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(Chest. 2002;121:143-150.)
© 2002 American College of Chest Physicians

Effects of Pranlukast on Chemical Mediators in Induced Sputum on Provocation Tests in Atopic and Aspirin-Intolerant Asthmatic Patients*

Yasushi Obase, MD; Terufumi Shimoda, MD; Shin-ya Tomari, MD; Kazuko Mitsuta, MD; Tetsuya Kawano, MD; Hiroto Matsuse, MD and Shigeru Kohno, MD, FCCP

* From The Second Department of Internal Medicine, Nagasaki University School of Medicine, Nagasaki, Japan.

Correspondence to: Yasushi Obase, MD, Skin and Allergy Hospital, Helsinki University Central Hospital, PO Box 160, HUS, Helsinki, Finland; e-mail: yasushi.obase{at}hus.fi


   Abstract
TOP
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 References
 
Background: Leukotrienes (LTs) are important in asthma, and LT modifiers modulate antigen-induced asthma. Overproduction of LT by suppression of cyclooxygenase activity is involved in patients with aspirin-intolerant asthma (AIA).

Methods: House dust mite (HDM) inhalation provocation tests were performed in HDM-sensitive asthmatic inpatients without AIA (HDM group; n = 6), and aspirin oral provocation tests were performed in AIA patients (ASA group; n = 7). Tests were repeated using the same regimen after 7 days of treatment with pranlukast, an LT receptor antagonist (LTRA). The effects of pranlukast on changes in sputum LTC4-LTD4, eosinophil cationic protein (ECP), eosinophil count, urinary LTE4/creatinine, 11-dehydrothromboxane B2 (11-dhTXB2)/creatinine, serum LTC4-LTD4, ECP, and peripheral blood eosinophil count, during immediate asthmatic reaction (IAR) and late asthmatic reaction (LAR) in the HDM group and during IAR in the ASA group for each test, were compared in each group.

Results: In the HDM group, IAR and LAR were observed. Sputum LTC4-LTD4 and urinary LTE4/creatinine increased significantly both during IAR and LAR. Sputum ECP increased during IAR and further increased during LAR. Eosinophil count in the sputum did not increase during IAR but significantly increased during LAR. Pranlukast suppressed the fall in FEV1 both during IAR and LAR (73.8% and 51.9%, respectively) and inhibited the increase in sputum eosinophil count during LAR and sputum ECP during IAR and LAR. In the ASA group, aspirin-induced IAR was associated with a fall in urinary 11-dhTXB2/creatinine, increased the levels of sputum LTC4-LTD4 and ECP and urinary LTE4/creatinine. Pranlukast suppressed IAR and inhibited the increase of the level of sputum ECP, but failed to change aspirin-induced LT production in the sputum and urine. The levels of sputum LTC4-LTD4 and urinary LTE4/creatinine in the stable phase in the ASA group were significantly greater than those in the HDM group.

Conclusion: Our results indicated that HDM-provoked asthma is associated with overproduction of LT with an antigen-antibody reaction, while AIA is associated with overproduction of LT with a shift to the 5-lipoxygenase series of the arachidonate cascade. LTRA may be useful against both types of asthma through inhibition of LT activity and eosinophilic inflammation of the airways.

Key Words: allergen provocation • aspirin-intolerant asthma • aspirin oral challenge • asthma • chemical mediators • induced sputum • leukotriene receptor antagonist


   Introduction
TOP
 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 References
 
The pathogenesis of bronchial asthma involves eosinophilic airway inflammation, and leukotrienes (LTs) participate in this inflammatory process.1 Leukotriene receptor antagonists (LTRAs) and LT synthesis inhibitors have been used recently in the care of bronchial asthma, and their efficacy is currently broadly recognized.2 3 Several studies4 5 have reported the use of LTRAs for asthma in allergen-induced bronchoprovocation tests (BPTs). However, it is reported6 that aspirin-intolerant asthma (AIA) accounts for approximately 10% of adult asthma, but its pathogenesis is not yet clear. Studies6 7 8 have demonstrated that LTs play an important role in airway narrowing and other signs in patients with AIA, based on findings that urinary LTE4 was twofold to 10-fold higher in AIA patients than in aspirin-tolerant asthmatic patients. Several LT modifiers inhibit the asthma response in oral or inhaled bronchial provocation tests, such as acetylsalicylic acid (aspirin) and nonsteroidal anti-inflammatory drugs,9 10 and improve respiratory function by expanding the airway in patients with AIA.11

