Review

Glucocorticoid resistance in inammatory diseases

Peter J Barnes, Ian M Adcock

Glucocorticoid resistance or insensitivity is a major barrier to the treatment of several common inammatory diseasesincluding chronic obstructive pulmonary disease and acute respiratory distress syndrome; it is also an issue for some patients with asthma, rheumatoid arthritis, and inammatory bowel disease. Several molecular mechanisms of glucocorticoid resistance have now been identied, including activation of mitogen-activated protein (MAP) kinase pathways by certain cytokines, excessive activation of the transcription factor activator protein 1, reduced histone deacetylase-2 (HDAC2) expression, raised macrophage migration inhibitory factor, and increased P-glycoprotein-mediated drug eux. Patients with glucocorticoid resistance can be treated with alternative broad-spectrum anti-inammatory treatments, such as calcineurin inhibitors and other immunomodulators, or novel anti-inammatory treatments, such as inhibitors of phosphodiesterase 4 or nuclear factor B, although these drugs are all likely to have major side-eects. An alternative treatment strategy is to reverse glucocorticoid resistance by blocking its underlying mechanisms. Some examples of this approach are inhibition of p38 MAP kinase, use of vitamin D to restore interleukin-10 response, activation of HDAC2 expression by use of theophylline, antioxidants, or phosphoinositide-3-kinase- inhibitors, and inhibition of macrophage migration inhibitory factor and P-glycoprotein.

Lancet 2009; 373: 190517 National Heart and Lung Institute, Imperial College, London, UK (Prof P J Barnes FRS, Prof Ian M Adcock PhD) Correspondence to: Prof Peter J Barnes, Airway Disease Section, National Heart and Lung Institute, Dovehouse Street, London SW3 6LY, UK p.j.barnes@imperial.ac.uk

Introduction
Glucocorticosteroids (glucocorticoids; also known as corticosteroids or steroids) are the most eective antiinammatory treatments available for many inammatory and immune diseases, including asthma, rheumatoid arthritis, inammatory bowel disease, and autoimmune diseases. However, a few patients with these diseases show a poor or absent response even to high doses of glucocorticoids. Other inammatory diseases, such as chronic obstructive pulmonary disease (COPD), interstitial pulmonary brosis, acute respiratory distress syndrome, and cystic brosis, seem to be largely glucocorticoid resistant. Since chronic inammatory diseases are widespread and their prevalence is rising, glucocorticoid resistance or insensitivity represents an important barrier to eective treatment and accounts for substantial health-care spending. We discuss resistance to the anti-inammatory eects of corticosteroids and the recent identication of several molecular mechanisms of glucocorticoid resistance that might be amenable to new therapeutic approaches.

Glucocorticoid-resistant and insensitive diseases

Although most glucocorticoid resistance studies have focused on asthma, evidence is emerging that similar glucocorticoid resistance is found in many other allergic and chronic inammatory diseases. The prevalence of glucocorticoid resistance is dicult to measure because of dierences in how it is dened and variations over time.

dened as no clinical improvement after treatment with high-dose oral glucocorticoid (prednisolone 40 mg daily for 2 weeks; gure 1).2 There are no well dened methods for the quantication of clinical glucocorticoid responsiveness, although a trial of oral glucocorticoids or a single injection of a depot glucocorticoid (triamcinolone acetonide) can be used to identify patients who are completely resistant. Glucocorticoid resistance in asthma was rst described in 1968 in six patients who had no clinical response or reduction in blood eosinophilia after treatment with high doses of systemic glucocorticoids.3 Carmichael and colleagues4 reported a larger group of 58 patients with chronic asthma whose lung function was not improved (ie, forced expiratory volume in 1 s rose by less than 15%) after treatment with oral prednisolone (20 mg daily for at least 7 days). These patients with glucocorticoidresistant asthma had a longer duration of symptoms, lower morning lung function, a greater degree of airway hyperresponsiveness, and a more frequent family history of asthma than glucocorticoid-sensitive patients. They were not cortisol decient and did not have the abnormalities in sex hormones described in patients

Search strategy and selection criteria We searched PubMed for relevant reviews and original articles published during the past 10 years. Search terms were steroid, glucocorticoid, or corticosteroid, and resistance. We combined these terms with asthma, COPD, ARDS, cystic brosis, rheumatoid arthritis, inammatory bowel disease, ulcerative colitis, Crohns disease, and interstitial pulmonary brosis. Owing to space limitations, we cite recent review articles where possible and do not discuss steroid resistance in haematological malignancies or transplant rejection. We restricted our search to English language publications.

Glucocorticoid-resistant asthma
Asthma can be controlled with low doses of inhaled corticosteroids, which have now become rst-line treatment for most patients.1 However, approximately 10% of patients need the maximum inhaled dose, and around 1% need regular treatment with oral glucocorticoids (termed glucocorticoid-dependent asthma). A very small number of patients are glucocorticoid resistant, which is
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Ecacy

Mild Moderate Severe Glucocorticoid dependent Glucocorticoid resistant Systemic side-eects

Inhaled glucocorticoid dose

Oral glucocorticoid dose

Figure 1: Glucocorticoid responsiveness in asthma The clinical ecacy of glucocorticoids in controlling asthma denes severity of diseaseie, patients with severe asthma need higher doses of inhaled glucocorticoids. Some patients need regular oral glucocorticoid treatment and a small proportion of patients are completely resistant to high doses of oral glucocorticoids. Systemic side-eects (grey triangle) rise with increasing doses of glucocorticoids.

with familial glucocorticoid resistance.5 Plasma cortisol and adrenal suppression in response to exogenous glucocorticoids are normal in patients with glucocorticoid-resistant asthma, who develop the typical Cushingoid side-eects of corticosteroids.6 The absent response to oral glucocorticoids cannot be explained by reduced gastrointestinal absorption or other pharmacokinetic mechanisms,7 which suggests that there is a defect in the anti-inammatory eects of glucocorticoids rather than in their metabolic or endocrine eects. After treatment with high doses of glucocorticoids, bronchial biopsy samples from patients with glucocorticoid-resistant asthma had higher eosinophil and lymphocyte counts than samples from patients with glucocorticoid-sensitive asthma.8 Also, unlike in bronchoalveolar lavage cells from glucocorticoid-sensitive asthmatic patients, there was no suppression of the T-helper-2 (Th2) cytokines interleukin 4 and interleukin 5 in cells from patients with resistance.8 The ratio of matrix metalloproteinase (MMP) 9 to tissue inhibitor of MMP (TIMP) 1 in bronchoalveolar lavage uid is higher in patients with glucocorticoid-resistant asthma than in those with glucocorticoid-sensitive asthma, and macrophages from patients with resistance do not show the normal rise in TIMP1 after corticosteroid treatment in vitro.9 This defect in TIMP1 production might result in abnormal tissue remodelling in the airways of patients with glucocorticoid-resistant asthma, which could be the cause of reduced bronchodilator (reversibility) response in these individuals. Since patients with severe asthma are less responsive to glucocorticoids than those with mild asthma (gure 1), insensitivity to corticosteroids might be a mechanism that contributes to asthma severity.10 Indeed, asthma severity is largely dened on the basis of the dose of glucocorticoids that is needed to control symptoms. However, some patients with milder asthma might also be glucocorticoid insensitive.2 Approximately 25% of asthmatic patients smoke; these patients have a reduced response to inhaled
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and oral glucocorticoids, develop more severe asthma, and have a more rapid decline in lung function than asthmatic patients who do not smoke.11 An important nding that led to several subsequent mechanistic studies was that circulating cells from patients with glucocorticoid-resistant asthma showed reduced responses to glucocorticoids in vitro. The in-vitro proliferation of complement receptors on monocytes and peripheral blood mononuclear cells (PBMCs) from patients with glucocorticoid-sensitive asthma, after phytohaemagluttinin stimulation, was completely suppressed by steroids. However, steroid treatment did not inhibit the proliferation of cells and receptors from patients with glucocorticoid-resistant asthma, suggesting that circulating T lymphocytes and monocytes from these patients were resistant.12,13 Later studies showed that glucocorticoids neither inhibited monocyte function nor interleukin-2 and interferon- secretion in PBMCs after phytohaemagluttinin stimulation in patients with glucocorticoid-resistant asthma.14 The inhibitory eect of glucocorticoids on secretion of cytokines and chemokines from peripheral monocytes and alveolar macrophages was lower in patients with severe asthma that was not controlled with high doses of inhaled corticosteroids than in patients with glucocorticoid-sensitive asthma.15,16 Additionally, patients with glucocorticoid-resistant asthma also showed a reduced skin blanching response to topical glucocorticoids compared with glucocorticoid-sensitive individuals, suggesting a generalised abnormality in glucocorticoid responsiveness.17

