(Thorax 1999;54:1033-1035 Keywords: nitric oxide; asthma; airway hyperresponsiveness Evidence is accumulating that endogenous nitric oxide (NO) is involved in the pathophysiology of asthma. NO is formed by NO synthase (NOS) using L-arginine as a substrate. It has been shown that the level of NO in exhaled air is increased in subjects with asthma, and that it varies with disease severity.1 However, the functional role of NO in the pathophysiology of asthma is still unclear.Recent studies on the modulation of endogenous NO production have revealed protective features of NO during episodes of airways obstruction. Increased airway hyperresponsiveness to non-sensitising stimuli has been observed following inhalation of NOS inhibitors in mildly asthmatic subjects, 2 whereas this could not be found in patients with more severe asthma.
3Based on these findings, it can be postulated that airways obstruction in asthma is associated with an endogenous NO deficiency due to limited availability of NOS substrate. We therefore examined the protective eVect of oral supplementation of the natural substrate of NOS (L-arginine) on relatively mild and more severe histamine induced airways obstruction in patients with asthma.
MethodsThe study subjects comprised 14 nonsmoking, atopic, asthmatic patients using inhaled short acting 2 agonists on demand only. They had episodic chest symptoms, their baseline forced expiratory volume in one second (FEV 1 ) ranged from 82% to 115% predicted, and all were hyperresponsive to inhaled histamine (provocative concentration causing a fall in FEV 1 of 20% (PC 20 ) 0.04-6.5 mg/ml). They were asked to refrain from using bronchodilators for at least eight hours before testing.In a double blind, randomised, crossover study the patients received pretreatment with oral L-arginine or placebo on two separate days separated by an interval of 1-2 weeks. Exhaled NO, FEV 1 , blood pressure, and heart rate were measured before (baseline) and at 30, 60, and 90 minutes following pretreatment, after which a histamine challenge was performed. Gelatin capsules containing L-arginine (50 mg/kg body weight; Bufa, Uitgeest, The Netherlands) or placebo (cellulose) were given 90 minutes before standardised histamine challenges using the two minute tidal breathing method. To examine the eVects of L-arginine on mild as well as severe degrees of airways obstruction, the challenge test was continued until a 50% fall in FEV 1 from baseline was obtained or when the highest dose was reached. The response was expressed as PC 20 as a measure of airways sensitivity, whilst the dose-response slope was calculated (maximal % fall in FEV 1 / maximal dose of histamine (µmol)) as a measure of airways reactivity. 4 Exhaled NO was measured using a chemiluminescence analyser (Sievers, Boulder, Colo-