Soluble RAGE: Therapy and biomarker in unraveling the RAGE axis in chronic disease and aging

The multi-ligand Receptor for Advanced Glycation Endproducts (RAGE) is implicated in the pathogenesis and progression of chronic diseases such as diabetes and immune/inflammatory disorders. Recent studies are uncovering the precise mechanisms by which distinct RAGE ligands bind the extracellular (soluble) domain of the receptor at the V-, C1- and/or C2-immunoglobulin like domains. Experiments using soluble RAGE in animals as a ligand decoy have illustrated largely beneficial effects in reducing vascular and inflammatory stress and, thereby, preventing long-term tissue damage in models of diabetes and immune/inflammatory disorders. Measurement of soluble RAGE levels in the human, both “total” soluble RAGE and a splice variant-derived product known as endogenous secretory or esRAGE, holds promise for the identification of potential therapeutic targets and/or biomarkers of RAGE activity in disease. In this article, we review the evidence from the rodent to the human implicating RAGE in the diverse disease states in which its ligands accumulate.     

Small airways: an important but neglected target in the treatment of obstructive airway diseases

Changes in the structure and function of the small airways (<2mm diameter) are now recognized to play a major role in airflow limitation in both chronic obstructive pulmonary disease (COPD) and severe asthma. Increased thickness of the small airway wall causes lumenal narrowing, which can be further occluded by mucus and/or inflammatory cell exudate. This leads to increased peripheral resistance, air trapping and shortness of breath on exertion. Studies in animal models and in subjects with COPD have suggested that oxidant-driven transforming growth factor (TGF)-beta1 activation and subsequent increased airway wall collagen synthesis might be central to the changes in small airway structure. However, it remains difficult to measure small airway function in patients, and delivery of inhaled drugs to peripheral airways has not yet been optimised. The increased understanding of the processes underlying the development of small airways disease should facilitate pharmacological intervention targeted at this hitherto neglected compartment.     

The Role of Lymphocytes in the Pathogenesis of Asthma and COPD

Asthma and chronic obstructive pulmonary disease (COPD) are two different inflammatory disorders of the lungs which share a common functional abnormality, i.e. airflow limitation [1,2]. In asthma, airflow limitation is largely reversible, either spontaneously or with treatment, and does not progress in most cases [1]. On the other hand, airflow limitation in COPD is usually progressive and poorly reversible [2]. In asthma, the chronic inflammation causes an associated increase in airway responsiveness to a variety of stimuli, leading to recurrent episodes of wheezing, breathlessness, chest tightness and cough, particularly at night and in the early morning. Many cells are involved in the inflammatory response in asthma and, among these, CD4+ Type-2 lymphocytes, mast cells and eosinophils are thought to play a crucial role. In COPD, the poorly reversible airflow limitation is associated with an abnormal inflammatory response of the lungs to noxious particles or gases [2]. This chronic inflammation is characterized by an increased number of CD8+ Type-1 T-lymphocytes and macrophages in the lung tissue and neutrophils in the airway lumen. Lymphocytes, which are markedly different in the two inflammatory conditions, play a crucial role in the pathogenesis of asthma and COPD. In this review, we will discuss the current concepts on the recruitment, homing and activity of lymphocytes in these two respiratory diseases.     

Polymorphisms in TOLL-like receptor genes and their roles in allergic asthma and atopy

Allergic asthma is a chronic inflammatory disease of the lung airways cause by genetic and environmental factors. Two quantifiable phenotypes of this disease are airway hyperresponsiveness and atopy. TOLL-like receptors (TLRs) are a family of intracellular and cell surface receptors that can respond to pathogen associated molecular patterns involved in the pathogenesis of asthma. Macrophages, one of the main immune cells involved in asthma, express a variety of TLRs, including TLR 2, 4, 5, 6, 7, 8 and 9. This review focuses on polymorphisms found in TLR genes expressed in macrophages, and their role in asthma. Human studies have detected polymorphisms in TLR genes associated with asthma phenotypes, and studies using murine models have shown that some receptors and their agonistic or antagonistic ligands are capable of modulating the cytokine profile in asthmatics in a protective manner. Therefore, certain receptors and their ligands are being explored as potential immunotherapies for asthma. Recently, several patents have been filed protecting inventions for treating asthma through the use of TLRs and their ligands.     

