Asthma patients are classified by phenotype and endotype. Although symptoms in most asthma patients are well controlled by glucocorticoid treatment, certain populations of severe eosinophilic asthma patients in T-helper 2 (Th2)/type 2 asthma and neutrophilic asthma patients in non-Th2/type 2 asthma show insensitivity to inhaled or oral glucocorticoid therapy. In some cases of severe eosinophilic asthma, eosinophils remain in the lungs despite glucocorticoid therapy. It was reported that interleukin (IL)-33-induced activation of type 2 innate lymphoid cells (ILC2) was resistant to glucocorticoid treatment in certain allergic conditions. Regarding neutrophilic airway inflammation in steroid-resistant asthma, IL-17 derived from Th17 cells and IL-8 and tumor necrosis factor-α derived mainly from macrophages were reported to be involved in the pathogenesis. Recently, “NETosis,” a specific cell death of neutrophils, has been reported to be involved in asthmatic airway inflammation. When NETosis is induced in asthma, aggravation of inflammation and delay of tissue repair could occur, suggesting that NETosis may be associated with the development of steroid-resistant asthma. This article reviews the pathogenesis of steroid-resistant asthma by focusing mainly on neutrophils.

Neutrophilic airway inflammation is a hallmark of patients with severe asthma. Although we have reported that both IL-33 and IL-17A contributed to IgE-mediated neutrophilic inflammation in mice, the relationship remains unclear. In this article, we examined how IL-17A modifies IL-33–induced neutrophilic inflammation and airway hyperresponsiveness (AHR). IL-33 was intratracheally administered to BALB/c mice on days 0–2; furthermore, on day 7, the effect of the combination of IL-33 and IL-17A was evaluated. Compared with IL-33 or IL-17A alone, the combination exacerbated neutrophilic inflammation and AHR, associated with more increased levels of lung glutamic acid-leucine-arginine+ CXC chemokines, including CXCL1, CXCL2, and CXCL5, and infiltration by alveolar macrophages expressing CXCR2. Treatment with anti-CXCR2 mAb or depletion of alveolar macrophages repressed neutrophilic inflammation and AHR; in addition, depletion of neutrophils suppressed AHR. These findings prompted us to examine the role of CXCR2 in IgE-sensitized mice; a single treatment with anti-CXCR2 mAb in the seventh Ag challenge inhibited late-phase airway obstruction, AHR, and neutrophilic inflammation. In addition to inhibition, multiple treatments during the fourth to seventh challenge attenuated early-phase airway obstruction, eosinophilic inflammation, and goblet cell hyperplasia associated with the reduction of Th2 cytokine production, including IL-4, IL-5, and IL-13. Collectively, IL-33 cooperated with IL-17A to exacerbate AHR by enhancing neutrophilic inflammation via CXCR2 signaling; furthermore, CXCR2 signaling derived Th2 responses. We thus suggest the underlying mechanisms of IL-33 and IL-17A in allergic asthma and CXCR2 as potential therapeutic targets for the disease.

Interleukin (IL)-33, a member of the IL-1 family of cytokines, is produced when epithelial and endothelial cells are exposed to stimuli. Hematopoietic cells such as macrophages also produce IL-33. IL-33 is considered to function as an ‘alarmin’, activating various immune cells through its receptor ST2, which leads to the production of various molecules. The IL-33-induced production of pro-inflammatory cytokines is a critical event that aggravates atopic diseases such as asthma, atopic dermatitis, and pollenosis and suggests that IL-33-blocking agents could represent new therapeutic drugs. The anti-IL-33 antibody was effective in allergic models, whereas the anti-ST2 antibody has yielded controversial results because soluble ST2 functions as a decoy receptor for IL-33. IL-33-mediated pulmonary inflammation may be glucocorticoid-resistant especially when other cytokines act synergistically. Anti-tumor necrosis factor (TNF)-α therapy may also be effective against IL-33-mediated diseases. ERK1/2 inhibitors have also been shown to suppress the production of IL-33. On the other hand, activation of β2-receptors enhanced the expression of IL-33 mRNA in dendritic cells by activating protein kinase A (PKA), suggesting that PKA inhibitors may be candidates for IL-33–blocking agents. The effects of IL-33–blocking agents on atopic diseases need to be pharmacologically assessed in experimental and clinical studies.

Summary: Allergen‐specific IgE has long been regarded as a major molecular component of allergic asthma. Additionally, there is increasing evidence of the important roles of interleukin‐33 (IL‐33) in the disease. Here, we show that IL‐33 and alveolar macrophages play essential roles in the exacerbation of IgE‐mediated airway inflammation and remodelling. BALB/c mice passively sensitized with ovalbumin (OVA)‐specific IgE monoclonal antibody (mAb) were challenged with OVA seven times intratracheally. The seventh challenge exacerbated airway inflammation and remodelling compared with the fourth challenge; furthermore, markedly increased expression of IL‐33 in the lungs was observed at the fourth and seventh challenges. When anti‐IL‐33 or anti‐ST2 antibody was administered during the fourth to seventh challenge, airway inflammation and remodelling were significantly inhibited at the seventh challenge. Because increases of IL‐33⁺ and ST2⁺ alveolar macrophages and ST2⁺ CD4⁺ T cells in the lungs were observed at the fourth challenge, the roles of macrophages and CD4⁺ cells were investigated. Depletion of macrophages by 2‐chloroadenosine during the fourth to seventh challenge suppressed airway inflammation and remodelling, and IL‐33 production in the lung at the seventh challenge; additionally, anti‐CD4 mAb inhibited airway inflammation, but not airway remodelling and IL‐33 production. Meanwhile, treatment with 2‐chloroadenosine or anti‐CD4 mAb decreased IL‐33‐induced airway inflammation in normal mice; airway remodelling was repressed only by 2‐chloroadenosine. These results illustrate that macrophage‐derived IL‐33 contributes to the exacerbation of IgE‐mediated airway inflammation by mechanisms associated with macrophages and CD4⁺ cells, and airway remodelling through the activation of macrophages.

We examined whether nasal hyperresponsiveness to leukotriene (LT) D4 is seen in our allergic rhinitis model, which showed sneezing and biphasic nasal blockage by repeated antigen inhalation challenge, and whether a dilatation of mucosal blood vessels contributes to this hyperresponsiveness. Nasal blockage [increase of specific airway resistance (sRaw)] was indexed as nasal (hyper)responsiveness. The sensitized-challenged guinea pig showed a remarkable dose-dependent increase in sRaw by intranasal instillation of LTD4 (10 microl/nostril) at 10(-10) to 10(-6) M 10 h and 2 days but not 7 days after the challenge. The increase in sRaw induced by LTD4 was largely blocked by pranlukast or naphazoline, and this was dose-dependently suppressed by N(omega)-nitro-L-arginine methyl ester. Sodium nitroprusside induced an elevation of sRaw in the sensitized-challenged animal in the hyperresponsiveness state, but the degree did not differ from that in the non-sensitized-non-challenged group. The amount of NO2- and NO3- in nasal cavity lavage fluid after LTD4 instillation in the sensitized-challenged animal in the hyperresponsiveness state was significantly greater than that before the instillation. These results demonstrate that the hyperresponsiveness to LTD4 acquired by repeated antigen challenge is mainly due to dilatation of nasal blood vessels, which can be related to hyperproduction of nitric oxide through cysteinyl LT1-receptor activation.