The Effect of Disodium Cromoglycate on In Vitro Proliferation of Peripheral Blood Mononuclear Cells from Allergic and Healthy Donors

The effect of disodium cromoglycate on in vitro proliferative responses of peripheral blood mononuclear cells from healthy individuals, allergic patients with moderate serum IgE and patients with atopic dermatitis and high levels of serum IgE was investigated. Peripheral blood mononuclear cells were stimulated with mitogens (phytohaemagglutinin, Concanavalin A), recombinant interleukin-2, calcium ionophore + phorbol 12-myristate 13-acetate, purified protein derivative of tuberculin and allergens. It was possible to induce in vitro specific, allergen-triggered responses only in allergic individuals with moderate serum IgE and not in individuals with atopic dermatitis and high serum IgE. Generally, whenever the stimulatory signal(s) caused a significant proliferative response, disodium cromoglycate inhibited the proliferation. This inhibition was seen for all activation agents and for both healthy and allergic individuals. By contrast, for certain non- or low-responders (both healthy and allergic individuals) disodium cromoglycate seemed to amplify the proliferation to various activation signals. Only non- or low-responder cells derived from atopic dermatitis patients showed a biphasic kinetic response pattern when stimulated with the drug in combination with recombinant interleukin-2, recombinant interleukin-2 + ionophore or specific allergens.     

Nedocromil sodium inhibits IgE- and IgG-related antigen-induced contraction in guinea-pig trachea

The effects of nedrocromil sodium and disodium cromoglycate were studied on the anaphylactic contraction of guinea-pig trachea in two models of active sensitization (IgE and IgG models). The influence of epithelial removal on the effects of nedocromil sodium and disodium cromoglycate was examined because several studies have shown that the epithelial layer can modulate agonist- or antigen-induced contractile responses. Disodium cromoglycate (10(-4) M) and nedocromil sodium (10(-4) M) provided significant protection against antigen-induced contractions of guinea-pig tracheal smooth muscle in the IgG model. But only nedocromil sodium had an effect at this concentration in the IgG model and was also effective at 10(-5) M in the epithelium-denuded tracheal strips. At this concentration, disodium cromoglycate lost its protective effect. Comparison with the results obtained with FPL-55712, AA-861 and mepyramine suggested that these drugs affect histamine and particularly leukotriene synthesis and/or release by mast cells or other immunocompetent cells. These findings indicate that nedocromil sodium inhibits the IgE- and IgG-related antigen-induced contraction in guinea-pig airways, whereas disodium cromoglycate inhibits only the IgG-related processes. This study supports the hypothesis that these drugs modulate antigen-induced mediator synthesis and/or release from immunocompetent cells.     

Disodium cromoglycate in anaphylaxis and pollinois.

Because disodium cromoglycate is being used in treating the symptoms of allergic patients and its mode of action remains uncertain, morphological experiments were conducted in an attempt to further elucidate this compound's mode of action. Rabbits with an ear chamber underwent anaphylaxis, lethal or sublethal, with microscopic observations of the microcirculation during anaphylaxis. At death or a chosen interval tissue of the ear chamber was secured for histological examination. The mast cells and the state of their granules were counted for each section. In no instance did disodium cromoglycate have any effect in preventing the gross or microscopic changes and disodium cromoglycate did not protect mast cells in passive anaphylaxis. The nasal mucosa of a subject sensitive to ragweed pollen was exposed to ragweed pollen in a non-pollen season and the gross symptoms of hay fever were noted. When the nasal mucosa was pre-treated with disodium cromoglycate, however, no symptoms were observed and biopsies of nasal mucosa showed more normal mast cells and fewer degranulated mast cells.     

