pooled-dose MF/IND = 2.35%, pooled-dose MF = 2.18%, RD = 0.17% (-1.00%, 1.34%); (2) pooled-dose MF/IND/GLY = 3.65%, pooled-dose MF/IND = 3.77%, RD = -0.12% (-1.63%, 1.39%); (3a) high-dose MF/IND = 3.69%, medium-dose MF/IND = 3.35%, RD = 0.34% (-1.25%, 1.94%); (3b) high-dose MF/IND/GLY = 2.84%, medium-dose MF/IND/GLY = 2.02%, RD = 0.82% (-0.49%, 2.13%); (4a) high-dose MF/IND = 3.69%, F/S = 2.82%, RD = 0.87% (-0.66%, 2.40%); (4b) high-dose MF/IND/GLY = 1.26%, F/S + TIO = 1.05%, RD = 0.21% (-1.26%, 1.68%).CONCLUSIONS: There was no evidence of increased cardiovascular risk attributable to the addition of IND to MF or addition of GLY to MF/IND. Similarly, no evidence of increased cardiovascular risk was observed with an increase in the ICS-dose or relative to F/S ± TIO.

Patients with COPD who have higher eosinophil numbers in the airways and peripheral blood demonstrate a greater clinical response to inhaled corticosteroids (ICS) [1–3]. Furthermore, the effect of the oral phosphodiesterase-4 (PDE4) inhibitor roflumilast on exacerbations in severe COPD patients with chronic bronchitis, who are treated with ICS and long-acting bronchodilators, also appears to be greater at higher blood eosinophil counts [4]. The mechanisms responsible for these differential drug effects remain to be defined, but may relate to increased type-2 inflammation and/or decreased presence of colonising airway bacteria in COPD patients with more eosinophils [5, 6], leading to different responses to anti-inflammatory drugs. An association between blood and sputum eosinophils has been observed in some, but not all studies [7–12]. Accurate sputum eosinophil count measurement requires good quality samples to make cytospins where eosinophils can be clearly counted; variable quality of sputum samples, particularly in multicentre studies, will affect the ability to show a relationship with blood eosinophil counts., PDE4 inhibition reduces sputum eosinophils in those COPD patients with higher eosinophil counts. This evidence supports an effect of PDE4 inhibitors on eosinophilic inflammation. https://bit.ly/3airXw7

Background The efficacy and safety of once-daily (o.d.) fixed-dose combination of indacaterol (IND), glycopyrronium (GLY) and mometasone furoate (MF) via Breezhaler® versus concurrent administration of salmeterol/fluticasone (SAL/FLU) twice-daily (b.i.d.) via Accuhaler®+Tiotropium (TIO) o.d. via Respimat® was evaluated in patients with uncontrolled asthma. Methods Patients (aged ≥18 years), symptomatic (Asthma Control Questionnaire [ACQ]-7 ≥1.5) despite treatment with long-acting β2-agonist/inhaled corticosteroid medium- or high-dose, received IND/GLY/MF high- (150/50/160 μg) or medium-dose (150/50/80 μg) o.d. or SAL/FLU high-dose (50/500 μg) b.i.d.+Tio 5 μg o.d. for 24 weeks. The primary objective was to confirm the non-inferiority of either dose of IND/GLY/MF to SAL/FLU high dose + TIO in terms of Asthma Quality of Life Questionnaire (AQLQ). Additional endpoints: ACQ-7, lung function, health status (St George's Respiratory Questionnaire [SGRQ]), exacerbations, and safety after 24 weeks. Results IND/GLY/MF high- and medium-dose met the primary endpoint, confirming non-inferiority to SAL/FLU high dose + TIO for AQLQ (least square mean treatment difference [Δ]: 0.073 and −0.038, respectively; both p Conclusions IND/GLY/MF high- and medium-dose o.d. via a single inhaler were non-inferior to SAL/FLU high-dose b.i.d. + TIO o.d. via two inhalers for AQLQ. IND/GLY/MF high-dose o.d. improved lung function, asthma control and health status versus SAL/FLU high dose + TIO, while IND/GLY/MF medium-dose had comparable efficacy but at a corresponding lower steroid dose.

BackgroundThe long-term efficacy and safety of mepolizumab for treatment of severe eosinophilic asthma are well established. Here, we examine the clinical impact of stopping mepolizumab after long-term use.MethodsCOMET (NCT02555371) was a randomised, double-blind, placebo-controlled, parallel-group, multicentre study. Patients who had completed COLUMBA (NCT01691859) or COSMEX (NCT02135692) and received continuous mepolizumab treatment for ≥3 years were randomised 1:1 to stop (switch to placebo) or continue subcutaneous mepolizumab 100 mg every 4 weeks for 52 weeks. Primary end-point: time to first clinically significant exacerbation; secondary end-points: time to first exacerbation requiring hospitalisation/emergency department visit, time to decrease in asthma control (≥0.5-point increase in Asthma Control Questionnaire-5 score from COMET baseline) and blood eosinophil count ratio to COMET baseline. Safety was assessed.ResultsPatients stopping (n=151) versus continuing (n=144) mepolizumab had significantly shorter times to first clinically significant exacerbation (hazard ratio 1.61, 95% CI 1.17–2.22; p=0.004) and decrease in asthma control (hazard ratio 1.52, 95% CI 1.13–2.02; p=0.005), and higher blood eosinophil counts at week 52 (270 versus 40 cells·µL−1; ratio (stopping versus continuing) 6.19, 95% CI 4.89–7.83; pConclusionPatients who stopped mepolizumab had an increase in exacerbations and reduced asthma control versus those who continued.

Background Although phosphodiesterase-4 (PDE4) inhibitors have been shown to reduce COPD exacerbation rate, their biological mechanism of action is not completely elucidated at the molecular level. We aimed to characterise the whole genome gene expression profile of the inhaled PDE4-inhibitor CHF6001 on top of triple therapy in sputum cells and whole blood of patients with COPD and chronic bronchitis. Methods Whole genome gene expression analysis was carried out by microarray in 54 patients before and after 32 days treatment with CHF6001 800 and 1600 μg and placebo twice daily (BID) in a randomised crossover study. Results CHF6001 had a strong effect in sputum, with 1471 and 2598 significantly differentially-expressed probe-sets relative to placebo (p-adjusted for False Discovery Rate 87%) were downregulated, including macrophage inflammatory protein-1-alpha and 1-beta, interleukin-27-beta, interleukin-12-beta, interleukin-32, tumour necrosis factor-alpha-induced-protein-8, ligand-superfamily-member-15, and matrix-metalloproteinases-7,12 and 14. The effect in blood was not significant. Conclusions Inhaled PDE4 inhibition by CHF6001 on top of triple therapy in patients with COPD and chronic bronchitis significantly modulated key inflammatory targets and pathways in the lung but not in blood. Mechanistically these findings support a targeted effect in the lung while minimising unwanted systemic class-effects. Trial registration ClinicalTrial.gov, EudraCT, 2015–005550-35. Registered 15 July 2016.

