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Glycosaminoglycans, Airways Inflammation and Bronchial Hyperresponsiveness
Pulmonary Pharmacology & Therapeutics (2001) 14, 249–254 doi:10.1006/pupt.2001.0296, available online at http://www.idealibrary.com on
PULMONARY PHARMACOLOGY & THERAPEUTICS
Review Glycosaminoglycans, Airways Inflammation and Bronchial Hyperresponsiveness R. Lever, C. Page Sackler Institute of Pulmonary Pharmacology, GKT School of Biomedical Sciences, 5th Floor Hodgkin Building, Guy’s Campus, London SE1 9RT, UK
SUMMARY: Glycosaminoglycans (GAGs) are large, polyanionic molecules expressed throughout the body. The GAG heparin, co-released with histamine, is synthesised by and stored exclusively in mast cells, whereas the closely related molecule heparan sulphate is expressed, as part of a proteoglycan, on cell surfaces and throughout tissue matrices. These molecules are increasingly thought to play a role in regulation of the inflammatory response and heparin, for many years, has been considered to hold potential in the treatment of diseases such as asthma. Heparin and related molecules have been found to exert antiinflammatory effects in a wide range of in vitro assays, animal models and, indeed, human patients. Moreover, the results of studies carried out to date indicate that the antiinflammatory activities of heparin are dissociable from its well-established anticoagulant nature, suggesting that the separation of these characteristics could yield novel antiinflammatory drugs which may be useful in the future treatment of diseases such as asthma. 2001 Academic Press
KEY WORDS: Heparin, Asthma, Inflammation, Anticoagulant.
linkages. Both GAGs are synthesised in the endoplasmic reticulum, as proteoglycans containing multiple polysaccharide chains, the number and composition of which vary with the protein core. The major differences between these two molecules results from polymerisation modifications where heparan sulphate typically has a low level of N- and O-sulphation and retains much more of the original N-acetylglucosamine and glucuronate residues. Heparin, on the other hand, is more highly sulphated and contains a far greater percentage of iduronate residues which have been epimerised from glucuronate, factors which are thought to be responsible for its greater biological activity, when compared to heparan sulphate.3 The major sites of sulphation of the heparin molecule are at the 2-O position of iduronate residues as well as the 2-O position and 6-O position of glucosamine residues. In addition, these disaccharide polymers are occasionally sulphated on either the 2O position of glucuronic acid or the 3-O position of the disulphated glucosamine residues. These differences in composition and extent of sulphation make heparin more highly charged than heparan sulphate, again,
INTRODUCTION Heparin and the related polymer heparan sulphate are members of a family of polysaccharides termed glycosaminoglycans (GAGs). These linear carbohydrate polymers are composed of alternating hexosamine and hexuronic acid residues. Other members of the family include chondroitin sulphates, dermatan sulphate and hyaluronic acid. Proteoglycans are formed by the linkage of one or more GAG chains to a protein core via serine residues. These molecules are now recognised to possess a wide variety of biological activities, including being constituents of the extracellular matrix and basement membrane.1,2 Heparin and heparan sulphate, which have particular relevance to allergy and inflammation, have considerable heterogeneity in their GAG chains, with both polymers being comprised of alternating -glucosamine and hexuronate (--iduronate and -glucuronate) residues, joined by (1→4) glycosidic ∗ Author for correspondence: Prof. C. Page. 1094–5539/01/030249+06 $35.00/0
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an element thought to contribute to its biological activity.4 Heparin is synthesized exclusively in mast cells of the lung, intestine and liver. The heparin polymer contains around 20–100 monosaccharide units per polysaccharide chain, a high density of these chains being attached to the protein core. It is believed that these polysaccharide chains are involved in packaging of basic proteins and histamine in mast cell granules and, given that heparin-containing tissues are those in direct contact with the external environment, would suggest a possible role for heparin in host defence.5 Interestingly, it has been reported