Other normally responsive chronic inammatory and immune diseases

About 30% of patients with rheumatoid arthritis have a poor clinical response to glucocorticoids; most often these are patients with more severe disease, although sometimes they have mild or early disease.18 As in glucocorticoid-resistant asthma, PBMCs from patients with glucocorticoid-resistant rheumatoid arthritis have a lower antiproliferative and cytokine response to corticosteroids in vitro19,20 than cells from patients with glucocorticoid-sensitive disease.18 Furthermore, a similar proportion of patients with ulcerative colitis and Crohns disease have a poor or absent clinical response to steroids and reduced responses of circulating lymphocytes to glucocorticoids compared with glucocorticoid-sensitive individuals.21,22 Some patients with systemic lupus erythematosis have shown a poor clinical response and reduced T-cell responses to glucocorticoids in vitro.23 Some patients with atopic dermatitis have also shown no response to topical glucocorticoids.24

COPD
By sharp contrast with asthma, most patients with COPD respond very poorly to high doses of inhaled or oral glucocorticoids. Glucocorticoids have no eect on
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Annexin 1 SLPI MKP1 GILZ 2 adrenoceptor

Glucocorticoid

Anti-inammatory proteins GR

Cytoplasm

GRE mRNA

CBP GR GR HAT Nucleus Acetylation

Anti-inammatory gene Core histones Gene transcription Gene repression

Figure 2: Glucocorticoid activation of anti-inammatory gene expression After ligand binding, activated glucocorticoid receptors (GRs) translocate to the nucleus where they bind to glucocorticoid response elements (GREs) in the promoter region of glucocorticoid-responsive genes and also directly or indirectly to transcriptional coactivator molecules such as cyclic AMP response element binding protein (CBP). Coactivator molecules have intrinsic histone acetyltransferase (HAT) activity and cause acetylation of core histones, resulting in the activation of anti-inammatory genes. GILZ=glucocorticoid-induced leucine zipper protein. MKP1=mitogen-activated protein kinase phosphatase 1. SLPI=secretory leucoprotease inhibitor.

disease progression or mortality, but there is a small reduction in exacerbations,25 although this nding has recently been questioned.26 Several studies have shown that inhaled corticosteroids do not reduce inammation either measured in sputum or airways of COPD patients,2729 or by cytokine responses in alveolar macrophages in vitro.30 Approximately 10% of COPD patients show some clinical response to inhaled corticosteroids; these patients are characterised by increased numbers of eosinophils in the airways and more bronchodilator reversibility;31,32 thus, it is likely that they have concomitant asthma.33

a poor response to high doses of systemic glucocorticoids.37 Additionally, inammation has a key role in the development of atherosclerosis, but glucocorticoids do not have any clinical benet in the treatment or prevention of cardiovascular disease or in the development of atheromatous plaques.38

Side-eects
Although the anti-inammatory response to glucocorticoids is blunted or absent, glucocorticoid-resistant patients are still at risk from side-eects. Indeed, glucocorticoids are often used at high doses in these patients, therefore, they might be more susceptible to adverse events. The molecular mechanisms for systemic side-eects of glucocorticoids are not well understood; they might be dierent from the major mechanisms used by corticosteroids to suppress inammation.39 The nding that glucocorticoid resistance occurs alongside glucocorticoid side-eects provides important clues to the molecular mechanisms of these drugs.

Other normally glucocorticoid-resistant inammatory diseases

Patients with cystic brosis have very inamed airways and have infective exacerbations, but inhaled corticosteroids provide no clinical benet and might have adverse eects on growth in children with the disease.34,35 Similarly, clinical studies have shown that oral glucocorticoids are not eective for the treatment of interstitial pulmonary brosis (also known as usual interstitial pneumonia), which is characterised by chronic inammation of the lung parenchyma, although there have been few large controlled trials.36 Patients with acute respiratory distress syndrome, which is associated with an intense inammatory response in the lungs, also have
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How glucocorticoids suppress inammation

There have been major advances in the understanding of molecular mechanisms by which glucocorticoids suppress inammation,40,41 mainly as a result of research into the proinammatory and anti-inammatory genes that they activate and suppress.
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Gene activation
Glucocorticoids diuse across the cell membrane and bind to glucocorticoid receptors in the cytoplasm.41 Upon ligand binding, glucocorticoid receptors are activated and released from chaperone proteins (eg, heat shock protein 90 [HSP90]), and rapidly translocate to the nucleus where the receptor complex exerts its molecular eects. The mechanism of nuclear translocation is dependent upon the nuclear import proteins importin (karyopherin ) and importin 13.42,43 Glucocorticoid receptor is the only form of the receptor that binds to glucocorticoids. Glucocorticoid receptor , an alternatively spliced form, interacts with DNA; it might therefore act as a dominant-negative inhibitor of glucocorticoid action by interfering with the binding of activated glucocorticoid receptor to DNA.44 Glucocorticoid receptors homodimerise and bind to glucocorticoid response elements (GREs) in the promoter region of glucocorticoid-responsive genes and this interaction switches on (or occasionally switches o) gene transcription. Activation of glucocorticoid-responsive genes can also occur via an interaction between the DNA-bound glucocorticoid receptor and transcriptional coactivator molecules (such as cyclic AMP response element binding protein),

which have intrinsic histone acetyltransferase activity and cause acetylation of core histones (particularly histone 4). Acetylated histones recruit chromatin remodelling engines such as SWI/SNF proteins and subsequent association of RNA polymerase II results in gene activation (gure 2).45 Genes that are switched on by glucocorticoids include those that encode 2-adrenergic receptors and the anti-inammatory proteins secretory leucoprotease inhibitor and mitogenactivated protein (MAP) kinase phosphatase 1 (MKP1), which inhibits MAP-kinase pathways.46,47 Glucocorticoid receptor interaction with negative GREsor with GREs crossing the transcriptional start sitemight suppress gene transcription, which might be important in mediating many of the side-eects of glucocorticoids, such as the inhibition of osteocalcin, a protein associated with bone synthesis.48

Switching o inammation
The major action of glucocorticoids is to switch o multiple activated inammatory genes that encode cytokines, chemokines, adhesion molecules, inammatory enzymes, and receptors.49 These genes are switched on in the airways by proinammatory transcription factors, such as nuclear factor B (NFB) and activator protein 1 (AP1), which interact with

Inammatory stimuli eg, interleukin 1, TNF

Glucocorticoid

IKK NFB p65 p50 GR

Cytoplasm

B Inammatory genes Cytokines, chemokines, adhesion molecules, inammatory receptors, enzymes, proteins

p65 p50 Acetylation

CBP HAT GR HDAC2 Deacetylation Nucleus

Gene transcription

Gene repression

Figure 3: Glucocorticoid suppression of activated inammatory genes Inammatory stimuli activate inhibitor of nuclear factor B (NFB) kinase (IKK), which therefore activates NFB. A dimer of p50 and p65 NFB proteins translocates to the nucleus and binds to specic B recognition sites on the promoter regions of inammatory genes and also to coactivators, such as cyclic AMP response element binding protein (CBP). The coactivators cause acetylation of core histones, activating gene expression of inammatory proteins. Activated glucocorticoid receptors (GRs) bind to coactivators in the nucleus to inhibit histone acetyltransferase (HAT) activity directly. GRs also recruit histone deacetylase 2 (HDAC2), leading to suppression of the activated inammatory genes. TNF=tumour necrosis factor .