An evaluation of roflumilast and PDE4 inhibitors with a focus on the treatment of asthma

Introduction: Asthma is a common chronic airway inflammatory disease characterized by diverse inflammatory events leading to airway hyperresponsiveness and reversible airflow obstruction. Corticosteroids have been the mainstay for asthma treatment due to their broad anti-inflammatory actions; however, other medications such as phosphodiesterase 4 inhibitors also demonstrate anti-inflammatory activity in the airways.

Areas covered: This review describes tissue expression of phosphodiesterase 4 in the airways, the different phosphodiesterase 4 isoenzymes identified, and the anti-inflammatory activities of phosphodiesterase 4 inhibition in asthma and related findings in chronic obstructive pulmonary disease (COPD). The authors further review clinical trials demonstrating that drugs such as roflumilast have an excellent safety profile and efficacy in patients with asthma and COPD.

Expert opinion: Phosphodiesterase 4 inhibitors suppress the activity of immune cells, an effect similar to corticosteroids although by acting through different anti-inflammatory pathways and uniquely blocking neutrophilic inflammation. Roflumilast and other phosphodiesterase 4 inhibitors have been shown to provide additive protection in asthma when added to corticosteroid and anti-leukotriene treatment. Developmental drugs with dual phosphodiesterase 3 and 4 inhibition are thought to be able to provide bronchodilation and anti-inflammatory activities and will consequently be pushed forward in their clinical development for the treatment of asthma and COPD.     

The treatment targets of asthma: from laboratory to clinic

Asthma is a chronic disease characterised by airways hyperresponsiveness, airways inflammation, airways remodelling and reversible airways obstruction. Airway structural cells, recruited inflammatory cells and many mediators such as cytokines, chemokines and adhesion molecules are involved in the pathogenesis of asthma. Although asthma is treatable in most, but not all patients by currently available drugs, no treatment is preventive or curative and the disease has reached epidemic proportions worldwide and its incidence is continuing to increase. Many thousands have chronic, severe asthma and suffer daily symptoms making it imperative that we continue to improve our understanding of the mechanisms of asthma particularly related to airway inflammation and remodelling, the hallmarks of asthma, and to identify new therapeutic targets. In this review we will discuss current drugs and potential targets in the treatment of asthma.     

Club Cell Protein 16 (CC16) Augmentation: A Potential Disease-modifying Approach for Chronic Obstructive Pulmonary Disease (COPD)

Introduction: Club cell protein 16 (CC16) is the most abundant protein in bronchoalveolar lavage fluid. CC16 has anti-inflammatory properties in smoke-exposed lungs, and chronic obstructive pulmonary disease (COPD) is associated with CC16 deficiency. Herein, we explored whether CC16 is a therapeutic target for COPD.

Areas Covered: We reviewed the literature on the factors that regulate airway CC16 expression, its biologic functions and its protective activities in smoke-exposed lungs using PUBMED searches. We generated hypotheses on the mechanisms by which CC16 limits COPD development, and discuss its potential as a new therapeutic approach for COPD.

Expert Opinion: CC16 plasma and lung levels are reduced in smokers without airflow obstruction and COPD patients. In COPD patients, airway CC16 expression is inversely correlated with severity of airflow obstruction. CC16 deficiency increases smoke-induced lung pathologies in mice by its effects on epithelial cells, leukocytes, and fibroblasts. Experimental augmentation of CC16 levels using recombinant CC16 in cell culture systems, plasmid and adenoviral-mediated over-expression of CC16 in epithelial cells or smoke-exposed murine airways reduces inflammation and cellular injury. Additional studies are necessary to assess the efficacy of therapies aimed at restoring airway CC16 levels as a new disease-modifying therapy for COPD patients.     