Introduction: GINA recommends ICS/LABA as initial controller therapy in inadequately controlled asthma patients (pts) on low-dose ICS. We evaluated efficacy and safety of low-dose indacaterol acetate/mometasone furoate (IND/MF) 150/80 µg once daily (o.d.) via Breezhaler® versus MF 200 µg o.d. via Twisthaler® in symptomatic asthma pts Methods: This Phase III, 12-week, double-blind study randomised (1:1) asthma pts (≥12yrs) receiving low-dose ICS prior to study, to IND/MF or MF (Figure). Pts were symptomatic (ACQ-7 ≥1.5) prior to randomisation. Primary endpoint: trough FEV1 at Week 12. Key secondary endpoint: change in ACQ-7 score. Other secondary endpoints: ACQ-7 responders, AM and PM peak expiratory flow (PEF), rescue medication use, AQLQ and daily symptom score. We also assessed safety Results: Of 802 pts randomised, 768 completed study. IND/MF significantly improved trough FEV1 (least squares mean treatment difference [LSMTD]: 0.182L; P Conclusion: In symptomatic asthma pts, IND/MF significantly improved lung function and asthma control versus MF. This supports IND/MF as efficacious maintenance therapy for asthma

Background: CHF6001 is a selective inhaled PDE4i (NEXThaler®). The aim of this study was to assess the effects of CHF6001 on markers of inflammation in sputum and blood. Methods: In this randomized, double-blind, 3-way crossover study, moderate-to-severe COPD subjects with chronic bronchitis (CB) received CHF6001 1600 or 3200µg daily or placebo for 32 days on top of ICS/LABA/LAMA therapy. CHF6001 concentrations and biomarkers of inflammation were analyzed in sputum supernatant and whole blood, plasma or serum. A post-hoc microarray gene expression analysis in blood and sputum cells was also carried out. Results: 61 patients were randomized. CHF6001 sputum concentrations were ~2000-fold higher than in plasma. In sputum supernatant, both doses significantly (p Conclusion: Both doses of CHF6001 significantly decreased a number of key biomarkers of airway inflammation in COPD patients with CB. Moreover, these effects were essentially localized to the lung with inhaled delivery limiting systemic exposure

Background CHF6001 is a novel inhaled phosphodiesterase-4 inhibitor. This Phase IIa study assessed the effects of CHF6001 on markers of inflammation in induced sputum and blood in patients with chronic obstructive pulmonary disease (COPD). Methods This was a multicentre, three-period (each 32 days), three-way, placebo-controlled, double-blind, complete-block crossover study. Eligible patients had COPD, chronic bronchitis, and were receiving inhaled triple therapy for ≥2 months. Patients received CHF6001 800 or 1600 μg, or matching placebo twice daily via multi-dose dry-powder inhaler (NEXThaler). Induced sputum was collected pre-dose on Day 1, and post-dose on Days 20, 26 and 32. Blood was sampled pre-dose on Day 1, and pre- and post-dose on Day 32. Results Of 61 randomised patients, 54 (88.5%) completed the study. There were no significant differences between groups for overall sputum cell count, or absolute numbers of neutrophils, eosinophils or lymphocytes. CHF6001 800 μg significantly decreased the absolute number and percentage of macrophages vs placebo. In sputum, compared with placebo both CHF6001 doses significantly decreased leukotriene B4, C-X-C motif chemokine ligand 8, macrophage inflammatory protein 1β, matrix metalloproteinase 9, and tumour necrosis factor α (TNFα). In blood, both CHF6001 doses significantly decreased serum surfactant protein D vs placebo. CHF6001 1600 μg significantly decreased TNFα ex-vivo (after incubation with lipopolysaccharide). Conclusion The data from this study show that CHF6001 inhaled twice daily has anti-inflammatory effects in the lungs of patients with COPD already treated with triple inhaled therapy. Trial registration The study is registered on ClinicalTrials.gov (NCT03004417). Electronic supplementary material The online version of this article (10.1186/s12931-019-1142-7) contains supplementary material, which is available to authorized users.

Kai Michael Beeh,1 Anne-Marie Kirsten,2 Ana-Maria Tanase,3 Alexia Richard,3 Weihua Cao,4 Bettina Hederer,3 Jutta Beier,1 Oliver Kornmann,5 Richard N van Zyl-Smit6 1Insaf Respiratory Research Institute Wiesbaden, Wiesbaden, Germany; 2Pulmonary Research Institute at Lung Clinic Grosshansdorf, Airway Research Center North, German Center for Lung Research, Grosshansdorf, Germany; 3Novartis Pharma AG, Basel, Switzerland; 4Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA; 5IKF Pneumologie, Clinical Research Centre Respiratory Diseases, Frankfurt, Germany; 6Division of Pulmonology and UCT Lung Institute, University of Cape Town, Cape Town, South Africa Background and purpose: Fixed-dose combinations of a long-acting beta agonist and an inhaled corticosteroid are more effective than the individual components in COPD. The primary study objective was to demonstrate that the combination indacaterol acetate/mometasone furoate (IND/MF [QMF149]) was non-inferior to the twice-daily combination salmeterol xinafoate/fluticasone propionate (Sal/Flu) in terms of trough FEV1 at week 12 (day 85). Secondary objectives were to compare the efficacy of IND/MF (QMF149) vs Sal/Flu with respect to other lung function parameters, COPD exacerbations, symptoms and dyspnea, health status/health-related quality of life, and rescue medication use.Materials and methods: This was a 12-week multicenter, randomized, double-blind, double-dummy, parallel-group, Phase II study in patients with moderate-to-very-severe COPD, who were randomized (1:1) to IND/MF (QMF149) (150/160 µg once daily; n=316) or Sal/Flu (50/500 µg twice daily; n=313).Results: Over 90% of patients completed the study: 94.6% in the IND/MF (QMF149) group and 92.0% in the Sal/Flu group. The primary objective of non-inferiority of IND/MF (QMF149) to Sal/Flu for trough FEV1 at week 12 (day 85) was met: the lower limit of the CI (95% CI: 27.7, 83.3 mL) was greater than -60 mL. The analysis for superiority of IND/MF (QMF149) to Sal/Flu demonstrated superiority of IND/MF (QMF149), with a difference of 56 mL (P

Background Global initiative for asthma (GINA) 2019 recommends adding a long-acting β2-agonist (LABA) to an inhaled corticosteroid (ICS) as a maintenance controller therapy in patients with inadequately controlled asthma. Indacaterol acetate (IND, a LABA) in combination with mometasone furoate (MF, an ICS) is under development for the treatment of these patients. Objective This phase III QUARTZ was a multicentre, randomised, double-blind, double-dummy and parallel-group study to assess the efficacy and safety of low-dose IND/MF 150/80 μg once daily (o.d.) versus MF 200 μg o.d. in adult and adolescent patients with inadequately controlled asthma. Methods Eligible patients (n = 802) were randomised (1:1) to receive either low-dose IND/MF 150/80 μg o.d. via Breezhaler® or MF 200 μg o.d. via Twisthaler® for 12 weeks. Primary endpoint was trough forced expiratory volume in 1 s (FEV1) and key secondary endpoint was Asthma Control Questionnaire (ACQ-7) treatment difference after 12-week treatment. Other secondary endpoints included ACQ-7 responder analysis, morning and evening peak expiratory flow, Asthma Quality of Life Questionnaire total score, rescue medication use, daily symptom score, nighttime awakenings and rate of exacerbations, evaluated over 12-week treatment. Safety was also assessed including serious asthma outcomes. Results Low-dose IND/MF significantly improved trough FEV1 (least squares mean treatment difference [LSMTD]: 0.182 L; p Conclusion These results support the use of low-dose IND/MF 150/80 μg o.d. as a potential therapy for adult and adolescent patients with inadequately controlled asthma.