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transcriptional coactivator molecules to activate gene transcription (gure 3).50 Activated glucocorticoid receptors interact with co-repressor molecules to attenuate NFB-associated coactivator activity, thus reducing histone acetylation, chromatin remodelling, and RNA polymerase II actions.40,45 Reduction of histone acetylation occurs through the specic recruitment of histone deacetylase (HDAC) 2 to the activated inammatory gene complex by activated glucocorticoid receptor, thereby resulting in eective suppression of activated inammatory genes within the nucleus. This mechanism might account for why glucocorticoids are eective and safe in the control of inammation, since other genes are not aected. Glucocorticoid receptors become acetylated upon ligand binding, enabling them to bind to GREs and to be targeted by HDAC2, therefore allowing association with the NFB complex.51 HDAC6 can also aect glucocorticoid receptor function, since it can control HSP90 acetylation status and therefore inhibit glucocorticoid receptor nuclear translocation.52 Additional mechanisms are also important in the anti-inammatory actions of glucocorticoids. Glucocorticoids have potent inhibitory eects on MAP-kinase signalling pathways through the induction of MKP1, which can inhibit the expression of several inammatory genes.46,47 Some proinammatory genes, such as tumour necrosis factor (TNF), have unstable messenger RNA (mRNA) that is rapidly degraded by certain ribonucleases, but stabilised when cells are stimulated by inammatory mediators. Glucocorticoids reverse this eect, resulting in rapid degradation of mRNA and reduced inammatory protein secretion.53 This action might be mediated through the increased gene expression of proteins that destabilise mRNAs of inammatory proteins, such as the zinc nger protein tristetraprolin, which binds to the 3 adenine and uracil-rich untranslated region of mRNA.54

Panel 1: Molecular mechanisms of glucocorticoid resistance Familial glucocorticoid resistance Glucocorticoid receptor modication Phosphorylation (see gure 4) Nitrosylation Ubiquitination Increased glucocorticoid receptor- expression Increased proinammatory transcription factors AP1, JNK STAT5, JAK3 Defective histone acetylation Reduced acetylation of lysine 5 on histone 4 Reduced histone deacetylase 2 Increased oxidative stress Increased phosphoinositide-3-kinase- activation Increased P-glycoprotein Increased eux of steroids
AP1=activator protein 1. ERK=extracellular signal-regulated kinase. JNK=c-Jun N-terminal kinase. MAP=mitogen-activated protein. MIF=macrophage migration inhibitory factor. STAT=signal transduction-activated transcription factor.

Molecular mechanisms of glucocorticoid resistance

Several distinct molecular mechanisms that contribute to decreased anti-inammatory eects of glucocorticoids have now been identied; there is, then, heterogeneity of mechanisms even within a single disease (panel 1 and gure 4). Similar molecular mechanisms have been identied in dierent inammatory diseases, suggesting that common therapeutic approaches might be developed in the future.

Genetic susceptibility
The early descriptions of glucocorticoid-resistant asthma showed that it was often found within families;4 thus, genetic factors might determine glucocorticoid responsiveness. Microarray studies of PBMCs from glucocorticoid-sensitive and glucocorticoid-resistant asthmatic patients identied 11 genes that discriminated between
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these groups,55 suggesting that it might be possible to develop a genomic test for glucocorticoid resistance. This approach has not yet been applied to other inammatory diseases. However, a gene expression proling study in healthy volunteers that compared expression of circulating genes between the 10% of participants with the highest glucocorticoid responsiveness and the 10% with the lowest identied 24 genes that showed dierences between the groups. The most discriminant gene identied was bone morphogenetic protein receptor type II (BMPRII), which enhanced glucocorticoid responsiveness when transfected into cells.56 The very rare inherited syndrome familial glucocorticoid resistance is characterised by high circulating cortisol concentration without signs or symptoms of Cushings syndrome.5 Where clinical manifestations are present, they are caused by an excess of non-corticosteroid adrenal steroids, stimulated by high adrenocorticotropic hormone concentration. Resulting symptoms are either hypertension with hypokalaemia or signs of androgen excess (usually hirsutism and menstrual abnormalities in women), or both. Inheritance seems to be dominant with variable expression, but only about a dozen cases have so far been reported. Sporadic cases have also been described.5 Several abnormalities in glucocorticoid receptor function have been described in peripheral blood leucocytes or broblasts from patients with familial glucocorticoid resistance, including reduced binding anity for cortisol, a reduced rate of receptor expression, thermolability, and reduced binding to DNA, all of which are caused by mutations of the glucocorticoid receptor. By contrast, mutational analysis of glucocorticoid receptor complementary DNA from patients
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Interleukin 2 and interleukin 4 Interleukin 13

MIF

Glucocorticoid

Microbial superantigens

Inammatory cytokines

p38 MAPK

P Ub GR

P NO NO

ERK JNK

iNOS

Cytoplasm NFB GR GR GR GR GR AP1 Nucleus

GRE

Figure 4: Possible molecular mechanisms of glucocorticoid resistance The following kinases can phosphorylate (P) glucocorticoid receptors (GRs): p38 mitogen-activated protein kinase (MAPK), which is activated by interleukin 2 and interleukin 4, interleukin 13, or macrophage migration inhibitory factor (MIF); c-Jun N-terminal kinase (JNK), activated by proinammatory cytokines; or extracellular signal-regulated kinase (ERK), activated by microbial superantigens. Nitric oxide (NO) can nitrate tyrosine residues on GRs. GRs can also be ubiquitinated (Ub), which results in degradation of GR by the proteasome. GRs might be prevented from binding to glucocorticoid response elements (GREs) or inhibiting nuclear factor B (NFB) by sequestration by activator protein 1 (AP1), which is activated by JNK, or by the binding of increased GR to GRE binding sites. iNOS=inducible nitric oxide synthase.

with glucocorticoid-resistant asthma found no obvious abnormalities in receptor structure.57 Various single nuclear polymorphisms of glucocorticoid receptor have been linked to altered cellular responses to glucocorticoids, and a polymorphism of glucocorticoid receptor (GR-9) is associated with a reduced transrepressional response to glucocorticoids.58 However, these polymorphisms have yet to be associated with glucocorticoid resistance in inammatory diseases.

Defective glucocorticoid receptor binding and translocation

Interleukin 2 and interleukin 4 are overexpressed in the airways of patients with glucocorticoid-resistant asthma.8 In vitro, these cytokines in combination reduce glucocorticoid receptor nuclear translocation and binding anity within the nucleus of T cells.5961 Interleukin 13 alone mimics this eect in monocytes.60,62 The mechanism by which these cytokines reduce glucocorticoid receptor function might be mediated via phosphorylation of the receptor by p38 MAP kinase, since the eect is blocked by a p38 MAP-kinase inhibitor.60 In accordance with this theory, p38 MAP kinase has shown a greater degree of activation in alveolar macrophages from asthmatic patients with a poor response to glucocorticoids than from patients who show a normal response.16 The serine residue
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phosphorylated by p38 MAP kinase has not yet been conrmed and could be Ser226 or Ser211.60,63,64 Glucocorticoid receptors might be phosphorylated by several kinases that alter their binding anity for glucocorticoid, stability, translocation to the nucleus, binding to DNA, and interaction with other proteins, such as transcription factors and molecular chaperones.65 Interleukin 2 caused reduced nuclear translocation in murine T cells through a mechanism involving interaction of glucocorticoid receptor with the transcription factor signal transduction activated transcription factor 5 under the control of janus kinase 3 (JAK3).66 A large proportion of patients with glucocorticoid-resistant asthma showed reduced nuclear translocation of glucocorticoid receptor and reduced GRE binding in PBMCs after glucocorticoid exposure, and this might be explained by glucocorticoid receptor phosphorylation.61,64 Another MAP kinase, c-Jun N-terminal kinase (JNK), which is activated by TNF and other proinammatory cytokines, directly phosphorylates glucocorticoid receptor at Ser226 to inhibit GRE binding.67 Microbial superantigens induce glucocorticoid resistance in T cells in vitro via activation of extracellular receptor kinase pathways, resulting in glucocorticoid receptor phosphorylation.68 MKP1 is an endogenous inhibitor of MAP kinase. Macrophages from MKP1 gene knock-down mice showed reduced anti-inammatory responses to glucocorticoids
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in vitro.69 A study in asthmatic patients with poor glucocorticoid responses found a substantial reduction in MKP1 expression in alveolar macrophages after glucocorticoid exposure. This nding was associated with increased p38 MAP-kinase activity.16 In-vitro glucocorticoid receptor can be nitrosylated by nitric oxide donors, resulting in reduced binding anity for glucocorticoids.70 In inammatory diseases there is often increased expression of inducible nitric oxide synthase, which produces large amounts of nitric oxide. Whether nitric oxide reduces glucocorticoid responsiveness in vivo has not yet been investigated. Since glucocorticoid receptors can be ubiquitinated and tagged for proteasomal degradation, proteasome inhibitors might increase glucocorticoid responsiveness;71 however, this has not yet been shown in glucocorticoid-resistant disease.

