Differential effects of formoterol on thrombin- and PDGF-induced proliferation of human pulmonary arterial vascular smooth muscle cells
© Goncharova et al.; licensee BioMed Central Ltd. 2012
Received: 14 February 2012
Accepted: 3 September 2012
Published: 27 November 2012
Increased pulmonary arterial vascular smooth muscle (PAVSM) cell proliferation is a key pathophysiological component of pulmonary vascular remodeling in pulmonary arterial hypertension (PH). The long-acting β2-adrenergic receptor (β2AR) agonist formoterol, a racemate comprised of (R,R)- and (S,S)-enantiomers, is commonly used as a vasodilator in chronic obstructive pulmonary disease (COPD). PH, a common complication of COPD, increases patients’ morbidity and reduces survival. Recent studies demonstrate that formoterol has anti-proliferative effects on airway smooth muscle cells and bronchial fibroblasts. The effects of formoterol and its enantiomers on PAVSM cell proliferation are not determined. The goals of this study were to examine effects of racemic formoterol and its enantiomers on PAVSM cell proliferation as it relates to COPD-associated PH.
Basal, thrombin-, PDGF- and chronic hypoxia-induced proliferation of primary human PAVSM cells was examined by DNA synthesis analysis using BrdU incorporation assay. ERK1/2, mTORC1 and mTORC2 activation were determined by phosphorylation levels of ERK1/2, ribosomal protein S6 and S473-Akt using immunoblot analysis.
We found that (R,R) and racemic formoterol inhibited basal, thrombin- and chronic hypoxia-induced proliferation of human PAVSM cells while (S,S) formoterol had lesser inhibitory effect. The β2AR blocker propranolol abrogated the growth inhibitory effect of formoterol. (R,R), but not (S,S) formoterol attenuated basal, thrombin- and chronic hypoxia-induced ERK1/2 phosphorylation, but had little effect on Akt and S6 phosphorylation levels. Formoterol and its enantiomers did not significantly affect PDGF-induced DNA synthesis and PDGF-dependent ERK1/2, S473-Akt and S6 phosphorylation in human PAVSM cells.
Formoterol inhibits basal, thrombin-, and chronic hypoxia-, but not PDGF-induced human PAVSM cell proliferation and ERK1/2, but has little effect on mTORC1 and mTORC2 signaling. Anti-proliferative effects of formoterol depend predominantly on its (R,R) enantiomer and require the binding with β2AR. These data suggest that (R,R) formoterol may be considered as potential adjuvant therapy to inhibit PAVSM cell proliferation in COPD-associated PH.
Keywords(R R) formoterol ERK1/2 Pulmonary hypertension
Pulmonary arterial vascular smooth muscle (PAVSM) cell proliferation is one of the key pathophysiological components of vascular remodeling in pulmonary hypertension (PH) [1, 2]. PH is a common complication of chronic obstructive pulmonary disease (COPD), which is strongly associated with decreased quality of life, increased morbidity and reduced survival of COPD patients [3, 4]. The major pathological manifestations of PH are vasoconstriction and remodeling of small muscular pulmonary arteries (PA). Prolonged exposure to hypoxia, growth factors and pro-inflammatory cytokines induces PAVSM proliferation and pulmonary vascular remodeling leading to persistent elevation of pulmonary vascular resistance, right ventricular failure and death [2, 5, 6]. Systemic vasodilators, however, have not been found to be effective therapy for COPD-associated PH  and therapeutic options to target pulmonary vascular remodeling are needed.
β2 adrenoreceptor (AR), a member of the G-protein coupled receptor family, is the major subtype of βAR in SM cells. Binding with β2AR agonists induces β2AR coupling with Gs proteins, activation of adenylate cyclase and increase of cellular cAMP levels leading to parallel activation of protein kinase A (PKA) and Epac1 that synergize in mediating cAMP-dependent growth inhibition of VSM cells [7–11] suggesting that β2AR agonists may be considered as an attractive therapeutic approach to inhibit PAVSM cell proliferation in PH.
