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Follow-up protocol of patients with cystic fibrosis diagnosed by newborn screening. ANALES DE PEDIATRÍA (ENGLISH EDITION) 2019. [DOI: 10.1016/j.anpede.2018.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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152
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Taylor-Cousar JL, Mall MA, Ramsey BW, McKone EF, Tullis E, Marigowda G, McKee CM, Waltz D, Moskowitz SM, Savage J, Xuan F, Rowe SM. Clinical development of triple-combination CFTR modulators for cystic fibrosis patients with one or two F508del alleles. ERJ Open Res 2019; 5:00082-2019. [PMID: 31218221 PMCID: PMC6571452 DOI: 10.1183/23120541.00082-2019] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 04/19/2019] [Indexed: 12/26/2022] Open
Abstract
Cystic fibrosis (CF) is caused by mutations in the CF transmembrane conductance regulator gene (CFTR) that result in diminished quantity and/or function of the CFTR anion channel. F508del-CFTR, the most common CF-causing mutation (found in ∼90% of patients), causes severe processing and trafficking defects, resulting in decreased CFTR quantity and function. CFTR modulators are medications that increase the amount of mature CFTR protein (correctors) or enhance channel function (potentiators) at the cell surface. Combinations of CFTR correctors and potentiators (i.e. lumacaftor/ivacaftor, tezacaftor/ivacaftor) have demonstrated clinical benefit in subsets of patients. However, none are approved for patients with CF heterozygous for F508del-CFTR and a minimal function mutation, i.e. a mutation that produces either no protein or protein that is unresponsive to currently approved CFTR modulators. Next-generation CFTR correctors VX-659 and VX-445, each in triple combination with tezacaftor and ivacaftor, improve CFTR processing, trafficking and function in vitro and have demonstrated clinical improvements in phase 2 studies in patients with CF with one or two F508del-CFTR alleles. Here, we present the rationale and design of four randomised phase 3 studies, and their open-label extensions, evaluating VX-659 (ECLIPSE) or VX-445 (AURORA) plus tezacaftor and ivacaftor in patients with one or two F508del-CFTR alleles.
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Affiliation(s)
| | - Marcus A Mall
- Charité - Universitätsmedizin Berlin, Berlin Institute of Health, German Center for Lung Research, Berlin, Germany
| | | | - Edward F McKone
- St Vincent's University Hospital and University College Dublin School of Medicine, Dublin, Ireland
| | | | | | | | - David Waltz
- Vertex Pharmaceuticals Inc., Boston, MA, USA
| | | | | | | | - Steven M Rowe
- Gregory Fleming James Cystic Fibrosis Research Center, University of Alabama at Birmingham, Birmingham, AL, USA
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153
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Villella VR, Tosco A, Esposito S, Bona G, Raia V, Maiuri L. Mutation-specific therapies and drug repositioning in cystic fibrosis. Minerva Pediatr 2019; 71:287-296. [DOI: 10.23736/s0026-4946.19.05506-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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154
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Savi D, Schiavetto S, Simmonds NJ, Righelli D, Palange P. Effects of Lumacaftor/Ivacaftor on physical activity and exercise tolerance in three adults with cystic fibrosis. J Cyst Fibros 2019; 18:420-424. [PMID: 30879989 DOI: 10.1016/j.jcf.2019.03.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Revised: 03/01/2019] [Accepted: 03/01/2019] [Indexed: 10/27/2022]
Abstract
The combination of the corrector lumacaftor with the potentiator ivacaftor has been approved for treatment of cystic fibrosis (CF) patients homozygous for the Phe508del CFTR mutation. There are no reports detailing the effect of lumacaftor-ivacaftor on physical activity (PA) and exercise tolerance. We performed incremental cardiopulmonary exercise testing (CPET) and we assessed PA pre- and post 2 years initiation of lumacaftor-ivacaftor in three CF adults. PA of mild intensity improved by +13% in patient 1, + 84% in patients 2 and + 89% in patient 3. Oxygen uptake increased both at anaerobic threshold and at peak exercise (patient 1 + 33%, patient 2 + 42% and patient 3 + 20%). Daily physical activities and exercise tolerance improved after two years of lumacaftor-ivacaftor therapy.
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Affiliation(s)
- Daniela Savi
- Department of Public Health and Infectious Diseases, Adult Cystic Fibrosis Center, Sapienza University of Rome, 00185 Rome, Italy; Cystic Fibrosis Unit, Bambino Gesù Children's Hospital, Rome, Italy.
| | - Stefano Schiavetto
- Department of Public Health and Infectious Diseases, Adult Cystic Fibrosis Center, Sapienza University of Rome, 00185 Rome, Italy.
| | - Nicholas J Simmonds
- Department of Cystic Fibrosis, Royal Brompton Hospital and Imperial College, London SW3 6NP, UK.
| | - Dario Righelli
- Institute for Applied Mathematics "M. Picone" - National Research Council, 80131, Naples, Italy
| | - Paolo Palange
- Department of Public Health and Infectious Diseases, Adult Cystic Fibrosis Center, Sapienza University of Rome, 00185 Rome, Italy; Eleonora Lorrillard-Spencer Cenci Foundation, 00185 Rome, Italy.
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155
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Pranke I, Golec A, Hinzpeter A, Edelman A, Sermet-Gaudelus I. Emerging Therapeutic Approaches for Cystic Fibrosis. From Gene Editing to Personalized Medicine. Front Pharmacol 2019; 10:121. [PMID: 30873022 PMCID: PMC6400831 DOI: 10.3389/fphar.2019.00121] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 01/31/2019] [Indexed: 12/13/2022] Open
Abstract
An improved understanding of the cystic fibrosis (CF) transmembrane conductance regulator (CFTR) protein structure and the consequences of CFTR gene mutations have allowed the development of novel therapies targeting specific defects underlying CF. Some strategies are mutation specific and have already reached clinical development; some strategies include a read-through of the specific premature termination codons (read-through therapies, nonsense mediated decay pathway inhibitors for Class I mutations); correction of CFTR folding and trafficking to the apical plasma membrane (correctors for Class II mutations); and an increase in the function of CFTR channel (potentiators therapy for Class III mutations and any mutant with a residual function located at the membrane). Other therapies that are in preclinical development are not mutation specific and include gene therapy to edit the genome and stem cell therapy to repair the airway tissue. These strategies that are directed at the basic CF defects are now revolutionizing the treatment for patients and should positively impact their survival rates.