However, only a few studies have examined the effects of LT modifiers on chemical mediators, eosinophils, eosinophil cationic protein (ECP), LTs, thromboxane A2, antigen inhalation provocation and aspirin oral provocation. In the present study, we compared the changes in chemical mediators in the sputum, urine and blood in response to house dust mite (HDM)-antigen inhalation in HDM-sensitive asthmatics and to aspirin oral challenge in patients with AIA treated with or without an LTRA, pranlukast.


   Materials and Methods
TOP
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 References
 
Subjects
After obtaining informed consent, six HDM-sensitive asthmatic inpatients without AIA (HDM group) and seven AIA patients (ASA group) were enrolled in the study (Table 1) . All patients in the HDM group were identified as not sensitive to aspirin by previous oral provocation. The study was approved by the Ethics Committee of Nagasaki University Hospital. All patients were nonsmokers and had mild or moderate asthma diagnosed according to the updated criteria of the National Heart, Lung, and Blood Institute.12 All subjects had a positive response to a methacholine challenge test. In all patients, inhaled ß2 agonists were used when necessary. The patients were in stable condition and had been free of symptoms of respiratory infection for at least 6 weeks. The subjects were instructed to withhold inhaled adrenergic agents for 24 h, aminophylline for 24 h, antihistamines for 48 h, and inhaled steroids for 48 h prior to challenge. None of the subjects were treated with LT antagonists.


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  		Table 1. Clinical Features of Subjects*

 
HDM Inhalation Challenge in the HDM Group
An allergen inhalation challenge was performed using the standard method advocated by the International Society of Allergy, using a commercially available HDM allergen extract.13 In this test, the threshold for a positive skin reaction was first determined by skin sensitivity tests using 10-fold serial dilutions of the HDM antigen extract. The baseline FEV1 was measured with a spirometer (Superspiro, DISCOM-21FX; Chest; Tokyo, Japan) and confirmed to be > 80% of the predicted value.14 Clinical examination confirmed the lack of dyspnea and rales, even on forced expirations. No subject had falls in FEV1 due to nonspecific bronchoconstriction after inhalation of physiologic saline solution at 5 L/min for 2 min using a nebulizer (Clinical air pump, model REB 30-REPC; Medicare 24; Yokohama, Japan). Inhalation of the allergen commenced at a 10-fold dilution of the skin test threshold level. In cases where the fall in FEV1 was < 15% of the baseline 10 min after allergen inhalation for 2 min, the BPT was repeated using the next higher allergen concentration. In cases where the fall in FEV1 was between 15% and 20% of the baseline, FEV1 was measured again 10 min after the first measurement. When the fall in the second FEV1 was < 20% of the baseline, the BPT was performed at the same allergen concentration. In cases where the fall in FEV1 was > 20% of the baseline, the BPT result was considered to be positive and the test was terminated. FEV1 was measured after 10, 20, 30, and 60 min, and every 1 h until 12 h after the last antigen inhalation. Furthermore, FEV1 was measured at 9 AM on the next day (after 24 h) to confirm a return to the baseline value. In patients who exhibited >= 20% fall in FEV1, ß2 stimulants were administrated for an immediate asthmatic reaction (IAR), and ß2 stimulants and steroids (if necessary) were administrated for a late asthmatic reaction (LAR).

Protocol for the HDM Group
Each of six patients with atopic asthma completed two HDM inhalation challenge tests. The first test commenced at 9 AM without pranlukast premedication, and IAR and LAR were confirmed to be positive for the HDM antigen. The protocol involved performing the first test followed by a 7-day washout period, and administration of pranlukast, 225 mg bid (Ono Pharmaceutical; Osaka, Japan), for 7 days. At the end of this treatment, another test was performed using the same doses of the HDM allergen. Pranlukast was also administered 2 h before the test. Based on blood levels and half-lives of the tested drugs, 1-week intervals were considered to be necessary and adequate for washout. In each test, sputum, urine, and blood samples were obtained 15 min before the test, and during IAR and LAR.

