NORMAL CFTR

STATS
à 1 in 2500 babies in uk
à 1 in 17,000 Africans, 1 in 100,000 asians/orientals
à affects 80-100,000 people world-wide, ~11,000 in UK
Golgi vesicles inactive
à 1 in 25 in the UK are carriers, which is inherited as a
recessive characteristic ATP
- autosomal recessive disease (defective gene from Cl-
both parents) mRNA
PO4
nucleus ER active
GENETIC DEFECT: basal cell
membrane
à defective Cl- ion channel, CFTR, expressed in all
epithelial cells (MULTI-ORGAN DISEASE) à CF gene transcribed in nucleus + protein synthesised
à affects lungs, the gut, the reproductive tract, in ER, transported via golgi vesicles
pancreas, liver and sweat glands. à during transport undergoes post-translational
à The gene is on chromosome 7, cloned and sequenced modification, protein glycosylated via adding sugar
in 1989. residues, used for tracking CFTR
à More than 2000 different mutations in the CFTR gene à becomes integral part of cell surface membrane
have now been identified à protein activated by phosphorylation, allows
à ~ 90% of European patients carry at least one copy of channels to open, Cl- ions move through
the most common defect, DF508/DF508 à dephosphorylation closes channel
- D is deletion and F is phenylalanine at position à binding of ATP and hydrolysis regulates activity of
508 in CFTR amino acid sequence channel and rate of chloride conductance
father mother
(carrier) (carrier )
Regulation of CFTR chloride channel
GREGOR MENDEL
activity
à sweet pea plant TM1 TM2
à dominant characteristics show in offspring
à recessive characteristic is masked by dominant Gg Gg
X plasma
membrane
gene GG Gg Gg gg

à not sex linked + 25% chance of child having CF NH2

NBD1
P
NBD2
R P
P ATP
ATP P COOH
Protein kinase A
ACTIVATION OF CFTR Cl- CHANNEL VIA B2-ADRENERGIC RECEPTORS:
cAMP
b2 agonist
à 2 transmembrane domains: TM1 &
CFTR TM2
- Each have 6 membrane spanning
segments, making up pore which
P Gs AC
Cl- move and determines ion
N R P
PP
selectivity of channel
C
PKA EBP 50 C cAMP à 2 nucleotide binding domains: NBD1 &
cAMP EZRIN
NBD2
AC; adenyl cyclase
à unique intracellular regulatory (R)
domain
à increases cAMP levels (highly compartmentalised) in airway, G
à Activation of CFTR phosphorylation
protein stimulated, activating adenylyl cyclase
activated by cAMP dependent protein
à leads to increase PKA levels + phosphorylation + activation CFTR
kinase A
à compartmentalised as CFTR + B2 receptors co-localise in cell
- R domain phosphorylated at 4 sites
membrane of airway epithelial cells, both binding to ezrin binding
by PKA, causes conformation
protein 50 (EBP50), forms a trimolecular complex change in protein + channel to open
à ezrin is cytoskeletal protein that binds PKA, ensures PKA is at à ATP binds to NBD1/NBD2 it dimerises +
close proximity to CFTR, when activated, complex falls apart activated Cl- conductance
à protein-protein interaction essential for full activation of channel à ATP hydrolysis at NBD2 closes channel +
by B2-agonist receptor pathway inhibits chloride conductance
à Critical for rapid + specific signal transduction from receptor to à dephosphorylation of R domain ensures
channel channel remains close
à Chloride ions move through a pore that opens when CFTR is à extracellular loops in TM2 contain sites
activated by ATP and by phosphorylation of a regulatory domain for glycosylation of protein
SYNTAXIN 1A CYTOPLASMIC C TERMINAL TAIL
C CFTR CFTR ENaC

NBD1 NBD2
R
cYES
Syntaxin 1A NBD1 NBD2
NH2
R C YAP

COOH PK-A PDZ1

NH2 NH2 PDZ2
ACTIN
à inhibits CFTR activity via cytoplasmic N-terminal tail cytoskeleton EZRIN
EBP 50