that during foetal development, at times when skin, lungs and intestine are not functionally active, almost no heparin can be detected in these tissues.6 In contrast to heparin, heparan sulphate is distributed ubiquitously in nature, being found on cell surfaces and in the basement membrane and matrix of tissues. The presence of heparan sulphate on the surface of vascular endothelial cells is considered to be responsible for the lack of thrombogenicity of the blood vessel wall7 and, moreover, may have a role in preventing non-specific adhesion of inflammatory cells. Furthermore, related substances have been identified on the surface of marine organisms8 and parasites,9 suggesting an evolutionary role for such molecules. It is now recognised that heparin and heparan sulphate can modulate a wide variety of biological functions. Clinically, heparin has been used for many years as a potent anticoagulant, an effect mediated by its ability to interact with anti-thrombin III via a specific pentasaccharide sequence.10–13 However, many of the other biological properties of heparin are unrelated to anticoagulant activity and rely on other features of the molecule, distinct oligosaccharide sequences having been identified that bind specific proteins such as basic fibroblast growth factor and certain adhesion molecules.2 The remainder of this article will focus on the actions of heparin and related molecules that have relevance to our understanding of regulation of the inflammatory process and bronchial hyperresponsiveness, now thought to be central features of airway diseases such as asthma. NON-ANTICOAGULANT ACTIVITIES OF HEPARIN AND RELATED MOLECULES Heparin and related drugs have been demonstrated to inhibit a wide variety of biological functions of relevance to asthma. In particular, these molecules affect factors involved in the inflammatory cell recruitment and function which is known to accompany the late asthmatic response, as well as to underlie the ongoing inflammation and tissue damage associated with this condition and others.
In whole animal studies, pretreatment with heparin has been shown to reduce the eosinophil infiltration into guinea-pig lung which follows challenge with platelet-activating factor (PAF),14 or allergen15 to which the animal is sensitised. By use of control substances, poly--glutamic acid (for anionic charge) and high molecular weight dextrans (for molecular size), this effect was shown to be independent of the size and charge of heparin. A later study went on to show that this property is independent of anticoagulant processes.16 Similar effects were achieved in neonatally immunised rabbits, in that PAF-induced cellular infiltration of the lung was reduced by pretreatment with inhaled heparin. Furthermore, hyperresponsiveness to histamine challenge, following the exposure to PAF, was inhibited.17 In addition, a number of investigations have reported heparin and related molecules to be able to inhibit the recruitment of leukocytes to tissues other than the lung, such as the skin18–20 and gut.21–24 These effects may be explained, to an extent, by the fact that heparin has direct inhibitory effects on the adhesion of leukocytes to vascular endothelium.25–28 Again, this antiinflammatory effect of heparin is mimicked by non-anticoagulant derivatives of the parent molecule.25,26 Furthermore, the anti-adhesive activity of heparin is not related to inhibition of adhesion molecule expression on the endothelium, though is likely to be mediated, at least in part, by binding of adhesion molecules such as CD11b/CD18 (mac-1),29 as is suggested by the results of studies carried out in vivo,24 and L-selectin30 on leukocytes, or P-selectin31 and platelet endothelial cell adhesion molecule-1 (PECAM-1)32 on endothelial cells. The ability of heparin to regulate the activity of certain enzymes may also be involved in its ability to modulate cell trafficking. A number of inflammatory cells have been reported to release the endoglycosidase enzyme heparanase,33 of which two families have now been identified,34 enzymes which are increasingly thought to play an important role in cell diapedesis and trafficking into tissues.35 Heparin is known to act as a competitive inhibitor of these enzymes36,37 and this action has been suggested to contribute to its inhibitory effects on lymphocyte trafficking seen in a variety of situations, such as graft vs. host38 and delayed type hypersensitivity reactions.39 Further to this, it is well established that heparin is able to bind to vascular endothelium40 and, in addition, is able to displace molecules of heparan sulphate.41 It may be the case that some of the inhibitory effects of heparin on cell adhesion and trafficking rely on substitution of endothelial heparan sulphate GAGs with molecules of the more biologically active species. Moreover, circulating heparin, either released from mast cells during the allergic response or administered as a