Formoterol is a long-acting β2AR agonist that is commonly used as a bronchodilator to treat patients with COPD [12, 13]. Formoterol is available in two formulations: racemic formoterol that consists of equal amounts of (R,R) and (S,S) enantiomers, and purified (R,R) formoterol. (R,R) formoterol has 1000-times greater affinity to β2AR than (S,S) enantiomer and shows improved bronchodilator effects compared to formoterol racemate . Recent data demonstrate that, in addition to its function as a bronchodilator, racemic formoterol also acts as an anti-proliferative agent for airway smooth muscle cells  and human bronchial fibroblasts . Currently, no information is available about the effects of formoterol in PAVSM cell proliferation as it relates to COPD-associated PH, and comparative effects of racemic formoterol vs. its (R,R) and (S,S) enantiomers on PAVSM cell proliferation are also not examined.
The mechanisms by which formoterol regulates cell proliferation are not well understood. cAMP uptake regulates Raf1-extracellular signal-regulated kinases 1/2 (ERK1/2) cascade via PKA-specific direct phosphorylation of Raf1 or PKA- and Epac1-dependent Rap1 regulation [7, 15–18]. cAMP is also shown to down-regulate protein tyrosine phosphorylation in VSM cells . Studies from our laboratory and others demonstrate that ERK1/2 and mammalian target of rapamycin (mTOR), downstream effectors of receptor tyrosine kinases (RTK), are two major positive regulators of PAVSM cell proliferation induced by mitogens and chronic hypoxia [20–25]. ERK1/2 is required for PDGF-, insulin- and thrombin-induced proliferation of aortic and pulmonary arterial VSM cells [22, 23]; and pharmacological inhibition of MEK-ERK1/2 signaling abolishes chronic hypoxia-induced rat PAVSM cell proliferation . mTOR forms two functionally distinct complexes, mTORC1 and mTORC2 [25, 26]. Chronic hypoxia, PDGF, and thrombin activate mTORC1 in PAVSM and endothelial cells that, in turn, stimulates cell growth via regulation of S6 kinase 1 (S6K1) and 4 EB-P1 [20–25]. The mTORC1 inhibitor rapamycin attenuates pulmonary vascular remodeling in experimental PH [27, 28] and demonstrated benefits in treatment of patients with PH . mTORC2 activates serine-threonine kinase Akt via specific phosphorylation at S-473 . We recently reported that chronic hypoxia and PDGF activate mTORC2 signaling that is required for proliferation of human and rat PAVSM cells . The effects of formoterol and its enantiomers on ERK1/2 and mTOR signaling pathways in PAVSM cells, however, remain to be elucidated.
The goal of this study was to evaluate the effects of racemic formoterol and its (R,R) and (S,S) enantiomers on proliferation of human PAVSM cells induced by PDGF, thrombin, and chronic hypoxia, recognized triggers of PAVSM cell proliferation and vascular remodeling in COPD-associated PH . We found that formoterol inhibits basal, thrombin-, and chronic hypoxia-, but not PDGF-induced proliferation of human PAVSM cells and ERK1/2 phosphorylation while having little effect on mTOR signaling. We also show that the anti-proliferative effects of formoterol require its binding with β2AR and that (R,R) formoterol shows improved anti-proliferative effects compared to racemic formoterol. Taken together, our data demonstrate that formoterol inhibits human PAVSM cell proliferation caused by certain PH-related stimuli and suggest that (R,R) formoterol may be considered as a potential adjuvant therapy to attenuate PAVSM cell proliferation in COPD-associated PH.
Human PAVSM cells were dissociated from pulmonary arteries from failed donor lungs that were obtained from the National Disease Research Interchange (NDRI) (Philadelphia, PA), in accordance with procedures approved by the University of Pennsylvania Committee on Studies Involving Human Beings as previously described [20, 25]. Briefly, a segment of human pulmonary artery just proximal to the lung entry was removed under aseptic conditions, cleaned from connective and fat tissues and dissected as follows: the media of pulmonary artery was dissected from the adventitia and intima and subjected to an enzymatic digestion in 10 ml of buffer containing 0.2 mM CaCl2, 640 U/ml collagenase, 1 mg/ml soybean trypsin inhibitor and 10 U/ml elastase for approximately 60 min in a shaking water bath at 37°C. The cell suspension was filtered through 105 μm Nytex mesh, and the filtrate was washed with equal volumes of cold Ham's F-12 medium (Life Technologies, Grand Island, NY) supplemented with 10% FBS (HyClone, Logan, UT). Cells were plated on tissue culture plates covered with Vitrogen (Cohesion Technologies Inc., Palo Alto, CA). Cells were cultured in Ham's F-12 media supplemented with 10% FBS (Becton Dickinson, Bedford, MA), 100 U/ml penicillin, and 0.1 mg/ml streptomycin.
