Inhaled steroids modulate extracellular matrix composition in bronchial biopsies of COPD patients: a randomized, controlled trial

Lisette I Z Kunz, Jolanda Strebus, Simona E Budulac, Therese S Lapperre, Peter J Sterk, Dirkje S Postma, Thais Mauad, Wim Timens, Pieter S Hiemstra, GLUCOLD (Groningen Leiden Universities Corticosteroids in Obstructive Lung Disease) Study Group, H F Kauffman, D de Reus, H M Boezen, D F Jansen, J M Vonk, M D W Barentsen, W Timens, M Zeinstra-Smit, A J Luteijn, T van der Molen, G ter Veen, M M E Gosman, N H T ten Hacken, H A M Kerstjens, M S van Maaren, D S Postma, C A Veltman, A Verbokkem, I Verhage, H K Vink-Klooster, H A Thiadens, J B Snoeck-Stroband, J K Sont, J Gast-Strookman, P S Hiemstra, K Janssen, T S Lapperre, K F Rabe, A van Schadewijk, J A Schrumpf, J Smit-Bakker, P J Sterk, J Stolk, A C J A Tiré, H van der Veen, M M E Wijffels, L N A Willems, P J Sterk, T Mauad, Lisette I Z Kunz, Jolanda Strebus, Simona E Budulac, Therese S Lapperre, Peter J Sterk, Dirkje S Postma, Thais Mauad, Wim Timens, Pieter S Hiemstra, GLUCOLD (Groningen Leiden Universities Corticosteroids in Obstructive Lung Disease) Study Group, H F Kauffman, D de Reus, H M Boezen, D F Jansen, J M Vonk, M D W Barentsen, W Timens, M Zeinstra-Smit, A J Luteijn, T van der Molen, G ter Veen, M M E Gosman, N H T ten Hacken, H A M Kerstjens, M S van Maaren, D S Postma, C A Veltman, A Verbokkem, I Verhage, H K Vink-Klooster, H A Thiadens, J B Snoeck-Stroband, J K Sont, J Gast-Strookman, P S Hiemstra, K Janssen, T S Lapperre, K F Rabe, A van Schadewijk, J A Schrumpf, J Smit-Bakker, P J Sterk, J Stolk, A C J A Tiré, H van der Veen, M M E Wijffels, L N A Willems, P J Sterk, T Mauad

Abstract

Rationale: Smoking and inflammation contribute to the pathogenesis of chronic obstructive pulmonary disease (COPD), which involves changes in extracellular matrix. This is thought to contribute to airway remodeling and airflow obstruction. We have previously observed that long-term treatment with inhaled corticosteroids can not only reduce bronchial inflammation, but can also attenuate lung function decline in moderate-severe COPD. We hypothesized that inhaled corticosteroids and current smoking modulate bronchial extracellular matrix components in COPD.

Objective: To compare major extracellular matrix components (elastic fibers; proteoglycans [versican, decorin]; collagens type I and III) in bronchial biopsies 1) after 30-months inhaled steroids treatment or placebo; and 2) between current and ex-smokers with COPD.

Methods: We included 64 moderate-severe, steroid-naive COPD patients (24/40 (ex)-smokers, 62±7 years, 46 (31-54) packyears, post-bronchodilator forced expiratory volume in one second (FEV1) 62±9% predicted) at baseline in this randomized, controlled trial. 19 and 13 patients received 30-months treatment with fluticasone or placebo, respectively. Bronchial biopsies collected at baseline and after 30 months were studied using (immuno)histochemistry to evaluate extracellular matrix content. Percentage and density of stained area were calculated by digital image analysis.

Results: 30-Months inhaled steroids increased the percentage stained area of versican (9.6% [CI 0.9 to 18.3%]; p = 0.03) and collagen III (20.6% [CI 3.8 to 37.4%]; p = 0.02) compared to placebo. Increased collagen I staining density correlated with increased post-bronchodilator FEV1 after inhaled steroids treatment (Rs = 0.45, p = 0.04). There were no differences between smokers and ex-smokers with COPD in percentages and densities for all extracellular matrix proteins.

