Professional Documents
Culture Documents
Key Words ment of novel biologicals that target a diverse array of phe-
Asthma · Biologicals · Interleukins · Treatment · Tumor notype-specific molecular targets in patients suffering from
necrosis factor · CC chemokine receptor · severe asthma. This review summarizes potential therapeu-
Granulocyte-macrophage colony-stimulating factor · tic approaches that are likely to show clinical efficacy in the
Chemoattractant receptor-homologous molecule near future, focusing on biologicals as promising novel ther-
expressed on TH2 cells · Macrolides apies for severe asthma. © 2016 S. Karger AG, Basel
Abstract
Bronchial asthma is a heterogeneous, complex, chronic in- Introduction
flammatory and obstructive pulmonary disease driven by
various pathways to present with different phenotypes. A Bronchial asthma is a heterogeneous, complex, chron-
small proportion of asthmatics (5–10%) suffer from severe ic inflammatory and obstructive pulmonary disease char-
asthma with symptoms that cannot be controlled by guide- acterized by augmented mucus secretion, airway hyper-
line therapy with high doses of inhaled steroids plus a sec- reactivity, and, in the long term, functional and structur-
ond controller, such as long-acting β2 agonists (LABA) or leu- al lung tissue alterations [1]. Asthma currently affects an
kotriene receptor antagonists, or even systemic steroids. The estimated 235 million people worldwide. Most asthmat-
discovery and characterization of the pathways that drive ics are well controlled with asthma guideline therapies.
different asthma phenotypes have opened up new thera- Extrinsic (allergic) asthma is the predominant asthma
peutic avenues for asthma treatment. The approval of the subtype and usually manifests during childhood, while
humanized anti-IgE antibody omalizumab for the treatment late-onset asthma is mostly nonallergic [2]. However, a
of severe allergic asthma has paved the way for other cyto- small portion of asthma patients (5–10%) suffer from se-
kine-targeting therapies, particularly those targeting inter- vere asthma that is refractory to high doses of inhaled
leukin (IL)-4, IL-5, IL-9, IL-13, IL-17, and IL-23 and the epithe- steroids plus a second controller. In the uncontrolled sit-
lium-derived cytokines IL-25, IL-33, and thymic stromal lym- uation, long-acting β2 agonists (LABA) and/or phospho-
phopoietin. Knowledge of the molecular basis of asthma diesterase inhibitors and/or long-acting anticholinergics
phenotypes has helped, and continues to help, the develop- (LAMA) are also used to treat severe asthma. Treatment
© 2016 S. Karger AG, Basel Correspondence to: Dr. Quoc Thai Dinh
1018–2438/16/1684–0241$39.50/0 Saarland University Hospital and Saarland University Faculty of Medicine
Kirrberger Strasse, Geb. 61.4
E-Mail karger@karger.com
DE–66421 Homburg/Saar (Germany)
www.karger.com/iaa
E-Mail Thai.Dinh @ uniklinikum-saarland.de
Table 1. New potential drugs in the pipeline for asthma treatment and their target and developmental stage
Drug name Drug target Developmental stage Estimated time of market launch
NA = No estimated time of market launch has been announced; – = there will be no market launch (see text).
1 Already launched/approved to treat chronic granulocyte leukemia.
with systemic steroids is also often required to control ing or inhibiting diverse endogenous target functions. A
severe asthma, which not only affects the patient’s quality number of biologicals are currently being used or tested
of life but can also, in rare cases, cause death. Patients with in clinical lung research, and convincing data has been
severe asthma account for over 50% of the total healthcare published showing a reduction in asthma exacerbations
costs associated with bronchial asthma [3] due to fre- and improved lung function in asthma patients treated
quent hospital admissions, the need for emergency ser- with biologicals. The monoclonal anti-IgE antibody
vices, and high drug consumption. Therefore, there is an omalizumab was the first biological to be approved [i.e.
urgent need for novel, more effective strategies to treat by the US Food and Drug Administration (FDA) in 2003
severe asthma. and the European Medicine Agency (EMA) in 2005] for
Biologicals (or biologics) are mostly genetically syn- the treatment of severe allergic asthma as an alternative
thesized proteins that exert therapeutic effects by activat- to systemic steroids.