Increased expression of glucocorticoid receptor

Some studies have reported increased expression of glucocorticoid receptor in glucocorticoid-resistant patients of several diseases, including asthma, rheumatoid arthritis, and inammatory bowel disease,7275 but other studies do not support this nding.76,77 Glucocorticoid receptor is induced by proinammatory cytokines and competes with glucocorticoid receptor for the binding of GRE, thus acting as a dominant-negative inhibitor.78 Glucocorticoid receptor- expression is also increased by microbial superantigens, such as staphylococcal enterotoxins, which might account for the glucocorticoid resistance seen in patients with atopic dermatitis.79 However, increased glucocorticoid receptor is an unlikely mechanism for glucocorticoid resistance because in most cell types, apart from neutrophils, the expression of glucocorticoid receptor is much lower than that for glucocorticoid receptor .76 Another mechanism might be the disruption of glucocorticoid receptor- nuclear translocation, since knockdown of glucocorticoid receptor in alveolar macrophages from patients with glucocorticoid-resistant asthma resulted in enhanced glucocorticoid receptor- nuclear localisation and increased glucocorticoid responsiveness.80 Although glucocorticoid receptor does not bind to glucocorticoid, it is transcriptionally active and the glucocorticoid receptor antagonist mifepristone can bind to it, making it translocate to the nucleus. The endogenous ligand of glucocorticoid receptor is currently unknown.81

with glucocorticoid-resistant asthma, JNK is activated to a greater extent and there is higher expression of c-Fos than in cells and samples from patients with glucocorticoid-sensitive disease. Futhermore, in PBMCs from patients with glucocorticoid-resistant asthma, there is no reduction in JNK activity or c-Jun after high doses of oral glucocorticoids.84 These ndings might explain why the heightened inammation found in severe inammatory disease results in secondary glucocorticoid resistance and is a mechanism for perpetuating glucocorticoid resistance whatever the initial cause. Increased c-Jun results in depolymerisation of the cytoskeleton, which might reduce glucocorticoid receptor transactivating activity.85 Colin 1 is an actin-binding protein that also depolymerises the cytoskeleton. Gene array studies showed that the expression of this protein was higher in T cells from patients with glucocorticoid-resistant asthma than in patients with glucocorticoid-sensitive asthma.86 Overexpression of colin 1 results in glucocorticoid resistance in T cells. There is less known about this mechanism in other inammatory diseases, although one study of glucocorticoid-resistant rheumatoid arthritis did not show enhanced AP1 activation in PBMCs with reduced glucocorticoid responsiveness in vitro.19

Abnormal histone acetylation

As previously mentioned, glucocorticoids switch on glucocorticoid-responsive genes, such as MKP1, via acetylation of specic lysine residues (Lys5 and Lys16) on histone 4.45 In a small proportion of patients with glucocorticoid-resistant asthma, glucocorticoid receptors translocate normally to the nucleus after dexamethasone exposure, but do not acetylate Lys5; thus, transactivation of genes does not occur.61 These patients show a poor response to high-dose inhaled corticosteroids, but have fewer adverse events than patients with glucocorticoid resistance. This nding is because side-eects are mediated via GREs.48 Recruitment of HDAC2 to activated inammatory genes is a major mechanism of gene repression by glucocorticoids.87 HDAC2 activity and expression is reduced in patients with some diseases that respond poorly to glucocorticoid treatment (gure 5). For example, HDAC2 expression and activity are very low in alveolar macrophages, airways, and peripheral lung in patients with COPD.88 Similarly, low HDAC2 expression has been found in PBMCs and alveolar macrophages from patients with refractory asthma15 and in the airways of asthmatic patients who smoke.89 Overexpression of HDAC2 (by use of a plasmid vector) in bronchoalveolar macrophages from patients with glucocorticoid-resistant COPD restored glucocorticoid sensitivity to the level seen in controls.51 Whether HDAC2 expression is also reduced in glucocorticoid-resistant patients with other inammatory diseases, such as rheumatoid arthritis and inammatory
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Transcription factor activation

Excessive activation of AP1 has been identied as a mechanism of glucocorticoid resistance in asthma since this protein binds to glucocorticoid receptor and thus prevents its interaction with GRE and other transcription factors.82,83 AP1 is a heterodimer of Fos and Jun proteins and can be activated by proinammatory cytokines such as TNF through the JNK pathway. In PBMCs and bronchial biopsy samples from patients
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Normal asthma Stimuli Glucocorticoids

COPD Asthma+smoking Severe asthma Cigarette smoke

asthmatic patients, suggesting that this might be a useful therapeutic approach. Vitamin D is recognised as an important regulator of the immune system, particularly in the control of regulatory T cells. Therefore, low dietary intake of vitamin D or lack of sunlight might be contributory factors to reduced glucocorticoid responses in inammatory diseases.

Oxidative stress Alveolar macrophage GR

Increased P-glycoprotein
The multidrug-resistance gene MDR1 (ABCB1) encodes the drug eux pump P-glycoprotein 170, a member of the ATP-binding cassette transporters. P-glycoprotein 170 transports drugs, including glucocorticoids, out of cells, and might therefore be a mechanism for glucocorticoid resistance in inammatory diseases. High levels of MDR1 expression have been found in circulating lymphocytes from patients with glucocorticoid-resistant inammatory bowel disease21,97 and rheumatoid arthritis.98 Both diseases have been associated with some single nucleotide polymorphisms of MDR1.99,100 These polymorphisms aect response to drugs other than glucocorticoids, such as methotrexate. However, these ndings have not been supported by other studies and this mechanism has not been explored in glucocorticoid-resistant pulmonary disease.

NFB
HDAC2 HDAC2

NFB

Histone acetylation TNF Interleukin 8 GM-CSF

Histone acetylation

Histone acetylation TNF Interleukin 8 GM-CSF Theophylline PI3K inhibitor Antioxidants

Figure 5: Proposed mechanism of glucocorticoid resistance in COPD, severe asthma, and in asthmatic patients who smoke Stimulation of alveolar macrophages activates nuclear factor B (NFB) and other transcription factors to switch on histone acetyltransferase, leading to transcription of inammatory genes, such as tumour necrosis factor (TNF), interleukin 8, and granulocyte-macrophage colony stimulating factor (GM-CSF). Activated glucocorticoids recruit histone deacetylase 2 (HDAC2), which reverses the histone acetylation induced by NFB and switches o the genes. In patients with chronic obstructive pulmonary disease (COPD) and asthmatic patients who smoke, activated neutrophils and cigarette smoke generate oxidative stress, which impairs the activity of HDAC2. Drugs that enhance HDAC2 activity include theophylline and other drugs in clinical development. GR=glucocorticoid receptor. PI3K=phosphoinositide-3-kinase-.

Macrophage migration inhibitory factor

Macrophage migration inhibitory factor (MIF), a proinammatory cytokine that has potent anti-glucocorticoid eects, has been associated with several inammatory diseases.101 MIF is induced by glucocorticoids and inhibits their anti-inammatory eects mainly through inhibition of MKP1 induction.102 Enhanced MIF expression has been found in colonic mononuclear cells from patients with glucocorticoid-resistant ulcerative colitis and MIF antibody restores the anti-inammatory response to glucocorticoids in these cells.103 Similar ndings have been reported in glucocorticoid-resistant rheumatoid arthritis, systemic lupus erythematosis, and atherosclerosis.104 Polymorphisms of the MIF gene have been associated with glucocorticoid resistance in patients with rheumatoid arthritis and inammatory bowel disease,105,106 although these ndings have been disputed.104 MIF has also been implicated in the glucocorticoid resistance of acute respiratory distress syndrome and asthma.107,108 Thus, anti-MIF therapies might be eective in several glucocorticoid-resistant diseases.

bowel disease, has not yet been investigated; however, HDAC2 and SWI/SNF expression is reduced in glucocorticoid-resistant adenocarcinomas of patients with Cushings disease.90 The mechanisms for the inactivation of HDAC2 in COPD are now being studied.91 Figure 6 shows the pathways by which oxidative and nitrative stress might inhibit HDAC2. Since oxidative stress is frequently found in patients with severe and glucocorticoid-resistant inammatory diseases, it might be an important mechanism of glucocorticoid resistance.94