For chronic hypoxia experiments, cells were maintained either in normoxic (21% O2, 5% CO2) or in hypoxic (1% O2, 5% CO2) conditions for 7 days in complete media and then for 48 h in serum-free media supplemented with 0.1% BSA. 1% O2 was used as we described  to reproduce the tissue oxygen levels of moderate chronic hypoxia [32, 33] based on data obtained from the rat chronic hypoxia model of PH [34, 35]. To avoid re-oxygenation, fresh complete or serum-free media was pre-equilibrated at 1% O2, before adding to PAVSM cells grown under hypoxia. Primary human PAVSM cells in subculture during the second through tenth cell passages were used. All experiments were performed using a minimum of three different cell cultures. Each human PAVSM cell culture was established using pulmonary arterial tissue from a single human donor.
DNA synthesis analysis
Cells grown under normoxia or chronic hypoxia were serum deprived for 48 h, treated with 0.1, 1, or 10 ng/ml PDGF-BB, 1 U/ml thrombin, 0.2, 2, or 20 μM racemic, (R,R), or (S,S) formoterol, or diluent for 18 h followed by DNA synthesis analysis using the BrdU incorporation assays as we described [25, 36–38]. Briefly, cells were incubated with 10 μM BrdU for 24 h, fixed with 3.7% paraformaldehyde (Polysciences, Inc., Warrington, PA) for 15 min and permeabilized with 0.1% Triton X-100 for 30 min at room temperature. Following denaturation of DNA with 4 N HCl (3 min at room temperature), incubated for 1 h at 37oC with 2 μg/ml murine anti-BrdU primary (Becton Dickinson, San Jose, CA) and 10 μg/ml Texas Red-conjugated anti-mouse secondary (Jackson ImmunoResearch Laboratories, West Grove, PA) antibodies for 1 h at 37°C to detect BrdU-positive cells. To detect the total number of nuclei, cells were incubated with 1 μg/ml DAPI. Then, cells were visualized using Eclipse Nikon TE2000E fluorescent microscope (200x magnification), and automatic counts of BrdU-positive and total number of cells were performed using Image-Pro Plus 5.1 software.
Whole cell lysates were prepared using a buffer comprised of 40 mM HEPES (pH 7.5), 120 mM NaCl, 1 mM EDTA, 10 mM sodium pyrophosphate (Na4P2O7 x 10H2O), 10 mM β-glycerophosphate, 50 mM NaF, 1.5 mM Na3VO4, 1% Triton X-100, EDTA-free inhibitor cocktail. Protein contents were measured using a Bio-Rad protein assay reagent kit. Equal amounts of lysate, adjusted for protein content, were subjected to SDS-PAGE and then immunoblot analysis. The blots were exposed to anti-phospho-S6 ribosomal protein, anti-total S6, anti-phospho Akt Ser-473, anti-total Akt, anti-phospho ERK, anti-total ERK, anti-phospho S6K1 T-389, and anti-total S6K1 antibodies (Cell Signaling Technology, Inc., Beverly, MA). All antibodies were in 20 mM Tris (pH 7.5), 150 mM NaCl (TBS) plus 0.5% Tween 20 (TBST), and all incubations were for overnight at 4°C. After 3 washes in TBST, the nitrocellulose membranes were exposed to horseradish peroxidase-conjugated secondary antibody (Boehringer-Mannheim, Indianapolis, IN), washed five times in TBST and visualized using enhanced chemiluminescence (ECL) (Amersham, Arlington Heights, IL).
Data points from each condition are represented as the mean values ± SE. Three independent repetitions were performed for each experimental condition. Statistical analysis was performed using StatView software. Statistically significant differences among groups were assessed with the analysis of variance (ANOVA) (Bonferroni-Dunn) with values of p < 0.05 sufficient to reject the null hypothesis for all analyses. All experiments were designed with matched control conditions within each experiment to enable statistical comparison as paired samples.