GAGs and Airway Inflammation
pharmacological agent, could serve to ‘replace’ endothelial heparan sulphate molecules, lost through digestion by leukocyte-derived endoglycosidase enzymes, a feature which has been found to correlate directly with sites of active inflammation in Crohn’s disease and ulcerative colitis42 and which may well extend to other situations, including inflammatory diseases of the airway. Indeed, heparin and related drugs have been found to be of benefit in human subjects with ulcerative colitis,43,44 as well as in other inflammatory conditions, including arthritis,45 interstitial cystitis46,47 and allergic rhinitis.48 Interestingly, in these studies, no haemorrhagic side effects were observed as a result of the anticoagulant activity of heparin, even when delivered parenterally.43,44 Similarly, when given by inhalation, clotting parameters are unaffected by heparin, which persists for more than 24 h in both the lung (39% of received dose) and the blood (25% of received dose), following a single inhalation of the drug from a nebuliser.49 Heparin clearly has a potential role in reducing the accumulation of leukocytes in the lung in diseases such as asthma. However, a further property of this molecule, which may lead to attenuation of ongoing tissue damage, is its ability to bind and neutralise a wide array of mediators released from inflammatory cells. Many chemokines,50 cytokines51 and complement factors52 are known to be bound by heparin and hence, the activation of cells present in the lung, as well as the recruitment of further cells to the area, may be attenuated through neutralisation of these products, as they are released, from degranulating leukocytes. Cell-derived products which may be directly toxic to bronchial epithelium, such as major basic protein53 and eosinophil cationic protein,54 neutrophil elastase55,56 and cathepsin G,56 are counteracted by heparin. This particular property may have positive implications in modulating the development of bronchial hyperresponsiveness, along with the fact that, in vitro, heparin potently inhibits the proliferation of smooth muscle,57 including that of the airway,58,59 an effect which is likely to extend to the in vivo situation through its ability to bind several growth factors important for the growth of these cells.60 HEPARIN IN ASTHMA Heparin was first tested as a potential treatment for asthma in a small, subjectively assessed trial in 1960 and was found to be ninety percent effective in providing relief of symptoms, when administered intravenously.61 More recently, heparin delivered by inhalation was found to prevent reduction in specific airway conductance in subjects with exercise-induced asthma.62–64 In atopic asthmatics, a single inhaled dose of heparin
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was shown to reduce histamine-induced bronchoconstriction and the subsequent increase in bronchial hyperresponsiveness (BHR).65 However, a further study carried out in allergic asthmatics found inhaled heparin to have no effect upon BHR to histamine, nor the early asthmatic response, despite being delivered both before and following allergen challenge, although significant inhibition of the late asthmatic response was demonstrated (vide supra).66 In another controlled trial, the question was addressed as to whether the reported effects of inhaled heparin in asthma may involve neuronal factors associated with altered muscarinic receptor (M2) function, as has been suggested by the results of work carried out in guineapigs.68 No effects were observed against sodium metabisulphite or methacholine challenge in asthmatic patients in this study, suggesting that heparin affects neither neuronal pathways, nor airway smooth muscle tone directly.67 Other investigations in asthmatic human subjects have yielded conflicting results. Heparin has been found to attenuate both adenosine 5′-monophosphate-69 and methacholine-70–72 induced bronchoconstriction, when given up to 1 h prior to bronchoprovocation. None of these studies