Placebo-controlled double-blind food challenge in asthma

To determine the prevalence of food allergy as a cause of exacerbation of asthma, we studied 300 consecutive patients with asthma (7 months to 80 years of age) who attended a respiratory clinic. Each patient was screened for possible food allergy by means of a questionnaire and by skin prick tests with the six food allergens most common in our area. Patients with either a suggestive history and/or a positive prick test and/or RAST underwent double-blind food challenge with lyophilized food in capsules or food mixed in a broth to disguise its taste. Pulmonary function tests and symptoms were followed for 8 hours after each challenge. Of the 300 patients screened, only 25 had either a history or skin prick tests or RAST responses suggestive of food allergy. Twenty patients had interpretable food challenges. In these 20 patients, food challenge caused asthma in six and caused other symptoms (atopic dermatitis and gastrointestinal symptoms) in five. On rechallenge after pretreatment with disodium cromoglycate (300 mg 30 minutes before the food challenge), the asthmatic response was blocked in four of five subjects. The patients with asthma with food allergy were generally young, had a current or past history of atopic dermatitis, and high total serum IgE levels. Our findings confirm that food allergy can elicit asthma, but its incidence is low, even in the population attending a specialty clinic. Food elimination diets should not be prescribed for all patients reporting an adverse reaction to foods or having a positive skin prick test and/or RAST with food allergens. In patients with asthma caused by food allergy, disodium cromoglycate may be used to complement elimination diets.     

Prevention of pollen rhinitis symptoms: comparison of fluticasone propionate aqueous nasal spray and disodium cromoglycate aqueous nasal spray

Fluticasone propionate aqueous spray, a new intranasal corticosteroid preparation, and disodium eromoglyeate 2% aqueous nasal spray, an established preventive treatment for seasonal allergic rhinitis, were compared in a double-blind, double-dummy, parallel-group, multicentric study in France. A total of 218 patients with seasonal allergic rhinitis caused by grass pollen (verified by positive skin prick test) were preventively treated before the onset of the grass pollen season with either fluticasone propionate 200 μg once daily or disodium cromoglycate 5.2 mg four times daily. Half of these doses was given in each nostril. Treatment started before the onset of the pollen season in most patients (178/218). Diary cards, including symptoms of rhinitis and usage of nasal sprays, were filled in twice daily for 5 weeks.
Terfenadine in 60-mg tablets and eye-drops could be used as rescue medications. We treated 110 patients with fluticasone propionate and 108 patients with disodium cromoglycate. Patients treated with flutieasone propionate had significantly more days free of primary efficacy symptoms of sneezing ( P < 0.001) and nasal discharge during the day ( P = 0.002), as well as free of all the other nasal symptoms ( P < 0.0l), and significantly lower median scores ( P < 0.05) for all nasal symptoms except nasal discharge than patients treated with disodium cromoglycate. There was no difference in eye symptoms or in rescue medication use between the two groups. Compliance with the treatment was assessed. Eleven patients recorded incorrect use of both nasal sprays for over 25% of days, and 55 patients recorded incorrect use of four-times-daily spray only; no patient recorded incorrect use of morning spray only. Both treatments were generally well tolerated.     

Mode of action of disodium cromoglycate, studies on immediate type hypersensitivity reactions using `double sensitization'' with two antigenetically distinct rat reagins

The mode of action of disodium cromoglycate has been investigated to determine at what stage in immediate type hypersensitivity reactions the compound is effective. In vitro studies using rat subcutaneous connective tissue sensitized with rat reagin revealed that the compound inhibited the allergic release of histamine if present during antigen challenge. The presence of the compound during sensitization had no effect on antigen-induced release of histamine provided the compound was removed prior to antigen challenge. Tissues which had undergone a primary antigen challenge in the presence of disodium cromoglycate did not release histamine when the compound was removed and the tissues rechallenged. These findings indicated that antigen/antibody interaction occurred in the presence of the compound resulting in desensitization to a subsequent antigen challenge. To corroborate the evidence of the in vitro studies in vivo passive cutaneous anaphylactic reactions (PCA) were undertaken using tissue sites sensitized with two reaginic antibodies which permitted a sequence of antigen challenges. Results from these in vivo reactions demonstrated that it was possible to desensitize tissue, without the release of the mediators of anaphylaxis, by an antigen challenge and disodium cromoglycate treatment. In these sites sensitized with two antibodies the immunological reactivity was maintained following a primary antigen challenge and disodium cromoglycate treatment, as a subsequent challenge with the dissimilar antigen produced a good PCA reaction. It would appear that disodium cromoglycate acts either directly or indirectly at a stage following antigen/antibody reaction but prior to the release of the mediators of anaphylaxis.     

