Combining inhaled glucocorticoids and long acting beta(2)-adrenoceptor agonists in asthma and COPD

Inhaled long-acting beta(2)-adrenoceptor agonists and glucocorticoids form the mainstay of maintenance treatment of asthma and chronic obstructive pulmonary disease (COPD), usually given as a combination inhaler. Most patients will have good asthma control if they comply with this therapy, although it is generally less effective in COPD. The traditional dogma has been that these agents act on distinct components of disease pathophysiology with beta(2) agonists acting on the bronchospastic component and glucocorticoids acting on the inflammatory component. Considerable evidence has emerged recently, however, to suggest that these two classes of agents interact at a molecular level. Understanding the mechanisms of these interactions may enable the development of new therapies for asthma and COPD.     

Inhaled beta 2-adrenoceptor agonists in asthma: help or hindrance?

Conventional low doses of inhaled beta 2-adrenoceptor agonists produce effective bronchodilation without systemic effects. Higher doses of inhaled beta 2-adrenoceptor agonists may produce substantial improvements in bronchodilator response, which may be helpful to patients with more severe airway obstruction. At higher than recommended doses, in asthmatic patients, fenoterol appears to cause greater dose-related systemic beta 2-responses compared with salbutamol or terbutaline, although there is no evidence to suggest that fenoterol is any less beta 2-selective in vivo. Furthermore, tolerance develops to systemic but not to bronchodilator effects during chronic treatment with inhaled beta 2-adrenoceptor agonists. The link between asthma mortality and systemic adverse effects of inhaled beta 2-adrenoceptor agonists at present remains unproven. A critical reappraisal of the regular use of inhaled beta 2-adrenoceptor agonists including long-acting drugs is now indicated in the light of their possible adverse effects on disease control. Patients requiring regular use of inhaled beta 2-adrenoceptor agonists should be given additional anti-inflammatory therapy with inhaled corticosteroids.     

A Holy Grail of asthma management: toward understanding how long-acting beta(2)-adrenoceptor agonists enhance the clinical efficacy of inhaled corticosteroids

There is unequivocal evidence that the combination of an inhaled corticosteroid (ICS) -- i.e. glucocorticoid -- and an inhaled long-acting beta(2)-adrenoceptor agonist (LABA) is superior to each component administered as a monotherapy alone in the clinical management of asthma. Moreover, Calverley and colleagues (Lancet 2003, 361: 449-456; N Engl J Med 2007, 356: 775-789) reporting for the 'TRial of Inhaled STeroids ANd long-acting beta(2)-agonists (TRISTAN)' and 'TOwards a Revolution in COPD Health (TORCH)' international study groups also demonstrated the superior efficacy of LABA/ICS combination therapies over ICS alone in the clinical management of chronic obstructive pulmonary disease. This finding has been independently confirmed indicating that the therapeutic benefit of LABA/ICS combination therapies is not restricted to asthma and may be extended to other chronic inflammatory diseases of the airways. Despite the unquestionable benefit of LABA/ICS combination therapies, there is a vast gap in our understanding of how these two drugs given together deliver superior clinical efficacy. In this article, we review the history of LABA/ICS combination therapies and critically evaluate how these two classes of drugs might interact at the biochemical level to suppress pro-inflammatory responses. Understanding the molecular basis of this fundamental clinical observation is a Holy Grail of current respiratory diseases research as it could permit the rational exploitation of this effect with the development of new 'optimized' LABA/ICS combination therapies.     

Questions about inhaled beta 2-adrenoceptor agonists in asthma.

The safety of the most widely prescribed antiasthma drugs, beta 2-adrenoceptor agonists, has recently been questioned. Issues such as their suitability for long-term and regular prophylactic use are addressed in this Comment article by Peter Barnes and Fan Chung, who examine the possibility that the beta 2-agonists themselves contribute to worsening symptoms in asthma patients, thus setting up a vicious circle with greater use of the drugs. They conclude that it would be prudent to restrict the use of beta 2-agonists in asthma to on-demand immediate symptom control.     