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Affiliation(s)
- Iwona Pranke
- INSERM U 1151, Institut Necker Enfants Malades, Université Paris Descartes, Paris, France
| | - Anita Golec
- INSERM U 1151, Institut Necker Enfants Malades, Université Paris Descartes, Paris, France
| | - Alexandre Hinzpeter
- INSERM U 1151, Institut Necker Enfants Malades, Université Paris Descartes, Paris, France
| | - Aleksander Edelman
- INSERM U 1151, Institut Necker Enfants Malades, Université Paris Descartes, Paris, France
| | - Isabelle Sermet-Gaudelus
- INSERM U 1151, Institut Necker Enfants Malades, Université Paris Descartes, Paris, France.,Centre de Référence Maladie Rare, Mucoviscidose et Maladies de CFTR, Paris, France.,Faculté de Médecine, Université Paris Descartes, Paris, France
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156
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Efficacy and Safety of CFTR Corrector and Potentiator Combination Therapy in Patients with Cystic Fibrosis for the F508del-CFTR Homozygous Mutation: A Systematic Review and Meta-analysis. Adv Ther 2019; 36:451-461. [PMID: 30554331 DOI: 10.1007/s12325-018-0860-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Cystic fibrosis (CF) is a progressive, genetic disease that causes persistent lung infections and limits the ability to breathe over time. The combination of a cystic fibrosis transmembrane conductance regulator (CFTR) corrector and potentiator has provided a benefit by decreasing sweat chloride concentration in CF for the F508del-CFTR homozygous mutation, but it remains controversial in lung function, nutritional status, clinical score and safety. METHODS The authors performed a systematic review and meta-analysis of randomized controlled trials (RCTs) to evaluate the efficacy and safety of combination therapy on lung function, nutritional status, clinical score and safety in CF for the F508del-CFTR homozygous mutation. Web of Science, Cochrane Central Register of Controlled Trials, Medline, and Embase were searched. The registered PROSPERO number was CRD42018085875. RESULTS Five RCTs, including a total of 1637 participants with the F508del-CFTR homozygous mutation who accepted CFTR corrector and potentiator combination therapy along with basic treatment were enrolled in this analysis. Primary analysis revealed that combination therapy improved the percent of predicted FEV1 (ppFEV1) (MD 2.38, 1.62-3.15, P < 0.00001), Cystic Fibrosis Questionnaire-Revised (CFQ-R) respiratory domain score (MD 2.59, 0.96-4.22, P = 0.002) and body-mass index (BMI) (MD 0.21, 0.03-0.39, P = 0.02). In the secondary analysis, combination therapy had no impact on the number of participants reporting adverse events (OR 0.88, 0.58-1.33, P = 0.53), but increased the proportion of discontinued treatments due to adverse events (OR 2.71, 1.3-5.63, P = 0.008). CONCLUSIONS CFTR corrector and potentiator combination therapy effectively improves lung function, nutritional status and clinical score in CF patients with the F508del-CFTR homozygous mutation, and has an acceptable safety profile.
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157
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[Patients with cystic fibrosis become adults : Treatment hopes and disappointments]. Internist (Berl) 2019; 60:98-108. [PMID: 30627755 DOI: 10.1007/s00108-018-0536-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Mucoviscidosis or cystic fibrosis (CF) is one of the most frequent monogenetic diseases in middle Europe. It is inherited in an autosomal recessive manner. A defect in the cystic fibrosis transmembrane conductance regulator (CFTR) channel reduces chloride ion transport to the cell membrane, which leads to malfunctions in all exocrine glands. This results in a progressive multiorgan disease, which leads to chronic inflammation and infections of the lungs. The progressive destruction of lung tissue with respiratory insufficiency is the most common cause of death in CF. Progress in symptomatic treatment over the past decades has led to a dramatic improvement in life expectation and quality of life for those affected, so that nowadays in nearly all industrial countries the majority of patients are adults. In 2012 the era of causal therapy of the CFTR protein defects was opened with the approval of ivacaftor. Long-term data now confirm the benefits. There is reason to hope that the success story of CF treatment will be continued, particularly by further CFTR modulators with innovative modes of action and improved efficacy; however, so far these are not available for all mutation classes, so that not all patients can reap the benefits. Therefore, the further development of symptomatic treatment becomes of great importance due to the complications that have already occurred before the implementation of the CFTR modulators. The implementation of modulators in early childhood can attenuate or prevent early irreversible complications. Therefore, in this article special emphasis is placed on new developments in symptomatic treatment and on new treatment options.
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158
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Abstract
INTRODUCTION Cystic fibrosis (CF) is a multisystem illness caused by abnormalities in the CF transmembrane conductance regulator (CFTR) gene and protein. CFTR is an ion channel regulating transport of chloride, bicarbonate, and water, and influencing sodium resorption. It is inherited as an autosomal recessive disorder, and with about 70,000 CF patients worldwide, it is the most common life shortening disease among persons of European descent. CFTR disease-causing mutations have been organized into six classes. : AREAS COVERED Recently, small molecule targeted therapy for specific classes of CFTR abnormalities have included CFTR correctors that decrease protein degradation and CFTR potentiators that increase channel open probability enhancing chloride transport. EXPERT OPINION Although there are many novel medications in preclinical and clinical testing, there is need for safe and effective CFTR modulating drugs and immunomodulatory medications to decrease the abundant neutrophilic inflammation response in the airway without unwanted adverse effects. Thymosin alpha 1 treatment of airway cells isolated from phe508del CF patients and from CF knockout mice, decreased inflammation, increased CFTR maturation, and facilitated translocation of CFTR protein to the plasma membrane increasing channel activity. If similar results are seen in humans with CF, thymosin alpha 1 has the unique potential to be a single molecule therapy for treating CF airway disease.
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Affiliation(s)
- Bruce K Rubin
- a Children's Hospital of Richmond , Virginia Commonwealth University , Richmond , VA , USA
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159
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Vadagam P, Kamal KM, Covvey JR, Giannetti V, Mukherjee K. Cost-Effectiveness and Budget Impact of Lumacaftor/Ivacaftor in the Treatment of Cystic Fibrosis. J Manag Care Spec Pharm 2018; 24:987-997. [PMID: 30247102 PMCID: PMC10397671 DOI: 10.18553/jmcp.2018.24.10.987] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Cystic fibrosis (CF) is a chronic, progressive, genetic disease affecting more than 30,000 people in the United States and 70,000 people globally. The goals of treatment are to slow disease progression, reduce pulmonary exacerbations, relieve chronic symptoms, and improve the patient's quality of life. Lumacaftor/ivacaftor is a new therapy for CF that has demonstrated good clinical outcomes, including improved absolute percentage predicted forced expiratory volume in 1 second (FEV1%). However, given the high cost of therapy, there is a need to evaluate the overall value of lumacaftor/ivacaftor in CF management. OBJECTIVES To (a) conduct a cost-effectiveness analysis (CEA) of lumacaftor/ivacaftor to understand the overall effectiveness of the drug compared with its costs and (b) conduct a budget impact analysis (BIA) to understand the potential financial effect of introducing a new drug in a health plan. METHODS Two static decision models were developed using Microsoft Excel to evaluate the cost-effectiveness and budget impact of lumacaftor/ivacaftor over a 1-year time frame from a payer perspective. Model inputs included drug costs (wholesale acquisition costs), drug monitoring schedules (package inserts), drug monitoring costs (Centers for Medicare & Medicaid physician fee schedule and published literature), FEV1% predicted and pulmonary exacerbation values (clinical trials), and cost to treat pulmonary exacerbations (published literature). The outcomes in the CEA included total cost of therapy; average cost-effectiveness ratio (ACER), defined as cost per FEV1% predicted; and incremental cost-effectiveness ratio (ICER), defined as the difference in the ratio of cost per FEV1% predicted of lumacaftor/ivacaftor and placebo. Outcomes in the BIA included total budget impact; cost per member per month (PMPM), defined as total budget impact per hypothetical plan population; and cost per treated member per month (PTMPM), defined as total budget impact per target CF population. All costs were adjusted to 2016 dollars, and one-way sensitivity analyses were conducted to test the model robustness given uncertainty in model inputs and study assumptions. RESULTS The annual cost of therapy per patient for lumacaftor/ivacaftor was $379,780. The ACER for lumacaftor/ivacaftor was $151,912, while the ICER for lumacaftor/ivacaftor compared with placebo was $95,016 per FEV1% predicted. The annual total budget impact due to the inclusion of lumacaftor/ivacaftor on the health plan formulary was $266,046. The PMPM cost was $0.02 and the PTMPM cost was $6.21. CONCLUSIONS In patients with CF, lumacaftor/ivacaftor has demonstrated better clinical effectiveness compared with placebo alongside an increased drug acquisition cost. However, the therapy may be a viable alternative to existing standard therapy over a short time horizon. Health care payers, both private and public, need to evaluate the cost-effectiveness and the financial effect when considering expansion of new drug coverage in CF management. DISCLOSURES No outside funding supported this study. Covvey and Kamal have received research funding from Novartis Pharmaceuticals. Covvey, Giannetti, and Kamal have received research funding from the College of Psychiatric and Neurologic Pharmacists. Kamal serves as a consultant to the Lynx Group (Cranbury, NJ) and Manticore Consulting Group (Scottsdale, AZ). Mukherjee has nothing to disclose. A related poster abstract was presented at the AMCP Managed Care & Specialty Pharmacy Annual Meeting; March 27-30, 2017; Denver, CO.