Protocol for the ASA Group
Each of seven asthmatic patients completed two aspirin oral challenges. The first challenge was an aspirin oral challenge without pretreatment with pranlukast. The baseline FEV1 was measured with a spirometer (Superspiro; Chest) and confirmed to be > 80% of the predicted value (baseline FEV1). Clinical examination confirmed the lack of dyspnea and rales, even on forced expirations. Aspirin challenge commenced at 10 mg. In cases where the fall in FEV1 was < 15% of the baseline at 10, 30, 60, 90, and 120 min after oral challenge, the challenge was repeated using the next higher dose of aspirin. The doses were 20, 50, 100, 250, and 500 mg. In cases where the fall in FEV1 was > 20% of the baseline, the challenge test result was considered positive, the test was terminated, and the dose termed the threshold dose of aspirin. FEV1 was measured every hour until 12 h after the last aspirin challenge. All challenge tests commenced at 9 AM. The subject was classified as having AIA when the threshold was <= 250 mg, or classified as having aspirin-tolerant asthma when there was no reaction even after receiving 500 mg of aspirin. In patients with AIA, the same regimen was repeated for pranlukast after a 7-day washout period. Pranlukast was administered at a dose of 225 mg bid for 7 days, and 225 mg at the same time with aspirin at a dose one rank less than the threshold; it was confirmed that FEV1 did not fall by >= 15%. Then, the aspirin threshold was challenged 120 min later. Induced-sputum samples, urine samples, and blood samples were obtained 15 min before the test, at the time when FEV1 fell by 20% on the first challenge, and concomitantly on the second test.

Sputum Induction and Processing
When appropriate sputum for analysis could not be obtained during any phase, sputum production was induced by the method described by Pin et al15 using inhaled hypertonic saline solution. The subject was instructed to gargle using tap water, and then 3.6% saline solution at room temperature, nebulized via an ultrasonic nebulizer (NE-U12; OMRON; Tokyo, Japan), was inhaled. Subjects were instructed to cough deeply after 5-min and 3-min intervals. Gargling between and before each induced cough was encouraged in order to minimize salivary contamination. The initial sample from the first cough was discarded. Induced sputum was collected into a 50-mL polypropylene tube, kept at 4°C, and processed within 2 h. Spirometric tests were repeated after sputum induction. If FEV1 dropped to < 15% of the postsalbutamol value, the subject was required to stay in the laboratory until it returned to the baseline value. The volume of the sample was recorded, diluted with 2 mL of Hanks’ balanced salt solution containing 1% dithiothreitol (Sigma Chemicals; Poole, UK), and gently vortexed at room temperature. When uniform in consistency, samples were further diluted with Hanks’ balanced salt solution and again vortexed briefly. They were then centrifuged at 400g for 15 min at 4°C, the supernatant was decanted, and the cell pellet was resuspended. An adequate specimen was defined as one in which the number of squamous epithelial cells was < 30% of inflammatory cells. Slides were then stained with May-Grunwald-Giemsa for a differential cell count, which was performed by an observer blinded to the clinical characteristics of the subjects. At least two slides were used for counting, and at least 300 inflammatory cells were counted on each slide. The supernatant fluid was kept at - 80°C for a subsequent ECP assay. To measure LTC3-LTD4 levels, the supernatants were immediately diluted fourfold with an LT extract (ethyl acetate: methanol solution at 2:1) and cryopreserved at - 80°C.

Measurement of LTC4-LTD4 in Sputum and Serum, and LTE4 in Urine
The concentrations of LTC4, LTD4, and LTE4 were determined by a radioimmunoassay (RIA) with a low limit of detection of 20 pg/mL (Leukotriene C4 [3H] assay system, TRK 905 Amersham, peptidyl-leukotriene [3H] RIA kit, NEK-043 NEN; Life Science Products; Lansing, MI).

Measurement of Urinary 11-Dehydrothromoxane B2
Urinary samples for measurement of 11-dehydrothromboxane B2 (11-dhTXB2) were collected in specially designed tube (with ethylenediamine tetra-acetic acid-2Na, indomethacin, and trasylol) and immediately centrifuged. The supernatant was cryopreserved at - 80°C. The concentration of 11-dhTXB2 in the urine was determined by RIA (thromboxane B2 125I RIA Kit; DuPont NEN; Boston, MA). The low detection limit was 35 pg/mL.