Long-acting beta 2-adrenoceptor agonists and exercise-induced asthma: lessons to guide us in the future

The safety and efficacy of long-acting beta(2)-adrenoceptor agonists (LABAs) taken intermittently for the prevention of exercise-induced asthma (EIA) in children is well established. However, the safety and efficacy of LABAs taken twice daily, either alone or in combination with inhaled corticosteroids, for the prevention of EIA is not as clear because of issues of tolerance (defined as being less responsive to the influence of LABAs). There have been many observations on short-acting beta(2)-adrenoceptor agonists (SABAs) and EIA that should have alerted us to the potential for tolerance and desensitization to occur with LABAs. For example, we expected that the use of LABAs for EIA would overcome the problem of the short duration of protection of SABAs, and to some extent they have. The protective period of a LABA is two to three times longer in duration than that of a SABA. However, when a LABA is taken daily it is apparent that the duration of its protective effect is reduced and there is a risk of EIA occurring well within the 12-hour administration schedules. Furthermore, daily use of LABAs attenuates the bronchodilator effect of SABAs, an effect that is greater the more severe the bronchoconstriction. This 'tolerance' increases both the time and the amount of therapy that is needed to recover from bronchoconstriction, and thus, could potentially impact on the success of rescue therapy should severe EIA occur. The daily use of LABAs also increases the sensitivity of the bronchial smooth muscle to contractile agents. This increase in sensitivity is almost equivalent to the extent to which inhaled corticosteroids reduce sensitivity to the same contractile agents. The increased sensitivity to contractile agents may occur either by a reduction in the inhibitory effect of beta(2)-adrenoceptor agonists on release of mediators from mast cells or by a direct effect on the bronchial smooth muscle. These unwanted effects of LABAs are not necessarily reduced by concomitant treatment with inhaled corticosteroids. As the number of children being treated with LABAs increases, it is predicted that problems with breakthrough EIA will also increase. We need to know the percentage of children taking a LABA daily who are requiring either extra doses of a beta(2)-adrenoceptor agonist to prevent (or reverse) EIA or other provocative stimuli. If this percentage is significant then we may need to reconsider the position of LABAs in the treatment of children with asthma who regularly perform strenuous physical activity.     

Bronchodilator activity of a new inhaled beta 2-adrenoceptor agonist, tulobuterol and its protective effect in exercise-induced asthma.

In fifteen patients with asthma tulobuterol, a new beta 2-adrenoceptor agonist, given by inhalation in 100 micrograms increments up to a cumulative dose of 600 micrograms produced dose related increases in both the FEV1 and FVC. The bronchodilation was observed within 5 min of the first dose. In a further nine patients tulobuterol 200 micrograms and 400 micrograms aerosol inhibited exercise-induced asthma following 6-8 min treadmill exercise and the effect was comparable to 200 micrograms salbutamol aerosol. Minor muscle tremors were observed in two patients with 400 micrograms of tulobuterol but no significant changes in pulse rate or blood pressure were noted.     

Identification and functional characterization of alpha(2)-adrenoceptor polymorphisms.

For each alpha(2)-adrenoceptor subtype (alpha(2A), alpha(2B) and alpha(2C)), sequence variations within the coding region of each gene have been identified in humans. These result in substitutions or deletions of amino acids in the third intracellular loops of each receptor. This article summarizes the genetics and molecular biology of alpha(2)-adrenoceptor polymorphisms, including the consequences of each polymorphism on receptor signaling, as determined in transfected cells. These effects include alterations in G-protein coupling, desensitization and G-protein receptor kinase-mediated phosphorylation. Studies so far provide the mechanistic basis for future studies to investigate genetic risk factors and pharmacogenetics in pathophysiological conditions linked to alpha(2)-adrenoceptor function.     

beta(2) and beta(3)-adrenoceptor inhibition of alpha(1)-adrenoceptor-stimulated Ca(2+) elevation in human cultured prostatic stromal cells

