A clinical and immunologic in asthma
study of colchicine
Yehuda A. Schwarz, MD,* Shmuel Kivity, MD,* David N. Ilfeld, MD,** Menachem Schlesinger, MD, *** Joel Greif, MD,* Marcel Topilsky, MD,* and Moshe S. Garty, MD ** Tel Aviv, Petah Tikva, and Ashkelon, Israel A double-blind, randomized, crossover chronic study was done to determine the e@cacy of colchicine in 10 atopic patients with asthma. A constant dose of sustained-release theophylline and albuterol by inhalation, as needed, was administered. Compared to placebo, colchicine, 0.5 mg twice daily, significantly reduced the mean ( +SEM) daily clinical score from 2 .I8 * 0.34 to I.64 2 0.32 (p < O.OS), and the daily number of inhalations of albuterolfrom 5.89 +- I.48 to 4.01 ? 1.26 (p < 0.02). Colchicine significantly (p < 0.05) increased the concanavalin A-induced suppressor cell function from 16.2 t 4.6% to 39.0 ? 10.7%, which was similar to healthy volunteers (41.1 f 3.5%). Furthermore, colchicine sign$cantly (p < 0.05) decreased serum IgE from 248 +- 63 to 188 ? 46 Wlml. Colchicine had no significant effect on pulmonary function tests, the early phase reaction of antigen-induced bronchial inhalation challenge, and immediate skin test responses. Thus, colchicine has immunomodulatory effects that may perhaps have a mild benejit in the treatment of asthma. (J ALLERGYCLIN iMMUNOL 1990;85:578-82.)
Colchicine is an anti-inflammatory drug that has been reported to be useful in the treatmentof patients with gout, pseudogout,’ psoriatic arthritis,* chronic cutaneousleukocytoclastic vasculitis,3 familial Mediterranean feveq4and cirrhosis.5.6 Colchicine has also beendemonstratedto be an immunomodulating agent. Patients with familial Mediterranean fever have a deficiency of Con A-induced suppressorcell function that is corrected by either in vitro or in vivo colchitine.” 8 Patients with primary biliary cirrhosis also have a deficiency of Con A-induced suppressorcell function that is corrected in vitro by a pharmacologic concentration of colchicine.’ Patients with asthma have a deficiency of Con A-induced suppressorcell function,10-‘4which is partially correctedby either oral
From tbe *Institute of Pulmonary and Allergic Diseases,Tel Aviv Medical Center, Tel Aviv, **Clinical Pharmacology UnitMedicine F, Beiliison Medical Center, Petab Tikva, and ***Allergy and Immunology Unit, Barzilai Medical Center, Asbkelon, Israel. Received for publication Nov. 15, 1988. Revised April 28, 1989. Accepted for publication July 6, 1989. Correspondenceaddress:David N. Ilfeld, MD, 8 Levitan St., Apt. No. 3, Tel Aviv 69204, Israel. Reprint requests:Mosbe S. Garty MD, Clinical PharmacologyUnitMedicine F, Beilinson Medical Center, Petab Tikva, Israel. l/1/17555
578
Abbreviations used
ConA: ConcanavalinA PEFR: PHA: b.i.d.: LTB,:
Peak expiratory flow rate Phytohemagglutinin Twice daily LeukotrieneB,
theophylline or oral colchicine and almost completely corrected by oral theophylline together with in vitro colchicine at a pharmacologic concentration.14*I5 These observations, together with the in vitro synergistic effect of colchicine with agentsthat elevate intracellular levels of cyclic adenosine monophosphate,I6raised the possibility that oral colchicine may be useful in the treatmentof asthma.Accordingly, we conducted a randomized, double-blind, crossover study of the effect of colchicine in patients with asthma. MATERIAL Subjects
AND METHODS
Sevenmaleandthreefemalepatients,aged18 to 43 years (mean, 25.2 years), with perennialasthma(mean duration of disease, 12.4 years), participated in a double-blind, crossover, randomized chronic study. This study was approved
VOLUMLNUMBER
Clinical study of colchicine iit ,ssthma 579
85 3
P
PLACEBO
COLCHICINE
-I PLACEBO
COLCHICINE PLACEBO
FK;. 1. Effect of colchicine on daily clinical score and on the number of inhalations of albuterol per day. Results are illustrated
as individually
paired
data and mean.
by the Helsinki committee at the Tel Aviv Medical Center. All subjectsgaveinformed consent.All patientshad positive immediate skin test responsesto the house dust mite, Dermatophagoidesfarinae (Pharmacia Fine Chemicals, Uppsala, Sweden). Without bronchodilators, the FEV, of the patients, expressedas a percentageof normal predictedvalues, was 15% after inhalation of 200 kg of albuterol. The patients had no other significant health problems as assessedby complete history, physical examination, and routine blood tests. No patient was receiving cromoglycate, glucocorticosteroids, oral @adrenergic agonists, or medications interacting with theophylline, such as erythmmycin, phenytoin, or cimetidine. Eight male and two female healthy volunteers, aged 25 to 41 years (mean, 32 years), served as a control group for measurementof Con A-induced suppressorcell function. Protocol All subjects were receiving sustained-releasetheophylline (Theo-Dur; Key Pharmaceuticals Inc., Kenilworth, N.J.), 200 to 300 mg b.i.d. The mean serum theophylline steady-statelevel was 10.6 &g/ml. Inhalations of albuterol (Ventolin: Glaxo Inc., ResearchTriangle Park, N.C.) were taken, as needed,and recordedin a daily diary. Tablets of colchicine (Rafa; Jerusalem, Israel), 0.5 mg, or placebo were each taken orally, b.i.d., for 4 weeksduring either the third to sixth weeks or during the ninth to twelfth weeks, asdeterminedby a randomizedtable. The first 2 weekswere the run in, and the seventhand eighth weekswere the washout periods. A clinical score for shortnessof breath and wheezing from 0 for no symptomsto 9 for severesymptoms was recordedin a daily diary. Compliance was >90% for the colchicine and placebo, as measuredby daily diary report and residual tablet count.