reported heparin to reduce subsequent bronchial hyperresponsiveness to either stimulus. By contrast, heparin has also been found to be ineffective against methacholine- or adenosine-induced bronchoconstriction.64,69,70 The lack of a consistent effect of heparin on these parameters is not confined to studies carried out in humans. In sheep, heparin has been shown to reduce antigen induced bronchoconstriction and airway hyperresponsiveness, without affecting the response to carbachol or histamine.73,74 In addition, when delivered to the lung as a stoichiometric complex with secretory leukocyte protease inhibitor, the late response to antigen was also inhibited.75 These effects would appear to be unrelated to the antithrombotic nature of the drug, as a study published by the same group reported inhibition of allergic bronchoconstriction by a non-anticoagulant fraction of heparin.76 In guinea-pigs77 and rabbits,78 however, heparin pre-treatment had no effect on antigen-induced bronchoconstriction. The reasons for these discrepancies are not well understood, although when inhibition of allergen-induced bronchoconstriction has been observed, it has been postulated to be related to inhibition of mast cell degranulation,74 possibly via inhibition of the second messenger IP3.74,79 Such effects are unlikely to be attributable to direct relaxant effects on smooth muscle as heparin has no effect on isolated airway smooth muscle contractions elicited by muscarinic agonists,80–83 although antigen-induced contraction in airway smooth muscle from immunised sheep is sensitive to heparin,81 further supporting the hypothesis that the acute bronchoprotective actions of this molecule are mediated through effects on mast
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cells. However, it seems likely that the ability of heparin to modulate other aspects of the inflammatory response may also be important in explaining the beneficial effects of heparin in the treatment of asthma and other inflammatory diseases. In summary, heparin possesses a wide range of biological effects aside from anticoagulant activity, many of which are antiinflammatory. Whereas it is noteworthy that direct administration of unfractionated heparin to the lung has been found, repeatedly, to have no significant effect upon haemostasis, the fact that the antithrombotic nature of heparin appears to be separable from its other actions should be built upon. It may well be possible to design new agents, based upon heparin, which exploit the antiinflammatory actions of the parent molecule but which lack its anticoagulant activity and potential for immunogenicity,84 as these factors currently limit the use of unfractionated heparin on a chronic basis. The results of the many studies carried out in this area suggest not only a rationale for the design and development of new therapeutic agents for use in inflammatory diseases such as asthma but also, a possible immunomodulatory role for heparin as an endogenous molecule.
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Date accepted 21 February 2001.
PULMONARY PHARMACOLOGY & THERAPEUTICS
Review Glycosaminoglycans, Airways Inflammation and Bronchial Hyperresponsiveness R. Lever, C. Page Sackler Institute of Pulmonary Pharmacology, GKT School of Biomedical Sciences, 5th Floor Hodgkin Building, Guy’s Campus, London SE1 9RT, UK
SUMMARY: Glycosaminoglycans (GAGs) are large, polyanionic molecules expressed throughout the body. The GAG heparin, co-released with histamine, is synthesised by and stored exclusively in mast cells, whereas the closely related molecule heparan sulphate is expressed, as part of a proteoglycan, on cell surfaces and throughout tissue matrices. These molecules are increasingly thought to play a role in regulation of the inflammatory response and heparin, for many years, has been considered to hold potential in the treatment of diseases such as asthma. Heparin and related molecules have been found to exert antiinflammatory effects in a wide range of in vitro assays, animal models and, indeed, human patients. Moreover, the results of studies carried out to date indicate that the antiinflammatory activities of heparin are dissociable from its well-established anticoagulant nature, suggesting that the separation of these characteristics could yield novel antiinflammatory drugs which may be useful in the future treatment of diseases such as asthma. 2001 Academic Press
KEY WORDS: Heparin, Asthma, Inflammation, Anticoagulant.