Phosphoinositide 3-kinase δ (PI3Kδ) is a lipid kinase involved in leukocyte recruitment and activation. Activation of PI3Kδ has been linked to airway inflammation and asthma pathogenesis. This randomized, double-blind, placebo-controlled, crossover study investigated the efficacy, safety, tolerability, and pharmacokinetics of a PI3Kδ inhibitor, nemiralisib (GSK2269557), in patients with persistent, uncontrolled asthma. Patients (n = 50) received once-daily inhaled nemiralisib (1000 µg) or placebo for 28 days, with a crossover to the alternative treatment following a 4-week washout period. Spirometry demonstrated no discernible difference in trough forced expiratory volume in 1 second (FEV1) from baseline (adjusted posterior median 7 ml; 95% credible interval -83, 102 ml) between nemiralisib and placebo treatment at day 28 (primary endpoint). These results were supported by most secondary endpoints, including weighted mean FEV1 (0-4 hours) and change in trough forced vital capacity at day 28. Nemiralisib was generally well-tolerated, with few side effects except for post-inhalation cough (nemiralisib: 35%; placebo: 9%). At day 14, sputum interleukin (IL)-5, IL-13, IL-6, and IL-8 levels were reduced by a median of 17%, 7%, 15%, and 8%, respectively, when comparing nemiralisib with placebo [n = 15 (IL-5, IL-8) or 16 (IL-6, IL-13); posterior probability of a true ratio >0%: 78%, 64%, 76%, and 63%, respectively]. These results suggest that nemiralisib inhibited PI3Kδ locally; however, this did not translate into meaningful clinical improvement. Further studies will investigate the potential efficacy of nemiralisib in patients with asthma with other specific more severe phenotypes, including those who are colonized with bacteria and frequently exacerbate.

GSK961081 is an inhaled bi-functional molecule with both muscarinic antagonism and β2-agonism (MABA) properties. This randomised, double-blind, double-dummy, crossover study evaluated 14 days treatment with the MABA GSK961081 400 μg and 1200 μg once daily and tiotropium 18 μg once daily plus salmeterol 50 μg twice daily (TIO + SAL), versus placebo in 50 patients with moderate COPD. The primary endpoint was forced expiratory volume in 1 s (FEV1) at 24 h on Days 1 and 14. MABA 400 (n = 29), MABA 1200 (n = 32) and TIO + SAL (n = 41) resulted in significant increases in FEV1 over 24 h. Mean (95% CI) 24 h trough FEV1 (L) values relative to placebo (n = 43) were, for Day 1, MABA 400: 0.141 (0.060, 0.222); MABA 1200: 0.184 (0.105, 0.263); TIO + SAL: 0.162 (0.092, 0.231); for Day 14, MABA 400: 0.115 (0.024, 0.205); MABA 1200: 0.168 (0.080, 0.255); TIO + SAL: 0.103 (0.026, 0.180). Onset of bronchodilation was faster for both MABA doses versus TIO + SAL. No clinically relevant systemic pharmacodynamic effects were observed. Adverse events were similar across groups; however tremor (n = 2, MABA 1200), dysgeusia (n = 2, MABA 1200; n = 2, MABA 400) and dry mouth (n = 1, MABA 1200) were reported after GSK961081 only. GSK961081 demonstrated sustained bronchodilation similar to TIO + SAL, but with a more rapid onset, and was well tolerated at the tested doses.

Objective Mepolizumab is a humanized IgG1 monoclonal antibody that blocks human IL-5 from binding to the IL-5 receptor, which is mainly expressed on eosinophils. Eosinophils are key cells in the inflammatory cascade of various diseases, including asthma. This study investigated the pharmacokinetic (PK)/pharmacodynamic (PD) relationship between exposure of mepolizumab subcutaneous (SC) administration and blood eosinophil reduction compared with intravenous (IV) administration in adult subjects with asthma. Methods In this multi-center, randomized, open-label, parallel-group, repeat-dose study, 70 adult subjects received one of four possible treatment regimens: mepolizumab 12.5, 125, or 250 mg SC or 75 mg IV. In addition to analyzing the dose and PK/PD relationship, absolute bioavailability, safety, tolerability, and incidence of anti-mepolizumab antibodies were evaluated. Results Blood eosinophil levels decreased in a dose-dependent manner with the lowest (12.5 mg) dose clearly differentiating from the other doses. A non-linear inhibition Imax model based on blood eosinophil levels at week 12 identified that the SC doses providing 50% and 90% of maximal blood eosinophil inhibition were 11 mg (95% confidence interval (CI): 5.19 - 16.85) and 99 mg (95% CI: 47 - 152), respectively. The route of administration did not affect the exposure-response relationship. The estimated mepolizumab SC absolute bioavailability (arm) was 74% (90% CI: 54 - 102%). The safety profile of mepolizumab was favorable. Conclusions A dose-dependent reduction in blood eosinophils across all mepolizumab doses investigated was observed. The subcutaneous absolute bioavailability was 74%. The route of administration did not affect the mepolizumab exposure eosinophil response relationship.

