Airway responses and inflammation in subjects with asthma after four days of repeated high-single-dose allergen challenge

Johannes Schulze, Sandra Voss, Ulrich Zissler, Markus A Rose, Stefan Zielen, Ralf Schubert, Johannes Schulze, Sandra Voss, Ulrich Zissler, Markus A Rose, Stefan Zielen, Ralf Schubert

Abstract

Background: Both standard and low-dose allergen provocations are an established tool in asthma research to improve our understanding of the pathophysiological mechanism of allergic asthma. However, clinical symptoms are less likely to be induced. Therefore, we designed a protocol for repetitive high-dose bronchial allergen challenges to generate clinical symptoms and airway inflammation.

Methods: A total of 27 patients aged 18 to 40 years with positive skin-prick tests and mild asthma underwent repetitive high-dose allergen challenges with household dust mites for four consecutive days. Pulmonary function and exhaled NO were measured at every visit. Induced sputum was analysed before and after the allergen challenges for cell counts, ECP, IL-5, INF-γ, IL-8, and the transcription factor Foxp3.

Results: We found a significant decrease in pulmonary function, an increased use of salbutamol and the development of a late asthmatic response and bronchial hyperresponsiveness, as well as a significant induction of eNO, eosinophils, and Th-2 cytokines. Repeated provocation was feasible in the majority of patients. Two subjects had severe adverse events requiring prednisolone to cope with nocturnal asthma symptoms.

Conclusions: Repeated high-dose bronchial allergen challenges resulted in severe asthma symptoms and marked Th-2-mediated allergic airway inflammation. The high-dose challenge model is suitable only in an attenuated form in diseased volunteers for proof-of-concept studies and in clinical settings to reduce the risk of severe asthma exacerbations.

Trial registration: ClinicalTrials.govNCT00677209.

Figures

Figure 1
Figure 1
Study design.
Figure 2
Figure 2
Salbutamol use during the provocation period (overall mean 3.5 puffs). The mean day to day use did not change significantly (p = 0.59). The bronchodilator use directly after the challenges is not included.
Figure 3
Figure 3
Maximal drop in FEV1during the early asthmatic response after the single-step challenges. (a). All subjects (n = 27), V0 represents the screening values. The mean drop in FEV1: V0, 15.6% ± 4.3; V1, 9.6% ± 9.9; V2, 17.5% ± 14.6; V3, 11.2% ± 10.5; V411, 2% ± 15.9. The values were not different between visits 2 and 4 (p = 0.30). (b). The 15 subjects that developed LARs. The mean drop in FEV1: V1, 11.8% ± 10.4; V2, 28.7% ± 15.3; V3, 23.8% ± 11.2; V4, 27.4% ± 18.9. The values were not different between visits 2 and 4 (p = 0.85).
Figure 4
Figure 4
The PD20FEV1methacholine on a logarithmic scale before and after the bronchial allergen challenges. The PD20FEV1 decreased significantly from1.30 mg ± 1.08 to 0.45 mg ± 0.72 (p < 0.001).
Figure 5
Figure 5
Increase of exhaled NO 24 hours after the single-step challenges. After each visit, the values increased stepwise. The data points are connected by lines that indicate individual courses of high, medium, and low responders.
Figure 6
Figure 6
Sputum cells and ECP before and after the bronchial allergen challenges. (a). The total cell number was equally distributed in both samples (p = 0.80). (b and c). The total count and percentage of eosinophils increased significantly (p < 0.001). (d and e). The ECP increased significantly (p < 0.01), whereas the cytokine levels were unchanged in relation to the eosinophil cell counts (p = 0.64).
Figure 7
Figure 7
Cytokine expression in the sputum before and after bronchial allergen challenges. The values are related to the total cell numbers. (a). A significant increase in IL-5 expression (p < 0.01). (b). The IFN-γ expression did not significantly decline (p = 0.09). (c). The IL-8 expression was unchanged (p = 0.89). (d). A significant increase in Foxp3 expression (p < 0.05).