à CFTR negatively regulated by another membrane

protein, syntaxin 1A
à binds at the amino (N) terminus of CFTR and negatively
regulates channel opening time and CFTR trafficking to the
cell membrane
à protein networks important both for positive (β2-AR)
and negative (syntaxin 1A) regulation of CFTR
à Protein-protein interactions are mportant in the way
that CFTR regulates other ion channels such as the
epithelial sodium channel
DIFFERENT CFTR MUTATIONS:
Class 1: Premature termination of the translation of the
CFTR mRNA caused by base substitutions that create stop
codons or insertions that shift the reading frame. No protein
synthesis.
à regulates other ion channels such as ENaC
à C terminus of CFTR interacts with proteins
linking CFTR complex network of regulatory
proteins through the protein binding domains (PDZ)
of EBP50, to ENaC
à CFTR normally assembled as complex with ezrin,
protein kinase A (PK-A), and the YAP and cYES
proteins. As before, the function is to tether PK-A
near to CFTR and to link CFTR to the cytoskeleton
and localise it to the plasma membrane.
à EBP50 interacts with YAP and recruiting cYES to
complex, which acts to INHIBIT ENaC activity
à Since CFTR is defective in CF, complex is
disrupted in CF, so there is both decreased chloride
channel activity and increased sodium channel
activity in CF

Class 2: Trafficking defects, mis-folded CFTR protein is Processing of the DF508 CFTR
degraded in proteosomes and fails to reach the plasma
membrane, (DF508) Cl-

Class 3: Regulatory mutants which reach the surface of the Golgi vesicles
cell, but don’t respond normally to activation signals
(G551D). (glycine replaced with aspartate) Cl-

Class 4: Mutant proteins reach plasma membrane, but have mRNA

nucleus ER
altered channel properties and chloride conductance proteosome
defects, Cl- cant effectively move through channels
à 70% of CF chromosomes is the delta F 508
mutation
Class 5: Unstable mRNA, reduced synthesis of functional
à deletion of 3 base pairs in CF gene, codes for
CFTR
single amino acid in final product, responsible for
the CF phenotype
Class 6: Reduced stability of CFTR protein in the plasma
à missing phenylalanine responsible for post-
membrane
translational defects in the CFTR protein
à Immature forms of the protein synthesised,
but they do not become glycosylated, do not
traffic through the Golgi system and are not
inserted into the cell membrane
à missing amino acid in the tertiary structure,
the protein does not fold properly and it is taken
up and quickly destroyed in the proteosomes
à chloride channel is missing, leading to a wide
range of physiological defects in those epithelial
cells
ORGANS AFFECTED BY CF
à sweat glands
- Na+ & Cl- normally reabsorbed by epithelial cells lining duct, so only
water reaches surface to cool skin
- In CF fail to absorb Cl- from secreted sweat so Na+ is poorly absorbed
- Salty sweat
à Pancreas
- Defective Cl- secretion results in defective HCO3- transport + water into
lumen of pancreatic ducts, becoming obstructed
- Amylase, lipase + trypsinogen not delivered to gut
- Require supplements with missing enzymes
- Lipids not digested + absorbed, patient deficient in uptake of fat soluble
vitamins, A, D, E, important anti-oxidants
à Lungs
- Defective Cl- secretion + increased Na+ + water absorption, clogs and
infects airways impeding breathing
- Infection leads to inflammation + lung damage
- Respiratory failure is usually cause of death

DIAGNOSIS
à excessively salty sweat (Cl- > 70mM) CFTR IN NORMAL BRONCHIAL
- Defective Cl- absorption in sweat glands EPITHELIUM:
à failure to thrive and gain weight
- Blocked digestive enzymes Na+ Cl- Cl-

à persistent chest infection ENaC CFTR

Cla
- defective Cl- secretion and increased Na+ and water absorption in
the airways, leading to thick desiccated secretions that invite
Na+ PKA
infection and inflammation
H2O cAMP
Cl-
K+
Diagnostic triad
Na+ K+ Na+/K+/Cl-
CFTR IN NORMAL EPITHELIAL CELL: Na+/K+ ATPase
cotransporter