Reduction in regulatory T cells

Interleukin 10 is an important anti-inammatory and immunoregulatory cytokine secreted by regulatory T cells in response to glucocorticoids.95 An in-vitro study found that T-helper cells from patients with glucocorticoid-resistant asthma did not secrete interleukin 10 after culture with glucocorticoid; however, after addition of vitamin D3 (calcitriol), secretion of interleukin 10 rose to levels seen in cells from glucocorticoid-sensitive patients cultured with glucocorticoid alone.96 Furthermore, treatment with vitamin D3 restored the T-cell interleukin-10 response to glucocorticoids in three glucocorticoid-resistant
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Therapeutic implications
There are several therapeutic strategies for management of glucocorticoid-resistant diseases, but the most important general approaches are to use alternative anti-inammatory (steroid sparing) treatments or to reverse the molecular mechanisms of glucocorticoid resistance, if these are known (panel 2). Selective glucocorticoid receptor agonists (SEGRAs; or dissociated
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steroids) are more eective in transrepression than in transactivation and therefore have few side-eects. However, it is unlikely that SEGRAs will be able to overcome glucocorticoid resistance because they might be as ineective as conventional glucocorticoids in triggering gene activation or repression.109

Oxidative stress Peroxynitrite Cell membrane

Nitrative stress

Alternative anti-inammatory treatments

Several alternative anti-inammatory drugs are currently available for the treatment of glucocorticoid-resistant diseases. Calcineurin inhibitors, such as ciclosporin A and tacrolimus, are eective in some patients with glucocorticoid-resistant inammatory bowel disease and rheumatoid arthritis, but they have not proved to be eective in glucocorticoid-resistant asthma.110112 Immunomodulators such as methotrexate might be ineective in cases of glucocorticoid-resistant inammatory bowel disease and rheumatoid arthritis caused by increased P-glycoprotein expression, because there might be resistance to the drug, which is also euxed by this pump. This setback has led to a search for novel anti-inammatory treatments, particularly for diseases with marked glucocorticoid resistance, such as COPD and acute respiratory distress syndrome. Phosphodiesterase-4 inhibitors are broad-spectrum anti-inammatory treatments in clinical development for several inammatory diseases, such as COPD and inammatory bowel disease,113 but these have so far proved disappointing because side-eects such as nausea, diarrhoea, and headaches are dose limiting.113 Several p38 MAP-kinase inhibitors are in clinical development and could theoretically be eective in glucocorticoid-resistant asthma caused by interleukin 2 and interleukin 4.60 They might also be useful in other glucocorticoid-insensitive inammatory diseases such as rheumatoid arthritis, inammatory bowel disease, and COPD in which p38 MAP kinase is activated. p38 MAP-kinase inhibitors have shown ecacy in glucocorticoid-resistant animal models of these diseases;114,115 however, the drugs have been associated with toxicity and side-eects.116 The use of selective inhibitors to block inhibitor of NFB kinase (IKK)and, therefore, NFBis another way of treating glucocorticoid-resistant inammation, but these drugs are likely to have toxicity and side-eects, and are thus only suitable for topical application.117
PI3K

Akt

P NO Tyr HDAC2

Ub HDAC2 Degradation by proteasome

Ub Degradation by proteasome

Glucocorticoid resistance

Figure 6: Mechanism of reduced HDAC2 in glucocorticoid-resistant diseases Oxidative stress activates the enzyme phosphoinositide-3-kinase- (PI3K),92 which then phosphorylates downstream kinases such as Akt (protein kinase B), resulting in the phosphorylation and inactivation of histone deacetylase 2 (HDAC2). Additionally, oxidative and nitrative stress generate peroxynitrite, which nitrates (NO) tyrosine residues (Tyr) on HDAC2 to inhibit its activity. These modications of HDAC2 result in its ubiquitination (Ub), targeting the enzyme for degradation by the proteasome, and thus leading to profound glucocorticoid resistance.93

Panel 2: Treatments for glucocorticoid resistance Alternative broad-spectrum anti-inammatory treatments Calcineurin inhibitorseg, ciclosporin, tacrolimus Immunomodulatorseg, methotrexate Phosphodiesterase-4 inhibitors p38 MAP kinase inhibitors IKK inhibitors Reversal of glucocorticoid resistance p38 MAP kinase inhibitors JNK inhibitors (decrease AP1) Vitamin D in steroid-resistant asthma (increase regulatory T cells) MIF inhibitors Histone deacetylate-2 activators Theophylline Phosphoinositide-3-kinase- inhibitors Antioxidants iNOS inhibitors P-glycoprotein inhibitors
AP1=activator protein 1. IKK=inhibitor of nuclear factor B kinase. iNOS=inducible nitric oxide synthase. JNK=c-Jun N-terminal kinase. MAP=mitogen-activated protein. MIF=macrophage migration inhibitory factor.

Reversing glucocorticoid resistance

The most attractive option for treating glucocorticoid resistance is to reverse its cause. For example, this could be achieved by smoking cessation in asthmatic patients who smoke.118 In the future, reversal might be possible for some patients with glucocorticoid-resistant asthma by treatment with p38 MAP kinase inhibitors, JNK inhibitors, and vitamin D3.60,83,96 A monoclonal antibody to interleukin-2 receptor (anti-CD25, basiliximab) was found to be clinically eective in patients with
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glucocorticoid-resistant ulcerative colitis in an uncontrolled study.119 Inhibitors of JAK3which is activated by interleukin 2might be useful for the treatment of glucocorticoid-resistant asthma and have
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proved eective in animal models of rheumatoid arthritis.115 There are several therapeutic strategies for inhibiting P-glycoprotein to prevent the eux of glucocorticoids, some of which are based on the nding that verapamil and quinidine act as eux blockers; several novel drugs based on this mechanism are now in development.120 Additionally, because of the association between increased MIF and glucocorticoid resistance in several diseases, strategies to inhibit MIF, including small molecule inhibitors and monoclonal antibodies, are currently being investigated.121 Selective activation of HDAC2 can be achieved with theophylline, which restores HDAC2 activity in COPD macrophages to normal levels and reverses glucocorticoid resistance (gure 5).122 Oral theophylline reversed glucocorticoid resistance in mice exposed to cigarette smoke that developed glucocorticoid-resistant inammation.123 Clinical trials to test theophylline in patients with COPD are now underway. Current studies suggest that the molecular mechanism of action of theophylline in restoring HDAC2 is via selective inhibition of phospho-inositide-3-kinase- (PI3K), which is activated by oxidative stress in patients with COPD.92 As a result, selective PI3K inhibitors might also be eective in treating COPD, and these drugs are currently in clinical development for this and other diseases.124 Furthermore, anti-PI3K strategies are eective in models of rheumatoid arthritisa disease in which PI3K activity is also increasedsuggesting that a similar glucocorticoid-sparing eect might be possible in patients with glucocorticoid-resistant rheumatoid arthritis.125 Since oxidative stress seems to be an important mechanism in the reduction of HDAC2 and leads to glucocorticoid resistance, antioxidants should also be eective, but those that are currently available are not. Several more potent antioxidants are now in clinical development.94 In the future, novel drugs that increase HDAC2 could be developed once the molecular signalling pathways that regulate HDAC2 are better understood.126

Conclusions
Glucocorticoid resistance is important in several common inammatory diseases and complicates their clinical management. Many dierent molecular mechanisms of glucocorticoid resistance have now been elucidated, which might lead to new therapeutic strategies in the future, including the prospect of reversing glucocorticoid resistance.
Contributors Both authors contributed to the structure of the Review. PJB did the literature search and wrote the initial draft and IMA made revisions to the manuscript. Conicts of interest PJB and IMA have received research funding from AstraZeneca, GlaxoSmithKline, Novartis, and Pzer, all of which have an interest in treatment of inammatory diseases.