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Affiliation(s)
- Pratyusha Vadagam
- 1 Division of Pharmaceutical, Administrative and Social Sciences, Duquesne University School of Pharmacy, Pittsburgh, Pennsylvania
| | - Khalid M Kamal
- 1 Division of Pharmaceutical, Administrative and Social Sciences, Duquesne University School of Pharmacy, Pittsburgh, Pennsylvania
| | - Jordan R Covvey
- 1 Division of Pharmaceutical, Administrative and Social Sciences, Duquesne University School of Pharmacy, Pittsburgh, Pennsylvania
| | - Vincent Giannetti
- 1 Division of Pharmaceutical, Administrative and Social Sciences, Duquesne University School of Pharmacy, Pittsburgh, Pennsylvania
| | - Kumar Mukherjee
- 2 Pharmacy Practice, Philadelphia College of Osteopathic Medicine, Suwanee, Georgia
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160
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Coulthard KP. Cystic fibrosis: novel therapies, remaining challenges. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2018. [DOI: 10.1002/jppr.1516] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Kingsley P. Coulthard
- School of Pharmacy and Medical Sciences University of South Australia Adelaide Australia
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161
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Morgan S, Duguez S, Duddy W. Personalized Medicine and Molecular Interaction Networks in Amyotrophic Lateral Sclerosis (ALS): Current Knowledge. J Pers Med 2018; 8:E44. [PMID: 30551677 PMCID: PMC6313785 DOI: 10.3390/jpm8040044] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 11/27/2018] [Accepted: 12/05/2018] [Indexed: 12/12/2022] Open
Abstract
Multiple genes and mechanisms of pathophysiology have been implicated in amyotrophic lateral sclerosis (ALS), suggesting it is a complex systemic disease. With this in mind, applying personalized medicine (PM) approaches to tailor treatment pipelines for ALS patients may be necessary. The modelling and analysis of molecular interaction networks could represent valuable resources in defining ALS-associated pathways and discovering novel therapeutic targets. Here we review existing omics datasets and analytical approaches, in order to consider how molecular interaction networks could improve our understanding of the molecular pathophysiology of this fatal neuromuscular disorder.
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Affiliation(s)
- Stephen Morgan
- Northern Ireland Centre for Stratified Medicine, Altnagelvin Hospital Campus, Ulster University, Londonderry, BT47 6SB, Northern Ireland, UK.
| | - Stephanie Duguez
- Northern Ireland Centre for Stratified Medicine, Altnagelvin Hospital Campus, Ulster University, Londonderry, BT47 6SB, Northern Ireland, UK.
| | - William Duddy
- Northern Ireland Centre for Stratified Medicine, Altnagelvin Hospital Campus, Ulster University, Londonderry, BT47 6SB, Northern Ireland, UK.
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162
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Dobra R, Edmondson C, Hughes D, Martin I, Davies JC. Potentiators and Correctors in Paediatric Cystic Fibrosis Patients: A Narrative Review. Paediatr Drugs 2018; 20:555-566. [PMID: 30328089 DOI: 10.1007/s40272-018-0315-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Cystic fibrosis is the most common inherited condition in the Caucasian population and is associated with significantly reduced life expectancy. Recent advances in treatment have focussed on addressing the underlying cause of the condition, the defective production, expression and function of the cystic fibrosis transmembrane conductance regulator (CFTR) protein. Several drugs with different modes of action have produced promising results in clinical trials, and some have been incorporated into routine clinical care for specific patients in many countries worldwide. Further trials continue to explore the safety and efficacy of these drugs in the youngest age groups and to search for more effective therapies to treat the most common disease-causing gene mutations in an ever-expanding drug pipeline. As evidence mounts for the early onset of disease in young patients, the prospect of introducing disease-modifying therapy in early life becomes more pertinent, although the cost implications of these expensive drugs are significant. In this review, we summarise these new therapy advances and review those currently being explored in clinical trials.
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Affiliation(s)
- R Dobra
- The Department of Cystic Fibrosis and Chronic Lung Infection, National Heart and Lung Institute, Imperial College London, Emmanuel Kaye Building, 1B Manresa Road, London, SW36LR, UK
| | - C Edmondson
- The Department of Cystic Fibrosis and Chronic Lung Infection, National Heart and Lung Institute, Imperial College London, Emmanuel Kaye Building, 1B Manresa Road, London, SW36LR, UK
| | - D Hughes
- The Department of Cystic Fibrosis and Chronic Lung Infection, National Heart and Lung Institute, Imperial College London, Emmanuel Kaye Building, 1B Manresa Road, London, SW36LR, UK
| | - I Martin
- The Department of Cystic Fibrosis and Chronic Lung Infection, National Heart and Lung Institute, Imperial College London, Emmanuel Kaye Building, 1B Manresa Road, London, SW36LR, UK
| | - J C Davies
- The Department of Cystic Fibrosis and Chronic Lung Infection, National Heart and Lung Institute, Imperial College London, Emmanuel Kaye Building, 1B Manresa Road, London, SW36LR, UK.
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163
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Rang C, Wilson J. Remarkable progress in cystic fibrosis-But why? Respirology 2018; 24:17-18. [PMID: 30467918 DOI: 10.1111/resp.13440] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Accepted: 10/24/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Catherine Rang
- Alfred Health Cystic Fibrosis Service, Monash University, Melbourne, VIC, Australia
| | - John Wilson
- Alfred Health Cystic Fibrosis Service, Monash University, Melbourne, VIC, Australia
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164
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Gong X, Liao Y, Ahner A, Larsen MB, Wang X, Bertrand CA, Frizzell RA. Different SUMO paralogues determine the fate of wild-type and mutant CFTRs: biogenesis versus degradation. Mol Biol Cell 2018; 30:4-16. [PMID: 30403549 PMCID: PMC6337916 DOI: 10.1091/mbc.e18-04-0252] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
A pathway for cystic fibrosis transmembrane conductance regulator (CFTR) degradation is initiated by Hsp27, which cooperates with Ubc9 and binds to the common F508del mutant to modify it with SUMO-2/3. These SUMO paralogues form polychains, which are recognized by the ubiquitin ligase, RNF4, for proteosomal degradation. Here, protein array analysis identified the SUMO E3, protein inhibitor of activated STAT 4 (PIAS4), which increased wild-type (WT) and F508del CFTR biogenesis in CFBE airway cells. PIAS4 increased immature CFTR threefold and doubled expression of mature CFTR, detected by biochemical and functional assays. In cycloheximide chase assays, PIAS4 slowed immature F508del degradation threefold and stabilized mature WT CFTR at the plasma membrance. PIAS4 knockdown reduced WT and F508del CFTR expression by 40–50%, suggesting a physiological role in CFTR biogenesis. PIAS4 modified F508del CFTR with SUMO-1 in vivo and reduced its conjugation to SUMO-2/3. These SUMO paralogue-specific effects of PIAS4 were reproduced in vitro using purified F508del nucleotide-binding domain 1 and SUMOylation reaction components. PIAS4 reduced endogenous ubiquitin conjugation to F508del CFTR by ∼50% and blocked the impact of RNF4 on mutant CFTR disposal. These findings indicate that different SUMO paralogues determine the fates of WT and mutant CFTRs, and they suggest that a paralogue switch during biogenesis can direct these proteins to different outcomes: biogenesis versus degradation.