COLC‘WlNE
FIG. 2. Effect of colchicine on suppressor call function. Con A-induced suppressor cell function of peripheral blood mononuclear cells was measured for subjects with asthma during the administration of placebo and colchitine and for normal volunteers. Results are illustrated as individually paired data and mean.
The PEFR was measuredwith a Wright peak flow meter every morning and evening at home, and the best of three measurementswas recorded. The mean for each patient’s PEFR was calculated for weeks 3 to 6 and for weeks 9 to 12. At the end of each regimen (drug or placebo at week 6 or 12). pulmonary function tests(Spyro analyzer CSA-800, Fukuda Sangyo Co., Tokyo, Japan), bronchial provocation tests, immediate skin test responses, serum loge (microELBA, WalkerLaboratories, Syracuse.N.Y. 1, and Con Ainduced suppressorcell function were measured. Bronchial
inhalation
challenge
Patientshad bronchial provocation with increasing doses of the house dust mite D. farinae (PharmaciaFine Chemicals), and the dose was recordedthat causeda decreaseof at least 20% of the FEV, .” Immediate
skin test respanses
The house dust mite D. farime was injected intradermally at a concentration of 1000biological units in 0.03 ml. For nonspecific reactivity, 0.03 ml of the compound 48180 at a concentration of 0.5 mg/ml was injected intradermally. As a control, the diluent phenol-buffered saline albumin was injected. The wheal was measuredat 20 minutes, and the results were expressedas areain square centimeters. Con A-induced
suppressor
ceH fune$ion
Peripheral blood mononuclear cells were isolated flwm heparinized blood by density centrifugation on Ficoll-
580 Schwarz et al. TABLE I. Effect of colchicine
J. ALLERGY
on pulmonary
function
Run in
FVC (L) =v, (L) FEV,/FVC% FEF,.,,, (LI set) V mm (L/W V miulS W sed
4.27 + 3.23 r 77 k 2.96 k 3.36 2 1.53 ?
0.35 0.33 3 0.40 0.51 0.26
CLIN. IMMUNOL. MARCH 1990
tests Placebo
4.38 * 0.33 3.33 +- 0.35 74 t 4 3.07 ? 0.42 3.24 + 0.47 1.50 * 0.24
Colchicine
4.48 +- 0.32 3.38 ? 0.35 73 -+ 3 2.86 k 0.39 3.00 + 0.45 1.48 c 0.25
FEF,.,m Forced expiratory flow between 25% and 75% of vital capacity; VW,,, maximum expiratory flow at 50% of vital capacity; VWu, maximum expiratory flow at 25% of vital capacity. Patients were tested at the end of the 2-week run-in and at the end of 4 weeks of placebo or colchicine administration.
Hypaque. Mononuclear cells (5 X 106) were cultured at 37” C in 1 ml of culture medium (RPM1 1640, penicillin, streptomycin, and glutamine), including 10% heatinactivated human AB serumwithout (control cells) or with (suppressorcells) 10 kg/ml of Con A (three times crystallized, Miles Yeda Inc., Rehovot, Israel) in a 5% CO, Per 95% air-humidified environment. After 44 hours, thesecells were. incubated for 30 minutes with 50 p.g/mI of mitomytin C (Sigma Chemical Co., St. Louis, MO.) and washed, and then 1 x 105of these cells were cocultured at 37” C for 72 hours with 1 x lo5 fresh allogeneic healthy volunteers’ mononuclear responder cells and 1 pg/ml of PHA (Difco LaboratoriesInc., Detroit, Mich.) in 0.2 ml of culture medium. Tritiated thymidine was addedat the last 16 hours of culture. Samplesin triplicate were harvested, and thymidine uptake was measuredin a B-scintillation counter. Percentagesuppressionof mtiated thymidine uptake was calculated according to the following formula: %suppression = [l - [cpm(respondercells + suppressorcells + PHA) cpm(respondercells + suppressorcells)] / [cpm (respondercells + control cells + PHA) - cpm (respondercells + control cells)]] x 100
Statistical analysis Results are presentedas mean f SEM, and significance was calculated by two-tailed Wilcoxon matched-pairs signed-rankstest.
RESULTS During colchicine administration, the subjects had a significantly (p < 0.05) lower daily clinical score (1.64 r 0.32) than during placebo administration (2.18 r 0.34) (Fig. 1). Nine of the 10 patients had lower clinical scores while they were receiving colchicine. The subjects had significantly (p < 0.02) lower number of inhalations of albuterol per day (4.01 + 1.26) during colchicine administration than during placebo administration (5.89 + 1.48) (Fig. 1). For the eight patients receiving albuterol during placebo administration, seven patients decreased the number of inhalations of albuterol during the admin-
istration of colchicine, and the other patient had the same number of inhalations. There was no significant difference during placebo or colchicine administration for daily PEFR (456 + 36 and 452 2 36 L/min, respectively) or pulmonary function tests measured at the end of 4 weeks of placebo or colchicine administration (Table I). Similarly, at the end of 4 weeks of treatment, there was no significant difference between placebo and colchicine for the early phase reaction of bronchial inhalation challenge (27,919 t 14,257 and 40,601 + 24,787 biological units, respectively; n = 6). There was no immediate skin test response to the allergen D. farinae (3.4 + 0.6 and 3.0 & 0.5 cm’, respectively) or a nonspecific skin reaction to compound 48/80 (2.6 2 0.6 and 3.1 _+ 1.1 cm*, respectively). Seven patients had suppressor cell function measured during the administration of placebo and colchicine. During placebo administration, patients had a deficiency of Con A-induced suppressor cell function (16.2 + 4.6%) that was significantly (p < 0.05) increased during colchicine administration to levels (39.0 & 10.7%) that were similar to levels of healthy volunteers (41.1 ? 3.5%) (Fig. 2). Colchicine significantly (p < 0.05) decreased serum IgE as compared to placebo (188 + 46 versus 248 t 63 IU/ ml, respectively).
