ARI TREATMENT IN CHILDREN: POSSIBILITIES OF IMMUNE CORRECTION
L.V. Osidak, E.A. Dondurey, V.V. Zarubaiev, Ye.G. Golovacheva,V.F. Sukhovetskaya, V.P. Drinevskiy, O.V. Kashaeva
RF Ministry of Public Health Protection and Social Development's Research Institute of Influenza, FSFI, Saint-Petersburg RF Ministry of Public Health Protection and Social Development's SEI HVE the Moscow State Medical Dental University, Moscow
In vivo animal models have been used for experiments to confirm Derinat (sodium deoxyribonucleate) protective activity against A(H1N1) pdm 2009 virus. Placebo-controlled randomised clinical laboratory tests carried out in accordance with GCP Regulations have confirmed therapeutic efficacy and safety of Derinat at its inclusion into comprehensive treatment regimen for children >0 years with flu and ARI of other aetiology, which manifested itself in the form of statistically significant reduction of duration of the main disease symptoms, restoration of the initial shifts in lab ranges back to normal and faster elimination of causative agents from nasal passages of the patients.
Keywords: children, treatment, sodium deoxyribonucleate, immunity, antioxidant activity, flu and ARI.
Acute respiratory infections (ARI), flu included, are weakly controlled infections that persistently take the lead in the structure of children infectious pathologies. ARI cases registered in the RF every year in the period between flu epidemics range from 75 to 85.000 per 100 thousand population aged between 0 and 14 years (> 4 times more prevalent than in the adult cohort) without any downward trend in sight. In the year when flu pandemic broke out (2009) some 97.679 ARI cases per 100 thousand of population in the above age cohort were registered .
These diseases may be associated with various viruses and intracellular agents of Mp. pneumonia and Chl. pneumonia types  with data about new pathogens (metapneumovirus, new types of enterovirus and coronavirus, bocavirus) appearing from time to time [2, 8, 9, 11]. The number of flu patients reaches its peak when a new, or substantially altered agent appears in circulation like it was observed during 2009 flu pandemic caused by a reassortant in the form of a combination of genes of the swine (classic, Eurasian and Northern-American lines), bird and human flu viruses [3, 13, 20].
It is known that clinical particularities, the severity of disease progress as well as the duration of symptoms and frequency of development of complications are conditioned by both pathogenicity of agents and massiveness of the injurious dose and the level of protection in patients . Given the rather limited choice of efficient and safe chemotherapeutic causal treatment medications for ARI therapy and with a view that registered products have age-specific and specially directed (antiflu virus only) limits, the treatment of children, particularly in infancy, should be advisably carried out with medications with multi-targeting, including immunotropic, antioxidant and pathogen-specific efficacy .
Derinat, a modern domestic immune-modulating, cyto-protecting natural reparant drug by FP TekhnoMedService, CJSC (Russia), is a highly-purified natural DNA sodium salt (sodium deoxyribonucleate) in NaCl aqueous solution. Derinat has been approved for administration to both children from the first day of life and adults, pregnant women included (Reg. No. 002916/02 of 18.08.2008) . The drug is capable to restore imbalanced immune status at cellular and humoral levels through the increase of CD4, CD8 and CD25 lymphocyte and NK cell numbers, leukocyte microbicidal activity and of the number and activity of B cells as well as through the activation of the complement system and immunoglobulin synthesis restoration back to normal. It contributes to the activation of macrophages and dendrite cells, the restoration of cytokine
production (IFN-á, IL-1, IL-6, 8, 12 etc.) and NK cell number restoration, which brings about the anti-in-flammatory effect, reduced apoptotic response and faster restoration of morphological injuries in tissues.
Owing to its multi-factor mechanisms the product has immune-regulating and immune-modulating effects and anti-inflammatory, reparative and cytoprotective action and activates antiviral and antibacterial protection at the local and systemic levels. Derinat is efficient against infectious processes of viral, bacterial and mucous origin as well as against immune deficit conditions of various aetiologies.
Derinat is supplied in two preparation forms: as a 0.25% solution for external and topical use and a 15 mg/ml solution for IM injection.
The pre-clinical studies of Derinat included researches into its acute, reproductive and chronic toxicity, cytogenetic (including embryotoxic and teratogenic) effects, and allergy-inducing characteristics. The experimental and clinical lab tests have confirmed it lacking mutagenic, teratogenic, embryotoxic or cancerogenic as well as allergy-inducing or cytogenetic effects, which provides for high safety level of the medication. Moreover, its moderate anti-mutagenic, radioprotective and wound-healing effects have been shown [7, 16].
Derinat 15 mg/ml parenteral solution has been successfully administered to patients with cardiovascular diseases, pneumonia, severe surgical pathologies and burns [4, 12, 14, 19].