Emerging trends in the therapy of COPD: bronchodilators as mono- and combination therapies

Chronic obstructive pulmonary disease (COPD) is a chronic inflammatory disease that is characterized by progressive airway obstruction that, unlike asthma, is relatively insensitive to bronchodilators and to the classic anti-inflammatory therapy, corticosteroids. In this review we consider the potential of bronchodilator drugs and corticosteroid drugs that are in clinical development for COPD and discuss how the best treatments might be achieved with combinations of drugs that are either already launched or close to launch.     

Vitamin D modulates airway smooth muscle function in COPD

COPD is a disease manifested as persistent airflow obstruction with an enhanced inflammatory response in the airways and lungs to noxious particles and gases which evokes symptoms of dyspnea on exertion, cough and mucus production. Airway smooth muscle plays a central role in the COPD diathesis and is implicated in many aspects of COPD pathogenesis. Vitamin D deficiency has been associated with COPD severity and studies suggest a role for Vitamin D as a treatment for COPD. In this review, we describe the effects of 1,25-dihydroxyvitamin D on airway smooth muscle function, including agonist-induced shortening, secretion of inflammatory mediators, and myocyte hypertrophy and hyperplasia.     

Asthma severity: histopathologic correlations

Asthma is a disorder characterized by inflammation of the airways which leads to variable airflow obstruction and symptoms of wheezing, chest tightness, cough, and dyspnea. Decisions concerning the type and intensity of therapy for asthma are generally based on the severity of the disease in a given individual. Guidelines for asthma management classify disease severity on the basis of symptom frequency and intensity as well as the degree of physiological impairment. Because treatment decisions are currently not based on markers of airway inflammation, it is important to know how well the underlying inflammatory pathology correlates with clinical and physiological variables and whether airway inflammation, if undertreated, leads to longer term adverse outcomes such as chronic persistent airway obstruction. Studies of asthma pathology reveal an inflammatory response characterized by infiltration of the airways with eosinophils, mast cells and lymphocytes; disruption of the epithelium; thickening of the reticular basement membrane; and increases in smooth muscle mass. These findings are qualitatively found in mild as well as severe asthmatics, and attempts to draw quantitative correlations between severity and intensity of inflammation have yielded discordant results. Although antiinflammatory therapy with corticosteroids decreases the intensity of the inflammation in association with improved clinical variables, the association is circumstantial and it is unclear which marker of inflammation correlates best with the severity of acute episodes or the severity of the disease in patients who are stable. Problems in relating the underlying pathology to disease severity are largely due to inadequate tissue sampling as bronchoscopically obtained specimens do not permit an evaluation of the outer airway wall or small airways and their surrounding parenchyma.     

Adenosine signalling in airways

Current research endeavours indicate that adenosine elicits strong inflammatory responses in the lung and might be involved in the pathogenic mechanisms of chronic inflammatory disorders of the airways such as asthma and chronic obstructive pulmonary disease (COPD). The contribution of adenosine-associated effector mechanisms to the initiation, persistence and progression of the inflammatory response is highly heterogeneous and is dictated by the expression pattern of four different adenosine receptors. Selective activation or blockade of these sites can therefore be exploited in an attempt to generate novel therapies for asthma and COPD. In addition, an important development is the use of adenosine (or AMP) as a diagnostic test for discriminating asthma from COPD, and as an accurate biomarker to monitor corticosteroid requirements in asthma. It is likely that therapies interfering with adenosine signalling in the airways will offer a considerable advance in the management of asthma and COPD.     

Role of beta2 agonists in respiratory medicine with particular attention to novel patents and effects on endocrine system and immune response

Beta adrenergic receptors are very important in respiratory medicine. Traditionally, the stimulation of beta adrenergic receptors by beta2-agonists is commonly used for giving bronchodilation in chronic airflow obstruction However; the wide distribution of these receptors in cells and tissues other than airway smooth muscle suggests that beta agonists should offer other beneficial effects in respiratory disease. Recent studies have shown the importance of these receptors in the modulation of endocrine and immune system that affect respiratory function and may decrease therapy effectiveness in asthma and chronic obstructive pulmonary disease. New patented compound and uses have provided new insights in future therapeutics of respiratory diseases in which genetic, endocrine and immune response should be considered.     