mucus layer
à CFTR expressed in large airways,
H2O
fluid layer
e.g. bronchi
cilia à Cl- secreted at apical membrane
_ through CFTR + into airway lumen,
epithelial Na+ Cl-
layer channel activated by phosphorylation
ENaC CFTR goblet cell à increased cAMP levels activates
PKA
à CFTR expressed in surface epithelium + predominantly in
à regulatory protein networks link
submucosal glands
CFTR to ENaC + supress activity
à thin film of fluid coats entire surface of epithelium, where
limiting sodium uptake
volume composition of airway fluid depends of salt
à at basal membrane, Cl- transported
reabsorption/secretion
into cell via Na/K/Cl co transporter +
à salt secretion due to secretion of Cl- through CFTR ion channel
electrochemical gradient pushes Cl out
- CFTR has negative regulatory effects on ENaC, limiting
uptakes of Na+ + water reabsorbed through CFTR
à salt reabsorption due to passive diffusion of Na+ down conc à energy derived from pump drives
gradients into cell through ENaC, intracellular Na+ maintained at system + keeps Na+ conc in cell low
low levels by Na/K pump in basolateral membrane of cells which that Na+ is able to move into cell via
pump Na+ back out of cell ENaC conc gradient
- Sodium reabsorption is limited in airway epithelium à secretory epithelium
- Net movement of water into airway produces water fluid à Na+ flows between the cells to
- Inhaled dirt and debris, bacteria and viruses, collect in a neutralize Cl- secreted via CFTR +
thin layer of mucus that is produced by goblet cells and the water follows movement of salt
submucosal glands and sits on top of this fluid layer

CFTR in the CF bronchial epithelium:
Na+ Cl-
ENaC CFTR
Cla
Cl- Cl-
H2O
Cl-
K+ K+
Na+ Na+ K+ Na+/K+/Cl-
cotransporter
Na+/K+ ATPase
à CFTR is either absent or defective. Leading to
reduced Cl- channel activity + secretion into airway
lumen
à no negative effect of CFTR on ENaC
à increased Na+ reabsorption and compensatory
increase in acitivity of Na/K pump in basal
membrane
à this is an absorptive epithelium, and chloride
ions flow between cells to neutralize the excess
uptake of sodium ions and water follows the
movement of salt.
Polybacterial infection in the CF airways…
• Staphylococcus aureus Early
• Haemophilus influenza (less common) infection
• Pseudomonas aeruginosa - inevitably
• Burkholderia cepacia complex Later infection –
inherently
• Stenotrophomonas maltophilia multiresistant
à opportunistic microorganisms
à Pseudomonas is associated with rapid
decline in lung function, higher sputum
volume and more intense inflammation.
Obstruction and destruction of the airways
leads to rapid clinical decline. Pseudomonas
is acquired from environmental water
reservoirs, showers, sinks, toilets, humidifiers
etc.
à Burkholderia complex is a group of at
least nine closely related species
à Other organisms include S maltophilia as
well as fungi including aspergillus and
nontuberculosis mycobacteria
à the B cepacia is most serious as it is
associated with high fever, bacteremia, rapid
progression to severe necrotizing
pneumonia, pulmonary deterioration and
death.
à S maltophilia is seen more commonly than
B cepacia, but is less virulent
DEHYDRATED SECRETIONS:
mucus
bacterial infection hypersecretion
(Pseudomonas aeruginosa)
inflammation;
reabsorption
of excessive neutrophils are
amounts of Cl- recruited to
water Na+ fight infection
H2O
à CFTR expressed in the surface epithelium and more
predominantly in the submucosal glands which are
enlarged, or hyperplastic, in CF patients
à Mucus is secreted by the goblet cells of the bronchial
epithelium and by the submucosal glands, which are the
primary source and produce viscoelastic secretions which
accumulate in the airways
à Airway epithelial cells also have altered ion transport
properties.
à dehydration of the secreted mucus results in thick,
sticky secretions that invite infection
à CF in 1938 most patients died by the age of 5years due
to staphylococcus aureus infection, penicillin used to treat
à most prevalent pathogen in airways, Pseudomonas
aeruginosa and CF patients are chronically infected with it
à altered composition of the airway fluid may also favour
bacterial growth
à A neutrophilic inflammatory response is mounted to try
to fight the infection
Events leading to chronic infection;
à Normal airway epithelia-Thin mucus layer on top of watery
periciliary fluid facilitates MCC. Normal epithelial O2 consumption
(QO2 ).
- periciliary liquid layer with a height of the extended cilium
(~7um
à CF epithelium-Depletion of periciliary fluid, mucus transport
slows/stops. Increased O2 consumption with increased ion
channel activity.
à Continued mucus secretion increases the height of the mucus
layer and raised QO2 generates steep O2 gradients
- Increased metabolic activity of CF epithelial cells
generates steep hypoxic gradients in the thick mucus layer
à Pseudomonas deposited on mucus surface penetrates into
hypoxic zones within the mucus.
à Pseudomonas adapts to hypoxic niche with increased alginate
production and formation of macrocolonies.
à Macrocolonies resist secondary defences, including
neutrophils, setting the stage for chronic infection. Increased
numbers of bacteria and neutrophils render the mucus hypoxic.
Pseudomonas products that inhibit the immune response Production of the neutrophil chemoattractant
Bacterial product Action
IL-8 in the normal airway
Mucoid exopolysaccharide Barrier to phagocytes; inhibits complement and
(alginate) antibody binding endotoxin (LPS)

