Prevention of lung deterioration is one of the most important goals in Cystic Fibrosis therapy. Persistent pulmonary infection causes a hyperactive inflammatory response and inflammation mediators give an important contribution to airway damage. The inflammation of the CF lung is dominated by neutrophils, that release oxidants and proteases, particularly elastase, in the CF airway secretions. As affirmed (Cantin AM, 2015), several defective inflammatory responses have been linked to CFTR deficiency including innate and acquired immunity dysregulation, cell membrane lipid abnormalities, various transcription factor signaling defects, as well as altered kinase and toll-like receptor responses.
Inflammation precedes the appearance of bronchiectasis and correlates with lung function deterioration. So, drugs that target inflammation have been hypotized to slow the decline in lung function and improve survival. Up to date, in addition to systemic corticosteroids and azithromycin, between non-steroidal anti-inflammatory drugs (NSAIDs) only ibuprofen at high doses (serum concentration higher than 50 micrograms per millilitre), has been recommended to prevent the loss of lung function.
International Guidelines (Flume PA, 2007), had suggested that ibuprofen had to be prescribed in individuals with FEV1 greater than 60% predicted, even if, more recently, an international committee (Mogayzel PJ, 2013) has narrowed the previous recommendation to include only children 6–17 years of age, because of the insufficient information about adult population and has stressed the necessity to maintain the ibuprofen serum concentration of 50–100 mg/m, because of neutrophil migration increases, rather than decreases, at lower serum levels.
In 2018 (Konstan MW,2018) an association was observed between high-dose ibuprofen use and both slower lung function decline and improved long-term survival, in a study about 775 high-dose ibuprofen users and 3,665 non-users CF children.
The necessity to study efficacy and safety of antinflammatory new drugs has been, far back, discussed (Banner KH, 2009), revised three years later (Rowe SM, 2012) and in 2015 (Cantin A, 2015), (Sagel SD, 2015). In particular, on the basis of the results about the LTB4 receptor antagonist use in CF (Konstan MW, 2014), it has been speculated that the administration of potent anti-inflammatory compounds to individuals with chronic infections, may increase the risk of infection-related adverse events, because of the potential to significantly suppress the inflammatory response.
The Cystic Fibrosis Foundation, in early 2014, established a working group to address antiinflammatory drug development in CF. It has been suggested that, before bringing new antiinflammatory drugs to clinical trial, preclinical safety studies must be conducted in disease-relevant models, to assuage safety concerns and that pharmacokinetic-pharmacodynamic studies and early-phase safety studies have to be performed before proceeding to larger studies of longer duration (Torphy TJ, 2015).
In the 2019 CFF drug development Pipeline, besides Ibuprofene, four compounds are taken into consideration regarding anti-inflammatory therapy:
3 in phase two: Acebilustat (CTX-4430); Lenabasum (JBT-101; a form of the retinoid fenretinide (LAU-7b).
1 in phase one: a compound designed to block the function of neutrophil elastase (POL 6014)
- NSAIDs efficacy in preventing pulmonary deterioration, evaluated in terms of lung function evolution, lung infection exacerbation frequency, quality of life and survival.
- Short-term and long-term NSAIDs therapy-associated adverse events (above all increase of pulmonary infective exacerbations, haemorrhagic episodes, gastrointestinal symptoms, allergic reactions, fluid retention, kidney and liver problems).
- Useful markers of inflammatory status.
What is known
One CDSR (Lands LC, 2016) identified 10 trials; four have been included in the review (287 participants aged five to 39 years; maximum follow up of four years): three trials compared ibuprofen to placebo and one trial assessed piroxicam versus placebo. Combined data from the two largest ibuprofen trials showed a significantly lower annual rate of decline for lung function in the ibuprofen group in younger children. In one trial, long-term use of high-dose ibuprofen was associated with reduced intravenous antibiotic use, improved nutritional and radiological pulmonary status. No major adverse effects were reported. In the trial comparing piroxicam to placebo, no data were available to show difference between the groups.
Other studies include the following:
One RCT published in June 2002 (20 enrolled patients) did not show any significant efficacy of i.v. prostaglandin (PGE1) in reducing serum inflammation markers.
One RCT published in 2007 showed a clear reduction of airway inflammation after alpha1-antitrypsin treatment, although no effect on lung function was observed.
In 2015 a RCT has studied the safety of therapy with Inhaled alpha1-proteinase inhibitor prescribed once daily for 3 weeks in 30 CF adults and has showed that it is safe and well tolerated.
One RCT published in 2009 (4 enrolled patients) showed lung function improvement with Aminotryptilin for 14 days.
One phase II RCT published in 2013 studied the sphingomyelinase inhibitor acid Amitriptyline, which showed, in mices, to be able to normalize mucociliary clearance, chronic inflammation and infection susceptibility to pulmonary P. aeruginosa by reducing ceramide levels. In this study Amitriptilyna, showed to reduce ceramide levels in nasal epithelial cells, to be safe and to increase FEV1 values in the 44 CF enrolled patients In 2016 an RCT showed that Amitriptyline significantly increases FEV1, reduces ceramide in lung cells and increases weight in patients treated with 25mg amitriptyline twice daily and observed after one, two and three years after continuous use of the drug.
One RCT published in 2012, in which 11 patients homozygous for the F508del mutation received oral miglustat, showed no effect on nasal potential difference variables.
One RCT published in 2012 evaluated the safety and the efficacy of the neutrophil elastase inhibitor AZD9668 on clinical outcomes, inflammation biomarkers and tissue damage. In the AZD9668 group, there was a trend towards reduction in sputum inflammatory biomarkers (interleukin-6, RANTES, and urinary desmosine).
In 2015 it has been published an open-label, controlled trial to assess IL-6, IL-8, TNF-α, IL-1-β, free neutrophil elastase, and white cell counts, in patients randomized to high dose of ibuprofen or to routine care. IL-6 was the only biomarker with significant within-group change among ibuprofen-treated subjects and no change in the control group.
One RCT published in 2018 (Jain R, 2018) showed that KB001-A, an anti-PcrV PEGylated monoclonal antibody fragment to the Type III secretion system of P.aeruginosa, is safe, well-tolerated and associated with a modest FEV1 benefit and reduction in select sputum inflammatory markers.
- Efficacy and safety of the new antinfiammatory drugs.
- Efficacy and safety of ibuprofen therapy for a prolonged period of time, mainly in children, also in pre-symptomatic ones.
Several RCT are ongoing:
A Phase 2 RCT on anti-inflammatory effect of digitoxin on IL-8 and neutrophil counts in induced sputum in stable patients (NCT00782288)
A Phase 2 RCT to evaluate the efficacy, safety, and tolerability of CTX-4430 administered orally once-daily for 48 weeks in Adults. (NCT02443688)
A Phase 2, double-blind, Multicenter RCT to evaluate safety, tolerability, pharmacokinetics, and efficacy of JBT-101 in adults. (NCT02465450)
A Phase 2 RCT evaluating safety and efficacy of Roscovitine in CF patients homozygous for the F508del-CFTR mutation (NCT02649751)
A Phase 2, Muticenter RCT to evaluate efficacy and safety of Lenabasum 5 mg vs placebo CF patients older than 12 years of age is recruiting (NCT03451045)
A Phase 2 RCT Study about Efficacy and Safety of LAU-7b in the Treatment of Cystic Fibrosis in Adults - (NCT03265288)
A Phase IIa, RCT to evaluate safety and efficacy of subcutaneous administration of Anakinra in Patients With Cystic Fibrosis who are ≥ 12 years of age (NCT03925194)