References 1 Bateman ED, Hurd SS, Barnes PJ, et al. Global strategy for asthma management and prevention: GINA executive summary. Eur Respir J 2008; 31: 14378. 2 Barnes PJ, Greening AP, Crompton GK. Glucocorticoid resistance in asthma. Am J Respir Crit Care Med 1995; 152: 125S40. 3 Schwartz HJ, Lowell FC, Melby JC. Steroid resistance in bronchial asthma. Am J Int Med 1968; 69: 49399. 4 Carmichael J, Paterson IC, Diaz P, Crompton GK, Kay AB, Grant IW. Corticosteroid resistance in asthma. BMJ 1981; 282: 141922. 5 Lamberts SW. Hereditary glucocorticoid resistance. Ann Endocrinol (Paris) 2001; 62: 16467. 6 Lane SJ, Atkinson BA, Swimanathan R, Lee TH. Hypothalamic-pituitary axis in corticosteroid-resistant asthma. Am J Respir Crit Care Med 1996; 153: 151014. 7 Lane SJ, Palmer JB, Skidmore IF, Lee TH. Corticosteroid pharmacokinetics in asthma. Lancet 1990; 336: 1265. 8 Leung DY, Martin RJ, Szeer SJ, et al. Dysregulation of interleukin 4, interleukin 5, and interferon gene expression in steroid-resistant asthma. J Exp Med 1995; 181: 3340. 9 Goleva E, Hauk PJ, Boguniewicz J, Martin RJ, Leung DY. Airway remodeling and lack of bronchodilator response in steroid-resistant asthma. J Allergy Clin Immunol 2007; 120: 106572. 10 Moore WC, Bleecker ER, Curran-Everett D, et al. Characterization of the severe asthma phenotype by the National Heart, Lung, and Blood Institutes Severe Asthma Research Program. J Allergy Clin Immunol 2007; 119: 40513. 11 Thomson NC, Chaudhuri R, Livingston E. Asthma and cigarette smoking. Eur Respir J 2004; 24: 82233. 12 Poznansky MC, Gordon AC, Douglas JG, Krajewski AS, Wyllie AH, Grant IW. Resistance to methylprednisolone in cultures of blood mononuclear cells from glucocorticoid-resistant asthmatic patients. Clin Sci 1984; 67: 63945. 13 Kay AB, Diaz P, Carmichael J, Grant IW. Corticosteroid-resistant chronic asthma and monocyte complement receptors. Clin Exp Immunol 1981; 44: 57680. 14 Corrigan CJ, Brown PH, Barnes NC, Tsai J-J, Frew AJ, Kay AB. Peripheral blood T lymphocyte activation and comparison of the T lymphocyte inhibitory eects of glucocorticoids and cyclosporin A. Am Rev Respir Dis 1991; 144: 102632. 15 Hew M, Bhavsar P, Torrego A, et al. Relative corticosteroid insensitivity of peripheral blood mononuclear cells in severe asthma. Am J Respir Crit Care Med 2006; 174: 13441. 16 Bhavsar P, Hew M, Khorasani N, et al. Relative corticosteroid insensitivity of alveolar macrophages in severe asthma compared to non-severe asthma. Thorax 2008; 63: 78490. 17 Brown PH, Teelucksingh S, Matusiewicz SP, Greening AP, Crompton GK, Edwards CR. Cutaneous vasoconstrictor responses to glucocorticoids in asthma. Lancet 1991; 337: 57680. 18 Chikanza IC, Kozaci DL. Corticosteroid resistance in rheumatoid arthritis: molecular and cellular perspectives. Rheumatology (Oxford) 2004; 43: 133745. 19 Onda K, Rimbara E, Hirano T, et al. Role of mRNA expression of transcription factors in glucocorticoid sensitivity of peripheral blood mononuclear cells and disease state in rheumatoid arthritis. J Rheumatol 2004; 31: 46469. 20 Sliwinska-Stanczyk P, Pazdur J, Ziolkowska M, Jaworski J, Kaminska-Tchorzewska E, Lacki JK. The eect of methylprednisolone on proliferation of PBMCs obtained from steroid-sensitive and steroid-resistant rheumatoid arthritis patients. Scand J Rheumatol 2007; 36: 16771. 21 Farrell RJ, Kelleher D. Glucocorticoid resistance in inammatory bowel disease. J Endocrinol 2003; 178: 33946. 22 Hearing SD, Norman M, Probert CS, Haslam N, Dayan CM. Predicting therapeutic outcome in severe ulcerative colitis by measuring in vitro steroid sensitivity of proliferating peripheral blood lymphocytes. Gut 1999; 45: 38288. 23 Seki M, Ushiyama C, Seta N, et al. Apoptosis of lymphocytes induced by glucocorticoids and relationship to therapeutic ecacy in patients with systemic lupus erythematosus. Arthritis Rheum 1998; 41: 82330.

1914

www.thelancet.com Vol 373 May 30, 2009

Review

24

25

26

27

28

29

30

31

32

33 34 35

36

37

38 39

40 41

42

43

44

45

46 47

Leung D. Superantigens, steroid insensitivity and innate immunity in atopic eczema. Acta Derm Venereol Suppl (Stockh) 2005; 215: 1115. Yang IA, Fong KM, Sim EH, Black PN, Lasserson TJ. Inhaled corticosteroids for stable chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2007; 2: CD002991. Suissa S, Ernst P, Vandemheen KL, Aaron SD. Methodological issues in therapeutic trials of COPD. Eur Respir J 2008; 31: 92733. Keatings VM, Jatakanon A, Worsdell YM, Barnes PJ. Eects of inhaled and oral glucocorticoids on inammatory indices in asthma and COPD. Am J Respir Crit Care Med 1997; 155: 54248. Culpitt SV, Nightingale JA, Barnes PJ. Eect of high dose inhaled steroid on cells, cytokines and proteases in induced sputum in chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1999; 160: 163539. Bourbeau J, Christodoulopoulos P, Maltais F, Yamauchi Y, Olivenstein R, Hamid Q. Eect of salmeterol/uticasone propionate on airway inammation in COPD: a randomised controlled trial. Thorax 2007; 62: 93843. Culpitt SV, Rogers DF, Shah P, et al. Impaired inhibition by dexamethasone of cytokine release by alveolar macrophages from patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2003; 167: 2431. Papi A, Romagnoli M, Baraldo S, et al. Partial reversibility of airow limitation and increased exhaled NO and sputum eosinophilia in chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2000; 162: 177377. Brightling CE, McKenna S, Hargadon B, et al. Sputum eosinophilia and the short term response to inhaled mometasone in chronic obstructive pulmonary disease. Thorax 2005; 60: 19398. Barnes PJ. Immunology of asthma and chronic obstructive pulmonary disease. Nat Immunol Rev 2008; 8: 18392. Dezateux C, Walters S, Balfour-Lynn I. Inhaled corticosteroids for cystic brosis. Cochrane Database Syst Rev 2000; 2: CD001915. De Boeck K, De Baets F, Malfroot A, Desager K, Mouchet F, Proesmans M. Do inhaled corticosteroids impair long-term growth in prepubertal cystic brosis patients? Eur J Pediatr 2007; 166: 2328. Richeldi L, Davies HR, Ferrara G, Franco F. Corticosteroids for idiopathic pulmonary brosis. Cochrane Database Syst Rev 2003; 3: CD002880. Peter JV, John P, Graham PL, Moran JL, George IA, Bersten A. Corticosteroids in the prevention and treatment of acute respiratory distress syndrome (ARDS) in adults: meta-analysis. BMJ 2008; 336: 100609. Yan ZQ, Hansson GK. Innate immunity, macrophage activation, and atherosclerosis. Immunol Rev 2007; 219: 187203. Schacke H, Schottelius A, Docke WD, et al. Dissociation of transactivation from transrepression by a selective glucocorticoid receptor agonist leads to separation of therapeutic eects from side eects. Proc Natl Acad Sci USA 2004; 101: 22732. Barnes PJ. How corticosteroids control inammation. Br J Pharmacol 2006; 148: 24554. Rhen T, Cidlowski JA. Antiinammatory action of glucocorticoidsnew mechanisms for old drugs. N Engl J Med 2005; 353: 171123. Goldfarb DS, Corbett AH, Mason DA, Harreman MT, Adam SA. Importin alpha: a multipurpose nuclear-transport receptor. Trends Cell Biol 2004; 14: 50514. Tao T, Lan J, Lukacs GL, Hache RJ, Kaplan F. Importin 13 regulates nuclear import of the glucocorticoid receptor in airway epithelial cells. Am J Respir Cell Mol Biol 2006; 35: 66880. Lewis-Tun LJ, Cidlowski JA. The physiology of human glucocorticoid receptor beta (hGRbeta) and glucocorticoid resistance. Ann N Y Acad Sci 2006; 1069: 19. Ito K, Barnes PJ, Adcock IM. Glucocorticoid receptor recruitment of histone deacetylase 2 inhibits IL-1-induced histone H4 acetylation on lysines 8 and 12. Mol Cell Biol 2000; 20: 6891903. Barnes PJ. Corticosteroid eects on cell signalling. Eur Respir J 2006; 27: 41326. Clark AR. MAP kinase phosphatase 1: a novel mediator of biological eects of glucocorticoids? J Endocrinol 2003; 178: 512.