Formoterol inhibits basal and thrombin-, but not PDGF-induced human PAVSM cell proliferation
Formoterol inhibits PAVSM cell proliferation caused by chronic hypoxia exposure
Binding with β2AR is required for formoterol-induced inhibition of human PAVSM cell proliferation
(R,R) formoterol inhibits basal and thrombin-, but not PDGF-induced ERK1/2 phosphorylation in human PAVSM cells
Formoterol has no effect on mTOR signaling in human PAVSM cells
PH is a progressive disease with poor prognosis, the pathological manifestations of which include vasoconstriction and pulmonary vascular remodeling [5, 45]. PH may be familial, idiopathic, or associated with other diseases. Notably, patients with COPD-associated PH have higher morbidity and reduced survival compared to other COPD patients [3, 4]. Pulmonary vascular remodeling in PH is associated with marked medial thickening of small muscular PAs due, at least in part, to increased proliferation of PAVSM cells. PAVSM cell proliferation in COPD-associated PH is caused by multiple factors including persistent hypoxia and increased production of growth factors and pro-inflammatory cytokines [2, 31, 46]. Our study demonstrates that β2AR agonist formoterol inhibits proliferation of PAVSM cells induced by thrombin and chronic hypoxia, but not PDGF. Anti-proliferative activity of formoterol requires binding with β2AR, and (R,R) enantiomer of formoterol shows improved anti-growth effects compared to racemic and (S,S) formoterol. We also report that formoterol inhibits basal and thrombin-induced activation of ERK1/2, but has no effect on mTOR signaling in human PAVSM cells.
Deregulated PAVSM cell proliferation is one of the major pathological components of pulmonary vascular remodeling in PH. The long-term β2AR agonist formoterol, which is currently in use as bronchodilator in COPD, shows anti-proliferative activities in human airway smooth muscle cells and bronchus fibroblasts [9, 14]. In the present study, we explored effects of formoterol on human PAVSM cell proliferation caused by different stimuli involved in PH pathogenesis [2, 31, 47] and found that the growth-inhibitory potency of formoterol highly depends on extracellular stimuli. Thus, formoterol and, especially, its (R,R) enantiomer, inhibited proliferation of non-stimulated PAVSM cells under chronic hypoxia, decreased thrombin-induced proliferation, but had no significant effect on PDGF-dependent PAVSM cell growth.
The mechanisms of β2AR-dependent regulation of cell proliferation are relatively unexplored and appear to be highly cell type-specific. β2AR-induced PKA activation, while inhibiting proliferation in the majority of cell types including vascular smooth muscle cells [8–11, 48, 49] stimulates proliferation of human uveal melanoma cells  and cardiomyocyte hypertrophy . Activation of β2AR-cAMP signaling also up-regulates Epac1, the predominant Epac isoform in VSM cells . Epac1 synergizes with PKA in inhibiting VSM cell proliferation , but increases DNA synthesis in macrophages and prostate cancer cells [52, 53]. Our data show that formoterol-dependent inhibition of human PAVSM cells requires its binding with β2AR. Accordingly, (R,R) formoterol, which has much higher receptor affinity and greater potency to induce β2AR-Gs-dependent cAMP production and PKA activation compared to (S,S) formoterol [8, 54], demonstrates greater anti-proliferative effects than formoterol racemate while (S,S) formoterol has modest effects on PAVSM cell proliferation.
Emerging evidence shows that, in addition to classical Gs-cAMP pathway, β2AR may interact with Gi proteins that, in contrast to Gs, leads to reduction of cAMP levels and inhibition of PKA-dependent signaling . Currently, no evidence exists about involvement of Gi in PAVSM cell proliferation and pulmonary vascular remodeling in PH. In contrast, Gs-dependent activation of cAMP-PKA signaling is well documented in human ASM and PAVSM cells upon formoterol treatment and is required for bronchodilatory and vasodilatory effects of formoterol on COPD patients and for inhibition of SM cell proliferation [7–11, 56]. Gi overexpression, however, has been reported in heart and aorta of spontaneously hypertensive rats; and Gi suppression with pertussis toxin attenuated development of high blood pressure in this model [55, 57–59] suggesting differential mechanisms of β2AR signaling in heart vs. pulmonary vasculature.