Measurement of Sputum and Serum ECP
Blood samples for measurement of ECP were collected in specially designed tubes (Vacutainer Brand Blood Collection tube; Becton Dickinson; Franklin Lakes, NJ), left at room temperature for 1 h, and centrifuged at 1,300g for 10 min. The concentrations of ECP in the serum and sputum were determined by RIA with a lower limit of detection of 2.0 µg/L (Pharmacia ECP RIA; Pharmacia; Uppsala, Sweden).

Data Analysis
Data are expressed as mean ± SEM. Changes in FEV1 and the concentrations of chemical mediators on each phase in each test were analyzed using a two-tailed Student’s t test with the level of significance (p value) set at 0.05. The unpaired t test was used for comparison of each parameter between the HDM and ASA groups.


   Results
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 References
 
Effect of Pranlukast on Bronchoprovocation Challenge Tests
In the HDM group, both IAR (fall in FEV1 of - 28.2 ± 3.8%) and LAR (fall in FEV1 of - 20.5 ± 6.1%) responses were observed in the provocation without pranlukast (Fig 1 , top). In the ASA group, the threshold value ranged from 20 to 250 mg (Table 1 ). A fall of > 20% (20.2 ± 5.9%) in FEV1 was observed 15 to 30 min after oral administration of the threshold dose of aspirin (Fig 1 , bottom). FEV1 was measured hourly up to 12 h after the test, but no patient in this study developed LAR.



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  		Figure 1. Top: HDM allergen inhalation test with or without pranlukast in the HDM group. Bottom: Aspirin oral provocation test with or without pranlukast in the ASA group. {circ}: provocation with pranlukast. •: provocation without pranlukast. Data are given as mean ± SEM. *p < 0.05, **p < 0.01.

 
In the HDM group, treatment with pranlukast improved IAR (73.8%) and LAR (51.9%) [p < 0.01 and p < 0.05, respectively; Fig 1 , top]. In the ASA group, treatment with pranlukast improved the aspirin-induced fall in FEV1 (p < 0.01).

Bronchoprovocation Challenge Tests and Measured Sputum Variables
In the HDM group, LTC4-LTD4 levels rose significantly both in IAR and LAR compared to the prechallenge phase (baseline, 88 ± 45; IAR, 420 ± 78 pg/mL, p < 0.05; LAR, 476 ± 47 pg/mL, p < 0.05, respectively; Fig 2 ). The LTC4-LTD4 concentration was significantly higher in the sputum of the ASA group than in that of the HDM group at baseline (228 ± 140 pg/mL vs 88 ± 45 pg/mL, p < 0.05), and rose significantly during aspirin challenge (228 ± 140 to 1,651 ± 133 pg/mL, p < 0.01; Fig 2 ). Pranlukast failed to alter the increase in both HDM and ASA groups.



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  		Figure 2. Changes in sputum LTC4-LTD4 and ECP concentrations and eosinophil rate in the sputum. Open bars: provocation with pranlukast. Closed bars: provocation without pranlukast. Data are given as mean ± SEM. *p < 0.05, **p < 0.01. PRE = pretreatment.

 
In the HDM group, ECP levels in the sputum rose significantly in IAR and even more in LAR (baseline, 136 ± 43; IAR, 305 ± 194 µg/mL, p < 0.05; LAR, 511 ± 36 µg/mL, p < 0.01; Fig 2 ). There was no difference between the ASA group and the HDM group with respect to sputum ECP levels before each challenge. In the ASA group, sputum ECP increased significantly with aspirin challenge without pretreatment with pranlukast (113 ± 28 to 310 ± 58 µg/mL, p < 0.01). The high level of sputum ECP in IAR and LAR in the HDM group and IAR in the ASA group were abrogated by pretreatment with pranlukast (IAR, 305 ± 194 µg/mL vs 199 ± 102 µg/mL, p < 0.05; LAR, 511 ± 36 µg/mL vs 211 ± 41 µg/mL, p < 0.01; and IAR, 310 ± 58 µg/mL vs 92 ± 87 µg/mL, p < 0.01; Fig 2 ).

