Statistical modeling in pharmaceutical research and development.
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COPD Pathogenesis and Inflammatory Mediators
1.
2. COPD
Gamal Rabie Agmy, MD,FCCP Professor of Chest Diseases, Assiut university
3.
4. Goal of this learning modules
â˘To Provide a framework to make informed decisions regarding the diagnosis and treatment of Chronic obstructive pulmonary disease
5. Learning objectives
After completing this module you should know:
â˘know the definition of COPD
â˘Understand the burden of COPD
â˘know the risk factors of COPD occurrence
â˘Learn about the pathology, pathogenesis and Pathophysiology of COPD.
6. History of COPD
â˘A British medical textbook (1860s )â C/P of chronic bronchitis as an advanced disease with repeated bronchial infections that ended in right-sided heart failure.
â˘20th century, Ciba symposium of 1958 proposed definitions of chronic bronchitis and emphysema â concept of airflow obstruction.
â˘Chronic bronchitis: chronic productive cough for 3 months during each of 2 consecutive years (other causes of cough being excluded).
â˘Emphysema: an abnormal, permanent enlargement of the air spaces distal to the terminal bronchioles, accompanied by destruction of their walls and without obvious fibrosis
7. Definition & Overview Common preventable & treatable disease Characterized by persistent airflow limitation that is usually progressive Associated with an enhanced chronic inflammatory response in the airways & the lung to noxious particles or gases Exacerbations & comorbidities contribute to the overall severity in individual patients
8. COPD is a progressive disease The Downward Spiral in COPD
9. Burden of COPD COPD is a leading cause of morbidity & mortality worldwide The burden will increase in coming decades due to continued exposure to risk factors & the aging of the worldâs population COPD is associated with significant economic burden
10. Prevalence Buist AS, McBurnie MA, Vollmer WM, et al. International variation in the prevalence of COPD (the BOLD Study): a population- based prevalence study. Lancet. 2007;370:741-750. 11.8% 8.5% 10.1% overall
11. COPD Misdiagnosis Is Common in Women
Chapman KR, Tashkin DP, Pye DJ. Gender bias in the diagnosis of COPD. Chest. 2001;119:1691-1695
12. Under diagnosis of COPD in the United States
⢠Over 12 million people in the United
States have been diagnosed with
COPD; another 12 million are
estimated to be undiagnosed1
⢠Data from NHANES III indicate that
approximately 24 million US adults
have evidence of impaired lung
function indicative of COPD2,3
⢠Most (70%) of patients with
undiagnosed COPD are <65 years
70%
<Age 65
30%
âĽAge
65
Percent With Undiagnosed COPD
1. NHLBI; available at http://www.nhlbi.nih.gov/health/public/lung/copd/index.html. 3. Mannino DM, et al. Proc Am Thorac Soc. 2007;4:502-306
2. Mannino DM, et al. MMWR Surveill Summ. 2002;51:1-16.
13. Mortality :
Global burden of Disease study: COPD rank Murray and Lopez Lancet 1997
15. Mortality :
Global burden of Disease study
â˘Almost 90% of COPD deaths occur in low- and middle-income countries.
16. Economic and social burden
Economic
â˘USA: Direct costs $ 29.5 billion & Indirect costs $ 20.4 billion
â˘Europe: 38.6 billion Euros
â˘In developing countries:
âWorkplace & home productivity loss > Medical costs loss
Social
â˘Disability-Adjusted Life year (DALY)
â1990â 12th leading cause of DALYs
â2030 â 7th leading cause of DALYs
17. Risk factors for COPD Influence disease development & progression
18. Genes
â˘Gene-environmental interaction are the key for development of COPD.
â˘Susceptibility to COPD is not dichotomous variable and a range of susceptibility exits.
âSome smokers develop the disease earlier than others.
âProgression in COPD is very heterogeneous
19. Genes
â˘In patients with COPD
âemphysema represents accelerated ageing of the lung
âstudies showed telomere shortening & dysfunction
â˘Telomerase null mice with short telomeres
âincreased emphysema
âdouble-strand DNA breaks
â˘after exposure to chronic cigarette smoke
â˘with evidence of reduced epithelial repair
â˘Family with a telomerase mutation
âhave early-onset emphysema
21. Airway Responsiveness-Dutch Hypothesis
â˘Increased airways responsiveness and allergy are clinical phenotypes that predict increased susceptibility to cigarette smoke.
â˘Methacholine and histamine responsiveness precedes and predicts accelerated decline in lung function, thus a risk factor for COPD.*
â˘Increased airways responsiveness noted among 1st degree relatives of patients with early onset COPD.^
*Silva, GE et al. Asthma as a risk factor for COPD in a longitudinal study. Chest 2004; 126:59.