linkages. Both GAGs are synthesised in the endoplasmic reticulum, as proteoglycans containing multiple polysaccharide chains, the number and composition of which vary with the protein core. The major differences between these two molecules results from polymerisation modifications where heparan sulphate typically has a low level of N- and O-sulphation and retains much more of the original N-acetylglucosamine and glucuronate residues. Heparin, on the other hand, is more highly sulphated and contains a far greater percentage of iduronate residues which have been epimerised from glucuronate, factors which are thought to be responsible for its greater biological activity, when compared to heparan sulphate.3 The major sites of sulphation of the heparin molecule are at the 2-O position of iduronate residues as well as the 2-O position and 6-O position of glucosamine residues. In addition, these disaccharide polymers are occasionally sulphated on either the 2O position of glucuronic acid or the 3-O position of the disulphated glucosamine residues. These differences in composition and extent of sulphation make heparin more highly charged than heparan sulphate, again,
INTRODUCTION Heparin and the related polymer heparan sulphate are members of a family of polysaccharides termed glycosaminoglycans (GAGs). These linear carbohydrate polymers are composed of alternating hexosamine and hexuronic acid residues. Other members of the family include chondroitin sulphates, dermatan sulphate and hyaluronic acid. Proteoglycans are formed by the linkage of one or more GAG chains to a protein core via serine residues. These molecules are now recognised to possess a wide variety of biological activities, including being constituents of the extracellular matrix and basement membrane.1,2 Heparin and heparan sulphate, which have particular relevance to allergy and inflammation, have considerable heterogeneity in their GAG chains, with both polymers being comprised of alternating -glucosamine and hexuronate (--iduronate and -glucuronate) residues, joined by (1→4) glycosidic ∗ Author for correspondence: Prof. C. Page. 1094–5539/01/030249+06 $35.00/0
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an element thought to contribute to its biological activity.4 Heparin is synthesized exclusively in mast cells of the lung, intestine and liver. The heparin polymer contains around 20–100 monosaccharide units per polysaccharide chain, a high density of these chains being attached to the protein core. It is believed that these polysaccharide chains are involved in packaging of basic proteins and histamine in mast cell granules and, given that heparin-containing tissues are those in direct contact with the external environment, would suggest a possible role for heparin in host defence.5 Interestingly, it has been reported that during foetal development, at times when skin, lungs and intestine are not functionally active, almost no heparin can be detected in these tissues.6 In contrast to heparin, heparan sulphate is distributed ubiquitously in nature, being found on cell surfaces and in the basement membrane and matrix of tissues. The presence of heparan sulphate on the surface of vascular endothelial cells is considered to be responsible for the lack of thrombogenicity of the blood vessel wall7 and, moreover, may have a role in preventing non-specific adhesion of inflammatory cells. Furthermore, related substances have been identified on the surface of marine organisms8 and parasites,9 suggesting an evolutionary role for such molecules. It is now recognised that heparin and heparan sulphate can modulate a wide variety of biological functions. Clinically, heparin has been used for many years as a potent anticoagulant, an effect mediated by its ability to interact with anti-thrombin III via a specific pentasaccharide sequence.10–13 However, many of the other biological properties of heparin are unrelated to anticoagulant activity and rely on other features of the molecule, distinct oligosaccharide sequences having been identified that bind specific proteins such as basic fibroblast growth factor and certain adhesion molecules.2 The remainder of this article will focus on the actions of heparin and related molecules that have relevance to our understanding of regulation of the inflammatory process and bronchial hyperresponsiveness, now thought to be central features of airway diseases such as asthma. NON-ANTICOAGULANT ACTIVITIES OF HEPARIN AND RELATED MOLECULES Heparin and related drugs have been demonstrated to inhibit a wide variety of biological functions of relevance to asthma. In particular, these molecules affect factors involved in the inflammatory cell recruitment and function which is known to accompany the late asthmatic response, as well as to underlie the ongoing inflammation and tissue damage associated with this condition and others.