References

    1. Gauvreau GM, Watson RM, Rerecich TJ, Baswick E, Inman MD, O'Byrne PM. Repeatability of allergen-induced airway inflammation. J Allergy Clin Immunol. 1999;104:66–71. doi: 10.1016/S0091-6749(99)70115-6.
    1. Schulze J, Rosewich M, Dressler M, Riemer C, Rose MA, Zielen S. Bronchial allergen challenge using the medicaid dosimeter. Int Arch Allergy Immunol. 2012;157:89–97. doi: 10.1159/000324473.
    1. Fahy JV, Fleming HE, Wong HH, Liu JT, Su JQ, Reimann J, Fick RB, Boushey HA. The effect of an anti-IgE monoclonal antibody on the early- and late-phase responses to allergen inhalation in asthmatic subjects. Am J Respir Crit Care Med. 1997;155:1828–1834.
    1. Gauvreau GM, Becker AB, Boulet LP, Chakir J, Fick RB, Greene WL, Killian KJ, O'byrne PM, Reid JK, Cockcroft DW. The effects of an anti-CD11a mAb, efalizumab, on allergen-induced airway responses and airway inflammation in subjects with atopic asthma. J Allergy Clin Immunol. 2003;112:331–338. doi: 10.1067/mai.2003.1689.
    1. Rosewich M, Rose MA, Eickmeier O, Travaci M, Kitz R, Zielen S. Montelukast as add-on therapy to beta-agonists and late airway response. Eur Respir J. 2007;30:56–61. doi: 10.1183/09031936.00063106.
    1. van Rensen EL, Evertse CE, van Schadewijk WA, van Wijngaarden S, Ayre G, Mauad T, Hiemstra PS, Sterk PJ, Rabe KF. Eosinophils in bronchial mucosa of asthmatics after allergen challenge: effect of anti-IgE treatment. Allergy. 2009;64:72–80. doi: 10.1111/j.1398-9995.2008.01881.x.
    1. Djukanović R, Feather I, Gratziou C, Walls A, Peroni D, Bradding P, Judd M, Howarth PH, Holgate ST. Effect of natural allergen exposure during the grass pollen season on airways inflammatory cells and asthma symptoms. Thorax. 1996;51:575–581. doi: 10.1136/thx.51.6.575.
    1. Sulakvelidze I, Inman MD, Rerecich T, O'Byrne PM. Increases in airway eosinophils and interleukin-5 with minimal bronchoconstriction during repeated low-dose allergen challenge in atopic asthmatics. Eur Respir J. 1998;11:821–827. doi: 10.1183/09031936.98.11040821.
    1. Arshad SH, Hamilton RG, Adkinson NF. Repeated aerosol exposure to small doses of allergen. A model for chronic allergic asthma. Am J Respir Crit Care Med. 1998;157:1900–1906.
    1. Roquet A, Lagging E, Ihre E, van Hage-Hamsten M, Halldén G, Härfast B, Zetterström O. No signs of activity markers in peripheral blood despite increased bronchial reactivity after repeated low-dose allergen exposure. APMIS. 1998;106:293–299. doi: 10.1111/j.1699-0463.1998.tb01349.x.
    1. Lensmar C, Prieto J, Dahlén B, Eklund A, Grunewald J, Roquet A. Airway inflammation and altered alveolar macrophage phenotype pattern after repeated low-dose allergen exposure of atopic asthmatic subjects. Clin Exp Allergy. 1999;29:1632–1640. doi: 10.1046/j.1365-2222.1999.00757.x.
    1. de Kluijver J, Evertse CE, Schrumpf JA, van der Veen H, Zwinderman AH, Hiemstra PS, Rabe KF, Sterk PJ. Asymptomatic worsening of airway inflammation during low-dose allergen exposure in asthma: protection by inhaled steroids. Am J Respir Crit Care Med. 2002;166:294–300. doi: 10.1164/rccm.2112097.