^Celedon JC et al. Bronchodilator responsiveness and serum total IgE levels in families of probands with severe early-onset COPD. Eur Respir J 1999; 14:1009.
23. These data are communicated for scientific purpose only. Confidential slide set
23
Apoptotic Pathways in COPD
Demedts IK, et al. Respir Res. 2006;7:53. Reproduced with permission from Biomed Central.
Survival factor
Granzyme B
Perforin
TNF-Îą
sFasL
cytoplasm
nucleus
ER Stress
Apoptosome
Apaf 1
Procasp-9
Procasp-9
Casp-9
Casp-8
CAD
CAD
ICAD
Casp-8
Procasp-8
Procasp-8
FADD
Bid
tBid
Bax
Bak
Cyt C
ER stress
DNA fragmentation
1
2
4
3
5
?
Fas
COPD Pathogenesis
24. These data are communicated for scientific purpose only. Confidential slide set
25. These data are communicated for scientific purpose only. Confidential slide set
25
Angiogenesis in COPD
Reprinted from International Journal of COPD, 2, Siafakas NM, et al., Role of angiogenesis and vascular remodeling in chronic obstructive pulmonary disease, 453-462, Copyright 2007, with permission from Dove Medical Press Ltd.
extravasated plasma proteins
Inflammatory cells (Mac, Neu, Epith, Lymph)
Release of angiogenic mediators
Fibrinogen products
Inflammation
Tissue hypoxia
Airway fibrosis
Mechanical Injury
Increased blood flow
Vessel growth Angiogenesis Vascular remodeling
Up-regulation of Angiogenic factors
Shear stress on the endothelium
COPD Pathogenesis
26. These data are communicated for scientific purpose only. Confidential slide set
Angiogenic and Angiostatic Factors in COPD
â˘Angiogenic CXC Chemokines, CC Chemokines, and Growth Factors:
âCXCL1
âCXCL5
âCXCL8
âCCL2
âVEGF
âbFGF
âAngiopoietin-1
âHGF
âEGF
⢠Angiostatic CXC Chemokines, CC Chemokines, and Growth Factors:
âCXCL10
Siafakas NM, et al. Int J Chron Obstruct Pulmon Dis. 2007;2:453-462.
COPD Pathogenesis
28. These data are communicated for scientific purpose only. Confidential slide set
Inflammatory Cells in Stable COPD
Gamal Agmy 2-5-2014
Inflammation in COPD
29. These data are communicated for scientific purpose only. Confidential slide set
29
Neutrophils in COPD
Mucous hypersecretion
Serine proteases
Neutrophil Elastase
Cathepsin G
Proteinase-3
ďO2-
MPO
LTB4, IL-8, GRO-ďĄ
LTB4, IL-8
Adapted from Barnes PJ. N Engl J Med. 2000; 343: 269-280
Adapted from Barnes PJ, et al. Eur Respir J. 2003; 22: 672-688
Emphysema
Severe emphysema
Images courtesy R Buhl.
Inflammation in COPD
30. These data are communicated for scientific purpose only. Confidential slide set
30
Sputum Neutrophil Count Correlates With Declining Lung Function
Reproduced with permission of Thorax from âAirways obstruction, chronic expectoration and rapid decline of FEV1 in smokers are associated with increased levels of sputum neutrophils,â Stanescu et al, Vol 51, Copyright Š 1996; permission conveyed through Copyright Clearance Center, Inc.
> 30
< 20
100
0
Neutrophils in iInduced sputum (%)
90
20 â 30
80
60
70
50
40
FEV1 decline (mL/year)
P<0.01
Inflammation in COPD
31. These data are communicated for scientific purpose only. Confidential slide set
31
Neutrophils Infiltrating Bronchial Glands in COPD
Saetta M, et al. Am J Respir Crit Care Med. 1997;156:1633-1639. Reproduced with permission from American Thoracic Society. Copyright Š 1997
Inflammation in COPD
32. These data are communicated for scientific purpose only. Confidential slide set
32
Reduction in Neutrophil Apoptosis in COPD
Adapted from Brown V, et al. Respir Res. 2009;10:24.
Apoptotic neutrophils (arrows)
*P<0.05
*P<0.01
Morphology
Tunel
NS
HS
COPD
60
50
40
30
20
10
0
Apoptotic neutrophils [%]
Image courtesy of R Buhl.