Prostatic beta-adrenoceptors inhibit alpha(1)-adrenoceptor-stimulated contractility. This study examines the effects of beta-adrenoceptor stimulation upon phenylephrine-induced elevations of intracellular Ca(2+)([Ca(2+)](i)) in human cultured prostatic stromal cells, and contractility of human prostatic tissue. Human cultured prostatic stromal cells were used for [(3)H]-cAMP accumulation studies or were loaded with 5-oxazolecarboxylic acid, 2-(6-(bis(2-((acetyloxy)methoxy)-2-oxoethyl)amino)-5-(2-(2-(bis(2-((acetyloxy)methoxy)-2-oxoethyl)amino)-5-methylphenoxy)ethoxy)-2-benzofuranyl)-, (acetyloxy)methyl ester (FURA-2AM, 10 microM) for Ca(2+) imaging studies. The beta-adrenoceptor agonist isoprenaline increased the accumulation of [(3)H]-cAMP (pEC(50)+/-S.E.M. 6.58+/-0.11) in human cultured prostatic stromal cells, an effect antagonized by the beta(2)-adrenoceptor antagonist (+/-)-1-[2,3-(dihydro-7-methyl-1H-inden-4-yl)oxy]-3-[(1-methylethyl)amino]-2-butanol (ICI 118,551), but not by the beta(1)-adrenoceptor antagonist, atenolol. Isoprenaline (3 microM), the adenylyl cyclase activator, forskolin (20 microM) and the phosphodiesterase-4 inhibitor, rolipram (10 microM) inhibited the elevation of [Ca(2+)](i) elicited by phenylephrine (20 microM). The effect of isoprenaline could be blocked by ICI 118,551 (100 nM), the adenylyl cyclase inhibitor cis-N-(2-phenylcyclopentyl)-azacyclotridec-1-en-2-amine (MDL 12,330A, 20 microM) and the K(Ca) channel blocker, iberiotoxin (100 nM), but not by atenolol (1 microM) or the K(ATP) channel blocker, glibenclamide (3 microM). Agonists selective for beta(1)-(xamoterol and prenalterol), beta(2)-(procaterol and salbutamol) and beta(3)-((+/-)-(R(*), R(*))-[4-[2-[[2-(3-chlorophenyl)-2-hydroxyethyl]amino]propyl]phenoxy]acetic acid, BRL37344) adrenoceptors inhibited the elevation of [Ca(2+)](i) elicited by phenylephrine (20 microM) with a rank order of BRL37344> or =xamoterol> or =isoprenaline>procaterol> or =prenalterol>salbutamol. The xamoterol effect was reversed by ICI 118,551 (100 nM), but not by 1-(2-ethylphenoxy)-3-[[(1S)-1,2,3,4-tetrahydro-1-naphthalenyl]amino]-(2S)-2-propanol (SR59230A, 100 nM) or atenolol (1 microM). The BRL37344 effect was reversed by SR59230A (100 nM), but not by atenolol (1 microM) or ICI 118,551 (100 nM). Both xamoterol and BRL37344 inhibited phenylephrine-induced tissue contractility. This study shows that both xamoterol and BRL37344 are effective inhibitors of phenylephrine-induced effects in human cultured prostatic stromal cells and in prostatic tissue.     

Acute hypotensive effect of combined beta1-adrenoceptor blockade and beta2-adrenoceptor stimulation in spontaneously hypertensive rats (SHR).

The effect on heart rate (HR) and blood pressure (BP) of metoprolol, propranolol and terbutaline, applied alone or in combinations was studied in spontaneously hypertensive rats. Terbutaline had little effect on BP and HR. Propranolol combined with terbutaline had no effect while metoprolol combined with terbutaline decreased BP by 48 mm Hg without affecting HR. Thus the beta2-mediated increase in peripheral vascular resistance after terbutaline was revealed by a drop in BP after beta1-blockade by metoprolol, but not when both beta1-and beta2-receptors were blocked by propranolol.     