DISCUSSION Colchicine was mildly beneficial, as demonstrated by a mild decrease in the clinical score and the number of inhalations of albuterol. These clinical observations are preliminary because the number of patients studied was small, and patients were only mildly symptomatic. Colchicine had no effect on pulmonary function tests; therefore, it did not act as a bronchodilator. Colchicine had no effect on immediate skin test responses, which is consistent with our preliminary results of the lack of a significant effect of colchi-
VOLUME NUMBER
Clinical
85 3
tine on bronchial provocation in the early phase reaction. There is a preliminary study of antigeninduced bronchial provocation in ragweed-allergic patients in which colchicine, 0.6 mg b.i.d. for 7 days, decreasedthe late-phasereaction and sometimes the early phasereaction. I8This suggeststhat, by whatever unknown mechanisms colchicine might act in asthma, it may be predominantly affecting the latephaseresponse. We have previously demonstratedthat either oral theophylline or oral colchicine partially corrects the deficiency of Con A-induced suppressorcell function in patients with asthma.14.” Furthermore, in vitro colchicine at a pharmacologic concentration was synergistic with oral theophylline for almost completely correcting the deficiency of Con A-induced suppressor cell function.14 In our present study, during the regimen of oral theophylline administration, together with placebo administration, the patients had low levels of suppressorcell function, whereasduring oral theophylline administration, together with oral colchicine administration, they had normal levels of Con A-induced suppressorcell function. This raises the possibility that oral colchicine may be additive or synergistic with oral theophylline for correcting the Con A-induced suppressorcell function. The immunopathogeneticrole of the deficiency of nonspecific suppressorcell function in asthma is not known. Allergen-specific and nonspecific suppressor cells may inhibit the immune and inflammatory reaction to allergens. For example, the increased suppressorcell function during the administration of colchicine may have, in part, resulted in the decreaseof serumIgE and nonspecific suppressorcells may down regulate the late-phasereaction to nonspecific stimuli. In a study of allergen-induced bronchial provocation, patients with asthma who had an early but not latephasereaction had an increasednumber and percentage of T8 + suppressor/cytotoxic T-lymphocytes in their bronchoalveolar lavage fluid, whereas patients with asthma who had both early and late-phase reactions had no significant change in T8 + cells.” Thus, the mobilization of suppressorT cells into the lung after an allergen-induced early phase reaction might be associatedwith the prevention of a late-phase reaction. Colchicine has beendemonstratedto have a variety of effects. Colchicine inhibits leukocyte adhesiveness, lysosomal degradation, and neutrophil chemotaxis, and binds to tubulin, which prevents microtubule polymerization, resulting in a net effect of microtubule disassembly. In vitro studies have demonstratedthat the mechanismof action by which colchicine inhibits the formation by neutrophils of lipoxygenase prod-
study of colchicine
in asthma
581
ucts, such as LTB4, appearsto be causedby the effect of colchicine on microtubules.*’ However, in vivo studies of the anti-inflammatory activity of coichicine analogs suggestthat the effect on microtubules may not be the primary mechanism.2’The administration of colchicine in vivo inhibits the in vitro synthesis and/or release of neutrophil chemotactic factor,” LTB,,18and interleukin-l*’ (Ilfeld DN, Postlethwaite AE. Unpublished data.). Neutrophil chemotactic factor and LTB, are chemotactic for neutrophils. Interleukin- 1 is synthesizedby macrophagesand other cells and has a variety of actions that enhanceinflammatory reactions, including stimulating the proliferation of T-lymphocytes and acting as a chemotactic factor for helper/ inducer T-lymphocytes.” Thesefactors may, in part, be responsible for the recruitment of leukocytes into the lung, and colchicine may perhaps decreasethe late-phasereaction by suppressing the synthesis or releaseof these factors. In conclusion, colchicine is an immunomodulatory agentthat may perhapshave mild efficacy in the treatment of asthma;however, a study with more patients who are more symptomatic would be neededto determine the efficacy. The only frequent side effects of daily treatmentwith colchicine for more than 10years in patients with cirrhosis, familial Mediterranean fever, or gout who have normal renal function are abdominal discomfort, nausea,and, especially, diarrhea that can be avoided by titrating the dose and thus preventing the gastrointestinalside effects.’ ‘5Patients with renal insufficiency. when they are administered colchicine, can developea myoneuropathy.Z’The dose of colchicine used in our study (1 mg!day) is a small dose, and many patients can take larger dosesof colchicine. Thus, further clinical and immunologic studies are indicated to determine the effect of c%olchicine in patients with asthma. REFERENCES 1.
2. 3.
4.
5.
6.
I.