Pseudomonas elastase Cleaves antibodies; inactivates complement IL-8

TLR4 TNFα/IL-1
and cytokines; cleaves complement receptors. pulmonary
macrophage
Pyocyanin Inhibits lymphocyte proliferation; inactivates TLR4

mucociliary clearance
airway
Exotoxin A Cytotoxic to macrophages epithelium
IL-8 IL-10
Leukocidin Cytotoxic to neutrophils and lymphocytes
neutrophils

Production of the neutrophil chemoattractant à bacteria eradicated by macrophage + neutrophil

IL-8 in the hyperinflammatory CF airway à pulmonary macrophage is responsible for
initiating host response to bacterial infection.
endotoxin (LPS)
IL-8 However, cytokine networks are set up that
TLR4 TNFα/IL-1
neutrophil
pulmonary
subsequently induce neutrophils to migrate into
the lungs to fight the infection
macrophage
elastase
TLR4

à neutrophils recruited via IL-8

IL-8
airway
epithelium- àIL-8 produced by nearly all cells in the airways
(defective
CFTR)
and lungs, including the pulmonary macrophage
neutrophils
and bronchial epithelium, which respond to
à dysregulated inflammatory response occurs + IL-8 bacterial toxins such as lipopolysaccharide (LPS)
produced at magnitudes higher than normal from gram negative bacteria, by producing IL-8 as
- Due to absence of IL-10 well as other cytokines such as TNFa and IL-1
à recruitment of neutrophils in airways introduces another à receptor for LPS is one of the toll-like receptor
signal for IL-8 production (TLR) family that recognise bacterial products, in
- Neutrophils release neutrophil elastase stimulating this case TLR4
IL-8 synthesis by epithelial cells à cytokines have autocrine effects or paracrine
- Self amplifying à For example, TNFa and IL-1 stimulate bronchial
à inflammatory response is used to eradicate bacteria epithelial cells and fibroblasts to produce IL-8. The
- In CF bacterial infection is too great, inflammatory production of IL-8 is normally regulated by the anti-
response fails to clear bacteria inflammatory cytokine IL-10, which inhibits IL-8
- Tissue damage occurs and inflammatory response is production. IL-10 is normally produced by
amplified, more neutrophils recruited epithelial cells and macrophages.
- Becomes aggressive, leads to lung tissue damage
à hyperinflammatory Phagocytosis
- Due to CFTR defects such as trafficking defect à multi lobed nucleus
associated with DF508 mutation à Small secretory vesicles formed by endocytosis
- Immature CFTR gets trapped in ER + stimulates à Neutrophil phagocytosis involves two different
production of inflammatory cytokines by bronchial receptor classes, those that recognise activated
epithelium complement such as CR1 and CR3 and immunoglobulins
(FcgR).
à Complements + immunoglobulins opsonise bacteria,
then phagocytosed
à Proteases; elastase, cathepsin G, etc, enzymatically
breakdown bacterial cell walls, making them susceptible
to peptide antibiotics such as the defensins
à Defensins; small peptides have antimicrobial
properties, highly basic (positively charged) peptides act
by inducing the permeability of microbial membranes,
and act on both gram negative + positive bacteria
à BPI; bactericidal/permeability increasing protein
binds endotoxin (LPS) and is therefore toxic to gram
negative bacteria
à reactive oxygen: hypochlorous acid
Why do neutrophils damage tissues they should protect? à proteases highly tissue damaging
à natural defence provided by protease inhibitors
à attempt to phagocytose Pseudomonas, become à protease inhibitors degraded by excessive levels
activated and release elastase, matrix metalloproteinases of protease in airway
(MMPs), reactive oxygen and myeloperoxidase (MPO) à high conc of proteases in lung tissues with
into the tissue as granules fuse with the cell membrane potential to damage tissue
à Pseudomonas evades the immune system by growing à inhibitors of neutrophil elastase include:
in large colonies covered in alginate. This mucoid layer - Alpha1-antitrypsin (α1-AT) which is found in
also prevents antibiotics working high concentrations in the blood and is an
à Pseudomonas is an organism that has a number of effective and potent inhibitor of neutrophil
immunoevasive properties elastase (as well as trypsin).
à Frustrated phagocytosis leads to the release of - Alpha2-macroglobulin is found in high
proteases and reactive oxygen species into the tissue concentrations in the blood and inhibits a
surrounding the neutrophil broad range of proteases including neutrophil
elastase.
- SLPI (secretory leukocyte protease inhibitor)
à naturally occurring defence mechanisms protect the and elafin are made by epithelial cells and are
host from tissue damage but in CF these are often therefore found in the airway fluids and
defective inhibit neutrophil elastase.
à deficiency in anti-oxidants relates to the pancreatic - TIMP is the tissue inhibitor of matrix
deficiency in CF, inadequate delivery of digestive enzymes metalloproteases (MMPs) and inhibts their
to the intestine means that there is inadequate lipase activity. Many of the TIMPs can also
activity, and therefore lipid uptake in the gut. This breakdown elastin and contribute to lung
tissue damage
influences the uptake of the fat soluble vitamins A and E,
which are important anti-oxidants and free radicals which Tissue injury vs tissue protection in CF;
the protease/antiprotease imbalance
are not removed by the naturally occurring anti-oxidants
• Anti-Proteases;
à Reactive oxygen species damage the natural inhibitor of a1-antitrypsin,
neutrophil
neutrophil elastase, alpha1-antitrypsin, and the tissue elastase a2-macroglobulin,
inhibitor of matrix metalloproteinases (TIMP). In this way • Proteases; inhibtors SLPI,
neutrophil elastase, elafin,
the oxidant/antioxidant imbalance also contributes to the cathepsin G, TIMP.
protease/antiprotease imbalance collagenase,
gelatinase. MMPs
Tissue injury vs tissue protection in CF;
the oxidant/antioxidant imbalance