HMGB1, TLR and RAGE: a functional tripod that leads to diabetic inflammation

Introduction: Despite advances in treatment of diabetes mellitus, its prevalence continues to rise globally. Medications available are unable to control the vascular complications. Proposals for new therapeutic targets must take into account the hyperglycemia-induced signaling pathways that give rise to the inflammatory profile of the disease.

Areas covered: How high-mobility-group box-1 (HMGB1) protein, acting as an activator of Toll-like receptors (TLR) and receptors for advanced glycation end products (RAGE), creates a functional tripod that contributes to increased production of pro-inflammatory mediators, and sustains the chronic inflammatory state associated with diabetes. The interaction of TLR2 and TRL4 with host-derived ligands, which links diabetic complications with the innate immune response, and the activation of RAGE, which induces a cascade of metabolic responses, leading to the production and secretion of pro-inflammatory cytokines.

Expert opinion: Considering the involvement of the innate immune system, in association with the role of HMGB1 as an activator of TLR and RAGE, diabetes should be considered and treated as a metabolic and immunological disease, triggered by hyperglycemia. HMGB1 plays a central role in mediating injury and inflammation, and interactions involving HMGB1–TLR–RAGE constitute a tripod that trigger NF-κB activation. Blockade or downregulation of HMGB1, and/or control of the inflammatory tripod, represent a promising therapeutic approach for the treatment of diabetes.     

Mediators of chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is a major and increasing global health problem that is now a leading cause of death. COPD is associated with a chronic inflammatory response, predominantly in small airways and lung parenchyma, which is characterized by increased numbers of macrophages, neutrophils, and T lymphocytes. The inflammatory mediators involved in COPD have not been clearly defined, in contrast to asthma, but it is now apparent that many lipid mediators, inflammatory peptides, reactive oxygen and nitrogen species, chemokines, cytokines, and growth factors are involved in orchestrating the complex inflammatory process that results in small airway fibrosis and alveolar destruction. Many proteases are also involved in the inflammatory process and are responsible for the destruction of elastin fibers in the lung parenchyma, which is the hallmark of emphysema. The identification of inflammatory mediators and understanding their interactions is important for the development of anti-inflammatory treatments for this important disease.     

Agents against cytokine synthesis or receptors

Various cytokines play a critical role in pathophysiology of chronic inflammatory lung diseases including asthma and chronic obstructive pulmonary disease (COPD). The increasing evidence of the involvement of these cytokines in the development of airway inflammation raises the possibility that these cytokines may become the novel promising therapeutic targets. Studies concerning the inhibition of interleukin (IL)-4 have been discontinued despite promising early results in asthma. Although blocking antibody against IL-5 markedly reduces the infiltration of eosinophils in peripheral blood and airway, it does not seem to be effective in symptomatic asthma, while blocking IL-13 might be more effective. On the contrary, anti-inflammatory cytokines themselves such as IL-10, IL-12, IL-18, IL-23 and interferon-gamma may have a therapeutic potential. Inhibition of TNF-alpha may also be useful in severe asthma or COPD. Many chemokines are also involved in the inflammatory response of asthma and COPD through the recruitment of inflammatory cells. Several small molecule inhibitors of chemokine receptors are now in development for the treatment of asthma and COPD. Antibodies that block IL-8 reduce neutrophilic inflammation. Chemokine CC3 receptor antagonists, which block eosinophil chemotaxis, are now in clinical development for asthma therapy. As many cytokines are involved in the pathophysiology of inflammatory lung diseases, inhibitory agents of the synthesis of multiple cytokines may be more useful tools. Several such agents are now in clinical development.     

Airway nitrergic pathways: is there therapeutic potential in asthma and COPD?