Passive cutaneous anaphylaxis in the rat, induced with two homologous reagin-like antibodies, and its specific inhibition with disodium cromoglycate

Rats immunized with egg albumin and Bordetella pertussis organisms produce a `mast cell sensitizing' antibody (MCSAb) which is thermolabile, a potent skin sensitizer and reagin in character. Similarly the immune response to Nippostrongylus brasiliensis in rats is closely associated with the formation of antibodies which also resembles human reagins. Homologous passive cutaneous anaphylactic (PCA) reactions induced by N. brasiliensis serum were found to be similar to those produced using the adjuvant induced antibody in that both were completely inhibited by, combined treatment with mepyramine and 2-bromo-D-lysergic acid diethylamide (BOL148), cyproheptadine or pretreatment with compound 48/80. In contrast, skin reactions involving passive sensitization of rats with rabbit hyperimmune antiserum were much less affected. Studies on mast cell disruption at the site of PCA reactions showed that such reactions using N. brasiliensis serum were accompanied by degranulation of mast cells, and confirmed that mast cell damage occurs in PCA induced with MCSAb. Both the PCA and the mast cell disruption were maximal 5 minutes after antigen challenge in both rat reagin systems. The skin reaction produced using rabbit hyperimmune antiserum was not primarily dependent on, or associated with, mast cell disruption, since it was still possible to induce skin reactions when the mast cells had been disrupted by compound 48/80, and skin reactions could be obtained without significant mast cell disruption.

Disodium cromoglycate, a new compound introduced for the treatment of asthma, was shown to inhibit both the PCA and mast cell disruption induced using both rat reagin antibodies but not the skin reactions produced with rabbit anti-serum. It was possible to obtain substantial inhibition of mast cell disruption induced by rat reagin, even when the PCA was inhibited only slightly. At higher doses the discharge of the mediators from mast cells was also prevented. This interference with mast cell permeability was not unspecific since disodium cromoglycate did not prevent the skin reaction or mast cell disruption produced by compound 48/80. As expected mepyramine was able to partially inhibit the skin reaction without affecting mast cell disruption induced by rat reagin or compound 48/80. It is suggested that disodium cromoglycate acts at some critical pathway in the events after the union of antigen with reagin antibody and that this critical pathway might be common to both the human and rat reagin systems.

     

Comparison of ketotifen, disodium cromoglycate and placebo in the treatment of adult patients with mild extrinsic asthma

Sixty-four patients with mild or moderate extrinsic asthma were treated with placebo for i month and thereafter with ketotifen (1 mg twice daily, orally), disodium cromoglycate (inhalation of 20 mg, four times daily), or placebo for 2 subsequent months. The trial was performed at four different centres and the treatments were compared using double-blind technique. We found no difference between the effect of ketotifen, disodium cromoglycate and placebo on the patients' daily measurements of evening peak expiratory flow, daily score values for respiratory symptoms or the number of salbutamol puffs required to control symptoms. There was no difference between the treatment groups with regard to the patients' estimates of changes in airway sensitivity to different non-specific stimuli: fumes, tobacco smoke, cold air, and exercise. The only significant effect of DSCG was a minor (4%) increase in the mean morning value for peak expiratory flow. The findings suggest that the addition of ketotifen or disodium cromoglycate to the regimen is unlikely to give further benefit in asthmatic patients, whose symptoms are reasonably well controlled by small doses of bronchodilating drugs.     