Alvarellos A, Spilberg 1. Colchicine prophylaxic in pseudogout. J Rheumatol 1986;13:804-5. Seideman P, Fjellner B, Johannesson A. Psoriatic arthritis treated with oral colchicine. J Rheumatol 1987:14:777-9. Callen JP. Colchicine is effective in controlling chronic cutaneous leukocytoclastic vasculitis. J Am Acad Dermatol 1987;13:193-200. Dinarello CA, Wolff SM, Goldfinger SE, Dale DC, Ailing DW. Colchicine therapy for familial Mediterranean fever: a double-blind study. N Engl J Med 1974;291:934-7. Kershenobich D, Vargas F, Garcia-Tsao G, Tamayo RP, Gent M, Rojkind M. Colchicine in the treatment of cirrhosis of the liver. N Engl J Med 1988;318:1709-13. Kaplan MM, Alling DW, Zimmerman HJ, et al. A prospective trial of colchicine for primary biliary cirrhosis. N Engl J Med 1986;3 15: 1448-54. Ilfeld D, Kuperman 0. Correction of a suppressor cell deticiency in four patients with familial Mediterranean fever by
582
Schwarz
et al.
in vitro or in vivo colchicine. Clin Exp Immunol 1982;50:99106. 8. SchlesingerM, Ilfeld D, Handzel ZT, et al. Effect of colchicine on immunoregulatory abnormalities in familial Mediterranean fever. Clin Exp Immunol 1983;54:73-9. 9. Ilfeld D, Theodor E, Delpre G, Kuperman 0. In vitro correction of a deociency of Con A-induced suppressorcell function in primary biliary cirrhosis by a pharmacologicalconcentration of colchicine. Clin Exp Immunol 1984;57:438-42. 10. Harper TB, Gaumer HR, Waring W, Brannon RB, Salvaggio JE. A comparison of cell-mediated immunity and suppressor T-cell function in asthmaticand normal children. Clin Allergy 1980;10:555-63. 11. Rola-Pleszczynski M, Blanchard R. Suppressorcell function in respiratory allergy. Int Arch Allergy Apply Immunol 1981$X361-70. 12. Rivlin J, Kuperman 0, Freier S, Godfrey S. SuppressorTlymphocyte activity in wheezy children with and without treatment by hyposensitization. Clin Allergy 1981;11:353-6. 13. Hwang KC, Fig SM, Friedman HM, Gupta S. Deficient concanavalin A-induced suppressor-cell activity in patients with bronchial asthma, allergic rhinitis, and atopic dermatitis. Clin Allergy 1985;15:67-72. 14. Ilfeld D, Kivity S, Feierman E, Topilsky M, Kuperman 0. Effect of in vitro colchicine andoral theophylline on suppressor cell function of asthmatic patients. Clin Exp Immunol 1985; 61:360-7. 15. Ilfeld DN, Mazar A, Garty M, et al. Effect of oral colchicine on T cell subsets,monocytesand concanavalinA-induced suppressor cell function in asthmatic patients. Clin Allergy 1986;16:407-16. 16. Rudolph SA, GreengardP, Malawista SE. Effects of colchicine on cyclic AMP levels in human leukocytes. Proc Nat1 Acad Sci USA 1977;74:3404-8. 17. Chai H, Farr RS, Froehlich LA, Mathison DA, et al. Stan-
J. ALLERGY
CLIN. IMMUNOL. MARCH 1990
dardization of bronchial inhalation challengeprocedures.J ALLERGYCLIN IMMUNOL1975;56:323-7. 18. Peters SP, Freeland HS, Kelly SJ, et al. Is leukotriene B, an important mediator in human IgE-mediated allergic reactions? Am Rev Respir Dis 1987;135:S42-S5. 19. Gonzalez MC, Diaz P, Galleguillos FR, Antic P, Cromwell 0, Kay AB. Allergen-induced recruitmentsof bronchoalveolar helper (OKT4) and suppressor(OKT8) T-cells in asthma:relative increasesin OKT8 cells in single early responderscompared with those in late-phaseresponders.Am Rev Respir Dis 1987;136:600-4. 20. Reibman J, Haines KA, Rich AM, Cristello P, Giedd KN, WeissmannG. Colchicine inhibits ionophore-inducedformation of leukotriene B, by human neutrophils: the role of microtubules. J Immunol 1986;136:1027-32. 21. Sugio K, Maruyama M, Tsurufugi S, Sharma P, Brossi A. Separation of tubulin-binding and anti-inflammatory activity in colchicine analogsand congeners.Life Sci 1986;40;35-9. 22. Spilberg I, Mandell B, Mehta J, Simchowitz L, RosenbergD. Mechanisms of action of colchicine in acute urate crystalinduced arthritis. J Clin Invest 1979;64:775-80. 23. KershenobichD, Alcocer J, Quiroga A, Rojkind M. Effect of colchicine on immunoregulatory T-lymphocytes and monocytes in patients with primary biliary cirrhosis [Abstract]. Clin Res 1984;32:490a. 24. Hunninghake GW, Glazier AJ, Monick MM, Dinarello CA. Interleukin- I is a chemotacticfactor for humanT-lymphocytes. Am Rev Respir Dis 1987;135:66-71. 25. Peters RS, Lehman TJ, Schwabe AD. Colchicine use for familial Mediterraneanfever: observationsassociatedwith longterm treatment. West J Med 1983;138:43-6. 26. Kuncl RW, DuncanG, WatsonD, Alderson K, Rogawski MA, PeperM. Colchicine myopathy and neuropathy.N Engl J Med 1987:316:1562-8.
