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Clinical Investigations: BRONCHODILATORS |

A Bolus of Inhaled Budesonide Rapidly Reverses Airway Subsensitivity and β2-Adrenoceptor Down-regulation After Regular Inhaled Formoterol*

Imran Aziz, MBBS; Brian J. Lipworth, MD
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*From the Department of Clinical Pharmacology and Therapeutics and Department of Respiratory Medicine, Ninewells Hospital and Medical School, Dundee, Scotland, UK.



Chest. 1999;115(3):623-628. doi:10.1378/chest.115.3.623
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Background: Subsensitivity of airwayβ 2-adrenoceptors develops readily in asthmatics receiving regular long-acting β2-agonists. This subsensitivity may be rapidly reversed by using systemic corticosteroids. The purpose of the present study was to investigate whether the same acute facilitatory effects occur when using a bolus dose of inhaled corticosteroid.

Methods: Ten subjects with stable mild-to-moderate asthma, with a mean age of 27 years, mean (± SD) FEV1 of 2.95 L (0.94 L), 81% (15%) of predicted, all receiving inhaled corticosteroids, reactive to adenosine monophosphate (AMP) with a provocative concentration producing a 20% fall in FEV1 (PC20) < 200 mg/mL, were recruited into a randomized double-blind crossover study. The subjects received two separate 1-week treatment periods with formoterol dry powder, 24 μg bid, with an initial 1-week run-in and a 1-week washout period between the treatments. A single dose of placebo or budesonide turbuhaler, 1,600 μg, was taken in conjunction with the last dose of both treatment periods. AMP challenge was performed 2 h after the first and last dose of formoterol. Blood for lymphocyteβ 2-adrenoceptor density (Bmax) was also measured before and after treatment with formoterol.

Results: There was no significant difference in the geometric mean PC20 after the first dose of formoterol comparing the two treatment periods: 362 mg/mL vs 391 mg/mL. The PC20 after the last dose of formoterol was significantly higher (p < 0.05) in conjunction with budesonide than with placebo: 427 mg/mL vs 99 mg/mL, amounting to a 4.3-fold difference (95% confidence interval [CI], 1.1 to 16.6). For comparison within each treatment period, there was significant subsensitivity (p < 0.05) between the first and last dose of formoterol when the latter was given with placebo: 391 mg/mL vs 99 mg/mL, a 3.9-fold fall (95% CI, 1.0 to 15.2), but not when the latter was given with budesonide: 362 mg/mL vs 427 mg/mL, a 1.2-fold rise (95% CI, 0.5 to 2.8). Lymphocyte β2-adrenoceptor density (geometric mean Bmax: fmol/106 cells) also showed significant down-regulation (p < 0.05) by formoterol given with placebo: preformoterol 2.53 vs postformoterol 1.91, but not by formoterol given with budesonide: preformoterol 2.43 vs postformoterol 2.67. The Bmax was significantly higher (p < 0.05) with formoterol + budesonide as compared to formoterol + placebo, amounting to a 1.40-fold difference (95% CI, 1.09 to 1.80).

Conclusion: We have shown that a bolus dose of inhaled budesonide rapidly reverses subsensitivity to AMP bronchoprotection and associated β2-adrenoceptor down-regulation in asthmatics taking regular formoterol. Further studies are indicated to assess whether high-dose inhaled corticosteroids should be administered as soon as possible along with β2-agonists during an acute episode of bronchoconstriction.

Abbreviations: AMP = adenosine monophosphate; Arg = arginine;β 2-AR = β2-adrenoceptor; Bmax = lymphocyte β2-adrenoceptor binding density; CI = confidence interval; FEF25–75 = forced expiratory flow rate between 25% and 75% of vital capacity; Gln = glutamine; Glu = glutamic acid; Gly = glycine; Kd = lymphocyteβ 2-adrenoceptor binding affinity as dissociation constant; PC20 = provocation concentration producing a 20% fall in FEV1

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