The intranasal administration of Derinat (0.25% solution) has been efficient for treatment of children with various somatic and infectious diseases [5, 18].
Derinat is used for prevention and treatment of flu and other ARVI infections (including those aggravated with bacterial infections) in children as well as for rehabilitation of debilitated and sickly patients. Clinical efficacy has been proven and considerable clinical experience of Derinat 0.25% solution's intranasal administration for flu and ARI treatment and prevention (emergency one included) in all age groups of patients, including pregnant women and infants on their first day of life, has been accumulated. The drug's immediate effect in the inflammation area «at the door of infection» during nasal drops administration substantially reduces the duration and severity of the main disease symptoms and contributes to faster recovery of the little patient. The drug administration prevents development of flu complications and allows reducing bacterial complications in ear, nose and throat and in the bronchopulmonary complex (bronchitis, sinusitis, pneumonias); it also facilitates children's adaptation in groups. The efficacy of the drug is the higher the sooner it has been administered.
The drug can be appropriately combined with symptomatic medications or, in the case of complications, with antibiotic and antiviral drugs. Derinat in combination with antibiotic and antiviral drugs reduces adverse effects of the latter and contributes to their earlier discontinuation, and shortens overall duration of treatment of ARI complications.
Derinat is indicated for prevention and treatment of flu and other ARVI in FSC children with rhinosinusitis, adenoiditis, tonsillitis, otitis and frontitis. It is efficient in the treatment of children from the risk group with allergic diseases, bronchial asthma and other chronic bronchopulmonary conditions as well as those with chronic inflammatory ear, nose and throat pathologies.
Derinat is well-tolerated and has no side or other adverse effects at its administration.
The objective of this study was to look into clinical and lab efficacy and safety of Derinat administration for treatment of flu and other ARI in children aged between 0 and 17 years.
Research Material and Methods
Initially, animal experiments were used to prove the protective activity of the product during lethal influenza pneumonia development in response to infection with actual A/(H1N1)pdm/09 virus and in absence of
any evidence of product's virus-inhibiting effect against model flu strains A/Puerto Rico/8/34 (H1N1), В/Victoria/35/72, — A/California/07/09 (H1N1) and A/Duck/Potsdam/1402-6/86 (H5N2) (Table 1).
A reduction of animal mortality rates in trial groups to 40% vs. the control group and an increase of their average lifespans by 0.6–1.9 days depending on the viral dose were registered. Moreover, lung tissues of the animals on Derinat showed about 10 time reduction of the viral infection activity compared with the control group and the group administered Remantadin as the reference drug without any protective effect.
That allowed a conclusion on the availability of mechanisms in Derinat that provide summary antiviral protective activity and are likely related to activation of the natural immunity system through stimulation of cell TLR receptors responsible for nonspecific recognition of foreign matter .
Therapeutic efficacy of Derinat for ARI treatment in children was assessed in accordance with the RF and European GCP Regulations . The trial involved 100 children aged between 0 and 17 with flu and other ARVI that had been admitted to hospital within the first two days since the onset. The children were split into two groups, each 50 strong. The children in the main group were administered Derinat and those in the control group received placebo (sterile 0.1% sodium chloride solution in a visually identical package). Patients in both groups were also administered antipyretics, expectorants and decongestants based on indications. The product and the placebo were administered as per the product leaflet: two drops in each nasal channel (every 1 to 1.5 hours during the first day; then three times a day).
The disease aetiology was determined by detecting viral antigens in nasal swabs with ummunofluorescence method (IFL) using test kits produced by Diagnostic Product Manufacturing Enterprise, Ltd. with the Influenza Research Institute of the Ministry of Public Health Protection and Social Development of the Russian Federation and by serological identification. Results of a dynamic laboratory research served additional criteria of clinical efficacy of the product.
The research aimed at determining the following:
- Serum total IgE and secretory immunoglobulin A (sIgA) levels with enzyme-linked immunoassay of nasal washings (assay kits by Vektor Best, CJSC, Novosibirsk);
- IFNá and IFNã levels, both in blood circulation and of their spontaneous and induced in vitro production (kits by Tsitokin, Ltd., Saint Petersburg);
- Serum main IL-4, IL-8, IL-1â and IL-10 cytokines;
- Immune-competent blood cell markers (CD3, CD4, CD8, CD16, CD20);
- Antioxidant protection components: serum total antioxidant (TAO) and superoxide dismutase (SOD) in erythrocytes; also lipid peroxidation products (LPO): malondialdehyde (MDA), both spontaneous and ferrous sulphate-induced;
- Bactericidal activity of neutrophils (spontaneous and induced) was assessed with nitroblue tetrazolium assay (NBT test by Lachema, Czech Republic).