SummaryForced inspiratory measures have been described to reflect the reduction in dyspnoea upon bronchodilation in severe COPD. Based on this we evaluated the applicability and usefulness of a portable device for the assessment of forced inspiration. In 37 patients with COPD (GOLD II/II/IV n = 16/15/6, mean ± SD FEV1 46.2 ± 15.4%pred) lung function was recorded prior to inhalation of 24 μg formoterol and 30 min later. Assessments comprised spirometry including forced inspiration, body plethysmography, maximum inspiratory flow (InCheck, Clement Clarke), and changes in dyspnoea via visual analogue scale (VAS). The sequence was repeated on a second day to assess reproducibility. Bronchodilation by formoterol was detectable in all functional indices (p

Background and objective: Exhaled nitric oxide (NO) is used as a surrogate marker to monitor eosinophilic airway inflammation, assist in diagnosis, and support treatment decisions for asthma patients. The aim of this study was to compare five NO analysers: Medisoft (M), Aerocrine Niox (N), Aerocrine Niox flex (NF), Aerocrino Niox mino (NM) and EcoMedics (E). Methods: In 85 subjects (25 asthma patients, 25 COPD patients, 35 healthy volunteers; median age 36.5 years, range 23–79, 47% female), three NO measurements per individual were performed, using each analyser according to the American Thoracic Society/European Respiratory Society guidelines. Subjects evaluated the devices on the basis of comfort and ease of performing the measurement. Results: Median NO concentrations were 24.8 parts per billion (ppb) (range 6.3–262.7) for M, 14.5 ppb (0.0–196.6) for N, 15.2 ppb (5.6–67.7) for NF, 16.3 ppb (5.0–208.3) for NM, and 13.1 ppb (4.0–103.0) for E. There was significant correlation among the absolute NO values measured with all the devices (0.743 for M vs NF

Omalizumab is a humanized monoclonal anti-immunoglobulin E (IgE) antibody indicated in Europe for the treatment of uncontrolled severe persistent allergic (IgE-mediated) asthma despite optimal therapy with inhaled corticosteroids and long-acting beta(2) agonists. Between 2005 and 2007 280 patients (58% female, mean age 44+/-16 yrs., 46% on oral corticosteroids, median serum IgE level 235IU/ml) who met the EU criteria for add-on therapy with anti-IgE were treated prospectively with omalizumab by 134 physicians as part of a post-marketing surveillance trial and were followed-up for 6 months. The median follow-up time was 195 days, the patients were treated with a median dose of 450mg omalizumab every 4 weeks. After 6 months there was a marked effect of omalizumab treatment on daily (-76%) and nocturnal symptoms (-84%), exacerbations (-82%), unscheduled health care contacts (-81%), hospitalizations (-78%) and quality of life (Mini-AQLQ: score increase from 2.9 to 4.5). Overall, efficacy of omalizumab was rated as excellent or good by the majority of physicians (82%) and patients (86%). In 19 patients (7%) omalizumab-related adverse events were recorded. This post-marketing surveillance trial confirms the marked and clinically relevant effect of omalizumab on asthma symptoms and level of asthma control in the majority of patients with severe persistent allergic (IgE-mediated) asthma in a real-life situation.

This study aimed to evaluate the effect of a LTB 4 receptor antagonist on inflammatory markers in induced sputum, in particular sputum neutrophilia, in ex-smokers with moderate stable chronic obstructive pulmonary disease (COPD). The trial followed a double-blind, randomized, cross-over design including two treatment periods (4 weeks) separated by a 4-week washout period. Sputum inductions and lung function measurements were carried out at the beginning of each period, and after 2 and 4 weeks. Twenty-four patients were included (18/6 m/f; mean (±S.D.) age 64±5 years; FEV 1 57±10% predicted); the per-protocol population comprised 17 patients. No significant differences occurred between LTB019 and placebo regarding the percentage of sputum neutrophils (treatment means, 68.0% vs. 69.3%), total cell count (in units of 10 6 /mL, log e of treatment means: 1.56 vs. 1.27), or the levels of MPO, IL-8, and TNF-α. There were also no differences in FEV 1 , FVC, or the use of rescue medication. We therefore conclude that a 4-week treatment with LTB019 had no effect on sputum neutrophil numbers and related cytokine levels in these patients, despite the plasma concentrations achieved being similar to those shown to prevent the ex vivo LTB 4 -induced upregulation of CD11b/18 on neutrophils. The present data suggest that LTB 4 antagonism by LTB019 is not a promising therapeutic approach for attenuating chronic airway neutrophilia, at least in patients with moderate COPD.

Background: Indacaterol is an inhaled, once-daily, ultra-long-acting beta(2)-agonist for the treatment of chronic obstructive pulmonary disease (COPD). We report on the effectiveness of indacaterol and other bronchodilators compared with placebo in patients across the Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2011 categories A to D.Methods: A post-hoc, subgroup pooled analysis of 6-month efficacy data from three randomized, placebo-controlled, parallel-group studies involving 3862 patients was performed across GOLD 2011 categories A to D, according to baseline forced expiratory volume in 1 s (FEV1) % predicted, modified Medical Research Council (mMRC) dyspnea scale, and exacerbation history in the 12 months prior to entry. Efficacy of once-daily indacaterol 150 and 300 mu g, open-label tiotropium 18 mu g, twice-daily salmeterol 50 mu g, and formoterol 12 mu g was compared with placebo. End points analysed were trough FEV1, transition dyspnea index (TDI), and St George's Respiratory Questionnaire (SGRQ) total score, all at Week 26, and mean rescue medication use over 26 weeks.Results: Indacaterol 150 and 300 mu g significantly improved FEV1, compared with placebo across all GOLD groups. Indacaterol 150 and 300 jig also significantly improved TDI, SGRQ total score, and mean rescue medication use compared with placebo across most GOLD subgroups.Conclusions: Treatment selection according to patient's symptoms as well as lung function is an important consideration in maintenance treatment of COPD. Indacaterol 150 and 300 mu g effectively improved lung function and symptoms in patients across all GOLD 2011 categories. (C) 2015 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

Background The most prevalent phenotype of asthma is characterized by eosinophil-dominated inflammation that is driven by a type 2 helper T cell (Th2). Therapeutic targeting of GATA3, an important transcription factor of the Th2 pathway, may be beneficial. We evaluated the safety and efficacy of SB010, a novel DNA enzyme (DNAzyme) that is able to cleave and inactivate GATA3 messenger RNA (mRNA). Methods We conducted a randomized, double-blind, placebo-controlled, multicenter clinical trial of SB010 involving patients who had allergic asthma with sputum eosinophilia and who also had biphasic early and late asthmatic responses after laboratory-based allergen provocation. A total of 40 patients could be evaluated; 21 were assigned to receive 10 mg of SB010, and 19 were assigned to receive placebo, with each study drug administered by means of inhalation once daily for 28 days. An allergen challenge was performed before and after the 28-day period. The primary end point was the late asthmatic response as quantified by the change in the area under the curve (AUC) for forced expiratory volume in 1 second (FEV1). Results After 28 days, SB010 attenuated the mean late asthmatic response by 34%, as compared with the baseline response, according to the AUC for FEV1, whereas placebo was associated with a 1% increase in the AUC for FEV1 (P=0.02). The early asthmatic response with SB010 was attenuated by 11% as measured by the AUC for FEV1, whereas the early response with placebo was increased by 10% (P=0.03). Inhibition of the late asthmatic response by SB010 was associated with attenuation of allergen-induced sputum eosinophilia and with lower levels of tryptase in sputum and lower plasma levels of interleukin-5. Allergen-induced levels of fractional exhaled nitric oxide and airway hyperresponsiveness to methacholine were not affected by either SB010 or placebo. Conclusions Treatment with SB010 significantly attenuated both late and early asthmatic responses after allergen provocation in patients with allergic asthma. Biomarker analysis showed an attenuation of Th2-regulated inflammatory responses. (Funded by Sterna Biologicals and the German Federal Ministry of Education and Research; ClinicalTrials.gov number, NCT01743768.)