Conclusions: These data show that long-term inhaled corticosteroids treatment partially changes the composition of extracellular matrix in moderate-severe COPD. This is associated with increased lung function, suggesting that long-term inhaled steroids modulate airway remodeling thereby potentially preventing airway collapse in COPD. Smoking status is not associated with bronchial extracellular matrix proteins.

Trial registration: ClinicalTrials.gov NCT00158847.

Conflict of interest statement

Competing Interests: Mrs. Kunz, Mrs. Strebus, and Mrs. Budulac have no relationships that present a potential conflict of interest. Mrs. Lapperre received payments for a lecture at GlaxoSmithKline. Prof. Sterk, Prof. Postma, Prof. Timens and Prof. Hiemstra received unrestricted grants for the GLUCOLD project from GlaxoSmithKline, The Netherlands Organisation for Scientific Research (NWO), The Netherlands Asthma Foundation, Stichting Astma Bestrijding (SAB), Leiden University Medical Center and University Medical Center Groningen. Prof. Sterk received a grant from Innovative Medicines Initiative (IMI), an EU public-private grant supported by 10 pharmaceutical industries. Prof. Postma has been a consultant to AstraZeneca, Boehringer Ingelheim, Chiesi, GlaxoSmithKline, Nycomed, and TEVA. She has received funding from AstraZeneca, GlaxoSmithKline, and Nycomed. Travel to ERS or ATS has been partially funded by AstraZeneca, GlaxoSmithKline, Chiesi, and Nycomed. Prof. Mauad received a grant from Brazilian National Council for Scientific and Technological Development (CNPq) for the GLUCOLD project. Prof. Timens received a grant from The Netherlands Asthma Foundation, an unrestricted grant from Merck Sharp Dohme and payments for lectures at GlaxoSmithKline. In addition, he received travel expenses for invited lectures at British Division of the International Academy of Pathology, University of Giessen Lung Center, University of Graz, European Respiratory Society, and Menarini Diagnostics. Prof. Hiemstra received grants from Boehringer Ingelheim, Centocor, and Galapagos. The authors have no patents and products in development to declare. The authors did use fluticasone propionate and salmeterol (either the combination or fluticasone alone), which is marketed by GlaxoSmithKline, for our investigator-initiated study. This does not alter the authors' adherence to all the PLOS ONE policies on sharing data and materials. There are no other employments, patents and products in development or modified products to declare.

Figures

Figure 1. Examples of (immuno)histochemical stainings.
Figure 1. Examples of (immuno)histochemical stainings.
The same bronchial biopsy section is shown for the histochemical staining for elastic fibers (A) and the immunohistochemical stainings for versican (B), decorin (C), collagen type I (D) and collagen type III (E). Original magnification 200×.
Figure 2. Percentage and density of stained…
Figure 2. Percentage and density of stained area for placebo and fluticasone for all ECM proteins.
Percentage (upper panel) and density (lower panel) of stained area in bronchial biopsies is presented. Open figures: baseline percentage stained area, closed figures: percentage stained area after 30 months. Horizontal bars represent medians.
Figure 3. Correlation between change in post-bronchodilator…
Figure 3. Correlation between change in post-bronchodilator FEV1 (L) and change in density of collagen I.
Both values represent values after 30 months minus values at baseline. Closed circles represent fluticasone treated subjects, open circles represent placebo treated subjects.
Figure 4. Percentage and density of stained…
Figure 4. Percentage and density of stained area at baseline of ex-smokers and smokers with COPD.
Percentage (upper panel) and density (lower panel) of stained area in bronchial biopsies is presented. Ex-smokers are presented as open circles, current smokers as closed circles. Horizontal bars represent medians. No significant differences were found for all studied extracellular matrix proteins (both percentage stained area and density).
Figure 5. Correlation between percentage collagen type…
Figure 5. Correlation between percentage collagen type I at baseline and lung function parameters.
Panel A presents post-bronchodilator FEV1 (% predicted) and panel B shows PC20 (in doubling dose).

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