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Affiliation(s)
- Xiaoyan Gong
- Departments of Pediatrics and Cell Biology, University of Pittsburgh School of Medicine, Pittsburgh, PA 15224
| | - Yong Liao
- Departments of Pediatrics and Cell Biology, University of Pittsburgh School of Medicine, Pittsburgh, PA 15224
| | - Annette Ahner
- Departments of Pediatrics and Cell Biology, University of Pittsburgh School of Medicine, Pittsburgh, PA 15224
| | - Mads Breum Larsen
- Departments of Pediatrics and Cell Biology, University of Pittsburgh School of Medicine, Pittsburgh, PA 15224
| | - Xiaohui Wang
- Departments of Pediatrics and Cell Biology, University of Pittsburgh School of Medicine, Pittsburgh, PA 15224
| | - Carol A Bertrand
- Departments of Pediatrics and Cell Biology, University of Pittsburgh School of Medicine, Pittsburgh, PA 15224
| | - Raymond A Frizzell
- Departments of Pediatrics and Cell Biology, University of Pittsburgh School of Medicine, Pittsburgh, PA 15224
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165
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Abstract
Cystic fibrosis (CF) is an autosomal recessive genetic disease caused by variants in the gene encoding the cystic fibrosis transmembrane conduction regulator (CFTR) protein. Loss of CFTR function disrupts chloride, bicarbonate and regulation of sodium transport, producing a cascade of mucus obstruction, inflammation, pulmonary infection, and ultimately damage in numerous organs. Established CF therapies treat the downstream consequences of CFTR dysfunction and have led to steady improvements in patient survival. A class of drugs termed CFTR modulators has recently entered the CF therapeutic landscape. These drugs differ fundamentally from prior therapies in that they aim to improve the function of disease-causing CFTR variants. This review summarizes the science behind CFTR modulators, including their targets, mechanism of action, clinical benefit, and future directions in the field. CFTR modulators have dramatically changed how CF is treated, validated CFTR as a therapeutic target, and opened the door to truly personalized therapies and treatment regimens.
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Affiliation(s)
- John P Clancy
- Department of Pediatrics, Cincinnati Childrens Hospital Medical Center, Cincinnati, Ohio
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166
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Lopes-Pacheco M, Kitoko JZ, Morales MM, Petrs-Silva H, Rocco PRM. Self-complementary and tyrosine-mutant rAAV vectors enhance transduction in cystic fibrosis bronchial epithelial cells. Exp Cell Res 2018; 372:99-107. [PMID: 30244179 DOI: 10.1016/j.yexcr.2018.09.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 09/13/2018] [Accepted: 09/20/2018] [Indexed: 10/28/2022]
Abstract
Recombinant adeno-associated virus (rAAV) vector platforms have shown considerable therapeutic success in gene therapy for inherited disorders. In cystic fibrosis (CF), administration of first-generation rAAV2 was safe, but clinical benefits were not clearly demonstrated. Therefore, next-generation vectors that overcome rate-limiting steps in rAAV transduction are needed to obtain successful gene therapy for this devastating disease. In this study, we evaluated the effects of single-strand or self-complementary (sc) rAAV vectors containing single or multiple tyrosine-to-phenylalanine (Y-F) mutations in capsid surface-exposed residues on serotypes 2, 8 or 9. For this purpose, CF bronchial epithelial (CFBE) cells were transduced with rAAV vectors, and the transgene expression of enhanced green fluorescence protein (eGFP) was analyzed at different time points. The effects of vectors on the cell viability, host cell cycle and in association with co-adjuvant drugs that modulate intracellular vector trafficking were also investigated. Six rAAV vectors demonstrated greater percentage of eGFP+ cells compared to their counterparts at days 4, 7 and 10 post-transduction: rAAV2 Y(272,444,500,730)F, with 1.95-, 3.5- and 3.06-fold increases; rAAV2 Y(252,272,444,500,704,730)F, with 1.65-, 2.12-, and 2-fold increases; scrAAV2 WT, with 1.69-, 2.68-, and 2.32-fold increases; scrAAV8 Y773F, with 57-, 6.06-, and 7-fold increases; scrAAV9 WT, with 7.47-, 4.64-, and 3.66-fold increases; and scrAAV9 Y446F, with 8.39-, 4.62-, and 4.4-fold increases. At days 15, 20, and 30 post-transduction, these vectors still demonstrated higher transgene expression than transfected cells. Although the percentage of eGFP+ cells reduced during the time-course analysis, the delta mean fluorescence intensity increased. These vectors also led to increased percentage of cells in G1-phase without eliciting any cytotoxicity. Prior administration of bortezomib or genistein did not increase eGFP expression in cells transduced with either rAAV2 Y(272,444,500,730)F or rAAV2 Y(252,272,444,500,704,730)F. In conclusion, self-complementary and tyrosine capsid mutations on rAAV serotypes 2, 8, and 9 led to more efficient transduction than their counterparts in CFBE cells by overcoming the intracellular trafficking and second-strand DNA synthesis limitations.
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Affiliation(s)
- Miquéias Lopes-Pacheco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil; Laboratory of Cellular and Molecular Physiology, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil.
| | - Jamil Z Kitoko
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil; Laboratory of Cellular and Molecular Physiology, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Marcelo M Morales
- Laboratory of Cellular and Molecular Physiology, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Hilda Petrs-Silva
- Laboratory of Neurogenesis, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil.
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McElvaney OJ, Gunaratnam C, McElvaney OF, Bagwe I, Reeves EP, McElvaney NG. Emerging pharmacotherapies in cystic fibrosis. Expert Rev Respir Med 2018; 12:843-855. [DOI: 10.1080/17476348.2018.1512409] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Affiliation(s)
- Oliver J McElvaney
- Irish Centre for Genetic Lung Disease, Royal College of Surgeons in Ireland, Beaumont Hospital, Dublin, Ireland
| | - Cedric Gunaratnam
- Irish Centre for Genetic Lung Disease, Royal College of Surgeons in Ireland, Beaumont Hospital, Dublin, Ireland
| | - Oisin Fiachra McElvaney
- Irish Centre for Genetic Lung Disease, Royal College of Surgeons in Ireland, Beaumont Hospital, Dublin, Ireland
| | - Isha Bagwe
- Irish Centre for Genetic Lung Disease, Royal College of Surgeons in Ireland, Beaumont Hospital, Dublin, Ireland
| | - Emer P Reeves
- Irish Centre for Genetic Lung Disease, Royal College of Surgeons in Ireland, Beaumont Hospital, Dublin, Ireland
| | - Noel G McElvaney
- Irish Centre for Genetic Lung Disease, Royal College of Surgeons in Ireland, Beaumont Hospital, Dublin, Ireland
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168
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Ratchford TL, Teckman JH, Patel DR. Gastrointestinal pathophysiology and nutrition in cystic fibrosis. Expert Rev Gastroenterol Hepatol 2018; 12:853-862. [PMID: 30019967 DOI: 10.1080/17474124.2018.1502663] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Cystic fibrosis (CF) is a severe, progressive, multisystemic disease that is caused by mutations in the cystic fibrosis transmembrane conductance regulator gene. Optimizing nutrition is critical, as higher growth parameters are associated with better pulmonary function and outcomes, but unfortunately patients with this disease are prone to malnutrition, growth failure, and vitamin deficiencies. The purpose of this review is to provide a timely highlight of the physiologic processes and outcome data to support today's management strategies, as well as review these principles themselves. Areas covered: This review covers the background of the importance of vigilant attention to nutrition and growth in these patients, the underlying physiology leading to an abnormal gastrointestinal tract and its role in CF malnutrition, and current evaluation and management strategies to address nutrition in CF. Analysis of up-to-date relevant literature was performed using PubMed. Expert commentary: Advances in research and clinical developments over the years have improved knowledge of this disease as well as patient outcomes. Of particular importance is optimizing nutrition especially in the early stages of life, as well as accounting for the markedly abnormal CF intestinal milieu when addressing the gastrointestinal and nutritional needs of these patients.