• Anti-oxidants; Tissue injury

vitamin E, MMPs; matrix metalloproteinases
vitamin A, SLPI; secretory leukocyte protease inhibitor
vitamin C TIMP; tissue inhibitor of matrix metalloproteinases

• Oxidant species
O2-, H2O2, HOCl Treatment of lung disease in Cystic Fibrosis
• Reducing airway obstruction - chest physiotherapy
- bronchodilators
Tissue injury, - mucolytics
inactivation of alpha1-antitrypsin
inactivation of TIMP-1 • Controlling infection - antibiotics
• Controlling inflammation - corticosteroids
- NSAIDs
- anti-proteases
EXCESSIVE MUCUS: • Correcting the basic defect - gene therapy
• Reduces airflow -activation of mutant CFTR
• Invites infection - manipulation of ion transport
• Restricts the delivery of other inhaled • Lung transplantation - lung cadaver donor
drugs, including gene therapy - heart-lung
vectors. - bi-lobar, living donor
 The central role for neutrophil elastase in the persistence
of bacterial infection and tissue damage in the CF lung.
bronchiectasis
IL-8
epithelial IL-8 elastin degradation
bacterial
infection neutrophils ELASTASE C3b and IgG cleavage
Generation of C5a ENaC
mucus secretion failure of opsonisation
and phagocytosis
DNA plugging of airway
Neutrophil elastase
• perpetuates the inflammatory response by
stimulating IL-8 production by epithelial cells,
and generating active complement
components that also induce neutrophil
recruitment, such as C5a.
• degrades elastin in the tissue matrix, altering
the structural properties of the tissue and
leading to bronchiectasis, (dilated airways).
Bronchiectasis results in loss of lung function
and respiratory failure.
• stimulates mucus production leading to
increased airway obstruction, and reduced
FEV1.
• cleaves the main bacterial opsonins, IgG and
C3b, leading to poor opsonisation and
clearance of bacteria by phagocytosis, and
therefore persistent bacterial infection.
• Elastase was recently shown to activate ENaC,
which would further enhance water uptake
and dehydration of airway surface liquid.
Chronic infection and inflammation leads to airway
obstruction with thick, sticky secretions. This is partly
due to dehydration of excessive amounts of mucus in
the airways, and also to high concentrations (1-15
mg/ml) of DNA released from neutrophils dying in the
airways by necrosis.
The identification of the central role played by
neutrophil elastase in the persistence of bacterial
infection and tissue damage in CF has led to the
development of new anti-inflammatory strategies
based on inhibiting the activity of this enzyme.
à inhaled colomycin (a polymyxin) with other oral
or intravenous antibiotics. More recently the
aminoglycoside tobramycin has been developed for
inhaled use. The early and aggressive use of
antibiotics has been shown to significantly improve
FEV1.
à lung transplantation has become an option for
patients with end-stage lung disease, when FEV1
less than 30% predicted
à disease in the intestine, vas deferens, pancreas and
liver may be present in utero, but the CF lung is normal
in utero and after birth, except for dilated submucosal
glands
The pathophysiologic sequalae of mutated CFTR in the lung
defective CF gene
defective / deficient CFTR
Cl- secretion, Na+ absorption
dessicated mucus
bronchial obstruction
infection
inflammation
bronchiectasis, respiratory failure, death