Background: Asthma and chronic obstructive pulmonary disease (COPD) are highly prevalent chronic diseases characterized by airflow limitation. Both diseases have a distinct pathogenesis and require unique treatment approaches. Due to some common characteristic traits, asthma and COPD are often lumped together in clinical practice. We sought to develop a simple questionnaire for the distinction of asthma and COPD.Methods: Clinical discriminants of asthma and COPD were retrospectively identified by multiple logistic regression using files from 547 consecutive adult patients presenting to a pulmonary specialist practice with a diagnosis of asthma or COPD. With these features, we generated a simple quantitative questionnaire supporting a diagnosis of COPD with high scores and asthma with low scores (range 0–15 points). Questionnaire results were compared with physician's diagnosis based on GINA and GOLD guidelines including skin tests, spirometry and reversibility data.Results: 210 patients had COPD and 337 had asthma. Age of onset, smoking history, atopy status, and cough quality were significantly associated with a diagnosis of asthma or COPD. Questionnaire scores for COPD patients were higher than those for asthmatics (mean score 10.5±0.18 vs. 4±0.12, P

Measurement of exhaled nitric oxide (eNO) and analysis of induced sputum are both established noninvasive methods for studying airway inflammation in asthma. Both methods are often used sequentially within short time frames. The aim of the present study was to evaluate the influence of sputum induction on eNO in adults and to follow the kinetics of airway eNO production after induction in relation to forced expiratory volume in one second (FEV 1 ). eNO and FEV 1 were measured in 41 adult patients (aged 29 (range 23–50) yrs, 56% male) with asymptomatic atopy or mild asthma (mean FEV 1 97.2±3% predicted) prior to and immediately after sputum induction with hypertonic saline (4%). Sputum induction with isotonic saline was also performed in 13 subjects (control group). Repeatability of eNO decrease after sputum induction was also studied in 27 patients on separate occasions and kinetics of eNO production after sputum induction were followed over 24 h in another 10 patients. Sputum induction with hypertonic, but not isotonic, saline led to a marked decrease in eNO (log) immediately after the procedure (pre: 3.85±0.13 parts per billion (ppb); post: 3.24±0.14 ppb). This decrease was shown to be highly reproducible and not related to a fall in FEV 1 following sputum induction. While FEV 1 returned to baseline within 1 h, decreased eNO levels were observed over 4 h and returned to baseline after 24 h. Hypertonic saline sputum induction leads to a prolonged reduction in exhaled nitric oxide in adult atopics that is reproducible within subjects and not related to a reduction in airflow following sputum induction. This methodological interference should be taken into account when sputum induction and exhaled nitric oxide measurements are performed in the same subject.

BACKGROUND Seasonal allergic rhinitis (SAR) is a risk factor for asthma in affected individuals. Nasal allergic inflammation enhances bone-marrow eosinophil production, mainly via IL-5, and rhinitis patients have increased airway inflammation during the pollen season. OBJECTIVE To assess the impact of nasal allergy on sputum inflammatory markers. METHODS In an open-labelled, randomized, placebo-controlled cross-over study with 16 non-asthmatic SAR patients (median age 25 years, 56% males), the effect of a single nasal allergen challenge performed out of season on induced sputum inflammatory parameters was evaluated. SAR patients were identified by history, skin-prick test and specific IgE. All patients had normal lung function/bronchial hyper-responsiveness out of season and a negative asthma/wheezing history. Sputum cells and supernatant levels of ECP, sICAM, IL-5 and IL-10, and plasma levels of IL-5 and ECP, were measured before and 24 h after nasal allergen challenge. After a washout period of at least 4 weeks, the procedure was repeated with placebo challenge (diluent). RESULTS Nasal allergen challenge led to an increase in sputum ECP (pre = 60 +/- 12, post = 212 +/- 63 micro g/L, P = 0.02 vs. placebo), and sICAM (4.8 +/- 2.7 to 6.5 +/- 2.9 ng/mL, P = 0.02 vs. placebo), whereas IL-10 decreased after provocation (44 +/- 11 to 29 +/- 6 pg/mL, P = 0.06 vs. placebo). Sputum IL-5 was undetectable in all patients. The absolute number of blood and sputum eosinophils did not change significantly after allergen or placebo challenge (P > 0.07, both comparisons). Plasma levels of IL-5 increased after allergen challenge (8.7 +/- 2.9 to 14.5 +/- 3.9 pg/mL, P = 0.001), and the increase in plasma IL-5 was positively correlated with the rise in sputum ECP in a subgroup of 'responders' (n = 12, r = 0.71, P = 0.01). CONCLUSIONS A single nasal allergen challenge in SAR patients increased markers of allergic inflammation in the lower respiratory tract, possibly via pronounced activation of inflammatory cells through circulating immediate-type reaction cytokines like IL-5. These findings may provide additional explanatory data for the high susceptibility of SAR patients to incident asthma.

Study objectives: Neutrophilic inflammation is a major feature of COPD. Several factors in bronchial secretions have been identified as chemoattractants for neutrophils. The present study was designed to assess the contribution of interleukin (IL)-8 and leukotriene B 4 (LTB 4 ) to neutrophil chemotaxis evoked by sputum obtained from patients with established COPD. Design: Sputum supernatant of 20 patients with COPD was used as chemoattractant in a 96-well chemotaxis chamber, with subsequent quantification of migrated cells by a luminescence assay. The contribution of IL-8 and LTB 4 to chemotaxis was determined by addition of a neutralizing antibody and a selective receptor antagonist, respectively. Measurements and results: COPD sputum caused neutrophil chemotaxis in a concentration-dependent manner, with a maximum response evoked with a 10-fold dilution of the original sample. Pretreatment of sputum or neutrophils with either an anti–IL-8 antibody or the LTB 4 antagonist, SB 201146, led to a concentration-dependent inhibition of sputum-induced neutrophil chemotaxis, with a maximum suppression (mean ± SEM) of 29.2 ± 4.9% (p Conclusions: These data confirm the importance of IL-8 and LTB 4 as chemoattractants for neutrophils in bronchial secretions from patients with COPD, and suggest that specific inhibitors may have therapeutic potential in COPD.