NS: nonsmoking controls (n=9) HS: healthy smoking controls (n=9)
TUNEL: the terminal transferase- mediated dUTP nick end-labeling method
Inflammation in COPD
33. These data are communicated for scientific purpose only. Confidential slide set
33
Alveolar Macrophages in COPD
ďŻ Phagocytosis
Cigarette smoke
Wood smoke
Elastolysis
MMP-9, MMP-12
Cathepsins K, L, S
Emphysema
Steroid resistance
NO
ONOO- ROS
ďŻ HDAC
ďŻ Steroid
response
Monocytes
MCP-1
GRO-ďĄ
Neutrophils
LTB4
IL-8
GRO-ďĄ
CD8+ Cells
IP-10
Mig
I-TAC
Adapted f rom Barnes PJ. J COPD. 2004;1:59-70. Copyright Š 2004 f rom "Alveolar Macrophages as Orchestrators of COPD" by
Barnes. Reproduced by permission of Taylor & Francis Group, LLC., www.taylorandf rancis.com
Emphysema
Severe emphysema
Images courtesy of R Buhl.
ď Numbers
ď Secretion
Inflammation in COPD
34. These data are communicated for scientific purpose only. Confidential slide set
34
Inflammatory Mediators in COPD â Summary
Cell
Neutrophils
Macrophages
T-cell
Epithelial cell
IL-8, TGF- ď˘1, IP-10, Mig, I-TAC, LTB4, GRO- ďĄ, MCP-1, MMP-9
Granzyme B, perforins, IFN-ď§, TNF-ďĄ
IL-8, IL-6, TGF-ď˘1 TGF-ďĄ, IP-10, Mig, I-TAC, LTB4, GRO-ďĄ, MCP-1, ROS, MMP-9
Serine proteases, TNF-ďĄ, ROS, IL-8, MPO, LTB4
Selected Mediators
Barnes PJ, et al. Eur Respir J. 2003;22:672-888.
Inflammation in COPD
35. These data are communicated for scientific purpose only. Confidential slide set
35
Examples of Chemotactic Factors in COPD
Barnes PJ. Curr Opin Pharmacol. 2004;4:263-272.
Hill AT, et al. Am J Respir Crit Care Med. 1999;160: 893-898.
Montuschi P, et al. Thorax. 2003;58:585-588.
ďŹMCP-1
ďŹGRO-ďĄ
ďŹElastin fragments
ďŹLTB4
ďŹIL-8
ďŹGRO-ďĄ
ďŹElastin fragments
ďŹIP-10
ďŹMig
ďŹI-TAC
Neutrophil
Monocyte
T-cell
Inflammation in COPD
36. These data are communicated for scientific purpose only. Confidential slide set
36
TNF-ďĄ Has Pro-inflammatory Actions in COPD
Mukhopadhyay S, et al. Respir Res. 2006;7:125. Reproduced with permission from Biomed Central.
Oxidative stress
Activation of NF-ďŤB and AP-1
Activation of proinflammatory molecules e.g. VCAM-1, ICAM-1 and RAGE
Subcellular ROS production
TNF-ďĄ
Antioxidants
e.g. GSH, Catalase
Scavenge free radicals,
detoxify cellular
hydrogen peroxide and
inhibit ROS generation
Proinflammation
+
+
+
+
+
+
+
-
-
Inflammation in COPD
37. These data are communicated for scientific purpose only. Confidential slide set
Modulation of Inflammation by Histone Deacetylase (HDAC)
Inflammation in COPD
Gamal Agmy 2-5-2014
38. These data are communicated for scientific purpose only. Confidential slide set
38
Decreased HDAC Expression May Promote
Inflammation and Decrease Response to
ICS in COPD
Normal
Histone
acetylation
Stimuli
Steroid
sensitive
Histone
hyperacetylation
nitration
ubiquitination
oxidation
âTNFďĄ
âIL-8
âGM-CSF
Stimuli
Steroid
resistant
HAT
TF
HAT
TF
TNFďĄ
IL-8
GM-CSF
Glucocorticoid
receptor
COPD
HDAC2
HDAC2
Glucocorticoid
peroxynitrite
Reproduced f rom Pharmacol Ther, Vol 116, Ito et al, âImpact of protein acetylation in inf lammatory lung diseases,â pp249-265.
Copyright Š 2007, with permission f rom Elsevier.
Inflammation in COPD
39. These data are communicated for scientific purpose only. Confidential slide set
39
Pulmonary HDAC Levels Decrease With COPD Severity
Adapted from Ito K, et al. N Engl J Med. 2005;352:1967-1976.
S = COPD Stage
0
.5
1.0
1.5
2.0
Non- smoker
N=11
P<0.001
HDAC2 expression (vs. lamin A/C)
P=0.04
P<0.001
P<0.001
S4
N=6
S0
N=9
S1
N=10
S2
N=10
â
â
â
â
â
Inflammation in COPD
40. These data are communicated for scientific purpose only. Confidential slide set
Inflammation Leads to Small Airway Narrowing
â˘Acute and chronic inflammation suspected to contribute to COPD- related small airway narrowing
â˘Airway narrowing leads to airway obstruction
â˘Narrowing results from several factors:
âCollagen deposition and increased lymphoid follicles in outer airway wall
âMucosal thickening of airway lumen
âInflammatory exudate in airway lumen
Barnes PJ, et al. Eur Respir J. 2003;22: 672-688.