    1. Liu LY, Swenson CA, Kelly EA, Kita H, Jarjour NN, Busse WW. Comparison of the effects of repetitive low-dose and single-dose antigen challenge on airway inflammation. J Allergy Clin Immunol. 2003;111:818–825. doi: 10.1067/mai.2003.1346.
    1. Schubert R, Kitz R, Beermann C, Rose MA, Lieb A, Sommerer PC, Moskovits J, Alberternst H, Böhles HJ, Schulze J, Zielen S. Effect of n-3 polyunsaturated fatty acids in asthma after low-dose allergen challenge. Int Arch Allergy Immunol. 2009;148:321–329. doi: 10.1159/000170386.
    1. Grainge C, Howarth PH. Repeated high-dose inhalation allergen challenge in asthma. Clin Respir J. 2011;5:150–155. doi: 10.1111/j.1752-699X.2010.00212.x.
    1. Boulet LP, Gauvreau G, Boulay ME, O'Byrne P, Cockcroft DW. The allergen bronchoprovocation model: an important tool for the investigation of new asthma anti-inflammatory therapies. Allergy. 2007;62:1101–1110. doi: 10.1111/j.1398-9995.2007.01499.x.
    1. Rose MA, Weigand B, Schubert R, Schulze J, Zielen S. Safety, tolerability, and impact on allergic inflammation of autologous E.coli autovaccine in the treatment of house dust mite asthma - a prospective open clinical trial. BMC Complement Altern Med. 2011;3:11–45.
    1. Brusasco V, Crapo R, Viegi G. ATS/ERS Task Force: Standardisation of spirometry. Eur Respir J. 2005;26:319–338. doi: 10.1183/09031936.05.00034805.
    1. Schulze J, Rosewich M, Riemer C, Dressler M, Rose MA, Zielen S. Methacholine challenge - comparison of an ATS protocol to a new rapid single concentration technique. Respir Med. 2009;103:1898–1903. doi: 10.1016/j.rmed.2009.06.007.
    1. Silkoff PE. et al.Recommendations for standardized procedures for the online and off-line measurement of exhaled lower nitric oxide and nasal nitric oxide in adults and children –1999. The official statement of the American Thoracic Society was adopted by the ATS Board of Directors, July 1999. Am J Respir Crit Care Med. 1999;1999(160):2104–2117.
    1. Livak KJ, Schmittgen TD. Analysis of relative gene expression data using real-time quantitative PCR and the 2(−Delta Delta C(T)) Method. Methods. 2001;25:402–408. doi: 10.1006/meth.2001.1262.
    1. Taylor DA, Harris JG, O'Connor BJ. Comparison of incremental and bolus dose inhaled allergen challenge in asthmatic patients. Clin Exp Allergy. 2000;30:56–63. doi: 10.1046/j.1365-2222.2000.00657.x.
    1. Wasserfallen JB, Leuenberger P. Comparison between incremental and single-dose allergen administration in bronchial provocation tests. J Asthma. 1996;33:169–178. doi: 10.3109/02770909609054549.
    1. Bland JM, Altman DG. Applying the right statistics: analyses of measurement studies. Ultrasound Obstet Gynecol. 2003;22:85–93.
    1. De Blay F, Krieger P, Spirlet F, Moreau L, Duvernelle C, Kassel O, Kopferschmitt MC, Gasser B, Demangeat C, Pauli G, Frossard N. Repeated inhalation of low doses of cat allergen that do not induce clinical symptoms increases bronchial hyperresponsiveness and eosinophil cationic protein levels. Int Arch Allergy Immunol. 1999;120:158–165. doi: 10.1159/000024234.
    1. Rosenthal RR, Norman PS, Summer WR. Bronchoprovocation: effect on priming and desensitization phenomenon in the lung. J Allergy Clin Immunol. 1975;56:338–346. doi: 10.1016/0091-6749(75)90127-X.