AVAILABLE NOW! The FIVE-YEAR (1981-1985) CUMULATIVE INDEX TO THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY can be purchasedfrom the Publisher for $42.00. This comprehensive,156-pagereferenceguide is a current presentation of all topics included in the JOURNALfrom January 1981 to December 1985 (volumes 6776)-the past 10 volumes. It incorporatescomplete referencesto over 672 original articles, abstracts,casereports, letters, editorials, and CME articles. It features 1,525 Subject Headings, under which there are 5,316 references.Each subject entry lists the complete article title, author(s), volume, page, and year of publication. It also includes 4,780 Author Entries, listing contributors, along with their respectivetitles, author-to-authorreferral, volume, page, and publication date. To purchase, call or write: Mosby-Year Book, Inc., 11830 Westline Industrial Dr., St. Louis, MO 63146-3318, or telephone FREE l-800-325-4177, Journal Fulfillment, ext. 7531 (in Missouri call collect at 314-872-8370, Journal Fulfillment, ext. 7531). Please referencebook code number 2605-6 when placing your order. PREPAYMENT REQUIRED. Make checkspayable to Mosby-Year Book, Inc. (All paymentsmust be in US funds drawn on a US bank.) Price: $42.00 in the US, $44.75 international (price includes mailing charges).
I
I
study of colchicine
Yehuda A. Schwarz, MD,* Shmuel Kivity, MD,* David N. Ilfeld, MD,** Menachem Schlesinger, MD, *** Joel Greif, MD,* Marcel Topilsky, MD,* and Moshe S. Garty, MD ** Tel Aviv, Petah Tikva, and Ashkelon, Israel A double-blind, randomized, crossover chronic study was done to determine the e@cacy of colchicine in 10 atopic patients with asthma. A constant dose of sustained-release theophylline and albuterol by inhalation, as needed, was administered. Compared to placebo, colchicine, 0.5 mg twice daily, significantly reduced the mean ( +SEM) daily clinical score from 2 .I8 * 0.34 to I.64 2 0.32 (p < O.OS), and the daily number of inhalations of albuterolfrom 5.89 +- I.48 to 4.01 ? 1.26 (p < 0.02). Colchicine significantly (p < 0.05) increased the concanavalin A-induced suppressor cell function from 16.2 t 4.6% to 39.0 ? 10.7%, which was similar to healthy volunteers (41.1 f 3.5%). Furthermore, colchicine sign$cantly (p < 0.05) decreased serum IgE from 248 +- 63 to 188 ? 46 Wlml. Colchicine had no significant effect on pulmonary function tests, the early phase reaction of antigen-induced bronchial inhalation challenge, and immediate skin test responses. Thus, colchicine has immunomodulatory effects that may perhaps have a mild benejit in the treatment of asthma. (J ALLERGYCLIN iMMUNOL 1990;85:578-82.)
Colchicine is an anti-inflammatory drug that has been reported to be useful in the treatmentof patients with gout, pseudogout,’ psoriatic arthritis,* chronic cutaneousleukocytoclastic vasculitis,3 familial Mediterranean feveq4and cirrhosis.5.6 Colchicine has also beendemonstratedto be an immunomodulating agent. Patients with familial Mediterranean fever have a deficiency of Con A-induced suppressorcell function that is corrected by either in vitro or in vivo colchitine.” 8 Patients with primary biliary cirrhosis also have a deficiency of Con A-induced suppressorcell function that is corrected in vitro by a pharmacologic concentration of colchicine.’ Patients with asthma have a deficiency of Con A-induced suppressorcell function,10-‘4which is partially correctedby either oral
From tbe *Institute of Pulmonary and Allergic Diseases,Tel Aviv Medical Center, Tel Aviv, **Clinical Pharmacology UnitMedicine F, Beiliison Medical Center, Petab Tikva, and ***Allergy and Immunology Unit, Barzilai Medical Center, Asbkelon, Israel. Received for publication Nov. 15, 1988. Revised April 28, 1989. Accepted for publication July 6, 1989. Correspondenceaddress:David N. Ilfeld, MD, 8 Levitan St., Apt. No. 3, Tel Aviv 69204, Israel. Reprint requests:Mosbe S. Garty MD, Clinical PharmacologyUnitMedicine F, Beilinson Medical Center, Petab Tikva, Israel. l/1/17555
578
Abbreviations used
ConA: ConcanavalinA PEFR: PHA: b.i.d.: LTB,:
Peak expiratory flow rate Phytohemagglutinin Twice daily LeukotrieneB,
theophylline or oral colchicine and almost completely corrected by oral theophylline together with in vitro colchicine at a pharmacologic concentration.14*I5 These observations, together with the in vitro synergistic effect of colchicine with agentsthat elevate intracellular levels of cyclic adenosine monophosphate,I6raised the possibility that oral colchicine may be useful in the treatmentof asthma.Accordingly, we conducted a randomized, double-blind, crossover study of the effect of colchicine in patients with asthma. MATERIAL Subjects
AND METHODS
Sevenmaleandthreefemalepatients,aged18 to 43 years (mean, 25.2 years), with perennialasthma(mean duration of disease, 12.4 years), participated in a double-blind, crossover, randomized chronic study. This study was approved
VOLUMLNUMBER
Clinical study of colchicine iit ,ssthma 579
85 3
P
PLACEBO
COLCHICINE
-I PLACEBO
COLCHICINE PLACEBO
FK;. 1. Effect of colchicine on daily clinical score and on the number of inhalations of albuterol per day. Results are illustrated
as individually
paired
data and mean.