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Affiliation(s)
- Thomas L Ratchford
- a Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition , Saint Louis University School of Medicine , Saint Louis , Missouri , USA
| | - Jeffrey H Teckman
- a Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition , Saint Louis University School of Medicine , Saint Louis , Missouri , USA
| | - Dhiren R Patel
- a Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition , Saint Louis University School of Medicine , Saint Louis , Missouri , USA
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Matos AM, Gomes-Duarte A, Faria M, Barros P, Jordan P, Amaral MD, Matos P. Prolonged co-treatment with HGF sustains epithelial integrity and improves pharmacological rescue of Phe508del-CFTR. Sci Rep 2018; 8:13026. [PMID: 30158635 PMCID: PMC6115363 DOI: 10.1038/s41598-018-31514-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Accepted: 08/20/2018] [Indexed: 02/06/2023] Open
Abstract
Cystic fibrosis (CF), the most common inherited disease in Caucasians, is caused by mutations in the CFTR chloride channel, the most frequent of which is Phe508del. Phe508del causes not only intracellular retention and premature degradation of the mutant CFTR protein, but also defective channel gating and decreased half-life when experimentally rescued to the plasma membrane (PM). Despite recent successes in the functional rescue of several CFTR mutations with small-molecule drugs, the folding-corrector/gating-potentiator drug combinations approved for Phe508del-CFTR homozygous patients have shown only modest benefit. Several factors have been shown to contribute to this outcome, including an unexpected intensification of corrector-rescued Phe508del-CFTR PM instability after persistent co-treatment with potentiator drugs. We have previously shown that acute co-treatment with hepatocyte growth factor (HGF) can significantly enhance the chemical correction of Phe508del-CFTR. HGF coaxes the anchoring of rescued channels to the actin cytoskeleton via induction of RAC1 GTPase signalling. Here, we demonstrate that a prolonged, 15-day HGF treatment also significantly improves the functional rescue of Phe508del-CFTR by the VX-809 corrector/VX-770 potentiator combination, in polarized bronchial epithelial monolayers. Importantly, we found that HGF treatment also prevented VX-770-mediated destabilization of rescued Phe508del-CFTR and enabled further potentiation of the rescued channels. Most strikingly, prolonged HGF treatment prevented previously unrecognized epithelial dedifferentiation effects of sustained exposure to VX-809. This was observed in epithelium-like monolayers from both lung and intestinal origin, representing the two systems most affected by adverse symptoms in patients treated with VX-809 or the VX-809/VX-770 combination. Taken together, our findings strongly suggest that co-administration of HGF with corrector/potentiator drugs could be beneficial for CF patients.
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Affiliation(s)
- Ana M Matos
- Department of Human Genetics, National Health Institute 'Dr. Ricardo Jorge', Av. Padre Cruz, 1649-016, Lisboa, Portugal.,University of Lisboa, Faculty of Sciences, BioISI - Biosystems & Integrative Sciences Institute, Campo Grande - C8, 1749-016, Lisboa, Portugal
| | - Andreia Gomes-Duarte
- Department of Human Genetics, National Health Institute 'Dr. Ricardo Jorge', Av. Padre Cruz, 1649-016, Lisboa, Portugal.,University of Lisboa, Faculty of Sciences, BioISI - Biosystems & Integrative Sciences Institute, Campo Grande - C8, 1749-016, Lisboa, Portugal
| | - Márcia Faria
- Department of Human Genetics, National Health Institute 'Dr. Ricardo Jorge', Av. Padre Cruz, 1649-016, Lisboa, Portugal.,University of Lisboa, Faculty of Sciences, BioISI - Biosystems & Integrative Sciences Institute, Campo Grande - C8, 1749-016, Lisboa, Portugal.,Serviço de Endocrinologia, Diabetes e Metabolismo, do CHLN - Hospital Santa Maria, Lisboa, Portugal
| | - Patrícia Barros
- Department of Human Genetics, National Health Institute 'Dr. Ricardo Jorge', Av. Padre Cruz, 1649-016, Lisboa, Portugal.,University of Lisboa, Faculty of Sciences, BioISI - Biosystems & Integrative Sciences Institute, Campo Grande - C8, 1749-016, Lisboa, Portugal
| | - Peter Jordan
- Department of Human Genetics, National Health Institute 'Dr. Ricardo Jorge', Av. Padre Cruz, 1649-016, Lisboa, Portugal.,University of Lisboa, Faculty of Sciences, BioISI - Biosystems & Integrative Sciences Institute, Campo Grande - C8, 1749-016, Lisboa, Portugal
| | - Margarida D Amaral
- University of Lisboa, Faculty of Sciences, BioISI - Biosystems & Integrative Sciences Institute, Campo Grande - C8, 1749-016, Lisboa, Portugal
| | - Paulo Matos
- Department of Human Genetics, National Health Institute 'Dr. Ricardo Jorge', Av. Padre Cruz, 1649-016, Lisboa, Portugal. .,University of Lisboa, Faculty of Sciences, BioISI - Biosystems & Integrative Sciences Institute, Campo Grande - C8, 1749-016, Lisboa, Portugal.
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170
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McColley SA, Konstan MW, Ramsey BW, Stuart Elborn J, Boyle MP, Wainwright CE, Waltz D, Vera-Llonch M, Marigowda G, Jiang JG, Rubin JL. Lumacaftor/Ivacaftor reduces pulmonary exacerbations in patients irrespective of initial changes in FEV 1. J Cyst Fibros 2018; 18:94-101. [PMID: 30146268 DOI: 10.1016/j.jcf.2018.07.011] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 07/31/2018] [Accepted: 07/31/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND Improved lung function and fewer pulmonary exacerbations (PEx) were observed with lumacaftor/ivacaftor (LUM/IVA) in patients with cystic fibrosis homozygous for F508del. It is unknown whether PEx reduction extends to patients without early lung function improvement. METHODS Post hoc analyses of pooled phase 3 data (NCT01807923, NCT01807949) categorized LUM/IVA-treated patients by percent predicted forced expiratory volume in 1 s (ppFEV1) change from baseline to day 15 into threshold categories (absolute change ≤0 vs >0; relative change <5% vs ≥5%) and compared PEx rates vs placebo. RESULTS LUM (400 mg q12h)/IVA (250 mg q12h)-treated patients (n = 369) experienced significantly fewer PEx vs placebo, regardless of threshold category. With LUM/IVA, PEx rate per patient per year was 0.60 for those with absolute change in ppFEV1 > 0 and 0.85 for those with absolute change ≤0 (respective rate ratios vs placebo [95% CI]: 0.53 [0.40-0.69; P < .0001], 0.74 [0.55-0.99; P = .04]). CONCLUSIONS LUM/IVA significantly reduced PEx, even in patients without early lung function improvement.
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Affiliation(s)
- Susanna A McColley
- Ann & Robert H. Lurie Children's Hospital of Chicago and Northwestern University Feinberg School of Medicine, 225 East Chicago Avenue #43, Chicago, IL 60611, USA.
| | - Michael W Konstan
- Case Western Reserve University School of Medicine and Rainbow Babies & Children's Hospital, 11100 Euclid Avenue, Cleveland, OH 44106, USA.
| | - Bonnie W Ramsey
- Seattle Children's Hospital and University of Washington School of Medicine, 4800 Sand Point Way NE, Seattle, WA 98105, USA.
| | - J Stuart Elborn
- Imperial College and Royal Brompton Hospital, London and Queens University Belfast, 97 Lisburn Road, Belfast BT9 7AE, UK.
| | - Michael P Boyle
- Johns Hopkins Medical Institution, 600 North Wolfe Street, Baltimore, MD 21287, USA.
| | - Claire E Wainwright
- Lady Cilento Children's Hospital and Child Health Research Centre, University of Queensland, 62 Graham Street, South Brisbane, Queensland 4104, Australia.
| | - David Waltz
- Vertex Pharmaceuticals Incorporated, 50 Northern Avenue, Boston, MA 02210, USA.
| | | | - Gautham Marigowda
- Vertex Pharmaceuticals Incorporated, 50 Northern Avenue, Boston, MA 02210, USA.
| | - John G Jiang
- Vertex Pharmaceuticals Incorporated, 50 Northern Avenue, Boston, MA 02210, USA
| | - Jaime L Rubin
- Vertex Pharmaceuticals Incorporated, 50 Northern Avenue, Boston, MA 02210, USA.