Study objectives: Neutrophilic inflammation is a major feature of COPD. Induced sputum is increasingly used to monitor inflammatory airway diseases. Although short-term repeatability of selected sputum markers has been extensively studied in several populations, data on the long-term repeatability of induced sputum markers in stable COPD are scant. Design: Sputum supernatant of 12 patients with stable COPD was analyzed on three separate occasions with 4-weekly intervals. Sputum cells and inflammatory markers interleukin (IL)-8 and soluble intercellular adhesion molecule (sICAM)-1 were measured in supernatant using enzymelinked immunosorbent assay. Repeatability of sputum markers was expressed by intraclass correlation coefficients (Ri). Measurements and results: Sputum induction was safe in all patients. None of the sputum parameters analyzed changed significantly throughout the study. The repeatability for cell differential counts in stable COPD was as follows: total cells, Ri 0.07; neutrophils, Ri 0.66; macrophages, Ri 0.47; eosinophils, Ri 0.49; and lymphocytes, Ri 0.58. The repeatability of soluble markers was as follows: IL-8, Ri 0.50; and sICAM, Ri 0.58. Sputum neutrophils were negatively correlated with lung function on each separate occasion, whereas soluble markers were not correlated with sputum cells (p > 0.16, all correlations) or lung function (p > 0.24, all correlations). Conclusions: Clinically stable, moderate COPD is associated with equally stable sputum inflammatory markers. Repeatability of induced-sputum markers of neutrophilic inflammation in stable COPD is satisfactory, even over extended periods of time. These data support the usefulness of serial monitoring of induced-sputum inflammatory markers in COPD. (CHEST 2003; 123:778 –783)

Background: Neutrophilic inflammation is a major feature of chronic obstructive pulmonary disease (COPD), and several novel therapies aim at the suppression of neutrophils in COPD. Due to the abundance and redundancy of mediators involved in neutrophilic inflammation, there is an ongoing controversy about the feasibility of such anti-neutrophilic approaches. Systemic chemotherapy has broad side effects, including neutrophil toxicity. Objectives: In this observational study, we have measured cellular and neutrophil-related inflammatory markers in induced sputum of COPD patients with unresectable non-small cell lung cancer (NSCLC) undergoing platinum-based chemotherapy. Methods: 15 COPD/NSCLC patients were followed during their first course of chemotherapy with cisplatin (60 mg/m2 days 1 and 7) and etoposide (100 mg/m2 days 3, 4, and 5). Sputum induction was performed before, and 3 weeks after chemotherapy. Peripheral blood count, sputum total cells and differentials, and the concentrations of the inflammatory markers interleukin (IL)-8, and matrix metalloproteinase (MMP)-9 in sputum supernatant were analyzed. Results: Similar to COPD controls (n = 12), COPD/NSCLC patients had increased levels of absolute and relative sputum neutrophils, IL-8, and MMP-9 at baseline, when compared with healthy controls (n = 14, p < 0.001, all comparisons). After chemotherapy, there was a significant reduction in peripheral blood leukocytes (pre: 10,736 ± 550, post: 6,536 ± 1,064 cells/µl, p = 0.002) and log neutrophils (pre: 8.9 ± 0.09, post: 8.1 ± 0.2 cells/µl, p = 0.004), whereas log sputum neutrophils (pre: 0.3 ± 0.37, post: 0.18 ± 0.3 cells × 106/ml, p = 0.1) , IL-8 (pre 15.9 ± 3.8, post: 17.7 ± 3.6 ng/ml, p = 0.7), and log MMP-9 (pre: 5.3 ± 0.57, post: 5.6 ± 0.7 ng/ml, p = 0.33) remained unchanged. Conclusion: A single course of platinum-based chemotherapy markedly decreases peripheral blood neutrophils, but has no effect on inflammatory patterns of induced sputum in COPD patients with unresectable NSCLC.

Background: Oxidative stress has repeatedly been linked to the pathogenesis of pulmonary disorders like asthma and chronic obstructive pulmonary disease. Measuring glutathione (GSH) in induced sputum (IS) offers a noninvasive tool to study oxidative stress in airway diseases. Objectives: This study assessed the stability of GSH in sputum supernatant under varying conditions. Methods: GSH in IS of 14 (7 healthy, 4 chronic obstructive pulmonary disease, 3 allergic rhinitis) nonsmoking subjects was quantified spectrophotometrically. The stability of GSH in supernatant was analyzed over 24 h under different ambient conditions (room temperature and cooling at 4°C). Reproducibility of GSH measurements in immediately processed and frozen supernatant (+72 h) was expressed by intraclass correlation coefficient (Ri) and coefficient of repeatability (CR). Results: GSH recovery in supernatant decreased in a time- and temperature-dependent manner. Samples stored at 4°C and room temperature showed a rapid decline of stability after 2 h. Mean GSH concentrations in IS after freezing (–20°C) and thawing after 72 h were not significantly different from GSH values measured immediately after processing of the samples (immediate processing: 17.9 ± 13.9 µM; 72 h freezing: 16.4 ± 12.9 µM, p = 0.2). The reproducibility between immediately processed and frozen samples was excellent (Ri = 0.97; CR = 5.7 µM). Conclusions: Storage of sputum supernatant at room temperature or 4°C leads to a rapid decline of GSH recovery compared with baseline values. Immediate freezing of samples is a suitable and valid alternative to rapid processing and allows collection and shipment of samples for subsequent analysis.

Background: In patients with allergic rhinitis, bronchial hyperresponsiveness (BHR) and airway inflammation may increase during pollen exposure. BHR can be assessed by adenosine-5′-monophosphate (AMP) or methacholine challenge. It has been suggested that BHR to AMP is more closely related to airway inflammation than BHR to methacholine. Seasonal allergic rhinitis offers a dynamic model to study changes in BHR and airway inflammation during natural allergen exposure. Methods: We measured BHR [provocative concentration causing a 20% fall (PC20) in forced expiratory volume in 1 s (FEV1)] to AMP and methacholine, and induced sputum cells in 16 rhinitis patients before and during the 2001 grass pollen season. Results: There was a decrease in PC20 methacholine during pollen exposure (geometric mean PC20 from 3.22 to 1.73 mg/ml, p = 0.0023), whereas no reduction was observed for PC20 AMP (p = 0.11). There was no increase in sputum eosinophils [pre: 0.69% (95% confidence interval 0.22–2.07); during: 1.85 (0.55– 5.6), p = 0.31]. Although the correlation of log PC20 methacholine and log PC20 AMP at baseline was good (r = 0.76, p = 0.001), individual seasonal changes (doubling concentrations) in PC20 methacholine were not correlated with changes in PC20 AMP (ρ = 0.21, p = 0.44). There was no correlation between baseline log PC20 methacholine or seasonal changes in PC20 methacholine and sputum eosinophils (p > 0.12, all correlations). In contrast, there was a significant correlation between seasonal changes in PC20 AMP and changes in sputum eosinophils (ρ = –0.59, p = 0.025). Conclusions: These data show dissimilarity between seasonal changes in PC20 AMP and methacholine in patients with seasonal allergic rhinitis. Moreover, PC20 AMP seems to be more closely related to sputum eosinophils than PC20 methacholine. The clinical significance of this discrepancy is unclear.

