Treatment of Obstructive Airway Disease With a Cysteine Donor Protein Supplement* A Case Report * Bryce Lothian, MD; Vijoylaxmi Grey, PRD; Ri John Kimoff, MD: and Larry C. Lands, MD, PhD OxidanVantioxidant imbalance can occur in obstruc- tive airways disease as a result of ongoing inflamma- tion. Glutathione (GSA) plays a major role in pulmo- nary antioxidant protection. As an alternative or complement to anti-inflammatory therapy, augment: ing antioxidant protection could diminish the effects of inflammation. We describe a case of a patient who had obstructive lung disease responsive to cortico- steroids, and low whole blood GSH levels. After 1 month of supplementation with a whey-based oral supplement designed to provide GSH precursors, whole blood GSH levels and pulmonary function inereased significantly and dramatically. The poten- tial for such supplementation in pulmonary inflam- matory conditions deserves further study. (CHEST 2000; 117:914-916) Key words: glutathione; inflammation; oxdatvestres; supple Abbreviations: ELF = epithelial lining fui: GSH ‘one, GSH-Pr = gtathione peroxidase, PFI tion test; ROS = reactive oxygen species stati. = pulmonary func vidence of oxidantlantioxidant imbalance has been demonstrated in obstructive airway disease.!# Contin- vued lung inflammation with the mobilization and activa “From the Deparment of Pediataes (Drs. Lothin and Grey. Department of Biochemistry (De. Grey), and Diasion of Resp ‘ratory Medicine (Dr. Lands), MeCl Univerty Health Cente Montreal Children's Hospi, Montreal, Quebe Canada, and Division of Respiratory Medicine (Dr. Kimo), MC Univer: ty Health Conto-Royal Vito Hospitd, Montreal, Quebec, Cinada LLC) Lands and 1. Kin are clinical investgstors with the Fonds de ls Rocherthe en Santé du Québec. ‘Manasript received une 2, 1990 revison accepted September 1, 1009, Correspondence to: Lary C. Lands, MD. PRD, Assistant iro. ton, Repiratory Mdhcine, The Montrecl Children's Homa, ‘oom D380, 200 Tupper St, Montreal, Quebec, Canada HSH 125, eal: larrylandsemuhs megilica ou tion of neutrophils, macrophages, and eosinophils and their release of free oxygen radicals and other reactive ‘oxygen species (ROS) is a source of oxidative stress. In addition to the direct effects of such ROS on cell mem- branes, DNA, and proteins, breakdown products act as signals perpetuating the inflaramatory cascede. Glutathi- fone (GSH) and the GSH system play a key role ia protecting agains the effects of ROS 4 Modulation ofthe ‘oxidantantioridant status in obstructive airway disease, primarily med at enhancement of the GSH system, has been limited by difficulties in delivery of an effective substrate#3* We describe the response to an oral, whey- based supplement designed to supply GSH precursors Case Rerorr ‘A 40-year-old woman of North Altiean origin was fllowed by the pulmonclogy service ata tertiary care hospital in 1997. Her rmetial history was significant for Hodgkin's lymphoma, dag nosed 27 yeas eatir and treated with radiation and chemother: apy. She had a 25-packyear smoking history and bad quit smoking in 1904. In 1995, she received a diagnosis of ald valvular heart disease (aortic and mitral regurgitation). At that time (time 1), pulmonary function tests (PFs) suggested mild sldflow obstruction (Fig 1); bronchodilators were not preseibed, In 1997 (time 2), she was edmitted to hospital with « vill Induced exacerbation of obstructive lung divease as wells ld hear faire. She improved with diuretics, bronchodilators (l= bbutamol and ipratropium bromide), and oral prednisone, 20 mg. She was discharged taking x tapering course of prednisone ‘When sen in follow-up 1 week later (tine 3), sh had suffered an exacerbation of her respiratory symptoms (shortness of breath, wheeze, chest tightness, and excessive mucue production) coin- tent with cessation of prednisone. Predalzone was prescribed "he retuned 2 weeks ater (Ue 4 wth sigcant symptom. atte improvement while stil taking systemic corticosteroids and regular bronchodilators (salbutamol metered-dose inhaler and ipratropium bromide metered-doso inhaler gid). An attempt was ‘ade to discontinue prednisone. When the patient was seen 1 ‘month later (tine 5), her symptoms had returned. At that time, review of her history revealed no environmental insult that coukd account for hor deterioration. Additionally, serum IgE was 52 KUL (laboratory contro, 0 to 100 FUL) and both allergen skin testing and Aspergillus precipitins testing were negative. A further course of oral prednisone was presebed (40 mgd inl; tapering over | month). Four months later (ime 6), the patient returned to clinic Independently, having begun taking HMS00 (Immunoel;Im notet Research Ltd: Vaudreuil, Qucboc, Canada), a whey-based protein supplement (10 g bid), 1 month belore. She had heard thatthe product could be helpful in inflammatory conditions and hha started taking the product of her own accord. She reported 4 remarkable improvement in her respiratory status and had discontinued all inhalers and steroids, and was not taking any other supplements, medications, or over-the-counter therapies She was asked to discontinue the Tiniunocal, and onthin 9 months her symptoms returned. PFTS were performed at thie time (time 7) She then restarted Immunceal of her ovn accord, and I month ltr (time 8), PFTs were again assessed, Addition aly, whole blood GSH levels were measured before and 1 month ter therapy was rented, using a modification of the method previously desorbed ®* Again, a remarkable improvement in| both symptoms and PTS was noted (Fig )-In addition, the total Jung capacity increased from 3.91 L at ime 70 5.00 L atime 8, and the residual olume/otal hing espacity rato fell from 33 to Sele ReportsLitres Time 1 FioUNE 1 Tracking of the pulmonary function values over time, TLC R residual velume. 