The effect of Gi-protein inactivation on basal, and beta(1)- and beta(2)AR-stimulated contraction of myocytes from transgenic mice overexpressing the beta(2)-adrenoceptor

The atria and ventricles of transgenic mice (TGbeta(2)) with cardiac overexpression of the human beta(2)-adrenoceptor (beta(2)AR) were initially reported to show maximum contractility in the absence of beta-AR stimulation. However, we have previously observed a different phenotype in these mice, with myocytes showing normal contractility but reduced betaAR responses. We have investigated the roles of cyclic AMP and Gi in basal and betaAR function in these myocytes. ICI 118,551 at inverse agonist concentrations decreased contraction by 32%. However, the cyclic AMP antagonist Rp-cAMPS had no effect on contraction in TGbeta(2) myocytes, indicating that there was no tonic influence of raised cyclic AMP. These findings cannot be explained by the proposed model for inverse agonism, where the activated receptor (R*) raises cyclic AMP levels and so increases contraction in the absence of agonist. After pertussis toxin (PTX) pretreatment to produce inactivation of Gi, the basal contraction in 1 mM Ca(2+) was increased in TGbeta(2) mice (7.82+/-0.47%, n=23) compared to LM mice (3.60+/-0.59%, n=11) (P<0.001). The contraction amplitude of myocytes to the maximal concentration of isoprenaline was also increased significantly by PTX in TGbeta(2) mice (9.40+/-1.22%, n=8) and was no longer reduced compared to LM mice (8.93+/-1.50%, n=11). Both beta(1)- and beta(2)AR subtypes were affected both by the original desensitization and by the resensitization with PTX. PTX treatment has therefore restored the original phenotype, with high basal contractility and little further effect of isoprenaline. We suggest that both beta-AR desensitization and lack of increased basal contraction in ventricular myocytes from our colony of TGbeta(2) mice were due to increased activity of PTX-sensitive G-proteins.     

Agonist-specific activation of the beta2-adrenoceptor/Gs-protein and beta2-adrenoceptor/Gi-protein pathway in adult rat ventricular cardiomyocytes

In rat ventricular cardiomyocytes beta2-adrenoceptors (AR) couple to Gs- and Gi-protein, and evidence has accumulated that beta2-AR agonists can differentially activate either Gs- or Gs- and Gi-protein. In this study, in isolated adult rat ventricular cardiomyocytes, we assessed the effects of pertussis toxin (PTX) on beta2-AR agonist (terbutaline (TER), salbutamol (SAL) and fenoterol (FEN)) evoked inhibition of phenylephrine (PE)-induced increase in the rate of protein synthesis (assessed as [3H]phenylalanine incorporation) to find out which beta2-AR agonist activates selectively Gs- or Gs- and Gi-protein. PE (1 microM) increased the rate of protein synthesis from 100% to 130+/-2% (n = 34). FEN, TER and SAL (1 nM-10 microM) inhibited PE-induced increase in the rate of protein synthesis concentration-dependently. FEN inhibited PE effects almost completely (from 132+/-3 to 101+/-1%), whereas TER and SAL caused only partial inhibition (from 131+/-2 to 114+/-2 and 129+/-1 to 111+/-2%, respectively). Pretreatment of cardiomyocytes with PTX (250 ng ml(-1) for 16 h at 37 degrees C) did not affect FEN effects, but converted TER- and SAL-evoked partial inhibition into complete inhibition.Inhibitory effects of the three beta2-AR agonists were markedly attenuated by beta1-AR selective antagonist CGP 20712A (CGP) (300 nM); in contrast, beta2-AR selective antagonist ICI 118,551 (55 nM) inhibited the inhibitory effects of the three beta2-AR agonists only in PTX-pretreated cardiomyocytes,with beta1-AR blocked by CGP. We conclude that, in adult rat ventricular cardiomyocytes, FEN activates selectively the Gs protein-pathway, while TER and SAL activate the Gs- and Gi-protein pathways. Part of the effects of these three beta2-AR agonists appears to be mediated by beta1-AR.     

K(ATP) channels mediate the beta(2)-adrenoceptor agonist-induced relaxation of rat detrusor muscle