In the HDM group, eosinophil count in the sputum did not change in IAR, but increased significantly in LAR (baseline, 39 ± 20%; LAR, 68 ± 7%, p < 0.05). There was no difference between the ASA group and the HDM group with respect to eosinophil count in the sputum before each challenge. In addition, there was virtually no change in sputum eosinophil counts following aspirin challenge. The rise in the sputum eosinophil count in LAR in the HDM group was abrogated by pretreatment with pranlukast (without pranlukast, 68 ± 7%; with pranlukast, 31 ± 8%, p < 0.05; Fig 2 ). In the ASA group, pretreatment with pranlukast did not modify the eosinophil count in the sputum.

Bronchoprovocation Challenge Tests and Measured Urinary Variables
Changes in urinary LTE4/creatinine in HDM group were similar to those noted in sputum LTC4-LTD4. Urinary LTE4/creatinine rose significantly both in IAR and LAR after the antigen inhalation challenge (baseline, 103 ± 61 pg/mg creatinine; IAR, 214 ± 38 pg/mg creatinine; p < 0.05; LAR, 187 ± 46 pg/mg creatinine, p < 0.05; Fig 3 ). In the ASA group, urinary LTE4/creatinine at baseline was significantly higher than in the HDM group (ASA, 340 ± 211 pg/mg creatinine; HDM, 103 ± 61 pg/mg creatinine, p < 0.05). Aspirin oral challenge significantly increased urinary LTE4/creatinine in the ASA group to 586 ± 278 pg/mg creatinine (p < 0.05, Fig 3 ). Pretreatment with pranlukast failed to influence these changes in the HDM and ASA groups.



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  		Figure 3. Changes in urinary LTE4/creatinine (Cr) and 11-dhTXB2/creatinine. Open bars: provocation with pranlukast. Closed bars: provocation without pranlukast. Data are given as mean ± SEM. *p < 0.05, **p < 0.01. See Figure 2 for expansion of abbreviation.

 
In the HDM group, challenges did not change urinary 11-dhTXB2/creatinine levels in IAR and LAR (Fig 3) . Urinary 11-dhTXB2/creatinine concentrations were similar at baseline in the ASA and HDM groups. Aspirin challenge resulted in a decrease in urinary 11-dhTXB2/creatinine in the ASA group (p < 0.01). The latter fall was not influenced by pretreatment with pranlukast (Fig 3) .

Bronchoprovocation Challenge Tests and Measured Blood Variables
HDM inhalation challenge did not influence serum LTC4-LTD4, ECP concentrations, and eosinophil count in the blood both in IAR and LAR (Fig 4 ). These parameters were similar at the baseline in ASA and HDM groups. Aspirin challenge did not influence serum LTC4-LTD4, ECP concentrations, or eosinophil count in the blood in the ASA group. Finally, pretreatment with pranlukast did not influence these parameters in HDM and ASA groups.



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  		Figure 4. Changes in serum LTC4-LTD4, ECP, and eosinophil counts in peripheral blood. Open bars: provocation with pranlukast. Closed bars: provocation without pranlukast. Data are given as mean ± SEM. *p < 0.05, **p < 0.01. N.S. = not significant; see Figure 2 for expansion of abbreviation.

 

   Discussion
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
References
 
The main findings of the present study are as follows: (1) A dual asthmatic response (IAR and LAR) was observed in the HDM group. Antigen inhalation tests resulted in increased sputum LTC4-LTD4, and ECP and urinary LTE4/creatinine concentrations in IAR. In LAR, LTs in the sputum and urine persisted at high levels similar to those at IAR, together with increased sputum eosinophil count, while the increase in sputum ECP was more than that in IAR; (2) In the ASA group, only IAR was observed after aspirin oral challenge. Sputum LTC4 and LTD4 and urinary LTE4/creatinine were higher in the ASA group than in the HDM group in the asthma stable state. Aspirin oral challenge increased the concentrations of LTC4-LTD4 and ECP in the sputum and LTE4/creatinine in the urine and induced asthma attacks. (3) Pretreatment with pranlukast abrogated HDM-induced increase in sputum ECP both in IAR and in LAR, sputum eosinophil count in LAR in the HDM group, and aspirin-induced increase in sputum ECP in the ASA group, but did not affect sputum LTs or urinary LTE4. (4) No changes were noted in chemical mediators or eosinophils in peripheral blood.