CHEST PHYSIOTHERAPY:
à postural drainage and chest percussion and vibration,
manually or with a mechanical percussor
à high frequency chest oscillation therapy vest
à success of the different techniques depends on the
age of the patient, the ability of children to master
them, and whether or not disease is localised to a
particular lobe or segment of the lung
à bronchodilators dilates small airways + facilitates
mucus clearance
à In some individuals bronchodilators may be harmful,
and there is a paradoxical decrease in pulmonary
function after bronchodilator use. This may occur in
patients with floppy airways who depend on smooth
muscle tone to keep the airway open, and prevent
expiratory collapse
à main components of CF sputum are the mucins (10-
50 mg/ml) produced by mucus glands, as well as DNA
(1-15 mg/ml) and actin (0.1-1 mg/ml) released from
neutrophils dying by necrosis, HMW, contributes to
viscosity. Protein core, heavily glycosylated with
oligosaccharide side chains. Disulphide bonds.
à When chromatin spills from the nucleus of necrotic
neutrophils in the CF airways, the histones are degraded
and highly negatively charged linear DNA is released
à Actin is a filamentous protein that forms the
cytoskeleton of neutrophils and is also relatively
negatively charged
à Physical entanglements, and interactions between
charged groups on sugar and amino acid residues, as
well as disulphide bonds in mucin molecules, and
hydrogen-bonding between carbohydrate side chains,
contribute to mucus viscoelasticity
 MUCOLYTICS:
à reduce viscosity by disrupting
Types of bonds occuring in sputum from inflamed airways;
polymer networks in the secretions
à Classic mucolytics sever disulphide
3. hydrogen bonds; link
oligosaccharide side chains bonds and depolymerise mucins, while
H 2. ionic bonds; positive and negative
charges on mucins interact
newer mucolytics degrade filaments of
O H O
NH3+ -
SO3
DNA (deoxyribonuclease/Pulmozyme
4. Van der Waals forces; oligo- In the clinic;
saccharide side chains interdigitate
àHypertonic saline and aerosolised
s
s
s s
s 1. covalent disulphide bonds; heparin breakdown ionic bonds and the
s link mucin glycoprotein chains relatively weak hydrogen bonds
5. physical entanglements
between mucin macromolecules between carbohydrate side chain
6. extracellular actin; forms à Deoxyribonuclease; (DNase,
parallel network in infection
7. extracellular DNA; forms Pulmozyme, Dornase alfa),
parallel network in infection
depolymerises DNA
Is micro organism Pathogenic? à Sulphydryl reagents; target -S-S-
bonds between mucin molecules, eg
It should be associated with; dithiothreitol, N-acetyl cysteine (type 1)
à acute pulmonary exacerbations of symptoms (sputum production, à High frequency oscillation; to disrupt
cough) physical entanglements (types 4+5)
à development of an antibody response à Mannitol; hyperosmotic to
à increasing chest radiographic signs of infection or altered high rehydrate the airways
resolution chest CT images (lung obstruction and destruction) à Hypertonic saline
à rapid decline in lung function (eg. mucoid Pseudomonas) In development;
à increased mortality (eg. Burkholderia cepacia) Heparin, dextran sulphate; highly ionic,
negatively charged, molecules that
Anti-pseudomonal therapy for cystic fibrosis disrupt ionic and hydrogen bonds
(types 2+3