We propose that ATP-sensitive K(+) (K(ATP)) channels are normally inactive but involved in beta(2)-adrenoceptor stimulated relaxation of the rat bladder. Spontaneous detrusor muscle contractions were unaffected by glibenclamide (K(ATP) channel blocker) but were reduced when pinacidil (K(ATP) channel opener) concentrations exceeded 10(-5) M. Inhibition by beta(2)-adrenoceptor agonist clenbuterol [10(-6) M] of 1 Hz electrical field stimulated contractions was abolished by glibenclamide [10(-6) M]. Glibenclamide [10(-6) M] decreased forskolin-induced relaxation [10(-9)-10(-4) M] in bladder muscle stimulated with 1 Hz electrical field. In the presence glibenclamide (10(-6) M) or myristoylated protein kinase A inhibitor (2)x[10(-6) M], clenbuterol [10(-9)-10(-5) M] failed to inhibit bladder contraction in response to 1 Hz electrical field stimulation. Therefore, K(ATP) channel opening and the subsequent hyperpolarization of cell membranes in response to beta(2)-adrenoceptor activation is mediated by raised cyclic-AMP levels and activation of protein kinase A. This counteracts ATP-stimulated depolarization in bladder muscle, thereby reducing cell contraction.     

beta(1)-Adrenoceptors compensate for beta(3)-adrenoceptors in ileum from beta(3)-adrenoceptor knock-out mice

1. This study examines beta(1)-, beta(2)- and beta(3)-adrenoceptor (AR)-mediated responses, mRNA levels and radioligand binding in ileum from beta(3)-AR knock-out (-/-) (KO) and wild type (+/+) (FVB) mice. 2. In KO and FVB mice, SR59230A (100 nM) (beta(3)-AR antagonist) antagonized responses to (-)-isoprenaline in both KO and FVB mice. (-)-Isoprenaline mediated relaxation of ileum was antagonized weakly by ICI118551 (100 nM) (beta(2)-AR antagonist). Responses to (-)-isoprenaline were more strongly antagonized by CGP20712A (100 nM) (beta(1)-AR antagonist), propranolol (1 microM) (beta(1)-/beta(2)-AR antagonist), carvedilol (100 nM) (non-specific beta-AR antagonist), and CGP12177A (100 nM) (beta(1)-/beta(2)-AR antagonist) in ileum from KO than in FVB mice. 3. Responses to CL316243 (beta(3)-AR agonist) in ileum from FVB mice were antagonized by SR59230A (100 nM) but not by propranolol (1 microM) or carvedilol (100 nM). CL316243 was ineffective in relaxing ileum from KO mice. 4. CGP12177A had no agonist actions in ileum from either KO or FVB mice. 5. beta(1)-AR mRNA levels were increased 3 fold in ileum from KO compared to FVB mice. This was associated with an increased maximum number of beta(1)-/beta(2)-AR binding sites (B(max)). beta(2)-AR mRNA levels were unaffected while no beta(3)-AR mRNA was detected in KO mice. 6. In mouse ileum, beta(3)-ARs and to a lesser extent beta(1)-ARs are the predominant adrenoceptor subtypes mediating relaxation in ileum from FVB mice. In KO mice beta(1)-ARs functionally compensate for the lack of beta(3)-ARs, and this is associated with increased beta(1)-AR mRNA and levels of binding.     

beta(1)- and beta(3)-adrenoceptor mediated smooth muscle relaxation in hypothyroid rat ileum

The effect of hypothyroidism on gastrointestinal beta(1)- and beta(3)-adrenoceptor function and expression was examined in rat ileal smooth muscle preparations. (-)-Isoprenaline and the selective beta(3) agonist disodium (R,R)-5-[2-[[2-3-chlorophenyl)-2-hydroxyethyl]-amino]propyl]-1,3-benzodioxole-2,2-dicarboxylate (CL 316234) relaxed both control and hypothyroid tissues in a dose-dependent manner. Responses to isoprenaline were reduced in tissues from hypothyroid rats, as was the shift produced with the beta(3)-adrenoceptor antagonist, 3-(2-ethylphenoxy)-1-[(1S)-1,2,3,4-tetrahydronaphth-1-ylamino]-(2S)-2-propanol oxalate (SR 59230A). No change was seen in responses to CL 316243. Experiments with a selective beta(1)-adrenoceptor antagonist produced results suggesting that isoprenaline did not act at this receptor. Messenger RNA levels for both beta(1)- and beta(2)-adrenoceptors were not affected by hypothyroidism. These results show that, unlike in adipose tissues, ileal beta(1)- and beta(3)-adrenoceptors are not directly regulated by thyroid hormone and that beta(3)-adrenoceptor coupling to the relaxation response is reduced in a rat model of hypothyroidism.