TH2 IL-13
IgE
AnƟ-IL-4/IL-13-Ab IL-4
• Dupilumab IL-4 TGFɴ IL-9
• Pitrakinra
TH9
TH0 AnƟ-IL-9-Ab
• MEDI-528
IL-5
- Cytokines
- Histamines
- Prostaglandins
AnƟ-IL-5-Ab
IL-6 • Mepolizumab
Allergens TGFɴ • Reslizumab
• Benralizumab
AnƟ-IL-17-Ab TH17
• Broadalumab
• Secukinumab
CXCL1
Subepithelial CXCL8
Fibroblasts
Neutrophil
Mucus Airway
muscles
Fig. 1. Key players in the TH2-mediated pathomechanism of asth- and finally causes increased mucus secretion in epithelial cells. The
ma. DC capture allergens within the cytoplasm, expose them on expression of IL-4 and TGF-β activates TH9 cells, which in turn re-
their surface, and present them to naive TH0 cells, which causes the lease IL-9 and thereby cause the release of different cytokines, his-
activation of TH2 cells and the secretion of IL-4 and IL-13. Both of tamines, and other inflammatory mediators. The release of TGF-β
these IL activate IgE production and secretion by inducing the mat- and IL-6 by TH0 cells activates TH17, which induces the release of
uration of B lymphocytes to plasma cells. The predominantly mem- IL-17A and IL-17F. Both of these IL initiate the recruitment and
branous IgE on mast cells initiates a signal cascade if activated by expansion of neutrophils via activation of the secretion of chemoat-
contact with an allergen. This leads to the secretion of histamines, tractants (CXCL1 and CXCL8). CXCL1 and CXCL8 are secreted by
prostaglandins, cytokines, and other inflammatory mediators. TH2 different cellular components of lung tissue, such as subepithelial
cells also release IL-5, which starts the maturation of eosinophils fibroblasts and respiratory bronchial cells.
early-onset allergic TH2-mediated and late-onset persis- type also includes exercise-induced asthma (EIA), in
tent eosinophilic asthma, with a range of severities [2]. which symptoms normally occur during and/or after
Early-onset asthma is often associated with other allergic physical activity and increased dry and cold conditions
comorbidities, and its progression can be mild to severe. [2]. Asthma symptoms are often relatively mild in EIA
Late-onset eosinophilic asthma is usually not atopic and patients, although both high and low levels of eosinophil-
is often severely progressive, characterized by increased ic inflammation have been reported in EIA [32].
numbers of sputum and blood eosinophils [2, 29]. Asth- Non-TH2-mediated asthma is also divided into differ-
ma may be triggered by environmental factors and a ge- ent subtypes, i.e. women with late-onset asthma, obesity-
netic predisposition [30, 31]. The TH2-mediated pheno- related asthma, smoking-associated asthma, neutrophilic
asthma, and smooth muscle-mediated, paucigranulocytic ing muscarinic receptor antagonist tiotropium is recom-
asthma [2]. Although these phenotypes represent a sub- mended for the treatment of severe asthma. Systemic ste-
stantial proportion of all asthmatics, little is known about roids are also often needed in patients with severe asthma.
their onset [2]. Obesity-related asthma is one of two non- The first biological licensed for asthma is an anti-IgE
TH2-related eosinophilic asthma phenotypes. Obesity has agent (omalizumab), which is recommended as the pre-
a negative effect on lung function, and obese patients are ferred controller for patients with severe perennial aller-
more susceptible to gastroesophageal reflux, chest tight- gic asthma and may be a suitable alternative treatment to
ness, and hypoventilation; therefore, asthma may be mis- systemic steroids (table 2).
diagnosed in obese patients. Neutrophil-related asthma is
another non-TH2-related asthma subtype that has yet to
be fully characterized [33]. There is evidence that TH17 Anti-IgE Therapy
cells may contribute to this neutrophil-related asthma by
promoting neutrophilic inflammation. TH17 cells release IgE levels are often increased in allergic asthmatics and
IL-17, a major neutrophil chemoattractant, into the air- they are sometimes associated with allergic symptoms
ways [34], and it has been shown that IL-17A and IL-17F [35]. To significantly reduce IgE-induced symptoms,
levels are associated with asthma severity and an increase monoclonal anti-IgE antibodies have been recommended
in neutrophilic inflammation [17]. for the treatment of severe allergic asthma. Anti-IgE an-
tibodies can bind free serous IgE and membranous IgE at
the surface of mast cells and B lymphocytes [36].