Improvement with disodium cromoglycate of neutrophil phagocytosis and respiratory burst activity in a patient with hyperimmunoglobulin E syndrome

We report a case of hyperimmunoglobulin E syndrome (HIE) complicated by neutrophil deficiency which was successfully treated with oral administration of disodium cromoglycate. A 48-year-old Japanese man with HIE developed Streptococcus pneumoniae meningitis. Laboratory tests after the meningitis revealed persistent neutropenia (300-800/mm³) and defects of phagocytosis and bacterial killing by neutrophils. Administration of disodium cromoglycate was started, and neutrophil counts gradually increased to 1200-1600/mm³ TTie impaired neutrophil activities returned to normal. The patient improved clinically; during the 2-year treatment, he had only two brief episodes of the common cold. Disodium cromoglycate may have potential clinical use in the treatment of cases of HIE even with neutrophil deficiency.     

Observations on the safety of disodium cromoglycate in long-term use in children

A group of eighty-two children aged 6–18 years were investigated specifically for evidence of toxic or allergic effects from the use of disodium cromoglycate (‘Intal’) for 3 years or more by:

• 1 Radiological examination of the lungs.
• 2 Records of growth.
• 3 Haemoglobin estimations.
• 4 White blood counts.
• 5 Serum transaminase estimations.
• 6 Urine examinations.
• 7 Skin tests by the prick method.
• 8 Inhalation tests with disodium cromoglycate and lactose powder.

There was no evidence of drug-induced toxic or allergic effects. Random urine samples from 186 patients on treatment with disodium cromoglycate were examined for the quantity of the drug excreted. These suggested that 13·4% were not taking the treatment as instructed and another 16% may not have been using the spinhaler effectively. The failure to take the treatment properly has been noted in other conditions requiring long continued treatment, such as tuberculosis, and must affect both the results and, to some extent, the possibility of toxic effects. It is concluded that disodium cromoglycate treatment is remarkably free of toxic or allergic effects but that an important problem in long-term management is supervision of the patient's use of the treatment prescribed.     

Eosinophil granule proteins in serum after allergen challenge of asthmatic patients and the effects of anti-asthmatic medication

Thirteen allergic asthmatic patients were challenged six times each and serum levels of ECP (eosinophil cationic protein), EPX (eosinophil protein-x) and blood counts of eosinophil granulocytes were measured in blood obtained before and at regular intervals after challenge. Three challenges were performed in a blinded and randomized fashion and included a one-dose pretreatment with the inhalant anti-asthmatic drugs disodium cromoglycate, terbutaline and budesonide. One challenge was performed after 4 weeks' pretreatment with the inhalant budesonide and one was a histamine challenge. Pre-challenge levels of ECP were significantly reduced both after 4 weeks and after a one-dose treatment with budesonide whereas the EPX levels were reduced only after the former. Blood eosinophil counts were unaffected by the challenge whereas the ECP levels were significantly reduced after the placebo challenge and when premedicated with disodium cromoglycate and terbutaline. The EPX levels stayed unaltered at the placebo challenge but were significantly reduced when the patients were premedicated with terbutaline. ECP and EPX levels as well as blood eosinophil counts before challenge were significantly related to the development of the late asthmatic reaction. The results again focus on a relation between the eosinophil granulocyte and asthma and suggest that an increased activity of the blood eosinophil, as suggested by the raised serum levels of the granule proteins ECP and EPX, is one prerequisite for the development of chronic asthma.     

A double-blind comparison of ketotifen and disodium cromoglycate in atopic adult asthmatics

The therapeutic effects of inhaled disodium cromoglycate (DSCG) and orally administered ketotifen were compared in thirty atopic asthmatics aged 15-34 years during a 22-week double-blind parallel group study. Ketotifen is a cycloheptathio-phene with experimental antihistaminic, anti-allergic and anti-anaphylactic effects equal or superior to those of DSCG. During the first 6 weeks of treatment, mean airflow meter readings increased and bronchodilator use diminished in those receiving DSCG, but no improvement was seen in those given ketotifen. In the next 10 weeks. concomitant therapy was reduced in both groups, but this reduction was greater in the group receiving DSCG. No serious adverse effects occurred. Asthma worsened after abrupt discontinuation of DSCG but not ketotifen. Although a small number of patients may have benefited from ketotifen. its effect on asthma was not comparable with that of inhaled disodium cromoglycate.     