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Abstract
INTRODUCTION Cystic fibrosis (CF) is the most common, life-limiting autosomal recessive disease in Caucasians, and is caused by defects in production of the CFTR ion channel. Until recently, there were no available treatments targeting the disease-causing defects in CFTR but newly developed CFTR modulators are changing the course of disease in CF. The newest modulator, tezacaftor, is a CFTR corrector that was recently approved by the FDA to be used in combination with the first approved CFTR potentiator, ivacaftor. Areas covered: A detailed review of the clinical trials and published literature, focusing on safety and efficacy, leading to the approval of tezacaftor in CF. Expert commentary: Recent trials have demonstrated that the combination of tezacaftor-ivacaftor is a slightly superior combination to its predecessor, lumacaftor-ivacaftor, with respect to an increase in FEV1, adverse event profile, and drug-drug interactions. It is also approved for a large number of non-F508del, residual function mutations that are predicted to respond based on in vitro testing. The horizon for continued improvements in CFTR-targeted treatments is promising, with three-drug combinations currently in Phase 3 clinical trials, and other drugs with novel mechanisms of action being studied. Within the next 5 years, the vast majority of patients with CF are expected to have a modulator approved for their genotype.
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Affiliation(s)
- Marc A Sala
- a Division of Pulmonary and Critical Care Medicine, Feinberg School of Medicine , Northwestern University , Chicago , IL , USA
| | - Manu Jain
- a Division of Pulmonary and Critical Care Medicine, Feinberg School of Medicine , Northwestern University , Chicago , IL , USA
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172
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Southern KW, Patel S, Sinha IP, Nevitt SJ. Correctors (specific therapies for class II CFTR mutations) for cystic fibrosis. Cochrane Database Syst Rev 2018; 8:CD010966. [PMID: 30070364 PMCID: PMC6513216 DOI: 10.1002/14651858.cd010966.pub2] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Cystic fibrosis (CF) is a common life-shortening condition caused by mutation in the gene that codes for that codes for the cystic fibrosis transmembrane conductance regulator (CFTR) protein, which functions as a salt transporter. F508del, the most common CFTR mutation that causes CF, is found in up to 80% to 90% of people with CF. In people with this mutation, a full length of protein is transcribed, but recognised as misfolded by the cell and degraded before reaching the cell membrane, where it needs to be positioned to effect transepithelial salt transport. This severe mutation is associated with no meaningful CFTR function. A corrective therapy for this mutation could positively impact on an important proportion of the CF population. OBJECTIVES To evaluate the effects of CFTR correctors on clinically important outcomes, both benefits and harms, in children and adults with CF and class II CFTR mutations (most commonly F508del). SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Cystic Fibrosis Trials Register. We also searched reference lists of relevant articles and online trials registries. Most recent search: 24 February 2018. SELECTION CRITERIA Randomised controlled trials (RCTs) (parallel design) comparing CFTR correctors to placebo in people with CF with class II mutations. We also included RCTs comparing CFTR correctors combined with CFTR potentiators to placebo. DATA COLLECTION AND ANALYSIS Two authors independently extracted data, assessed risk of bias and quality of the evidence using the GRADE criteria. Study authors were contacted for additional data. MAIN RESULTS We included 13 RCTs (2215 participants), lasting between 1 day and 24 weeks. Additional safety data from an extension study of two lumacaftor-ivacaftor studies were available at 96 weeks (1029 participants). We assessed monotherapy in seven RCTs (317 participants) (4PBA (also known as Buphenyl), CPX, lumacaftor or cavosonstat) and combination therapy in six RCTs (1898 participants) (lumacaftor-ivacaftor or tezacaftor-ivacaftor) compared to placebo. Twelve RCTs recruited individuals homozygous for F508del, one RCT recruited participants with one F508del mutation and a second mutation with residual function.Risk of bias varied in its impact on the confidence we have in our results across different comparisons. Some findings were based on single RCTs that were too small to show important effects. For five RCTs, results may not be applicable to all individuals with CF due to age limits of recruited populations (i.e. adults only, children only) or non-standard design of converting from monotherapy to combination therapy.Monotherapy versus placeboNo deaths were reported and there were no clinically relevant improvements in quality of life in any RCT. There was insufficient evidence available from individual studies to determine the effect of any of the correctors examined on lung function outcomes.No placebo-controlled study of monotherapy demonstrated a difference in mild, moderate or severe adverse effects; however, it is difficult to assess the clinical relevance of these events with the variety of events and the small number of participants.Combination therapy versus placeboNo deaths were reported during any RCT (moderate- to high-quality evidence). The quality of life scores (respiratory domain) favoured combination therapy (both lumacaftor-ivacaftor and tezacaftor-ivacaftor) compared to placebo at all time points. At six months lumacaftor (600 mg once daily or 400 mg once daily) plus ivacaftor improved Cystic Fibrosis Questionnaire (CFQ) scores by a small amount compared with placebo (mean difference (MD) 2.62 points (95% confidence interval (CI) 0.64 to 4.59); 1061 participants; high-quality evidence). A similar effect size was observed for twice-daily lumacaftor (200 mg) plus ivacaftor (250 mg) although the quality of evidence was low (MD 2.50 points (95% CI 0.10 to 5.10)). The mean increase in CFQ scores with twice-daily tezacaftor (100 mg) and ivacaftor (150 mg) was approximately five points (95% CI 3.20 to 7.00; 504 participants; moderate-quality evidence). Lung function measured by relative change in forced expiratory volume in one second (FEV1) % predicted improved with both combination therapies compared to placebo at six months, by 5.21% with once daily lumacaftor-ivacaftor (95% CI 3.61% to 6.80%; 504 participants; high-quality evidence) and by 2.40% with twice-daily lumacaftor-ivacaftor (95% CI 0.40% to 4.40%; 204 participants; low-quality evidence). One study reported an increase in FEV1 with tezacaftor-ivacaftor of 6.80% (95% CI 5.30 to 8.30%; 520 participants; moderate-quality evidence).More participants receiving the lumacaftor-ivacaftor combination reported early transient breathlessness, odds ratio 2.05 (99% CI 1.10 to 3.83; 739 participants; high-quality evidence). In addition, participants allocated to the 400 mg twice-daily dose of lumacaftor-ivacaftor experienced a rise in blood pressure over the 120-week period of the initial studies and the follow-up study of 5.1 mmHg (systolic blood pressure) and 4.1 mmHg (diastolic blood pressure) (80 participants; high-quality evidence). These adverse effects were not reported in the tezacaftor-ivacaftor studies.The rate of pulmonary exacerbations decreased for participants receiving and additional therapies to ivacaftor compared to placebo: lumacaftor 600 mg hazard ratio (HR) 0.70 (95% CI 0.57 to 0.87; 739 participants); lumacaftor 400 mg, HR 0.61 (95% CI 0.49 to 0.76; 740 participants); and tezacaftor, HR 0.64 (95% CI, 0.46 to 0.89; 506 participants) (moderate-quality evidence). AUTHORS' CONCLUSIONS There is insufficient evidence that monotherapy with correctors has clinically important effects in people with CF who have two copies of the F508del mutation.Combination therapies (lumacaftor-ivacaftor and tezacaftor-ivacaftor) each result in similarly small improvements in clinical outcomes in people with CF; specifically improvements quality of life (moderate-quality evidence), in respiratory function (high-quality evidence) and lower pulmonary exacerbation rates (moderate-quality evidence). Lumacaftor-ivacaftor is associated with an increase in early transient shortness of breath and longer-term increases in blood pressure (high-quality evidence). These adverse effects were not observed for tezacaftor-ivacaftor. Tezacaftor-ivacaftor has a better safety profile, although data are not available for children younger than 12 years. In this age group, lumacaftor-ivacaftor had an important impact on respiratory function with no apparent immediate safety concerns, but this should be balanced against the increase in blood pressure and shortness of breath seen in longer-term data in adults when considering this combination for use in young people with CF.