Chronic transplant rejection is characterized by progressive narrowing of small airways caused by matrix remodeling and fibrosis. Matrix-metalloproteinases (MMPs) and their inhibitors, the tissue inhibitors of metalloproteinases (TIMPs), are involved in the turnover of extracellular matrix.To clarify the contribution of MMPs and TIMPs to airway inflammation in patients after lung transplantation (LTx), we used enzyme immunoassays to measure induced sputum concentrations of MMP-9, TIMP-1, and controlling cytokines tumor necrosis factor (TNF)-alpha and interleukin (IL)-10 of 30 LTx patients and 15 control subjects.Sputum concentrations of MMP-9, TIMP-1, the MMP-9:TIMP-1 ratio, and TNF-alpha were higher in LTx patients than in control subjects (p0.04, all comparisons). The MMP-9, MMP-9:TIMP-1, and TNF-alpha levels were also significantly higher in LTx patients with chronic rejection compared with those with stable organ function (p0.03, all comparisons), whereas IL-10 levels were higher in the latter group (p = 0.05). In all LTx patients, MMP-9 and the MMP-9:TIMP-1 ratio were negatively correlated with forced expiratory volume in 1 second values (rho = -0.47, p = 0.01, and rho = -0.53, p = 0.003, respectively). We found that MMP-9 positively correlated with sputum neutrophils and TNF-alpha whereas MMP-9 and TIMP-1 did not correlate with IL-10.These data underline the possible contribution of proteases such as MMP-9 to chronic transplant rejection, and suggest that an imbalance of MMP-9 and TIMP-1 may be involved in the pathogenesis of airway obstruction after LTx. We found that MMP-mediated inflammation seems to be controlled by TNF-alpha whereas IL-10 might elicit anti-inflammatory effects through different pathways.

BACKGROUND: When first approved in the European Union (EU), the omalizumab dosing table had upper bodyweight and IgE limits of 150 kg and 700 IU/mL, respectively. In this study, we assessed the safety, pharmacokinetics (PK) and pharmacodynamics (PD) of omalizumab in patients with IgE/bodyweight combinations above those in the original dosing table. METHODS: A multicentre, open-label, parallel-group study assessed the safety, PK and PD of omalizumab in 32 patients with mild-to-moderate allergic (IgE-mediated) asthma. Patients received two subcutaneous injections of omalizumab at one of three dosage levels (450, 525, or 600 mg), chosen according to baseline IgE (300-2000 IU/mL) and bodyweight (40-150 kg), with a 14-day interval between injections. RESULTS: Overall, 69 adverse events (AEs), none of them serious, were reported by 26 (81.3%) patients. Analysis of laboratory measurements, vital signs and ECG data revealed no adverse findings of clinical relevance. The PK profile was consistent with previous data for lower doses. Mean maximum decrease of free IgE from screening was >=99% for all three doses, and mean free IgE concentrations remained

The efficacy and safety of inhaled long-acting β(2)-adrenergic agonists in asthmatic patients with the B16-Arg/Arg genotype has been questioned, and the use of antimuscarinics has been proposed as an alternative in patients whose symptoms are not controlled by inhaled corticosteroids (ICSs).We compared the efficacy and safety of the long-acting anticholinergic tiotropium with salmeterol and placebo added to an ICS in B16-Arg/Arg patients with asthma that was not controlled by ICSs alone.In a double-blind, double-dummy, placebo-controlled trial, after a 4-week run-in period with 50 μg of twice-daily salmeterol administered through a metered-dose inhaler, 388 asthmatic patients were randomized 1:1:1 to 16 weeks of treatment with 5 μg of Respimat tiotropium administered daily in the evening, 50 μg of salmeterol administered twice daily through a metered-dose inhaler, or placebo. Patients aged 18 to 67 years demonstrated reversibility to bronchodilators, and their symptoms were uncontrolled by regular ICSs (400-1000 μg of budesonide/equivalent). ICS regimens were maintained throughout the trial. The mean weekly morning peak expiratory flow (PEF) before randomization was 358 ± 115.7 L/min (range, 80.3-733.0 L/min).Changes in weekly PEF from the last week of the run-in period to the last week of treatment (primary end point: change in PEF) were -3.9 ± 4.87 L/min (n = 128) for tiotropium and -3.2 ± 4.64 L/min (n = 134) for salmeterol, and these were superior to placebo (-24.6 ± 4.84 L/min, n = 125, P .05). Tiotropium was noninferior to salmeterol (estimated difference, -0.78 L/min [95% CI, -13.096 to 11.53]; P = .002; α = .025, 1-sided; noninferiority, 20 L/min). Tiotropium and salmeterol were numerically superior to placebo in some patient-reported secondary outcomes. Adverse events were comparable across treatments.Tiotropium was more effective than placebo and as effective as salmeterol in maintaining improved lung function in B16-Arg/Arg patients with moderate persistent asthma. Safety profiles were comparable.

Exhaled nitric oxide (NO) is used as a surrogate marker to monitor eosinophilic airway inflammation, assist in diagnosis, and support treatment decisions for asthma patients. The aim of this study was to compare five NO analysers: Medisoft (M), Aerocrine Niox (N), Aerocrine Niox flex (NF), Aerocrino Niox mino (NM) and EcoMedics (E).In 85 subjects (25 asthma patients, 25 COPD patients, 35 healthy volunteers; median age 36.5 years, range 23-79, 47% female), three NO measurements per individual were performed, using each analyser according to the American Thoracic Society/European Respiratory Society guidelines. Subjects evaluated the devices on the basis of comfort and ease of performing the measurement.Median NO concentrations were 24.8 parts per billion (ppb) (range 6.3-262.7) for M, 14.5 ppb (0.0-196.6) for N, 15.2 ppb (5.6-67.7) for NF, 16.3 ppb (5.0-208.3) for NM, and 13.1 ppb (4.0-103.0) for E. There was significant correlation among the absolute NO values measured with all the devices (0.743 for M vs NFr0.979 for N vs NF). Bland-Altman plots suggested an acceptable degree of agreement among the results obtained with the three Niox analysers. Measurements obtained with the Medisoft and Ecomedics analysers were not directly comparable with those obtained with the other devices. The greatest differences in absolute NO levels for individual patients were between measurements with the M and E analysers (8.3 ppb, range 27.4-159.7, P0.001). Acceptance of the measurements by patients was high, independent of the device used.Exhaled NO values obtained with different devices were not directly comparable and may differ to a clinically relevant extent, depending on which device is used.