48

49 50

51

52

53

54

55

56

57

58

59

60

61

62

63

64

65

66

67

68

Dostert A, Heinzel T. Negative glucocorticoid receptor response elements and their role in glucocorticoid action. Curr Pharm Des 2004; 10: 280716. Barnes PJ, Adcock IM. How do corticosteroids work in asthma? Ann Intern Med 2003; 139: 35970. Barnes PJ, Adcock IM, Ito K. Histone acetylation and deacetylation: importance in inammatory lung diseases. Eur Respir J 2005; 25: 55263. Ito K, Yamamura S, Essile-Quaye S, et al. Histone deacetylase 2-mediated deacetylation of the glucocorticoid receptor enables NF-B suppression. J Exp Med 2006; 203: 713. Kovacs JJ, Murphy PJ, Gaillard S, et al. HDAC6 regulates HSP90 acetylation and chaperone-dependent activation of glucocorticoid receptor. Mol Cell 2005; 18: 60107. Bergmann MW, Staples KJ, Smith SJ, Barnes PJ, Newton R. Glucocorticoid inhibition of GM-CSF from T cells is independent of control by NF-B and CLE0. Am J Respir Cell Mol Biol 2004; 30: 55563. Smoak K, Cidlowski JA. Glucocorticoids regulate tristetraprolin synthesis and posttranscriptionally regulate tumor necrosis factor alpha inammatory signaling. Mol Cell Biol 2006; 26: 912635. Hakonarson H, Bjornsdottir US, Halapi E, et al. Proling of genes expressed in peripheral blood mononuclear cells predicts glucocorticoid sensitivity in asthma patients. Proc Natl Acad Sci USA 2005; 102: 1478994. Donn R, Berry A, Stevens A, et al. Use of gene expression proling to identify a novel glucocorticoid sensitivity determining gene, BMPRII. FASEB J 2007; 21: 40214. Lane SJ, Arm JP, Staynov DZ, Lee TH. Chemical mutational analysis of the human glucocortiocoid receptor cDNA in glucocorticoid-resistant bronchial asthma. Am J Respir Cell Mol Biol 1994; 11: 4248. van den Akker EL, Russcher H, van Rossum EF, et al. Glucocorticoid receptor polymorphism aects transrepression but not transactivation. J Clin Endocrinol Metab 2006; 91: 280003. Sher ER, Leung YM, Surs W, et al. Steroid-resistant asthma. Cellular mechanisms contributing to inadequate response to glucocorticoid therapy. J Clin Invest 1994; 93: 3339. Irusen E, Matthews JG, Takahashi A, Barnes PJ, Chung KF, Adcock IM. p38 mitogen-activated protein kinase-induced glucocorticoid receptor phosphorylation reduces its activity: role in steroid-insensitive asthma. J Allergy Clin Immunol 2002; 109: 64957. Matthews JG, Ito K, Barnes PJ, Adcock IM. Defective glucocorticoid receptor nuclear translocation and altered histone acetylation patterns in glucocorticoid-resistant patients. J Allergy Clin Immunol 2004; 113: 110008. Spahn JD, Szeer SJ, Surs W, Doherty DE, Nimmagadda SR, Leung DY. A novel action of IL-13: induction of diminished monocyte glucocorticoid receptor-binding anity. J Immunol 1996; 157: 265459. Miller AL, Webb MS, Copik AJ, et al. p38 mitogen-activated protein kinase (MAPK) is a key mediator in glucocorticoid-induced apoptosis of lymphoid cells: correlation between p38 MAPK activation and site-specic phosphorylation of the human glucocorticoid receptor at serine 211. Mol Endocrinol 2005; 19: 156983. Szatmary Z, Garabedian MJ, Vilcek J. Inhibition of glucocorticoid receptor-mediated transcriptional activation by p38 mitogen-activated protein (MAP) kinase. J Biol Chem 2004; 279: 4370815. Weigel NL, Moore NL. Steroid receptor phosphorylation: a key modulator of multiple receptor functions. Mol Endocrinol 2007; 21: 231119. Goleva E, Kisich KO, Leung DY. A role for STAT5 in the pathogenesis of IL-2-induced glucocorticoid resistance. J Immunol 2002; 169: 593440. Ismaili N, Garabedian MJ. Modulation of glucocorticoid receptor function via phosphorylation. Ann N Y Acad Sci 2004; 1024: 86101. Li LB, Goleva E, Hall CF, Ou LS, Leung DY. Superantigen-induced corticosteroid resistance of human T cells occurs through activation of the mitogen-activated protein kinase kinase/extracellular signal-regulated kinase (MEK-ERK) pathway. J Allergy Clin Immunol 2004; 114: 105969.

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70

71

72

73

74

75

76

77

78

79

80

81

82

83

84

85

86

87

88

89

Abraham SM, Lawrence T, Kleiman A, et al. Antiinammatory eects of dexamethasone are partly dependent on induction of dual specicity phosphatase 1. J Exp Med 2006; 203: 188389. Galigniana MD, Piwien-Pilipuk G, Assreuy J. Inhibition of glucocorticoid receptor binding by nitric oxide. Mol Pharmacol 1999; 55: 31723. Wallace AD, Cidlowski JA. Proteasome-mediated glucocorticoid receptor degradation restricts transcriptional signaling by glucocorticoids. J Biol Chem 2001; 276: 4271421. Hamid QA, Wenzel SE, Hauk PJ, et al. Increased glucocorticoid receptor beta in airway cells of glucocorticoid-insensitive asthma. Am J Respir Crit Care Med 1999; 159: 160004. Sousa AR, Lane SJ, Cidlowski JA, Staynov DZ, Lee TH. Glucocorticoid resistance in asthma is associated with elevated in vivo expression of the glucocorticoid receptor beta-isoform. J Allergy Clin Immunol 2000; 105: 94350. Kozaci DL, Chernajovsky Y, Chikanza IC. The dierential expression of corticosteroid receptor isoforms in corticosteroid-resistant and -sensitive patients with rheumatoid arthritis. Rheumatology (Oxford) 2007; 46: 57985. Orii F, Ashida T, Nomura M, et al. Quantitative analysis for human glucocorticoid receptor alpha/beta mRNA in IBD. Biochem Biophys Res Commun 2002; 296: 128694. Pujols L, Mullol J, Picado C. Alpha and beta glucocorticoid receptors: relevance in airway diseases. Curr Allergy Asthma Rep 2007; 7: 9399. Gagliardo R, Chanez P, Vignola AM, et al. Glucocorticoid receptor and in glucocorticoid dependent asthma. Am J Respir Crit Care Med 2000; 162: 713. Webster JC, Oakley RH, Jewell CM, Cidlowski JA. Proinammatory cytokines regulate human glucocorticoid receptor gene expression and lead to the accumulation of the dominant negative beta isoform: a mechanism for the generation of glucocorticoid resistance. Proc Natl Acad Sci USA 2001; 98: 686570. Fakhri S, Tulic M, Christodoulopoulos P, et al. Microbial superantigens induce glucocorticoid receptor beta and steroid resistance in a nasal explant model. Laryngoscope 2004; 114: 88792. Goleva E, Li LB, Eves PT, Strand MJ, Martin RJ, Leung DY. Increased glucocorticoid receptor beta alters steroid response in glucocorticoid-insensitive asthma. Am J Respir Crit Care Med 2006; 173: 60716. Lewis-Tun LJ, Jewell CM, Bienstock RJ, Collins JB, Cidlowski JA. Human glucocorticoid receptor beta binds RU-486 and is transcriptionally active. Mol Cell Biol 2007; 27: 226682. Adcock IM, Lane SJ, Brown CA, Lee TH, Barnes PJ. Abnormal glucocorticoid receptor/AP-1 interaction in steroid resistant asthma. J Exp Med 1995; 182: 195158. Loke TK, Mallett KH, Rato J, et al. Systemic glucocorticoid reduces bronchial mucosal activation of activator protein 1 components in glucocorticoid-sensitive but not glucocorticoid-resistant asthmatic patients. J Allergy Clin Immunol 2006; 118: 36875. Lane SJ, Adcock IM, Richards D, Hawrylowicz C, Barnes PJ, Lee TH. Corticosteroid-resistant bronchial asthma is associated with increased c-Fos expression in monocytes and T-lymphocytes. J Clin Invest 1998; 102: 215664. Vardimon L, Ben Dror I, Oren A, Polak P. Cytoskeletal and cell contact control of the glucocorticoid pathway. Mol Cell Endocrinol 2006; 252: 14247. Vasavda N, Eichholtz T, Takahashi A, et al. Expression of nonmuscle colin-1 and steroid responsiveness in severe asthma. J Allergy Clin Immunol 2006; 118: 109006. Barnes PJ, Ito K, Adcock IM. Corticosteroid resistance in chronic obstructive pulmonary disease: inactivation of histone deacetylase. Lancet 2004; 363: 73133. Ito K, Ito M, Elliott WM, et al. Decreased histone deacetylase activity in chronic obstructive pulmonary disease. N Engl J Med 2005; 352: 196776. Murahidy A, Ito M, Adcock IM, Barnes PJ, Ito K. Reduction is histone deacetylase expression and activity in smoking asthmatics: a mechanism of steroid resistance. Proc Am Thorac Soc 2005; 2: A889.