1. Early eradication of infection; Chronic infection with mucoid pseudomonas:

à Maintenance therapy with inhaled colistin or
Antibiotic Route Dose /day aminoglycosides to reach high airway concentrations
Ciprofloxacin po 20-30mg/Kg 2 à Acute exacerbations require intravenous therapy –
Colistin inhaled 2-3 million U 2-3
penicillins (ticarcillin, piperacillin), cephalosporins
(ceftazidime), aminoglycosides, colistin
Tobramycin inhaled 80-300 mg 2
à Chronic infection with Pseudomonas is much harder to
à initial Pseudo is non mucoid, no alinate treat with antibiotics
production, susceptible to pseudomonal-specific à High doses of intravenous antibiotics are recommended
antibiotics because of the inaccessibility of Pseudomonas in mucus
à possible to completely eradicate Pseudomonas plugs
infection with early intensive use of antibiotics,
à careful monitoring for side effects is needed
before chronic infection with macrocolonies of
à Increasing resistance of Pseudomonas to inhaled
bacteria in hypoxic plaques makes it impossible to
eradicate tobramycin means that patients often cycle between
à Ciprofloxacin-a quinolone, active against gram different combinations of antibiotics to delay or avoid the
positive and gram negative bacteria, but particularly development of resistance
active against Pseudomonas. à Major problems for antibiotic therapy are B cepacia
à Colistin-a polymyxin antibiotic active against gram complex and S. maltophilia which are inherently
negative organisms including Pseudomonas, but not multiresistant
absorbed by mouth, and therefore given by
inhalation.
à Tobramycin-an aminoglycoside active against
many gram negative organisms including
Pseudomonas. Not absorbed from the gut, therefore
given by inhalation. Possible side effects of ototoxicity
and nephrotoxicity
 Controlling inflammation
Modifying basic defect:
• Corticosteroids. Little evidence that they are beneficial in CF.
1. Gene therapy
• Non steroidal anti-inflammatory drugs (NSAIDs). Ibuprofen inhibits
à single defect & can be directly applied to the most obvious
neutrophil accumulation by inhibiting nuclear transcription factors NFκB and
AP-1 that induce the synthesis of pro-inflammatory cytokines.
cellular target, the airway epithelial cells
• Anti-protease. Neutrophil elastase is an important target for therapy. - à Viral (adenovirus) and non-viral (liposomal) vectors have been
Therapies based on the natural elastase inhibitors, include recombinant alpha1-
antitrypsin (alpha1-AT) and secretory leukocyte protease inhibitor (SLPI).
used to transfect the cells with the CFTR gene, but expression of
CFTR is transient and difficult to achieve
The protease-antiprotease balance in the airways;
neutrophil elastase
Alpha1-AT,
SLPI
à mucus significant barrier for delivery of gene therap vectors to
(1) airway epithelia cells
Alpha1-AT, neutrophil à vectors may induce an immune response and increase
SLPI elastase
(12)
inflammation
normal CF
2. Activating mutant CFTR
à Inflammation plays a central role in the
à improve the function of CFTR in the plasma membrane, or
destruction of lung tissue and the loss of
increase trafficking and stability of the protein in the membrane
pulmonary function in CF therefore anti-
using CFTR modulators, correctors & potentiators
inflammatory therapy may slow the
progression of pulmonary disease and
3. Altering other ion channels
decrease morbidity
à failure of cAMP-stimulated chloride transport through CFTR
à Anti-inflammatory therapy should be
may be offset by stimulating chloride transport through alternative
started early in life to prevent or delay
channels in the apical membrane
progression of lung disease, as the greatest
à increased uptake of sodium through ENaC can be blocked by
effect will likely be achieved before fixed
application of amiloride
structural damage develops
à corticoids in children is controversial Disease modifying drugs Ivacaftor is a CFTR potentiator for
G551D conductance defect (Kalydeko)
à Oral steroids (prednisone) over a four Active CFTR

year period were shown to improve lung

function, but side effects included growth golgi

retardation, glucose intolerance, cataract Lumacaftor is a Mis-folded

formation, and multiple fractures corrector; Correctly
folded CFTR protein
deltaF508 CFTR
protein directed
à Non-steroidal anti-inflammatory therapy directed to golgi for
glycosylation
to proteolysis in
proteasomes by

more appropriate for children

ER molecular
chaperones

à Ibuprofen reduced decline in lung endoplasmic

reticulum

function over a four year period, possible

(ER)