Inflammation in COPD
41. These data are communicated for scientific purpose only. Confidential slide set
41
Inflammation and Airway Destruction
Normal
COPD
Reproduced from The Lancet, Vol 364, Hogg JC. "Pathophysiology of airflow limitation in chronic obstructive pulmonary disease," pp709-721. Copyright Š 2004, with permission from Elsevier.
Inflammation in COPD
42. These data are communicated for scientific purpose only. Confidential slide set
42
Exacerbations of Chronic Bronchitis and Inflammatory Cell Types
Saetta M, et al. Am J Respir Crit Care Med. 1994;150:1646-1652. Maestrelli P, et al. Am J Respir Crit Care Med. 1995;152:1926-1931.
Barnes PJ. N Engl J Med. 2000;343:269-280.
COPD Exacerbation
Eosinophils
Eosinophils
T-Cells
Neutrophils
Cells Predominant in:
Induced sputum
Biopsy
Neutrophils
Inflammation in COPD
43. These data are communicated for scientific purpose only. Confidential slide set
43
Clinical Impact of Inflammation in COPD
Tsoumakidou M, et al. Respir Res. 2006;7:80. Reproduced with permission from Biomed Central.
Increased Airway Inflammation
Increased mucous production
Airway wall thickening
Airway wall oedema
Bronchoconstriction
Airway narrowing
Vâ/Qâ Mismatching
Hyperinflation
Worsening of gas exchange
Increased work of breathing
Increased oxygen consumption â
Decreased mixed venous oxygen
Cough, sputum, dyspnoea, Respiratory failure
Inflammation in COPD
44. These data are communicated for scientific purpose only. Confidential slide set
44
Inflammation: Clinical Consequences
Systemic
â˘Nutritional abnormalities and weight loss
â˘Hypoxaemia
â˘Skeletal muscle dysfunction
â˘Cardiovascular disease
â˘Depression
â˘Osteoporosis
â˘Anaemia
Agusti AG, et al. Eur Respir J. 2003;21:347-360.
Agusti AG. Proc Am Thorac. 2006;3:478-483.
Barnes PJ, Cell BR. Eur Respir J. 2009;33:1165-1185.
Pulmonary
ďŹDyspnoea
ďŹCough
ďŹSputum production
ďŹExacerbations
Inflammation in COPD
47. The site of pathology in COPD
Mucus gland hyperplasiaGoblet cellhyperplasiaMucus hypersecretionNeutrophilsin sputumSquamousmetaplasiaof epitheliumâMacrophagesNo basement membrane thickeningLittle increase inairway smooth muscleâCD8+lymphocytesChanges in Large Airways of COPD PatientsChanges Patients Source: Peter J. Barnes, MD
49. The site of pathology in COPD
Disrupted alveolar attachmentsInflammatory exudatein lumenPeribronchialfibrosisLymphoid follicleThickened wall with inflammatory cells-macrophages, CD8+ cells, fibroblastsChanges in Small Airways in COPD Patients Source: Peter J. Barnes, MD
50. The site of pathology in COPD Endothelial dysfunctionIntimalhyperplasiaSmooth muscle hyperplasiaâInflammatory cells(macrophages, CD8+lymphocytes) Changes in Pulmonary Arteries in COPD Patients Source: Peter J. Barnes, MD
53. Emphysema
â˘Centriacinar
âFocal destruction limited to the respiratory bronchioles and the central portions of the acini.
âassociated with cigarette smoking
âmost severe in the upper lobes
â˘Panacinar
âinvolves the entire alveolus distal to the terminal bronchiole.
âmost severe in the lower lung zones
âAAT deficiency
â˘Distal acinar or paraseptal
âleast common form and involves distal airway structures, alveolar ducts, and sacs.
loss of alveolar walls and dilatation of airspaces in emphysema
54. Natural History of Emphysema
â˘In non-smokers, maximal lung function
âattained at age 15 - 25 years
âafter a variable plateau phase, declines ~ 20 -25 mL/year
â˘Lung Health Study (large longitudinal study)
âsmoking is associated with an accelerated decline in lung function
â˘Females are at higher risk of lung damage
ârelated to smoke exposure than males
55. Fletcher C et al. 1977
FEV1 (% of value at age 25)
100
25
50 75 Never smoked or not susceptible to smoke Age (years)
Disability
Smoked regularly and susceptible to its effects
Death
0
25 50 75 Stopped at 65
Stopped at 45 Classical View of âDisease Progressionâ & âDisease Modificationâ