Oral disodium cromoglycate and ketotifen for a patient with eosinophilic gastroenteritis, food allergy and protein-losing enteropathy

We present a case report of a 10 years old boy with protein-losing enteropathy and eosinophilic gastroenteritis who had positive histamine release tests, increased allergen-specific IgE antibodies to some food items, and low levels of total serum protein and albumin. Upper gastrointestinal endoscopy revealed a number of polyps and diffuse gastritis. Biopsy specimens of the stomach and duodenum showed widespread eosinophilia and neutrophilia. Although a restricted diet was recommended, a diet which excluded foods with positive results to both histamine release test and allergen-specific IgE antibodies was poorly tolerated, and the patient rejected systemic administration of corticosteroids. Thus, we initiated an oral disodium cromoglycate (DSCG) and ketotifen therapy. After oral DSCG and ketotifen administration, the patient's condition improved gradually. Therefore, oral DSCG and ketotifen therapy might be considered as treatment option in patients with eosinophilic gastroenteritis and protein-losing enteropathy caused by food allergy.     

Eosinophil degranulation

Abstract-A method is described for the quantitative monitoring of human eosinophil degranulation using interference contrast microscopy. Using staphyloccoci as a stimulus, degranulated cells appeared larger than nondegranulating cells, were ameboid in shape and exhibited large nude areas of cytoplasm with prominent nuclei. Granules were observed to marginale along the plasma membrane and discharge into the exterior of the cell. Eosinophils that were not induced to degranulate were spherical in shape and the cytoplasm contained numerous granules that often obscured the nuclei. Pharmacological agents that increase intracellular cAMP prevented degranulation, whereas those that increase cGMP had no effect on degranulation. Colchicine inhibited degranulation but did not interfere with the phagocytosis of staphyloccoci. Endotoxin-activated serum, ECF-A, phytohemagglutinin, concanavalin A, levamisole, and compound 48/80 caused degranulation of eosinophils per se. The presence of disodium cromoglycate prevented this degranulation. Compound 48/80 and disodium cromoglycate had no effect on the level of intracellular cAMP and cGMP.     

Exercise induced asthma: response to disodium cromoglycate in skin-test positive and skin-test negative subjects

Thirty-nine asthmatic subjects, aged 5-50 and each with a history of exercise-induced asthma, were classified according to their skin response to prick tests using nineteen common antigens. Ten had negative skin tests, four responded only to D. farinae and twenty-five had multiple positive responses. Each patient then carried out three exercise tests on a treadmill, each test on a separate day. A control test was followed, in random order, by an exercise test after administration of disodium cromoglycate or of a placebo. In all groups, the mean fall in peak expiratory flow rate was less after disodium cromoglycate than after placebo, but the difference was significant only for the skin-test positive groups. Similarly, positive skin-test groups had a higher incidence of drug responders than did the negative skin-test group. These observations are discussed.     

Disodium cromoglycate in ragweed-allergic rhinitis.

This study was designed to test the effectiveness of disodium cromoglycate when compared to placebo in a double-blind study in patients with ragweed allergic rhinitis. Patients were selected on the basis of a clinical history and a 4+ reaction to the intradermal injection of water-soluble ragweed, 0.02 c.c. of 500 PNU/c.c. Active agent/placebo groups were selected at random and were on the drug for approximately 8 wk, commencing 1 wk prior to the onset of the ragweed pollen season. Patient response was evaluated using patient diary cards, number of antihistamine tablets taken, and patient interviews. In the Toronto study, of 17 patients on the active drug, 15 were graded as improved, compared to only 6 of 21 placebo-treated patients who were improved. However, in the Hamilton study, results were less impressive. Nonetheless, it appears that intranasal insufflation of disodium cromoglycate was more effective in reducing ragweed hay fever symptoms than placebo.     

Antigen-induced neutrophil chemotactic activity in man. Correlation with bronchospasm and inhibition by disodium cromoglycate.