These findings indicate that overproduction of LT and eosinophilic inflammation in the airway are involved in the onset of asthma, attack both in the ASA group and HDM group, and that LTRA may be useful for both types of asthma, though the production of LTs in the ASA group was much higher than that in the HDM group.

Changes in FEV1 during HDM inhalation tests reported in the present study (both IAR and LAR) were similar to those described in previous studies by our laboratories, as well those of other investigators.4 16 It has been suggested that increases in chemical mediators during BPTs with allergens are due to LT production, which is associated with infiltration and activation of eosinophils in the airways, as well as airway narrowing.16 17 In the present study, urinary LTE4 increased both in IAR and in LAR. In IAR, sputum LTs increased 4.8-fold, and sputum ECP increased 2.2-fold without a local increase in eosinophil number in the airways. In LAR, the increase in sputum LTs was still noted (5.4-fold), and the eosinophil number in the sputum increased significantly (1.7-fold), in addition to 1.7-fold increase in sputum ECP relative to that in IAR. Therefore, these results suggest that the pathogenesis of allergen provocation challenge involves an increase in LTs firstly in IAR and activation of eosinophils in the airways; in LAR, more activation of eosinophils occurs and ECP is secreted. With regard to the effects of LTRA, our results were similar to those of several studies,4 5 10 17 18 which have noted suppression of both IAR and LAR by pretreatment with LTRA (pranlukast, montelukast, and zafirlukast) in allergen-induced bronchoconstriction. With regard to changes in chemical mediators, pranlukast, an LTRA, could not inhibit increases in LTs in sputum or urine, either on IAR or on LAR,17 18 but suppressed increase in sputum ECP on IAR and increase in sputum eosinophil counts and ECP on LAR. Since LTRA has only an effect as receptor antagonist, if we had tested LT synthesis inhibitor, the increase of LT in urine or sputum during IAR and LAR in HDM provocation might be inhibited. In the present study, pretreatment with pranlukast suppressed the activity and migration of eosinophils and airway narrowing. Contrary to our expectations, sputum ECP, eosinophils in the sputum, serum ECP levels, and blood eosinophil counts at baseline failed to decrease significantly with pranlukast treatment for 7 days. One possibility is that these factors were not at very high levels initially, since the severity of asthma in our subjects ranged from mild to moderate and the tests were performed in a stable asthma state. We speculate that these elements may be suppressed by pranlukast treatment if these tests are performed in patients with more severe or unstable asthma.

However, previous studies6 9 have shown that during aspirin challenge, AIA subjects exhibited eosinophil and anti-ECP monoclonal antibody EG-2–positive eosinophil infiltration of the airway and a rise in urinary LTE4. These findings suggest that in patients with AIA, aspirin or nonsteroidal anti-inflammatory drugs cause airway narrowing by increasing the production of LTs and activation of eosinophils. In the present study, induced sputum LTs and urinary LTE4 increased 7.2-fold and 1.7-fold, respectively, and sputum ECP increased 2.7-fold without a local increase in eosinophil number in the airways. Therefore, these results suggest that the pathogenesis of AIA involves an increase in LTs and eosinophil activation in the airways (although recruitment of circulatory eosinophils may occur later) as in the HDM group, and secretion of ECP from eosinophils during a relatively early phase, which resulted in airway narrowing.

With regard to the differences between the ASA group and HDM group in terms of FEV1 changes and chemical mediators in each challenge, previous studies6 9 19 have shown that urinary LTE4 is twofold to 10-fold greater in AIA patients than in aspirin-tolerant asthmatic patients in a stable state. The present findings showed that urinary LTE4 in the ASA group was 3.3-fold that in HDM group subjects. In addition, sputum LTs, which reflect the condition of the airways, in the ASA group were 2.6-fold greater than those in the HDM group. These findings support the notion that there was greater overproduction of LT in the ASA group than in the HDM group. In addition, in the ASA group, LT was produced after aspirin challenge with increased eosinophilic inflammation in the airways. The present findings confirmed the hypothesis that aspirin- induced bronchoconstriction is caused by the shunting of the arachidonic acid metabolism away from the cyclooxygenase pathway toward the 5-lipoxygenase pathway.19