by the Helsinki committee at the Tel Aviv Medical Center. All subjectsgaveinformed consent.All patientshad positive immediate skin test responsesto the house dust mite, Dermatophagoidesfarinae (Pharmacia Fine Chemicals, Uppsala, Sweden). Without bronchodilators, the FEV, of the patients, expressedas a percentageof normal predictedvalues, was 15% after inhalation of 200 kg of albuterol. The patients had no other significant health problems as assessedby complete history, physical examination, and routine blood tests. No patient was receiving cromoglycate, glucocorticosteroids, oral @adrenergic agonists, or medications interacting with theophylline, such as erythmmycin, phenytoin, or cimetidine. Eight male and two female healthy volunteers, aged 25 to 41 years (mean, 32 years), served as a control group for measurementof Con A-induced suppressorcell function. Protocol All subjects were receiving sustained-releasetheophylline (Theo-Dur; Key Pharmaceuticals Inc., Kenilworth, N.J.), 200 to 300 mg b.i.d. The mean serum theophylline steady-statelevel was 10.6 &g/ml. Inhalations of albuterol (Ventolin: Glaxo Inc., ResearchTriangle Park, N.C.) were taken, as needed,and recordedin a daily diary. Tablets of colchicine (Rafa; Jerusalem, Israel), 0.5 mg, or placebo were each taken orally, b.i.d., for 4 weeksduring either the third to sixth weeks or during the ninth to twelfth weeks, asdeterminedby a randomizedtable. The first 2 weekswere the run in, and the seventhand eighth weekswere the washout periods. A clinical score for shortnessof breath and wheezing from 0 for no symptomsto 9 for severesymptoms was recordedin a daily diary. Compliance was >90% for the colchicine and placebo, as measuredby daily diary report and residual tablet count.
COLC‘WlNE
FIG. 2. Effect of colchicine on suppressor call function. Con A-induced suppressor cell function of peripheral blood mononuclear cells was measured for subjects with asthma during the administration of placebo and colchitine and for normal volunteers. Results are illustrated as individually paired data and mean.
The PEFR was measuredwith a Wright peak flow meter every morning and evening at home, and the best of three measurementswas recorded. The mean for each patient’s PEFR was calculated for weeks 3 to 6 and for weeks 9 to 12. At the end of each regimen (drug or placebo at week 6 or 12). pulmonary function tests(Spyro analyzer CSA-800, Fukuda Sangyo Co., Tokyo, Japan), bronchial provocation tests, immediate skin test responses, serum loge (microELBA, WalkerLaboratories, Syracuse.N.Y. 1, and Con Ainduced suppressorcell function were measured. Bronchial
inhalation
challenge
Patientshad bronchial provocation with increasing doses of the house dust mite D. farinae (PharmaciaFine Chemicals), and the dose was recordedthat causeda decreaseof at least 20% of the FEV, .” Immediate
skin test respanses
The house dust mite D. farime was injected intradermally at a concentration of 1000biological units in 0.03 ml. For nonspecific reactivity, 0.03 ml of the compound 48180 at a concentration of 0.5 mg/ml was injected intradermally. As a control, the diluent phenol-buffered saline albumin was injected. The wheal was measuredat 20 minutes, and the results were expressedas areain square centimeters. Con A-induced
suppressor
ceH fune$ion
Peripheral blood mononuclear cells were isolated flwm heparinized blood by density centrifugation on Ficoll-
580 Schwarz et al. TABLE I. Effect of colchicine
J. ALLERGY
on pulmonary
function
Run in
FVC (L) =v, (L) FEV,/FVC% FEF,.,,, (LI set) V mm (L/W V miulS W sed
4.27 + 3.23 r 77 k 2.96 k 3.36 2 1.53 ?
0.35 0.33 3 0.40 0.51 0.26
CLIN. IMMUNOL. MARCH 1990
tests Placebo
4.38 * 0.33 3.33 +- 0.35 74 t 4 3.07 ? 0.42 3.24 + 0.47 1.50 * 0.24
Colchicine
4.48 +- 0.32 3.38 ? 0.35 73 -+ 3 2.86 k 0.39 3.00 + 0.45 1.48 c 0.25
FEF,.,m Forced expiratory flow between 25% and 75% of vital capacity; VW,,, maximum expiratory flow at 50% of vital capacity; VWu, maximum expiratory flow at 25% of vital capacity. Patients were tested at the end of the 2-week run-in and at the end of 4 weeks of placebo or colchicine administration.
Hypaque. Mononuclear cells (5 X 106) were cultured at 37” C in 1 ml of culture medium (RPM1 1640, penicillin, streptomycin, and glutamine), including 10% heatinactivated human AB serumwithout (control cells) or with (suppressorcells) 10 kg/ml of Con A (three times crystallized, Miles Yeda Inc., Rehovot, Israel) in a 5% CO, Per 95% air-humidified environment. After 44 hours, thesecells were. incubated for 30 minutes with 50 p.g/mI of mitomytin C (Sigma Chemical Co., St. Louis, MO.) and washed, and then 1 x 105of these cells were cocultured at 37” C for 72 hours with 1 x lo5 fresh allogeneic healthy volunteers’ mononuclear responder cells and 1 pg/ml of PHA (Difco LaboratoriesInc., Detroit, Mich.) in 0.2 ml of culture medium. Tritiated thymidine was addedat the last 16 hours of culture. Samplesin triplicate were harvested, and thymidine uptake was measuredin a B-scintillation counter. Percentagesuppressionof mtiated thymidine uptake was calculated according to the following formula: %suppression = [l - [cpm(respondercells + suppressorcells + PHA) cpm(respondercells + suppressorcells)] / [cpm (respondercells + control cells + PHA) - cpm (respondercells + control cells)]] x 100
Statistical analysis Results are presentedas mean f SEM, and significance was calculated by two-tailed Wilcoxon matched-pairs signed-rankstest.