Indacaterol is a novel, inhaled, once-daily, ultra-long-acting β(2)-agonist bronchodilator recently approved in Europe for the treatment of chronic obstructive pulmonary disease (COPD). The aim of the present study was to investigate the efficacy and safety of indacaterol compared with placebo and the twice-daily β(2)-agonist, salmeterol, as an active control. Patients with moderate-to-severe COPD were randomised to 6 months double-blind treatment with indacaterol (150 μg once daily), salmeterol (50 μg twice daily) or placebo. The primary efficacy end-point was trough (24 h post-dose) forced expiratory volume in 1 s (FEV(1)) after 12 weeks. 1,002 patients were randomised and 838 (84%) completed the study. Indacaterol increased trough FEV(1) at week 12 by 170 mL over placebo (p

This dose-ranging study assessed the bronchodilator efficacy and tolerability of indacaterol, a novel once-daily inhaled beta2-agonist, in subjects clinically diagnosed with COPD. Comparative data with tiotropium were collected. In the double-blind, core period of the study, 635 subjects with COPD (prebronchodilator FEV(1)40% of predicted and > or =1.0L; FEV1/FVC

Late allergic reactions (LAR) following allergen challenge occur in different compartments. We studied the kinetics of nasal and bronchial nitric oxide (NO) in mild asthmatics after allergen challenge. Twelve males with intermittent asthma (28 yr, FEV1 97% of predicted, PC20methacholine8 mg/ml) and known LAR after bronchial allergen challenge underwent nasal and bronchial allergen provocation using the same allergen separated by a washout of 3 weeks. Nasal and bronchial NO were measured before challenge, during early (EAR) and late phase reactions, and 24 h after allergen. The mean (sem) maximum fall of FEV1 at EAR was 31.9+/-3.2% (P=0.001), and 17.6+/-2.2% (P=0.004) during LAR. All patients developed nasal EAR (max. fall in nasal rhinomanometric flow 64.8+/-7.6% of baseline) after nasal challenge, and 10 patients demonstrated nasal LAR with a fall in nasal flow of 65.9+/-6.6% (both P=0.002, respectively). During EAR, there was stronger reduction of nasal (-19.2+/-6.2%,P=0.039) than bronchial NO (-6.9+/-5.2% of baseline, P=ns). In contrast, bronchial NO also tended to decrease during bronchial LAR (-8.8+/-6.8%,P=ns), while nasal NO slightly increased non-significantly (+17+/-10.8%, P=ns). After 24 h, bronchial NO was significantly elevated (+78.1+/-40.1%, P=0.039), whereas nasal NO was unchanged (+6.1+/-15.1%, P=ns). The intraindividual difference between bronchial and nasal changes of NO during LAR, but not EAR or after 24 h, was significant (lung vs. nose: -35.6+/-14.1% relative difference, P=0.039). Despite similar functional responses in nose and bronchi, nasal NO kinetics following allergen challenge differ from bronchial NO. The concise mechanisms accounting for this discrepancy warrant further investigations.

Glutathione (GSH), a major antioxidant, has repeatedly been linked to the pathogenesis of pulmonary disease. The measurement of GSH in induced sputum (IS) offers a noninvasive tool for the study and monitoring of oxidative stress in airway diseases. In this study we assessed the validity and reproducibility of GSH quantification in IS from healthy subjects and individuals with mild asthma. We spectrophotometrically quantified total GSH in the IS of 31 healthy nonsmoking volunteers and 12 individuals with mild asthma. IS was processed with varying concentrations of dithiothreitol (DTT) in an effort to evaluate the effect of DTT on GSH measurements. We performed spiking experiments with defined concentrations of GSH and quantified the percentage of recovery and also analyzed the effect of induction time on GSH levels through sequential sampling of sputum portions (15, 30, and 45 minutes' induction). Finally we tested the reproducibility of GSH measurements at 2 separate time points (0 and 72 hours) and expressed it as an intraclass correlation coefficient (R(i)) with a coefficient of reliability (CR). Processing with DTT increased GSH values in IS (P.05 for each DTT concentration0.001%). Recovery of GSH after spiking was complete, with a mean recovery of 102% +/- 4.8%. Increasing duration of induction led to an increase in sputum GSH (15 minutes, 10.2 +/- 2.3 micromol/L; 30 minutes, 18.4 +/- 3.5 micromol/L; 45 minutes, 26.1 +/- 4 micromol/L; P.05 for all comparisons). Reproducibility of sputum GSH both in healthy subjects and asthmatic individuals was good (R(i) =.78, P.001; and R(i) =.51, P =.003, respectively). With the use of standardized protocols for duration of induction and sample processing, sputum GSH measurement in healthy subjects and asthmatic individuals is valid and reproducible.

Idiopathic pulmonary fibrosis (IPF) is a disease of unknown etiology. Biopsy and bronchoalveolar lavage studies have shown, that accumulation of inflammatory cells, particularily neutrophils, in the alveolar space is a relevant feature of the pathogenesis of IPF. This paper adresses the issue of whether the safe and non-invasive method of sputum induction is a suitable tool to study respiratory tract inflammation in IPF.In a cross-sectional analysis, 15 IPF patients and 14 healthy, non-smoking subjects underwent sputum induction. Total sputum cell counts, differentials, and the amount of interleukin (IL)-8, granulocyte-macrophage-colony stimulating factor (GM-CSF), and soluble ICAM-1 (sICAM) in sputum supernatant were analyzed.IPF patients had increased sputum neutrophils (60 +/- 6 vs 22 +/- 3%, p = 0.0003), and supernatant concentrations of IL-8 (19 +/- 3 vs. 7 +/- 1 ng/ml, p = 0.0002), GM-CSF (205 +/- 43 vs. 122 +/- 36 pg/ml, p = 0.08) and sICAM (12 +/- 3 vs. 5 +/- 3 ng/ml, p = 0.01), when compared with healthy controls. Sputum IL-8 was correlated with sputum neutrophils (rho = 0.61, p = 0.0006) in all patients. The extent of sputum neutrophilia was also correlated with lung function impairment (vital capacity, % of predicted) in IPF patients (rho = -0.68, p = 0.007).These data confirm the established role of neutrophilic inflammation in the pathogenesis of IPF, and show the potential of induced sputum to directly study inflammatory processes and surrogate markers in interstitial lung diseases like IPF.

Neutrophilic inflammation is a major feature of COPD. Several factors in bronchial secretions have been identified as chemoattractants for neutrophils. The present study was designed to assess the contribution of interleukin (IL)-8 and leukotriene B(4) (LTB(4)) to neutrophil chemotaxis evoked by sputum obtained from patients with established COPD.Sputum supernatant of 20 patients with COPD was used as chemoattractant in a 96-well chemotaxis chamber, with subsequent quantification of migrated cells by a luminescence assay. The contribution of IL-8 and LTB(4) to chemotaxis was determined by addition of a neutralizing antibody and a selective receptor antagonist, respectively.COPD sputum caused neutrophil chemotaxis in a concentration-dependent manner, with a maximum response evoked with a 10-fold dilution of the original sample. Pretreatment of sputum or neutrophils with either an anti-IL-8 antibody or the LTB(4) antagonist, SB 201146, led to a concentration-dependent inhibition of sputum-induced neutrophil chemotaxis, with a maximum suppression (mean +/- SEM) of 29.2 +/- 4.9% (p0.001) from baseline by 100 ng/mL of anti-IL-8 antibody, and 45.6 +/- 7% (p0.02) by 10 micro mol/L of SB 201146. The combination of the anti-IL-8 antibody and SB 201146 inhibited neutrophil chemotaxis, but this was not significantly greater than the effect of SB 201146 or anti-IL-8 alone.These data confirm the importance of IL-8 and LTB(4) as chemoattractants for neutrophils in bronchial secretions from patients with COPD, and suggest that specific inhibitors may have therapeutic potential in COPD.