The safety was assessed by identifying AE and interpreting results of the dynamic examination (carried out on the first and the last days of the trial) of complete blood count (CBC), complete urinalysis (CUR) and total IgE indicators.
The obtained data were statistically processed using the Stat Soft Statistica v 6.0 software package .
Trial Results and Their Discussion
The compared groups were comparable per all their main characteristics: age, sex, clinical presentations of the disease and background pathology. Nearly a half of the children in the two groups were up to three years old. The median age (Me) was three years and ten months; the interquartile range (IQR) at two years and one month and six years and eight months. The proportion of children with background pathology in the two groups made 68.0% and 80.0%, respectively; of those, one third had symptoms of allergic pathology. The proportion of frequently sick children (FSC) made 20.0% and 28.0%, accordingly.
In a third of cases the disease that had medium-severe form in all the children was complicated with bronchitis and in 14% and 10% cases respectively, with acute obstructive laryngotracheitis.
The onset of the disease in all the patients was acute with body temperature increase >37.5°С (in the majority of cases, >38.6°С), intoxication of varied intensity and nasopharyngeal catarrhal symptoms without statistically significant differences in registered prevalence.
The aetiology of diseases showed prevalence of influenza (А/H1N1, А/H3N2; on a rarer occasions, В) infection (mono-infection in 50.0% and 56.0% cases; mixed form, in 6.0 and 14.0% cases, respectively). Adenoviral infection of both mono and mixed types was registered in 22.0% and 34.0% cases; parainfluenzal infection was registered in 10.0% cases in the main group and was absent in children in the control group.
Mixed infection, mostly as a combination of influenza viruses with adenovirus, was registered in 10.0% and
20.0% cases, respectively (Table 2).
The dynamic examination of materials from nasal channels showed that the statistically significant reduction of the number of discovered antigens in children administered Derinat (in relation to the control group) was observed already after one or two days after the beginning of the therapy. A similar regular pattern followed further on with full sanitation of the pharyngonasal cavity of the main group patients on the day of release.
Detection of adenovirus antigens took the longest time to go.
The inclusion of Derinat into the therapy regimen of children contributed to a faster elimination of the main infection manifestations in that it led to a statistically significant reduction of the fever period, intoxication symptoms, catarrhal manifestations in the pharyngonasal cavity, conjunctivitis and the disease as a whole (р<0.001) (Table 3).
Already on the second day of the therapy on the background of Derinat intake, intoxication symptoms (distress and loss of appetite) remained in just a half of the main group patients — compare to 37 (76%) and 35 (71%) control group patients, accordingly (р=0.021 and р=0.038). The mentioned symptoms and febrile temperature in patients on Derinat were completely jugulated already by the day fifth vs. the placebo group
that had it by the day eighth.
A statistically significant reduction of the number of patients with catarrhal signs in nasopharynx was observed starting on the day four of the product administration: e.g., by that moment symptoms of rhinitis in patients on Derinat remained in 34 (71%) and in the placebo group, in 43 (88%) patients (р<0.05); however, the symptoms in the main group were completely dealt with by the day seven while in the placebo group they continued even on the tenth day of the trial. A statistically significant reduction of the number of patients with cough began starting on the sixth day of the trial when cough symptoms persisted in 15 (31%) patients from the main group vs. 27 (55%; р=0.024) in the placebo group.
A statistically significant increase of sIgA (the principal protective factor at work at the infection entry point) level from 1.6 to 2.1 μg/ml in 83.3% (27 out of 30) main group patients (compare this to its decrease from 1.5 to 1.2 μg/ml in 70% (21 out of 30) control group members) contributed to faster elimination of agents in the nasopharynx and quicker liquidation of disease symptoms (Table 4).
Activation of free radical (FR) oxidation processes in acute respiratory infections and particularly, in flu with development of an imbalance in the LPO-АPS system and accumulation of toxic compounds of malondialdehyde (MDA) type is known to be one of the determinants that define severity of the infection process manifested in a degree of intoxication syndrome manifestation . A disturbance of the equilibrium towards greater activity of oxidation processes frequently leads to generalisation of infection and development of complications and secondary immune deficiencies, and thus increases the relevance of the problem of studying into antioxidant products' potential effect on the disease progress.
This trial shows that the use of Derinat nasal drops formulation in complex therapy of flu and other ARI in children contributes to the reduction of intensity of LPO processes (at MDA level) and increases activity of the antioxidant protection (per SOD and TAO values) thus leading to faster recovery of the child (Table 5). In 26.7% cases, the TAO index of children in both groups at their admission was less than normal. According to dynamic research data, in 63.3% cases children on Derinat by the time of their release demonstrated a statistically significant (р=0.0170) increase of the index level as opposed to placebo group patients who showed TAO index increase against the base data in 46.7% cases without statistical significance (р=0.7577).