We have previously reported increased neutrophil chemotactic activity in sera obtained after positive antigen inhalation responses in atopic subjects. This report describes the kinetics of appearance of this serum activity and the effects of antigen dose and disodium cromoglycate pretreatment on the response in 10 ragweed-sensitive subjects. Significantly increased chemotactic activity was present as early as 1 min, peaked at 10 min, and persisted through 24 hr after inhalation of antigen. The increased chemotactic activity correlated with the degree of bronchospasm induced by antigen inhalation and the amount of antigen administered. The increased chemotactic activity and bronchospasm were blocked by administration of disodium cromoglycate prior to antigen challenge. These findings are consistent with a postulated antigen-induced anaphylactic release of chemotactic activity. The correlation of this activity with the degree of bronchospasm and its appearance after administration of even small doses of antigen suggest that this activity may be important in antigen-mediated bronchospasm.     

Asthma due to inhaled chemical fumes—amino-ethyl ethanolamine in aluminium soldering flux

Three patients with asthma due to the fumes of aluminium soldering flux containing amino-ethyl ethanolamine were tested by occupational type exposures to the fumes of the flux and the amino-ethyl ethanoiamine. Typical late asthmatic reactions not inhibited by disodium cromoglycate were produced, one patient also giving an immediate asthmatic reaction which was inhibited by disodium cromoglycate.     

Efficacy, cost-effectiveness, and tolerability of mometasone furoate, levocabastine, and disodium cromoglycate nasal sprays in the treatment of seasonal allergic rhinitis.

BACKGROUND: Current guidelines recommend intranasal glucocorticosteroids as first-line therapy for seasonal allergic rhinitis. OBJECTIVE: To compare the efficacy, cost-effectiveness, and tolerability of the topical glucocorticosteroid mometasone furoate, the topical antihistamine levocabastine hydrochloride, and the cromone disodium cromoglycate in seasonal allergic rhinitis. METHODS: This study was performed during the 2003 grass pollen season as an open, randomized, parallel-group, single-center study of 123 patients assigned to receive mometasone furoate (200 microg once daily), levocabastine hydrochloride (200 microg twice daily), or disodium cromoglycate (5.6 mg 4 times daily). Symptom scores and nasal inspiratory peak flow measurements were recorded in a patient diary. The global efficacy of the study medication was evaluated by patients after treatment. Eosinophil cationic protein concentrations were measured in nasal secretions before and after treatment. Cost-effectiveness was evaluated as medication cost per treatment success. RESULTS: Mometasone furoate therapy was significantly superior to the use of levocabastine or disodium cromoglycate with respect to all nasal symptoms, the global evaluation of efficacy, and eosinophil cationic protein concentration. Furthermore, mometasone furoate therapy was significantly superior to disodium cromoglycate therapy with respect to nasal inspiratory peak flow. Medication cost per treatment success was lowest with mometasone furoate use and highest with levocabastine use. CONCLUSION: This is the first study to compare mometasone furoate nasal spray with nonsteroidal topical treatments for seasonal allergic rhinitis. Mometasone furoate nasal spray was confirmed as a first-choice topical treatment option for seasonal allergic rhinitis.     

Study on the effect of disodium cromoglycate (DSCG) on antigen induced IL-2 responsiveness

We tested the effects of disodium cromoglycate (DSCG) on antigen-induced IL-2 responsiveness in lymphocytes from patients with atopic dermatitis and/or bronchial asthma. Patient lymphocytes pretreated with 5 x 10(3) micrograms/ml DSCG for 24 or 48 hours failed to induce the responsiveness to IL-2 on stimulation with Dermatophagoides farinae (Df) or ovalbumin (OVA) antigen. DSCG-treated adherent cells were blocked to present the antigen to nonadherent responding cells for induction of IL-2 responsiveness. In contrast, DSCG-treated non-adherent cells, recombined with antigen-activated adherent cells, acquired IL-2 responsiveness. However, Con A-activated lymphocytes from the same patients were not affected by the same treatment. The results indicate that DSCG is capable of suppressing antigen-induced IL-2 responsiveness but not the response induced by mitogen such as Con A.