The signaling pathways underlying formoterol-dependent inhibition of cell proliferation are not well evaluated. We and others previously demonstrated that thrombin promotes human PAVSM cell proliferation via ERK1/2 signaling while PDGF acts via activation of two major pro-proliferative pathways, PI3K-mTOR and MEK-ERK1/2 . In the majority of cells, including VSM, cAMP-dependent activation of PKA and Epac inhibits ERK1/2 signaling via modulating activities of small GTPases Raf-1 and Rap-1 downstream of Ras [15, 61, 62] clearly demonstrating functional cross-talk between ERK1/2 and β2AR-cAMP cascades.
Interestingly, we found that formoterol markedly inhibits thrombin-, but not PDGF-induced ERK1/2 phosphorylation. A possible explanation is that PDGF, in addition to ERK1/2, also promotes strong up-regulation of PI3K signaling [20, 25], and we found that PI3K is insensitive to formoterol. PI3K stimulates ERK1/2 activation via Raf-1 and Rap-1 in a Ras-independent manner [63, 64] and can counter-balance formoterol-β2AR-cAMP-dependent ERK1/2 inhibition. Indeed, our data show that formoterol markedly inhibits ERK1/2 phosphorylation in chronic hypoxia-exposed PAVSM cells, in which mTOR activation and proliferation occur in a PI3K-independent manner .
Chronic hypoxia-induced proliferation of PAVSM cells requires expression of hypoxia-inducible factor 1 α (HIF1α), which plays a critical role in PAVSM remodeling in human and experimental PH [31, 65]. Notably, ERK1/2 up-regulates HIF1α transcriptional activity via direct phosphorylation that promotes HIF1α nuclear translocation or via regulating binding of HIF1α with its major co-activator p300/cAMP response element-binding protein (CBP) [66–69]. Thus, formoterol may inhibit chronic hypoxia-induced PAVSM cell proliferation via down-regulation of ERK1/2-dependent HIF1α transcriptional activity.
Although much less is known about the regulation of the mTOR signaling pathway by cAMP/PKA, it is shown that cAMP elevation inhibits mTORC1/S6K1 in T lymphocytes , but not in CCL39 fibroblasts  suggesting that effects of cAMP/PKA on mTOR activation are cell type-specific. Our data show that formoterol has no effect on activation of mTORC1 and mTORC2 signaling pathways caused by either PDGF or chronic hypoxia. These data indicate that mitogen- and chronic hypoxia-induced mTOR activation in human PAVSM cells is β2AR-independent.
Taken together, our study demonstrates that formoterol inhibits basal, chronic hypoxia- and thrombin-, but not PDGF-induced human PAVSM cell proliferation potentially via β2AR-dependent inhibition of ERK1/2 signaling pathway; and that anti-proliferative activity of formoterol is provided predominantly by its (R,R) enantiomer. This data suggests that (R,R) formoterol, while having a limited effect as a single agent, may be considered as a potential adjuvant therapy for COPD-associated PH.
Collectively, our data demonstrate that the β2AR agonist formoterol inhibits basal, thrombin-, and chronic hypoxia-induced ERK1/2 activation and proliferation of human PAVSM cells, but has little effect on PDGF-induced ERK1/2 activation, proliferation and mTOR signaling. We also show that formoterol acts predominantly through its (R,R) enantiomer and that anti-proliferative effects of formoterol require β2AR binding. These data suggest that (R,R) formoterol inhibits human PAVSM cell proliferation in certain conditions and may be considered as a potential adjuvant therapy for COPD-associated PH.
Analysis of variance
Chronic obstructive pulmonary disease
Extracellular signal-regulated kinases ½
hypoxia-inducible factor 1 α
Mammalian target of rapamycin
Mitogen-activated protein kinase
MAP kinase kinase
National Disease Research Interchange
Pulmonary arterial vascular smooth muscle
platelet-derived growth factor
Protein kinase A
Receptor tyrosine kinase
p70 S6 kinase 1.
We thank the National Disease Research Interchange (NDRI) for providing us with human lung tissue and Ms. Mary McNichol for critical reading of the manuscript. This work is supported by Sepracor (V.P.K.) and, in part, by a Gilead Science Research Award (E.A.G.), an American Lung Association Research Award (E.A.G.), the University of Pennsylvania Research Foundation (E.A.G.), and NIH/NHLBI 1R01HL113178 (E.A.G).
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