This attests to the product's positive effect on the level of antioxidant protection in children patients.
Similar regularity has been also noted during the assessment of dynamics of SOD activity in erythrocytes, the base indexes of which in the groups were lower than the norm in 40.0% and 36.7% cases, respectively.
During the re-examination, the patients who were administered Derinat showed a statistically significant increase of the SOD index in 73.3% cases (р=0.0001) against just 4.3% (р=0.5440) in the placebo group. The base indicators of MDA, the principal toxic product of LPO reaction, were higher than normal in 26.7% cases in the main group and in 36.7% cases, in the control group. MDA level decrease on the background of Derinat administration was noted in 66.7% cases while in the placebo group, in 55.3% cases with only first group's results being statistically significant (-р1=0.0005 andр1=0.1881, accordingly).
A statistically significant increase of serum MDA increment rate as a response to stimulation with FeSO4*H2O was also registered (23.3% in the group on Derinat (р1=0.0000) vs. 53.3% cases in patients in the control group, р1=0.0736).
The immune system is particularly sensitive to the oxidation stress; an increased activity of LPO processes leads to solution of continuity of cell membranes and to debilitation of a whole range of immune functions, including the ones of lymphocyte proliferation, phagocytic activity, antibody synthesis and others.
It has been established that Derinat administration also contributed to restoration of reduced functional activity (bactericidal activity) of neutrophils (Table 6). While spontaneous (SP) NBT test indicators at the onset of the disease fluctuated mostly within the normal range, 25% children in the observed groups demonstrated a reduced cell response to РМА (Phorbol myristate acetate) induction (NBT ind.). By the time of recovery, the functional activity of neutrophils as assessed with NBT(SP) и NBT(ind.) tests in the group on Derinat was statistically significantly higher as opposed to the control group (р=0.0044 and р=0.0002, respectively).
The product administration was followed by restoration of imbalance of interleukins affecting the duration of inflammatory and intoxication processes and in particular, by statistically significant reduction of
serum IL-1â and IL-8 titres (Table 7). Conversely, the placebo group showed either no dynamics in these indicators or their statistically significant increase.
It should be noted that no considerable interferoninducing effect of the product was discovered during this trial; nevertheless, the third trial showed no signs of immune competent cells functional activity deterioration as opposed to the placebo group the participants of which demonstrated statistically significant reduction of the induced production of both IFN types.
Other positive effects of the product included: a reduction of level of anti-inflammatory IL-10 neutralising macrophage activity and synthesis of Th1-type cytokines both in the blood serum and nasal washings of the patients administered Derinat; reduction of the content of IL-4 that stimulates IgE production, thymocyte proliferation and growth of mast cells contributing to the development of allergic reactions.
Derinat administration did not draw any personal complaints from children, their parents or medical staff. The prevalence of adverse effects (AE) related to the treatment regimen administered to the compared groups showed no differences: each group had two urticaria cases (4.2% and 4.1%, respectively; р=1.0000) without treatment cancellation with only two children, one in each group, found in need of hyposensitization therapy. The safety of Derinat administration was confirmed by a dynamic absence of pathologic CBC and CUR shifts as well as by statistically significant reduction (compared with the base indicator) of total IgE level (70.0% cases or in 21 out of 30 main group members) as opposed to the control group where an increase of its level was registered in 63.3% (19 out of 30) cases.
That way the therapeutic efficacy of Derinat inclusion into the complex treatment of children patients with flu and other ARI aged between 0 and 17 years has been confirmed by the following:
- Statistically significant reduction of duration of main clinical symptoms of the disease (intoxication, fever, catarrhal signs in the nasopharynx) and also, of the acute phase of the disease in general;
- Reduced period of agents' elimination from the nasal channels of patients. The achieved effect is obtained owing to immune rehabilitating activity of this immune modulating product that manifests through:
- Increased sIgA production at the entry point for infection (nasopharynx) and bactericidal activity of neutrophils;
- Restoration of cytokine and LPO-АPS system balance, i.e., elimination of immune system imbalances in children caused by infectious disease;
- Preservation and enhancement of functional, including interferon-producing activity of patients' immune competent cells.
Good tolerance of the product is worth mentioning: there have been no cases of either pathological CBC or CUR changes or hyperresponsiveness developed after its administration which has been further confirmed by the non-increase — and even a trend to reduction — of total blood IgE levels.
With a view of statistically significant therapeutic efficacy and safety of the product administration, Derinat immune modulator can be recommended for inclusion into the complex therapy of children aged between 0 and 17 years with flu and ARI of other aetiology.
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