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Affiliation(s)
- Kevin W Southern
- University of LiverpoolDepartment of Women's and Children's HealthAlder Hey Children's NHS Foundation TrustEaton RoadLiverpoolMerseysideUKL12 2AP
| | - Sanjay Patel
- Stepping Hill Hopsital, Stockport NHS Foundation TrustPoplar GroveHazel GroveStockportCheshireUKSK2 7JE
| | - Ian P Sinha
- University of LiverpoolDepartment of Women's and Children's HealthAlder Hey Children's NHS Foundation TrustEaton RoadLiverpoolMerseysideUKL12 2AP
| | - Sarah J Nevitt
- University of LiverpoolDepartment of BiostatisticsBlock F, Waterhouse Building1‐5 Brownlow HillLiverpoolUKL69 3GL
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173
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A Case Report of Pulmonary Exacerbation after Initiation of Lumacaftor/Ivacaftor Therapy in a CF Female with Complicated Lung Disease. Case Rep Pulmonol 2018; 2018:8394370. [PMID: 30002941 PMCID: PMC5998152 DOI: 10.1155/2018/8394370] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2018] [Accepted: 04/10/2018] [Indexed: 12/04/2022] Open
Abstract
Novel targeted treatments for Cystic Fibrosis give rise to new hope for an ever-growing number of CF patients with various mutations. However, very little evidence and guidelines exist to steer clinical decisions regarding patients whose illness takes an unexpected course. In such cases, the benefits and risks of discontinuing these treatments must be carefully and individually weighed, since their long-term effects remain mainly uncharted territory. In this report we document the case of a homozygous F508del CF patient with severe lung disease who presented with a pulmonary exacerbation shortly after the beginning of treatment with lumacaftor/ivacaftor and the complicated initial phase of therapy, which was followed by significant improvements.
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174
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Diab-Cáceres L, Girón-Moreno RM, Pastor-Sanz MT, Quintana-Gallego E, Delgado-Pecellín I, Blanco-Aparicio M, Maiz L, García-Clemente MM, Luna-Paredes C, Mondéjar-López P, Ruiz-de-Valbuena M, Fernández O, Barrio M, González M, López-Neyra A, Cols-I-Roig M, Palou-Rotger A, Gómez-de-Terreros-Caro FJ. Compassionate Use of Lumacaftor/Ivacaftor in Cystic Fibrosis: Spanish Experience. Arch Bronconeumol 2018; 54:614-618. [PMID: 30518496 DOI: 10.1016/j.arbres.2018.05.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Revised: 04/09/2018] [Accepted: 05/01/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND The most common cystic fibrosis (CF)-causing mutation is deltaF508 (F508del), which is present in 28% of CF Spanish patients. While the literature based on real-life studies on CF patients homozygous F508del treated with lumacaftor/ivacaftor is limited, it demonstrates the need for better strategies to prevent related adverse events (AEs) as well as the development of newer drugs. METHODS We conducted a multicenter, retrospective, observational study to describe the effects of lumacaftor/ivacaftor treatment in real-life in Spain. 20 CF patients were included, all aged 6 and upwards and presented with ppFEV1<40%, chosen from CF units country-wide. For the purposes of the study, they were treated with lumacaftor/ivacaftor 200/125mg two tablets twice a day on a compassionate use programme throughout 2016. The primary endpoint was measured in all of the sample patients. Data were analysed from ppFEV1 at baseline and was measured every 6 months. RESULTS The mean age was 26.65 (range of 10-45), while the mean ppFEV1 before the treatment was 32.4% and mean BMI was 19.9kg/m2. We analysed the changes in ppFEV1 and BMI from baseline during the treatment with lumacaftor/ivacaftor, but no differences were found. However, a moderate association between days of intravenous antibiotic needed and the use of lumacaftor/ivacaftor (p=0.001) was established. Indeed, under the lumacaftor/ivacaftor, patients required 5.8 days of intravenous antibiotic treatment compared to 14.9 days prior to study. Also, severe pulmonary exacerbations requiring hospitalisation were statistically fewer under lumacaftor/ivacaftor treatment (p=0.003). Finally, 75% of the sample presented with AEs, which led 35% of the subjects to discontinue the treatment. CONCLUSIONS While treatment with lumacaftor/ivacaftor resulted in an improvement in the number of pulmonary severe exacerbations, no improvement in ppFEV1 or BMI was found.
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Affiliation(s)
| | | | | | - Esther Quintana-Gallego
- Hospital Universitario Virgen del Rocío, Sevilla, Spain. Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Isabel Delgado-Pecellín
- Hospital Universitario Virgen del Rocío, Sevilla, Spain. Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | | | - Luis Maiz
- Hospital Ramón y Cajal, Respirology, Madrid, Spain
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An Observational Study of Outcomes and Tolerances in Patients with Cystic Fibrosis Initiated on Lumacaftor/Ivacaftor. Ann Am Thorac Soc 2018; 14:1662-1666. [PMID: 28406713 DOI: 10.1513/annalsats.201701-058oc] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
RATIONALE In July 2015, the U.S. Food and Drug Administration approved lumacaftor/ivacaftor for use in patients with cystic fibrosis (CF). This drug targets the primary defect in the CFTR protein that is conferred by the F508del CFTR mutation. OBJECTIVE As there is limited experience with this therapy outside of clinical trials, this study aims to examine the clinical experience of this new drug in a population with CF. RESULTS Retrospective cohort study of individuals followed at the Johns Hopkins CF Center who initiated treatment with lumacaftor/ivacaftor. Patients were followed from 1 year before drug initiation to up to 11 months postinitiation. Key exclusion criteria include previous exposure to lumacaftor/ivacaftor through participation in a clinical trial. Of 116 individuals identified who started lumacaftor/ivacaftor treatment, 46 (39.7%) reported adverse effects related to lumacaftor/ivacaftor, with the vast majority (82.2%) being pulmonary adverse effects, and 20 (17.2%) discontinued lumacaftor/ivacaftor because of adverse effects. The mean change in FEV1% predicted was 0.11% (range: -39% to +20%; P = 0.9). Nineteen individuals had an FEV1% predicted of 40% or less before treatment, and there was a higher percentage of patients in this subgroup who reported adverse effects (57.9%) and a higher percentage of patients who discontinued lumacaftor/ivacaftor (31.6%). Female sex was associated with a higher odds of drug discontinuation (adjusted odds ratio, 3.12, 95% confidence interval, 1.04-9.38). CONCLUSIONS This study highlights the prevalence of adverse effects in a CF population newly exposed to lumacaftor/ivacaftor and demonstrates a relatively high rate of drug intolerance.