    1. Moscato G, Dellabianca A, Paggiaro P, Bertoletti R, Corsico A, Perfetti L. Peak expiratory flow monitoring and airway response to specific bronchial provocation tests in asthmatics. Monaldi Arch Chest Dis. 1993;48:23–28.
    1. Bérubé D, Cartier A, L'Archevêque J, Ghezzo H, Malo JL. Comparison of peak expiratory flow rate and FEV1 in assessing bronchomotor tone after challenges with occupational sensitizers. Chest. 1991;99:831–836. doi: 10.1378/chest.99.4.831.
    1. Cockcroft DW, Ruffin RE, Dolovich J, Hargreave FE. Allergen-induced increase in non-allergic bronchial reactivity. Clin Allergy. 1977;7:503–513. doi: 10.1111/j.1365-2222.1977.tb01481.x.
    1. Cartier A, Thomson NC, Frith PA, Roberts R, Hargreave FE. Allergen-induced increase in bronchial responsiveness to histamine: relationship to the late asthmatic response and change in airway caliber. J Allergy Clin Immunol. 1982;70:170–177. doi: 10.1016/0091-6749(82)90038-0.
    1. Kharitonov SA, O'Connor BJ, Evans DJ, Barnes PJ. Allergen-induced late asthmatic reactions are associated with elevation of exhaled nitric oxide. Am J Respir Crit Care Med. 1995;151:1894–1899.
    1. Thunberg S, Gafvelin G, Nord M, Grönneberg R, Grunewald J, Eklund A, van Hage M. Allergen provocation increases TH2-cytokines and FOXP3 expression in the asthmatic lung. Allergy. 2010;65:311–318. doi: 10.1111/j.1398-9995.2009.02218.x.
    1. Erpenbeck VJ, Hagenberg A, Krentel H, Discher M, Braun A, Hohlfeld JM, Krug N. Regulation of GATA-3, c-maf and T-bet mRNA expression in bronchoalveolar lavage cells and bronchial biopsies after segmental allergen challenge. Int Arch Allergy Immunol. 2006;139:306–316. doi: 10.1159/000091602.
    1. Liu L, Jarjour NN, Busse WW, Kelly EA. Enhanced generation of helper T type 1 and 2 chemokines in allergen-induced asthma. Am J Respir Crit Care Med. 2004;169:1118–1124. doi: 10.1164/rccm.200312-1659OC.
    1. De Monchy JG, Kauffman HF, Venge P, Koëter GH, Jansen HM, Sluiter HJ, De Vries K. Bronchoalveolar eosinophilia during allergen-induced late asthmatic reactions. Am Rev Respir Dis. 1985;131:373–376.
    1. Pin I, Freitag AP, O'Byrne PM, Girgis-Gabardo A, Watson RM, Dolovich J, Denburg JA, Hargreave FE. Changes in the cellular profile of induced sputum after allergen-induced asthmatic responses. Am Rev Respir Dis. 1992;145:1265–1269.
    1. Hori S, Nomura T, Sakaguchi S. Control of regulatory T cell development by the transcription factor Foxp3. Science. 2003;299:1057–1061. doi: 10.1126/science.1079490.
    1. Hartl D, Koller B, Mehlhorn AT, Reinhardt D, Nicolai T, Schendel DJ, Griese M, Krauss-Etschmann S. Quantitative and functional impairment of pulmonary CD4 + CD25hi regulatory T cells in pediatric asthma. J Allergy Clin Immunol. 2007;119:1258–1266. doi: 10.1016/j.jaci.2007.02.023.
    1. Akdis CA, Akdis M. Mechanisms and treatment of allergic disease in the big picture of regulatory T cells. J Allergy Clin Immunol. 2009;123:735–746. doi: 10.1016/j.jaci.2009.02.030.
    1. Orihara K, Narita M, Tobe T, Akasawa A, Ohya Y, Matsumoto K, Saito H. Circulating Foxp3 + CD4+ cell numbers in atopic patients and healthy control subjects. J Allergy Clin Immunol. 2007;120:960–962. doi: 10.1016/j.jaci.2007.05.036.

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