28%. Her whole blood GSH levee inreased from 235 to 457 moVL (abortry conta, 5892 2 1126 yey n= 10). 1 ‘ould bo futher remarked that the lt wo PFT performed ‘owed reversibility of the obstrctv airway dese {change in FEV, 49% al tine 1 to 15% at tine 8), wheres no pio PFT had shown revert. The patent cones to take HMSOO and no other respiratory medieatios,wthoat return of her symptoms. Discussion “The patient suffered from a worsening of her previously diagnosed obstructive airway disease, The relative conte butions of smoking, asthma, and cancer therapy to her baseline lung disease are unclear, as was the cause of her deterioration. She required multiple courses of systemic steroids to maintain lung function. Symptomatic improve- ‘ment correlating with pulmonary funesion coincided with her initiation of HMS90. More signiicantly, pulmonary function worsened with withdrawal of HMS90 and ien- proved with reintroduction. Her final respiratory status is objectively and subjectively better than at any time in the previous 4 year HMSQ0 is a bovine whey-protein concentrate purified by ultraflration and low-temperature pasteurization of nil The undenatured whey protein is rch in eystine (the oxidized form of cysteine) and >-gtamyleystine,? which fare precursors of CSH synthesis. The tripeptide GSH (ahyeyl-y-utamleysteine) i synthesized inthe cll in wo stops. The first step the synthesis of y-gutamyleysteine is limited by the availabilty of intracliolar csteine.* As well, yglutamyleysteine, as a>-gitamyl amino acid can easily be transported into the cell where it combines with slycine inthe second stop of GSH synthesis * Cells eannot take up extracellular GSH? Time2 Time3 Timed TimeS Timeé Time7 Time8 total lung capacity; In the patient deseribed, whole blood GSH levels were significantly increased (94%) following regular intake of HMS90. This is much higher than the reported intaindl vidual variation in whole blood GSH values (78 to 15.8%)? In order to avoid any possible influence of the timing of sampling on GSH levels and pulmonary fune- tion, the patient was tested between 10:00 anc and 11:00 ‘as on each visit. Animal studies of GSH metabolism have demonstrated that whole blood GSH is reflective, tempo- rally and quantitatively, of lymphocyte and tissue GSH levels. Although no direct markers of oxidant/antioxdant status or inflammation were measured in the patient described, the observed clinical effect is coincident with augmented GSH levels. Several specific abnormalities, or inadequacies, of the GSH antioxidant system have been identified in reversible obstructive airway disease. GSI itself is present in high concentrations in the lung epithelia lining fluid (ELF), ‘where it may act to directly reduce ROS.!4! Clinically stable asthmatics have higher ELF GSH than syraptom- atic asthmatics > while experimental models of oxidative stress show an inerease in ELF GSH with oxidative siress."” Upregulation of antioxidant defenses, although not in proportion to oxidative stress, is hypothesized to account forthe increased BAL fluid GSH levels observed in both these studies and other pulmonary conditions that tare attributed, in part, to excessive oxidative stress.'° GST is also a substrate for the enzyme glutathione peroxidase (GSH-PY), which catalyzes the decomposition of a large number of ROSs (including hydrogen and other peroxi- dases}t Studies have shown decreased peripheral blood GSHI-Px activity in asthmatic patents. Finally, it has been recently demonstrated in @ murine model that GSH levels (CHEST /117/3/ MARCH, 2000 915in the antigen presenting cell affect the differentiation of the T-helper cell Thl/Th2 cytokine response? Improvement in GSH status could result in augmented Jung function through several mechanisms. Within hing epithelial cel, augmented GSH may block the ativation of nuclear factor xB hy tumor necrosis factor-a, and so init the production and relea of proinflammatory cytokines. Augmented intracellular GSH may reduce the need to recycle GSH from the lung lining uid, and this maintain ‘extracellular lovels" Alternatively, increased intracellular GSH levels may lead to extracellular transport to buttress hung lining levels In the hang lining Mud, augmented GSH ‘may prevent oxidative damage to antiproteases "!* Tmprove- ‘ment in skeletal muscle function due to augmented GSH stores" may also partially account for our results, as the baseline FEV,/FVC ratio did not change between times 7 and 8 (66% and 62%, respectively. ‘The ELF GSI pool has been the target of direct adiin- istration of nebulized GSH, although” success has been limited by GSHT-induced bronchospasm? Trials of systemic Neacetyl gsteine, acting as both a cysteine donor and an ROS scavenger, for the treatment of chronic obstructive airway disease have met with Limited success, because of N-acetyl eysteine toxicity and limited clnial effet. * The relationship between whole blood GSH, lung epthe- lal cell GSH levels, ELF GSH, and peripherl blood GSH-Pr activity is poorly defined, There ae several possible mechanisms by which GSH could improve obstructive ar- way disease, ether via immunologic modulation or by im- ‘proving antioxidant defenses. More work needs tobe dene to further define the specific abnormalities of anticxidantfanc- tion, as well as the relative contribution of such abnormalities to the pathophysiology observed in obstructive airway dis- cease. Nevertheless, the modulation of GSH and antioxidant defenses in obstructive airvay disease (and many other diseases) represents an intriguing potential modabty for antiinflammatory therapy. 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