Current Pharmacotherapy Omalizumab binds free IgE with a high affinity by in-
teracting with its Cε3 domain [37], thereby reducing asth-
According to the Global Initiative for Asthma (GINA), ma exacerbations [38]. Moreover, omalizumab reduces
asthmatics should receive low- to high-dose inhaled ste- the expression of FcεRI on basophils and DC [39]. IgE
roids alone or in combination with other controllers such binding and the reduction in expressed FcεRI leads to in-
as LABA and/or leukotriene receptor antagonists (mon- hibition of further interactions with ligands and deactiva-
telukast) and/or theophylline. Additionally, the long-act- tion of signaling cascades. The reduced interaction be-
References
1 Dougherty RH, Fahy JV: Acute exacerbations nate lymphoid cells. Nat Immunol 2015; 17: 17 Al-Ramli W, Prefontaine D, Chouiali F, et al:
of asthma: epidemiology, biology and the ex- 65–75. T(H)17-associated cytokines (IL-17A and IL-
acerbation-prone phenotype. Clin Exp Aller- 9 Lluis A, Ballenberger N, Illi S, et al: Regulation 17F) in severe asthma. J Allergy Clin Immu-
gy 2009;39:193–202. of T17 markers early in life through maternal nol 2009;123:1185–1187.
2 Wenzel SE: Asthma phenotypes: the evolu- farm exposure. J Allergy Clin Immunol 2014; 18 Naji N, Smith SG, Gauvreau GM, O’Byrne
tion from clinical to molecular approaches. 133:864–871. PM: T helper 17 cells and related cytokines
Nat Med 2012;18:716–725. 10 Bouzigon E, Corda E, Aschard H, et al: Effect after allergen inhalation challenge in allergic
3 Custovic A, Johnston SL, Pavord I, et al: of 17q21 variants and smoking exposure in asthmatics. Int Arch Allergy Immunol 2014;
EAACI position statement on asthma exacer- early-onset asthma. N Engl J Med 2008; 359: 165:27–34.
bations and severe asthma. Allergy 2013; 68: 1985–1994. 19 Herbert C, Shadie AM, Kumar RK: Interleu-
1520–1531. 11 Sokol CL, Barton GM, Farr AG, Medzhitov R: kin-17 signalling in a murine model of mild
4 D’Agostino B, Advenier C, De PR, et al: The A mechanism for the initiation of allergen- chronic asthma. Int Arch Allergy Immunol
involvement of sensory neuropeptides in air- induced T helper type 2 responses. Nat Im- 2013;162:253–262.
way hyper-responsiveness in rabbits sensi- munol 2008;9:310–318. 20 Wang A, Wang Z, Cao Y, et al: CCL2/CCR2-
tized and challenged to Parietaria judaica. 12 Beier KC, Kallinich T, Hamelmann E: Master dependent recruitment of Th17 cells but not
Clin Exp Allergy 2002;32:472–479. switches of T-cell activation and differentia- Tc17 cells to the lung in a murine asthma mod-
5 Pascual RM, Peters SP: Airway remodeling tion. Eur Respir J 2007;29:804–812. el. Int Arch Allergy Immunol 2015;166:52–62.
contributes to the progressive loss of lung 13 Galli SJ, Tsai M: IgE and mast cells in allergic 21 Barnes PJ: The cytokine network in asthma
function in asthma: an overview. J Allergy disease. Nat Med 2012;18:693–704. and chronic obstructive pulmonary disease. J
Clin Immunol 2005;116:477–486. 14 Gould HJ, Sutton BJ: IgE in allergy and asth- Clin Invest 2008;118:3546–3556.
6 Loxham M, Davies DE, Blume C: Epithelial ma today. Nat Rev Immunol 2008;8:205–217. 22 Zhou B, Comeau MR, De ST, et al: Thymic
function and dysfunction in asthma. Clin Exp 15 Rivera J, Gilfillan AM: Molecular regulation stromal lymphopoietin as a key initiator of al-
Allergy 2014;44:1299–1313. of mast cell activation. J Allergy Clin Immu- lergic airway inflammation in mice. Nat Im-
7 Woodruff PG, Modrek B, Choy DF, et al: T- nol 2006;117:1214–1225. munol 2005;6:1047–1053.
helper type 2-driven inflammation defines 16 Veldhoen M, Uyttenhove C, Van SJ, et al: 23 Neighbour H, Boulet LP, Lemiere C, et al:
major subphenotypes of asthma. Am J Respir Transforming growth factor-beta ‘repro- Safety and efficacy of an oral CCR3 antagonist
Crit Care Med 2009;180:388–395. grams’ the differentiation of T helper 2 in patients with asthma and eosinophilic
8 Duerr CU, McCarthy CD, Mindt BC, et al: cells and promotes an interleukin 9-pro- bronchitis: a randomized, placebo-controlled
Type I interferon restricts type 2 immunopa- ducing subset. Nat Immunol 2008; 9: 1341– clinical trial. Clin Exp Allergy 2014; 44: 508–
thology through the regulation of group 2 in- 1346. 516.