Several studies have examined the effects of aspirin challenge testing on LT modifiers in AIA subjects. With regard to the effects of LTRA, previous studies examined the effect of pranlukast on dypyrone inhalation challenge,10 sulpyrine inhalation challenge,20 the effect of SK&F 104353 on aspirin oral challenge,9 and the effect of MK-0679 on lysine-aspirin inhalation challenge.21 With regard to LT synthesis inhibitors, previous studies22 23 examined the effects of zileuton and ZD2138, a 5-lipoxygenase inhibitor, on aspirin oral challenge. In all studies, each treatment blocked the degree of FEV1 fall during the provocation test. With regard to changes in urinary LTE4, LTRAs did not inhibit aspirin-induced increase in urinary LTE4 because of their merely antagonistic effect on LT receptor,9 10 20 21 while LT synthesis inhibitors abrogated aspirin-induced increase in urinary LTE4.22 23 However, there are no studies that have examined the changes in LT or ECP in the airways. Urinary LTE4 may reflect LT production in the airways, but to clarify the pathogenesis of asthma in AIA subjects, it will be necessary to use sputum, BAL fluid, or biopsy specimens from the airways.

With regard to the methods of provocation, inhalation provocation tests were used in about half of the above-mentioned studies, although clinically, aspirin oral challenge is more useful for a definite diagnosis.6 Therefore, our studies were performed using aspirin oral challenge and collection of induced sputum from the airway. Our results showed that pranlukast did not inhibit aspirin-induced increase in LT production, but inhibited the increase in sputum ECP and reversed the decrease in FEV1 during aspirin challenge in AIA subjects. Thus, pranlukast inhibited the activation of eosinophils and airway narrowing, two effects known to be induced by LT. These results suggest that LTRAs are effective against AIA, and that their effect is probably due to inhibition of mechanisms involved in airway inflammation.

In conclusion, our results suggest that LT overproduction due to arrangement in the 5-lipoxygenase cascade in aspirin-induced asthma, and LT overproduction from mast cells or eosinophils via an antigen-antibody reaction in allergen-induced asthma, play important roles in the respective types of asthma. We also suggested that the effect, based on the amount of LT overproduction, is stronger in aspirin-induced asthmatic patients than in allergen-induced asthmatic patients.


   Footnotes
 
Abbreviations: AIA = aspirin-intolerant asthma; ASA group = aspirin-intolerant asthma patients; BPT = bronchoprovocation test; 11-dhTXB2 = 11-dehydrothromboxane B2; ECP = eosinophil cationic protein; HDM = house dust mite; HDM group = house dust mite-sensitive asthmatic inpatients without aspirin-intolerant asthma; IAR = immediate asthmatic reaction; LAR = late asthmatic reaction; LT = leukotriene; LTRA = leukotriene receptor antagonist; RIA = radioimmunoassay

Received for publication January 3, 2001. Accepted for publication June 11, 2001.


   References
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 

  1. Drazen, JM, Israel, E, O’Byrne, PM (1999) Treatment of asthma with drugs modifying the leukotriene pathway. N Engl J Med 340,197-206[Free Full Text]
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  3. Liu, MC, Dube, LM, Lancaster, J, et al (1996) Acute and chronic effects of a 5-lipoxygenase inhibitor in asthma: a 6-month randomized multicenter trial. J Allergy Clin Immunol 98,859-871[CrossRef][ISI][Medline]
  4. Obase, Y, Shimoda, T, Matsuo, N, et al (1998) Effects of cysteinyl-leukotriene receptor antagonist, thromboxane A2 receptor antagonist, and thromboxane A2 synthetase inhibitor on allergen-induced bronchoconstriction in patients with asthma. Chest 114,1028-1032[Abstract/Free Full Text]
  5. Calhoun, WJ, Lavins, B, Minkwitz, MC, et al (1998) Effect of zafirlukast (Accolate) on cellular mediators of inflammation: bronchoalveolar lavage fluid findings after segmental antigen challenge. Am J Respir Crit Care Med 157,138-139
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