In whole animal studies, pretreatment with heparin has been shown to reduce the eosinophil infiltration into guinea-pig lung which follows challenge with platelet-activating factor (PAF),14 or allergen15 to which the animal is sensitised. By use of control substances, poly--glutamic acid (for anionic charge) and high molecular weight dextrans (for molecular size), this effect was shown to be independent of the size and charge of heparin. A later study went on to show that this property is independent of anticoagulant processes.16 Similar effects were achieved in neonatally immunised rabbits, in that PAF-induced cellular infiltration of the lung was reduced by pretreatment with inhaled heparin. Furthermore, hyperresponsiveness to histamine challenge, following the exposure to PAF, was inhibited.17 In addition, a number of investigations have reported heparin and related molecules to be able to inhibit the recruitment of leukocytes to tissues other than the lung, such as the skin18–20 and gut.21–24 These effects may be explained, to an extent, by the fact that heparin has direct inhibitory effects on the adhesion of leukocytes to vascular endothelium.25–28 Again, this antiinflammatory effect of heparin is mimicked by non-anticoagulant derivatives of the parent molecule.25,26 Furthermore, the anti-adhesive activity of heparin is not related to inhibition of adhesion molecule expression on the endothelium, though is likely to be mediated, at least in part, by binding of adhesion molecules such as CD11b/CD18 (mac-1),29 as is suggested by the results of studies carried out in vivo,24 and L-selectin30 on leukocytes, or P-selectin31 and platelet endothelial cell adhesion molecule-1 (PECAM-1)32 on endothelial cells. The ability of heparin to regulate the activity of certain enzymes may also be involved in its ability to modulate cell trafficking. A number of inflammatory cells have been reported to release the endoglycosidase enzyme heparanase,33 of which two families have now been identified,34 enzymes which are increasingly thought to play an important role in cell diapedesis and trafficking into tissues.35 Heparin is known to act as a competitive inhibitor of these enzymes36,37 and this action has been suggested to contribute to its inhibitory effects on lymphocyte trafficking seen in a variety of situations, such as graft vs. host38 and delayed type hypersensitivity reactions.39 Further to this, it is well established that heparin is able to bind to vascular endothelium40 and, in addition, is able to displace molecules of heparan sulphate.41 It may be the case that some of the inhibitory effects of heparin on cell adhesion and trafficking rely on substitution of endothelial heparan sulphate GAGs with molecules of the more biologically active species. Moreover, circulating heparin, either released from mast cells during the allergic response or administered as a
GAGs and Airway Inflammation
pharmacological agent, could serve to ‘replace’ endothelial heparan sulphate molecules, lost through digestion by leukocyte-derived endoglycosidase enzymes, a feature which has been found to correlate directly with sites of active inflammation in Crohn’s disease and ulcerative colitis42 and which may well extend to other situations, including inflammatory diseases of the airway. Indeed, heparin and related drugs have been found to be of benefit in human subjects with ulcerative colitis,43,44 as well as in other inflammatory conditions, including arthritis,45 interstitial cystitis46,47 and allergic rhinitis.48 Interestingly, in these studies, no haemorrhagic side effects were observed as a result of the anticoagulant activity of heparin, even when delivered parenterally.43,44 Similarly, when given by inhalation, clotting parameters are unaffected by heparin, which persists for more than 24 h in both the lung (39% of received dose) and the blood (25% of received dose), following a single inhalation of the drug from a nebuliser.49 Heparin clearly has a potential role in reducing the accumulation of leukocytes in the lung in diseases such as asthma. However, a further property of this molecule, which may lead to attenuation of ongoing tissue damage, is its ability to bind and neutralise a wide array of mediators released from inflammatory cells. Many chemokines,50 cytokines51 and complement factors52 are known to be bound by heparin and hence, the activation of cells present in the lung, as well as the recruitment of further cells to the area, may be attenuated through neutralisation of these products, as they are released, from degranulating leukocytes. Cell-derived products which may be directly toxic to bronchial epithelium, such as major basic protein53 and eosinophil cationic protein,54 neutrophil elastase55,56 and cathepsin G,56 are counteracted by heparin. This particular property may have positive implications in modulating the development of bronchial hyperresponsiveness, along with the fact that, in vitro, heparin potently inhibits the proliferation of smooth muscle,57 including that of the airway,58,59 an effect which is likely to extend to the in vivo situation through its ability to bind several growth factors important for the growth of these cells.60 HEPARIN IN ASTHMA Heparin was first tested as a potential treatment for asthma in a small, subjectively assessed trial in 1960 and was found to be ninety percent effective in providing relief of symptoms, when administered intravenously.61 More recently, heparin delivered by inhalation was found to prevent reduction in specific airway conductance in subjects with exercise-induced asthma.62–64 In atopic asthmatics, a single inhaled dose of heparin