90

91 92

93

94 95 96

97

98

99

100

101

102

103

104

105

106

107

108

109

110

Bilodeau S, Vallette-Kasic S, Gauthier Y, et al. Role of Brg1 and HDAC2 in GR trans-repression of the pituitary POMC gene and misexpression in Cushing disease. Genes Dev 2006; 20: 287186. Barnes PJ. Reduced histone deacetylase in COPD: clinical implications. Chest 2006; 129: 15155. Failla M, To Y, Ito M, Adcock IM, Barnes PJ, Ito K. Oxidative stress-induced PI3-kinase activation reduces HDAC activity and is inhibited by theophylline. Proc Am Thorac Soc 2007; 2: A45. Ito K, Tomita T, Barnes PJ, Adcock IM. Oxidative stress reduces histone deacetylase (HDAC)2 activity and enhances IL-8 gene expression: role of tyrosine nitration. Biochem Biophys Res Commun 2004; 315: 24045. Rahman I, Adcock IM. Oxidative stress and redox regulation of lung inammation in COPD. Eur Respir J 2006; 28: 21942. Hawrylowicz CM. Regulatory T cells and IL-10 in allergic inammation. J Exp Med 2005; 202: 145963. Xystrakis E, Kusumakar S, Boswell S, et al. Reversing the defective induction of IL-10-secreting regulatory T cells in glucocorticoid-resistant asthma patients. J Clin Invest 2006; 116: 14655. Farrell RJ, Murphy A, Long A, et al. High multidrug resistance (P-glycoprotein 170) expression in inammatory bowel disease patients who fail medical therapy. Gastroenterology 2000; 118: 27988. Tsujimura S, Saito K, Nawata M, Nakayamada S, Tanaka Y. Overcoming drug resistance induced by P-glycoprotein on lymphocytes in patients with refractory rheumatoid arthritis. Ann Rheum Dis 2008; 67: 38088. Potocnik U, Ferkolj I, Glavac D, Dean M. Polymorphisms in multidrug resistance 1 (MDR1) gene are associated with refractory Crohn disease and ulcerative colitis. Genes Immun 2004; 5: 53039. Drozdzik M, Rudas T, Pawlik A, et al. The eect of 3435C>T MDR1 gene polymorphism on rheumatoid arthritis treatment with disease-modifying antirheumatic drugs. Eur J Clin Pharmacol 2006; 62: 93337. Flaster H, Bernhagen J, Calandra T, Bucala R. The macrophage migration inhibitory factor-glucocorticoid dyad: regulation of inammation and immunity. Mol Endocrinol 2007; 21: 126780. Roger T, Chanson AL, Knaup-Reymond M, Calandra T. Macrophage migration inhibitory factor promotes innate immune responses by suppressing glucocorticoid-induced expression of mitogen-activated protein kinase phosphatase-1. Eur J Immunol 2005; 35: 340513. Ishiguro Y, Ohkawara T, Sakuraba H, et al. Macrophage migration inhibitory factor has a proinammatory activity via the p38 pathway in glucocorticoid-resistant ulcerative colitis. Clin Immunol 2006; 120: 33541. Ayoub S, Hickey MJ, Morand EF. Mechanisms of disease: macrophage migration inhibitory factor in SLE, RA and atherosclerosis. Nat Clin Pract Rheumatol 2008; 4: 98105. Baugh JA, Chitnis S, Donnelly SC, et al. A functional promoter polymorphism in the macrophage migration inhibitory factor (MIF) gene associated with disease severity in rheumatoid arthritis. Genes Immun 2002; 3: 17076. Griga T, Wilkens C, Wirkus N, Epplen J, Schmiegel W, Klein W. A polymorphism in the macrophage migration inhibitory factor gene is involved in the genetic predisposition of Crohns disease and associated with cumulative steroid doses. Hepatogastroenterology 2007; 54: 78486. Donnelly SC, Haslett C, Reid PT, et al. Regulatory role for macrophage migration inhibitory factor in acute respiratory distress syndrome. Nat Med 1997; 3: 32023. Rossi AG, Haslett C, Hirani N, et al. Human circulating eosinophils secrete macrophage migration inhibitory factor (MIF). Potential role in asthma. J Clin Invest 1998; 101: 286974. Schacke H, Berger M, Rehwinkel H, Asadullah K. Selective glucocorticoid receptor agonists (SEGRAs): novel ligands with an improved therapeutic index. Mol Cell Endocrinol 2007; 275: 10917. Actis GC, Fadda M, David E, Sapino A. Colectomy rate in steroid-refractory colitis initially responsive to cyclosporin: a long-term retrospective cohort study. BMC Gastroenterol 2007; 7: 13.

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111 Kitahara K, Kawai S. Cyclosporine and tacrolimus for the treatment of rheumatoid arthritis. Curr Opin Rheumatol 2007; 19: 23845. 112 Evans DJ, Cullinan P, Geddes DM. Cyclosporin as an oral corticosteroid sparing agent in stable asthma (Cochrane Review). Cochrane Database Syst Rev 2001; 2: CD002993. 113 Dastidar SG, Rajagopal D, Ray A. Therapeutic benet of PDE4 inhibitors in inammatory diseases. Curr Opin Investig Drugs 2007; 8: 36472. 114 Medicherla S, Fitzgerald M, Spicer D, et al. p38 selective MAP kinase inhibitor, SD-282, reduces inammation in a sub-chronic model of tobacco smoke-induced airway inammation. J Pharmacol Exp Ther 2007; 324: 92129. 115 Stanczyk J, Ospelt C, Gay S. Is there a future for small molecule drugs in the treatment of rheumatic diseases? Curr Opin Rheumatol 2008; 20: 25762. 116 Cuenda A, Rousseau S. p38 MAP-kinases pathway regulation, function and role in human diseases. Biochim Biophys Acta 2007; 1773: 135875. 117 Karin M, Yamamoto Y, Wang QM. The IKK NF-kappa B system: a treasure trove for drug development. Nat Rev Drug Discov 2004; 3: 1726. 118 Chaudhuri R, Livingston E, McMahon AD, et al. Eects of smoking cessation on lung function and airway inammation in smokers with asthma. Am J Respir Crit Care Med 2006; 174: 12733. 119 Creed TJ, Probert CS, Norman MN, et al. Basiliximab for the treatment of steroid-resistant ulcerative colitis: further experience in moderate and severe disease. Aliment Pharmacol Ther 2006; 23: 143542.

120 Nobili S, Landini I, Giglioni B, Mini E. Pharmacological strategies for overcoming multidrug resistance. Curr Drug Targets 2006; 7: 86179. 121 Hoi AY, Iskander MN, Morand EF. Macrophage migration inhibitory factor: a therapeutic target across inammatory diseases. Inamm Allergy Drug Targets 2007; 6: 18390. 122 Cosio BG, Tsaprouni L, Ito K, Jazrawi E, Adcock IM, Barnes PJ. Theophylline restores histone deacetylase activity and steroid responses in COPD macrophages. J Exp Med 2004; 200: 68995. 123 Fox JC, Spicer D, Ito K, Barnes PJ, Fitzgerald MF. Oral or inhaled corticosteroid combination therapy with low dose theophylline reverses corticosteroid insensitivity in a smoking mouse model. Proc Am Thorac Soc 2007; 2: A637. 124 Marone R, Cmiljanovic V, Giese B, Wymann MP. Targeting phosphoinositide 3-kinase: moving towards therapy. Biochim Biophys Acta 2008; 1784: 15985. 125 Rommel C, Camps M, Ji H. PI3K delta and PI3K gamma: partners in crime in inammation in rheumatoid arthritis and beyond? Nat Rev Immunol 2007; 7: 191201. 126 Barnes PJ. Targeting histone deacetylase 2 in chronic obstructive pulmonary disease treatment. Expert Opin Ther Targets 2005; 9: 111121.

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