RESULTS During colchicine administration, the subjects had a significantly (p < 0.05) lower daily clinical score (1.64 r 0.32) than during placebo administration (2.18 r 0.34) (Fig. 1). Nine of the 10 patients had lower clinical scores while they were receiving colchicine. The subjects had significantly (p < 0.02) lower number of inhalations of albuterol per day (4.01 + 1.26) during colchicine administration than during placebo administration (5.89 + 1.48) (Fig. 1). For the eight patients receiving albuterol during placebo administration, seven patients decreased the number of inhalations of albuterol during the admin-
istration of colchicine, and the other patient had the same number of inhalations. There was no significant difference during placebo or colchicine administration for daily PEFR (456 + 36 and 452 2 36 L/min, respectively) or pulmonary function tests measured at the end of 4 weeks of placebo or colchicine administration (Table I). Similarly, at the end of 4 weeks of treatment, there was no significant difference between placebo and colchicine for the early phase reaction of bronchial inhalation challenge (27,919 t 14,257 and 40,601 + 24,787 biological units, respectively; n = 6). There was no immediate skin test response to the allergen D. farinae (3.4 + 0.6 and 3.0 & 0.5 cm’, respectively) or a nonspecific skin reaction to compound 48/80 (2.6 2 0.6 and 3.1 _+ 1.1 cm*, respectively). Seven patients had suppressor cell function measured during the administration of placebo and colchicine. During placebo administration, patients had a deficiency of Con A-induced suppressor cell function (16.2 + 4.6%) that was significantly (p < 0.05) increased during colchicine administration to levels (39.0 & 10.7%) that were similar to levels of healthy volunteers (41.1 ? 3.5%) (Fig. 2). Colchicine significantly (p < 0.05) decreased serum IgE as compared to placebo (188 + 46 versus 248 t 63 IU/ ml, respectively).
DISCUSSION Colchicine was mildly beneficial, as demonstrated by a mild decrease in the clinical score and the number of inhalations of albuterol. These clinical observations are preliminary because the number of patients studied was small, and patients were only mildly symptomatic. Colchicine had no effect on pulmonary function tests; therefore, it did not act as a bronchodilator. Colchicine had no effect on immediate skin test responses, which is consistent with our preliminary results of the lack of a significant effect of colchi-
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tine on bronchial provocation in the early phase reaction. There is a preliminary study of antigeninduced bronchial provocation in ragweed-allergic patients in which colchicine, 0.6 mg b.i.d. for 7 days, decreasedthe late-phasereaction and sometimes the early phasereaction. I8This suggeststhat, by whatever unknown mechanisms colchicine might act in asthma, it may be predominantly affecting the latephaseresponse. We have previously demonstratedthat either oral theophylline or oral colchicine partially corrects the deficiency of Con A-induced suppressorcell function in patients with asthma.14.” Furthermore, in vitro colchicine at a pharmacologic concentration was synergistic with oral theophylline for almost completely correcting the deficiency of Con A-induced suppressor cell function.14 In our present study, during the regimen of oral theophylline administration, together with placebo administration, the patients had low levels of suppressorcell function, whereasduring oral theophylline administration, together with oral colchicine administration, they had normal levels of Con A-induced suppressorcell function. This raises the possibility that oral colchicine may be additive or synergistic with oral theophylline for correcting the Con A-induced suppressorcell function. The immunopathogeneticrole of the deficiency of nonspecific suppressorcell function in asthma is not known. Allergen-specific and nonspecific suppressor cells may inhibit the immune and inflammatory reaction to allergens. For example, the increased suppressorcell function during the administration of colchicine may have, in part, resulted in the decreaseof serumIgE and nonspecific suppressorcells may down regulate the late-phasereaction to nonspecific stimuli. In a study of allergen-induced bronchial provocation, patients with asthma who had an early but not latephasereaction had an increasednumber and percentage of T8 + suppressor/cytotoxic T-lymphocytes in their bronchoalveolar lavage fluid, whereas patients with asthma who had both early and late-phase reactions had no significant change in T8 + cells.” Thus, the mobilization of suppressorT cells into the lung after an allergen-induced early phase reaction might be associatedwith the prevention of a late-phase reaction. Colchicine has beendemonstratedto have a variety of effects. Colchicine inhibits leukocyte adhesiveness, lysosomal degradation, and neutrophil chemotaxis, and binds to tubulin, which prevents microtubule polymerization, resulting in a net effect of microtubule disassembly. In vitro studies have demonstratedthat the mechanismof action by which colchicine inhibits the formation by neutrophils of lipoxygenase prod-
study of colchicine
in asthma
581
ucts, such as LTB4, appearsto be causedby the effect of colchicine on microtubules.*’ However, in vivo studies of the anti-inflammatory activity of coichicine analogs suggestthat the effect on microtubules may not be the primary mechanism.2’The administration of colchicine in vivo inhibits the in vitro synthesis and/or release of neutrophil chemotactic factor,” LTB,,18and interleukin-l*’ (Ilfeld DN, Postlethwaite AE. Unpublished data.). Neutrophil chemotactic factor and LTB, are chemotactic for neutrophils. Interleukin- 1 is synthesizedby macrophagesand other cells and has a variety of actions that enhanceinflammatory reactions, including stimulating the proliferation of T-lymphocytes and acting as a chemotactic factor for helper/ inducer T-lymphocytes.” Thesefactors may, in part, be responsible for the recruitment of leukocytes into the lung, and colchicine may perhaps decreasethe late-phasereaction by suppressing the synthesis or releaseof these factors. In conclusion, colchicine is an immunomodulatory agentthat may perhapshave mild efficacy in the treatment of asthma;however, a study with more patients who are more symptomatic would be neededto determine the efficacy. The only frequent side effects of daily treatmentwith colchicine for more than 10years in patients with cirrhosis, familial Mediterranean fever, or gout who have normal renal function are abdominal discomfort, nausea,and, especially, diarrhea that can be avoided by titrating the dose and thus preventing the gastrointestinalside effects.’ ‘5Patients with renal insufficiency. when they are administered colchicine, can developea myoneuropathy.Z’The dose of colchicine used in our study (1 mg!day) is a small dose, and many patients can take larger dosesof colchicine. Thus, further clinical and immunologic studies are indicated to determine the effect of c%olchicine in patients with asthma. REFERENCES 1.