Pharmacological chaperone (Lumacaftor)

adverse effects, which include à Pharmacological chaperones such as Lumacaftor are correctors
gastrointestinal bleeding, ulceration and that suppress the folding defect in the common DF508 mutation,
nephrotoxicity, means that only 10% of so that more CFTR protein traffics through the golgi, to the cell
children receive ibuprofen membrane, where it is functional
à anti-protease therapy is being tested à Lumacaftor is currently in clinical trials, alone and in
à imbalance between elastase and its combination with the potentiator Kalydeko
inhibitors, alpha1-anti-trypsin (A1-AT) and à combination called Orkambi
secretory leukocyte protease inhibitor (SLPI), à Ivacaftor (Kalydeco), is a CFTR potentiator approved for
in CF and levels of endogenous A1-AT and patients with the G551D mutation
SLPI are not high enough to inhibit elastase à G551D is a mutation in which amino acid glycine (G) in position 551 is
activity replaced with aspartic acid (D). G551D is characterized by a dysfunctional
à Trials using aerosolised recombinant A1- CFTR protein on the cell surface. Protein is trafficked to correct area,
AT and SLPI indicate this may be effective in epithelial cell surface, but once there, protein cannot transport Cl-
reducing elastase activity and the through the channel. Ivacaftor, a CFTR potentiator, improves transport
inflammatory response in CF of Cl- through the ion channel by binding to the channels directly to
induce a non-conventional mode of gating which in turn increases
probability that channel is open. FDA approved for children age over 6
years
à patients with CF who have premature stop codons, gentamicin
can cause translational “read through,” resulting in the expression
of full-length CFTR protein at the apical cell membrane, and thus
can correct the typical electrophysiological abnormalities caused
by CFTR dysfunction
CFTR modulators:
The pathophysiology of CF and its treatment
à Potentiators; ivacaftor (Kalydeco-2016)
defective CF gene gene therapy
à Correctors; lumacaftor, tezacaftor, elexacaftor for
DF508 defective / deficient CFTR CFTR modulators
- Both beneficial in mild to moderate CF & also in
Cl- secretion, Na+ absorption
individuals with advanced pulmonary disease,
including candidates for lung transplantation. This dessicated mucus mucolytics, DNase
beneficial effect was an improvement in lung
function (FEV1) and reduced rate of exacerbation. bronchial obstruction bronchodilators, chest physiotherapy
à Adverse effects were breathlessness and chest tightness infection antibiotics
à Both TEZ/IVA and LUM/IVA had effects on lung function
inflammation NSAIDS/steroids, anti-
that were modest compared with the effects of IVA on elastase, anti-oxidants
people with G551D gating mutations bronchiectasis, transplantation
à Compared with LUM/IVA, TEZ/IVA administration was respiratory failure, death
more effective and has the advantage of fewer adverse
events and drug–drug interactions, making this drug
combination the better choice for use in triple combination
therapy for people with F508del CF
à The addition of a second corrector, ELX, to TEZ/IVA
resulted in improved CFTR function in excess of the
TEZ/IVA effect
à improved tolerability profile of TEZ/IVA is especially
important in individuals with severe pulmonary disease, in
many of whom severe adverse effects of LUM/IVA
precluded its use
à TEZ/IVA is more compatible than LUM/IVA with the
complexity of chronic medication regimens of many
individuals with advanced pulmonary disease
à Combinations;
1. Orkambi; ivacaftor plus lumacaftor
2. Symdeko (Symkevi); ivacaftor plus tezacaftor
3. Trikafta (Kaftrio); ivacaftor, tezacaftor, elexacaftor
(June 2020 UK-approved)
(UK name in bracket)