Airway diseases such as asthma and chronic obstructive pulmonary disease (COPD) are characterised by airway hyperresponsiveness, epithelial damage, oxidative stress and airway inflammation. Inflammatory cells, including macrophages, neutrophils, eosinophils and lymphocytes, are crucial in the pathogenesis of asthma and COPD. The prevalence of asthma and COPD is increasing, especially in Western countries. Symptomatic treatment is based on reduction of airway obstruction by inhalation of beta(2)-receptor agonists and attenuation of the underlying inflammatory reactions by inhalation of corticosteroids. Because these agents only suppress symptoms, there is a need for medicines that remove the cause of these airway diseases.     

Tachykinin receptor antagonists: potential in airways diseases.

Several lines of evidence indicate a role for the tachykinin peptides in airways diseases. For instance, elevated levels of tachykinins have been recovered from the airways of patients with asthma and chronic obstructive pulmonary disease (COPD), and airway inflammation leads to an upregulation of the tachykinin NK1 and NK2 receptors. Recent advances in tachykinin receptor pharmacology have allowed a more detailed analysis of this system and preclinical animal studies have indicated a role for the NK1 and NK2 receptors in bronchoconstriction, airway hyperresponsiveness and airway inflammation caused by allergic and nonallergic stimuli. In the past three years, work has entered the clinic and selective or dual-selective NK1/NK2 receptor antagonists appear to have the potential to affect the different aspects of asthma and COPD.     

Biology of the interleukin-9 pathway and its therapeutic potential for the treatment of asthma

Asthma is a complex disease characterized by variable airflow limitation, hyperresponsiveness, and airways inflammation. Despite valuable therapeutic advances to control asthma symptoms in the last decade, a quantifiable proportion of patients with moderate to severe asthma continue to experience inadequate disease control, highlighting an important unmet need. In animal models of asthma, interleukin (IL)-9 regulates the development of airway inflammation, mucus production, airway hyperresponsiveness, and airway fibrosis largely by increasing mast cell numbers and activity in the airways. Mast cells are involved in the pathogenesis of eosinophilic and noneosinophilic asthma. Thus, targeting the IL-9 pathway may provide a new therapeutic modality for asthma. The purpose of this review is to summarize the IL-9-mast cell axis in the pathogenesis of asthma and discuss clinical studies with a humanized anti-IL-9 monoclonal antibody, MEDI-528, in subjects with asthma.     

Emerging oligonucleotide therapies for asthma and chronic obstructive pulmonary disease

Chronic respiratory diseases such as asthma and chronic obstructive pulmonary disease (COPD) are disorders of the airways largely related to the presence of persistent inflammation. The approval of inhaled corticosteroids in the early 1970s pioneered a new age of therapy in treating chronic inflammatory airway diseases. This was the first time that an anti-inflammatory product was available to reduce the characteristic lung inflammation in airways and the associated obstruction, inflammation and hyper-responsiveness. Fast forward 40 years: corticosteroids are still an important therapeutic intervention; however, they exhibit limited use in moderate to severe asthma and COPD. Oligonucleotide therapies are an emerging class which include the antisense, the RNAi (siRNA and miRNA), the immunomodulatory, the aptamer and the decoy approaches. As these approaches are rather recent in the respiratory field, most are still early in development. Nevertheless, with limitations of current small molecule therapies and the hurdles faced with biologics, the use of oligonucleotides is relevant and the door is open to the development of this category of therapeutics. This review focuses on the major classes of oligonucleotides that are currently in late stage preclinical or clinical development for the treatment of asthma and COPD, and discusses the implications for their use as therapies for respiratory diseases.     

Chemokines and their receptors as potential targets for the treatment of asthma

Asthma is a chronic and sometimes fatal disease, which affects people of all ages throughout the world. Important hallmarks of asthma are airway inflammation and remodelling, with associated bronchial hyperresponsiveness and variable airflow obstruction. These features are orchestrated by cells of both the innate (eosinophils, neutrophils and mast cells) and the adaptive (T(H)2 T cells) immune system, in concert with structural airway cells. Chemokines are important for the recruitment of both immune and structural cells to the lung, and also for their microlocalisation within the lung tissue. Specific blockade of the responses elicited by chemokines and chemokine receptors responsible for the pathological migration of airway cells could therefore be of great therapeutic interest for the treatment of asthma.