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Alvarellos A, Spilberg 1. Colchicine prophylaxic in pseudogout. J Rheumatol 1986;13:804-5. Seideman P, Fjellner B, Johannesson A. Psoriatic arthritis treated with oral colchicine. J Rheumatol 1987:14:777-9. Callen JP. Colchicine is effective in controlling chronic cutaneous leukocytoclastic vasculitis. J Am Acad Dermatol 1987;13:193-200. Dinarello CA, Wolff SM, Goldfinger SE, Dale DC, Ailing DW. Colchicine therapy for familial Mediterranean fever: a double-blind study. N Engl J Med 1974;291:934-7. Kershenobich D, Vargas F, Garcia-Tsao G, Tamayo RP, Gent M, Rojkind M. Colchicine in the treatment of cirrhosis of the liver. N Engl J Med 1988;318:1709-13. Kaplan MM, Alling DW, Zimmerman HJ, et al. A prospective trial of colchicine for primary biliary cirrhosis. N Engl J Med 1986;3 15: 1448-54. Ilfeld D, Kuperman 0. Correction of a suppressor cell deticiency in four patients with familial Mediterranean fever by
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in vitro or in vivo colchicine. Clin Exp Immunol 1982;50:99106. 8. SchlesingerM, Ilfeld D, Handzel ZT, et al. Effect of colchicine on immunoregulatory abnormalities in familial Mediterranean fever. Clin Exp Immunol 1983;54:73-9. 9. Ilfeld D, Theodor E, Delpre G, Kuperman 0. In vitro correction of a deociency of Con A-induced suppressorcell function in primary biliary cirrhosis by a pharmacologicalconcentration of colchicine. Clin Exp Immunol 1984;57:438-42. 10. Harper TB, Gaumer HR, Waring W, Brannon RB, Salvaggio JE. A comparison of cell-mediated immunity and suppressor T-cell function in asthmaticand normal children. Clin Allergy 1980;10:555-63. 11. Rola-Pleszczynski M, Blanchard R. Suppressorcell function in respiratory allergy. Int Arch Allergy Apply Immunol 1981$X361-70. 12. Rivlin J, Kuperman 0, Freier S, Godfrey S. SuppressorTlymphocyte activity in wheezy children with and without treatment by hyposensitization. Clin Allergy 1981;11:353-6. 13. Hwang KC, Fig SM, Friedman HM, Gupta S. Deficient concanavalin A-induced suppressor-cell activity in patients with bronchial asthma, allergic rhinitis, and atopic dermatitis. Clin Allergy 1985;15:67-72. 14. Ilfeld D, Kivity S, Feierman E, Topilsky M, Kuperman 0. Effect of in vitro colchicine andoral theophylline on suppressor cell function of asthmatic patients. Clin Exp Immunol 1985; 61:360-7. 15. Ilfeld DN, Mazar A, Garty M, et al. Effect of oral colchicine on T cell subsets,monocytesand concanavalinA-induced suppressor cell function in asthmatic patients. Clin Allergy 1986;16:407-16. 16. Rudolph SA, GreengardP, Malawista SE. Effects of colchicine on cyclic AMP levels in human leukocytes. Proc Nat1 Acad Sci USA 1977;74:3404-8. 17. Chai H, Farr RS, Froehlich LA, Mathison DA, et al. Stan-
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dardization of bronchial inhalation challengeprocedures.J ALLERGYCLIN IMMUNOL1975;56:323-7. 18. Peters SP, Freeland HS, Kelly SJ, et al. Is leukotriene B, an important mediator in human IgE-mediated allergic reactions? Am Rev Respir Dis 1987;135:S42-S5. 19. Gonzalez MC, Diaz P, Galleguillos FR, Antic P, Cromwell 0, Kay AB. Allergen-induced recruitmentsof bronchoalveolar helper (OKT4) and suppressor(OKT8) T-cells in asthma:relative increasesin OKT8 cells in single early responderscompared with those in late-phaseresponders.Am Rev Respir Dis 1987;136:600-4. 20. Reibman J, Haines KA, Rich AM, Cristello P, Giedd KN, WeissmannG. Colchicine inhibits ionophore-inducedformation of leukotriene B, by human neutrophils: the role of microtubules. J Immunol 1986;136:1027-32. 21. Sugio K, Maruyama M, Tsurufugi S, Sharma P, Brossi A. Separation of tubulin-binding and anti-inflammatory activity in colchicine analogsand congeners.Life Sci 1986;40;35-9. 22. Spilberg I, Mandell B, Mehta J, Simchowitz L, RosenbergD. Mechanisms of action of colchicine in acute urate crystalinduced arthritis. J Clin Invest 1979;64:775-80. 23. KershenobichD, Alcocer J, Quiroga A, Rojkind M. Effect of colchicine on immunoregulatory T-lymphocytes and monocytes in patients with primary biliary cirrhosis [Abstract]. Clin Res 1984;32:490a. 24. Hunninghake GW, Glazier AJ, Monick MM, Dinarello CA. Interleukin- I is a chemotacticfactor for humanT-lymphocytes. Am Rev Respir Dis 1987;135:66-71. 25. Peters RS, Lehman TJ, Schwabe AD. Colchicine use for familial Mediterraneanfever: observationsassociatedwith longterm treatment. West J Med 1983;138:43-6. 26. Kuncl RW, DuncanG, WatsonD, Alderson K, Rogawski MA, PeperM. Colchicine myopathy and neuropathy.N Engl J Med 1987:316:1562-8.
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