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was shown to reduce histamine-induced bronchoconstriction and the subsequent increase in bronchial hyperresponsiveness (BHR).65 However, a further study carried out in allergic asthmatics found inhaled heparin to have no effect upon BHR to histamine, nor the early asthmatic response, despite being delivered both before and following allergen challenge, although significant inhibition of the late asthmatic response was demonstrated (vide supra).66 In another controlled trial, the question was addressed as to whether the reported effects of inhaled heparin in asthma may involve neuronal factors associated with altered muscarinic receptor (M2) function, as has been suggested by the results of work carried out in guineapigs.68 No effects were observed against sodium metabisulphite or methacholine challenge in asthmatic patients in this study, suggesting that heparin affects neither neuronal pathways, nor airway smooth muscle tone directly.67 Other investigations in asthmatic human subjects have yielded conflicting results. Heparin has been found to attenuate both adenosine 5′-monophosphate-69 and methacholine-70–72 induced bronchoconstriction, when given up to 1 h prior to bronchoprovocation. None of these studies reported heparin to reduce subsequent bronchial hyperresponsiveness to either stimulus. By contrast, heparin has also been found to be ineffective against methacholine- or adenosine-induced bronchoconstriction.64,69,70 The lack of a consistent effect of heparin on these parameters is not confined to studies carried out in humans. In sheep, heparin has been shown to reduce antigen induced bronchoconstriction and airway hyperresponsiveness, without affecting the response to carbachol or histamine.73,74 In addition, when delivered to the lung as a stoichiometric complex with secretory leukocyte protease inhibitor, the late response to antigen was also inhibited.75 These effects would appear to be unrelated to the antithrombotic nature of the drug, as a study published by the same group reported inhibition of allergic bronchoconstriction by a non-anticoagulant fraction of heparin.76 In guinea-pigs77 and rabbits,78 however, heparin pre-treatment had no effect on antigen-induced bronchoconstriction. The reasons for these discrepancies are not well understood, although when inhibition of allergen-induced bronchoconstriction has been observed, it has been postulated to be related to inhibition of mast cell degranulation,74 possibly via inhibition of the second messenger IP3.74,79 Such effects are unlikely to be attributable to direct relaxant effects on smooth muscle as heparin has no effect on isolated airway smooth muscle contractions elicited by muscarinic agonists,80–83 although antigen-induced contraction in airway smooth muscle from immunised sheep is sensitive to heparin,81 further supporting the hypothesis that the acute bronchoprotective actions of this molecule are mediated through effects on mast
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cells. However, it seems likely that the ability of heparin to modulate other aspects of the inflammatory response may also be important in explaining the beneficial effects of heparin in the treatment of asthma and other inflammatory diseases. In summary, heparin possesses a wide range of biological effects aside from anticoagulant activity, many of which are antiinflammatory. Whereas it is noteworthy that direct administration of unfractionated heparin to the lung has been found, repeatedly, to have no significant effect upon haemostasis, the fact that the antithrombotic nature of heparin appears to be separable from its other actions should be built upon. It may well be possible to design new agents, based upon heparin, which exploit the antiinflammatory actions of the parent molecule but which lack its anticoagulant activity and potential for immunogenicity,84 as these factors currently limit the use of unfractionated heparin on a chronic basis. The results of the many studies carried out in this area suggest not only a rationale for the design and development of new therapeutic agents for use in inflammatory diseases such as asthma but also, a possible immunomodulatory role for heparin as an endogenous molecule.
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Date accepted 21 February 2001.