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176
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Martiniano SL, Toprak D, Ong T, Zemanick ET, Daines CL, Muhlebach MS, Esther CR, Dellon EP. Highlights from the 2017 North American Cystic Fibrosis Conference. Pediatr Pulmonol 2018; 53:979-986. [PMID: 29660839 DOI: 10.1002/ppul.24000] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 03/07/2018] [Indexed: 11/06/2022]
Abstract
The 31st annual North American Cystic Fibrosis Conference (NACFC) was held in Indianapolis, IN on November 2-4, 2017. Abstracts of presentations from the conference were published in a supplement to Pediatric Pulmonology [2017; Pediatr Pulmonol Suppl. 52: S1-S776]. The current review summarizes several major topic areas addressed at the conference: the pathophysiology and basic science of cystic fibrosis (CF) lung disease, clinical trials, clinical management issues, and quality improvement (QI). In this review, we describe emerging concepts in several areas of CF research and care.
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Affiliation(s)
- Stacey L Martiniano
- Department of Pediatrics, University of Colorado Denver Anschutz Medical Campus, Aurora, Colorado
| | - Demet Toprak
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Washington, Seattle, Washington
| | - Thida Ong
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Washington, Seattle, Washington
| | - Edith T Zemanick
- Department of Pediatrics, University of Colorado Denver Anschutz Medical Campus, Aurora, Colorado
| | - Cori L Daines
- Department of Pediatrics, University of Arizona College of Medicine, Tucson, Arizona
| | - Marianne S Muhlebach
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Charles R Esther
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Elisabeth P Dellon
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Clancy JP, Cotton CU, Donaldson SH, Solomon GM, VanDevanter DR, Boyle MP, Gentzsch M, Nick JA, Illek B, Wallenburg JC, Sorscher EJ, Amaral MD, Beekman JM, Naren AP, Bridges RJ, Thomas PJ, Cutting G, Rowe S, Durmowicz AG, Mense M, Boeck KD, Skach W, Penland C, Joseloff E, Bihler H, Mahoney J, Borowitz D, Tuggle KL. CFTR modulator theratyping: Current status, gaps and future directions. J Cyst Fibros 2018; 18:22-34. [PMID: 29934203 DOI: 10.1016/j.jcf.2018.05.004] [Citation(s) in RCA: 165] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 05/07/2018] [Accepted: 05/08/2018] [Indexed: 12/22/2022]
Abstract
BACKGROUND New drugs that improve the function of the cystic fibrosis transmembrane conductance regulator (CFTR) protein with discreet disease-causing variants have been successfully developed for cystic fibrosis (CF) patients. Preclinical model systems have played a critical role in this process, and have the potential to inform researchers and CF healthcare providers regarding the nature of defects in rare CFTR variants, and to potentially support use of modulator therapies in new populations. METHODS The Cystic Fibrosis Foundation (CFF) assembled a workshop of international experts to discuss the use of preclinical model systems to examine the nature of CF-causing variants in CFTR and the role of in vitro CFTR modulator testing to inform in vivo modulator use. The theme of the workshop was centered on CFTR theratyping, a term that encompasses the use of CFTR modulators to define defects in CFTR in vitro, with application to both common and rare CFTR variants. RESULTS Several preclinical model systems were identified in various stages of maturity, ranging from the expression of CFTR variant cDNA in stable cell lines to examination of cells derived from CF patients, including the gastrointestinal tract, the respiratory tree, and the blood. Common themes included the ongoing need for standardization, validation, and defining the predictive capacity of data derived from model systems to estimate clinical outcomes from modulator-treated CF patients. CONCLUSIONS CFTR modulator theratyping is a novel and rapidly evolving field that has the potential to identify rare CFTR variants that are responsive to approved drugs or drugs in development.
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Affiliation(s)
- John Paul Clancy
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States.
| | | | - Scott H Donaldson
- University of North Carolina at Chapel Hill - Marsico Lung Institute, United States
| | - George M Solomon
- University of Alabama at Birmingham, University of Alabama at Birmingham
| | - Donald R VanDevanter
- Case Western Reserve University School of Medicine, Cleveland, OH, United States
| | - Michael P Boyle
- Cystic Fibrosis Foundation, Johns Hopkins University, United States
| | - Martina Gentzsch
- Marsico Lung Institute/Cystic Fibrosis Research Center, University of North Carolina, Chapel Hill, United States; Department of Cell Biology and Physiology, University of North Carolina, Chapel Hill, United States
| | - Jerry A Nick
- National Jewish Health, Denver, CO, United States
| | - Beate Illek
- UCSF Benioff Children's Hospital Oakland, United States
| | - John C Wallenburg
- Cystic Firbosis Canada, Directeur en chef des activites scientifiques, fibrose kystique, Canada
| | | | | | | | | | | | | | - Garry Cutting
- Johns Hopkins University School of Medicine, United States
| | - Steven Rowe
- University of Alabama at Birmingham, University of Alabama at Birmingham
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178
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Rayment JH, Quon BS. Back to the source - Modern insights into pulmonary exacerbations and lung function decline from CF registry data. J Cyst Fibros 2018; 17:425-427. [PMID: 29859835 DOI: 10.1016/j.jcf.2018.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2018] [Indexed: 11/24/2022]
Affiliation(s)
- Jonathan H Rayment
- Division of Respiratory Medicine, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada; BC Children's Hospital Research Institute, University of British Columbia, BC Children's Hospital, Vancouver, BC, Canada
| | - Bradley S Quon
- Centre for Heart Lung Innovation, University of British Columbia, St. Paul's Hospital, Vancouver, BC, Canada; Division of Respiratory Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada.
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179
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Abstract
The number of published articles on Cystic Fibrosis (CF) continues to increase year on year. The evidence base for small molecule therapies in CF has continued to expand, with evidence for lumacaftor/ivacaftor in younger patients and longer-term evidence in adults, and pivotal studies on tezacaftor/ivacaftor. There were reports on emerging CFTR mutation agnostic therapies, and new evidence for long standing therapies.
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Affiliation(s)
- Iolo Doull
- Department of Paediatric Respiratory Medicine and Paediatric Cystic Fibrosis Centre, Children's Hospital for Wales, Cardiff CF14 4XN, UK.
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180
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Abstract
PURPOSE OF REVIEW The aim of this study was to describe the newest development in cystic fibrosis (CF) care, CF transmembrane conductance regulator (CFTR) modulator therapies. RECENT FINDINGS Phase II results showing CFTR modulator triple therapies are more effective than current CFTR modulators. SUMMARY CFTR modulator therapy targets the protein defective in CF and boosts its function, but the drug must match mutation pathobiology. Ivacaftor, a CFTR potentiator, was the first modulator approved in 2012, with impressive improvement in lung function and other measures of disease in patients with gating and other residual function mutations (∼10% of CF patients). In 2015, the combination of lumacaftor, a CFTR corrector, and ivacaftor was approved for patients homozygous for the F508del mutation (∼40-50% of the CF population) with positive but less impressive clinical response and 10-20% incidence of intolerance. A next-generation CFTR corrector, tezacaftor, with ivacaftor equally effective and better tolerated than lumacaftor, has also received US Food and Drug Administration approval. Novel CFTR correctors, entering Phase 3 trials in triple modulator combination with tezacaftor-ivacaftor, appear substantially more effective for patients who are homozygous for the F508del mutation and can provide benefit for patients with a single F508del mutation. This offers promise of effective CFTR modulator therapy for nearly 90% of CF patients.
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181
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Bell SC, Wood ME. Biomarkers: Their Role in CFTR Modulator Therapies from Early Development to the Clinic. Am J Respir Crit Care Med 2018; 197:1375-1376. [DOI: 10.1164/rccm.201801-0177ed] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Scott C. Bell
- Adult Cystic Fibrosis CentreThe Prince Charles HospitalBrisbane, Australia
- Lung Bacteria Laboratory QIMR Berghofer Medical Research InstituteBrisbane, Australiaand
- Faculty of MedicineUniversity of QueenslandBrisbane, Australia
| | - Michelle E. Wood
- Adult Cystic Fibrosis CentreThe Prince Charles HospitalBrisbane, Australia
- Lung Bacteria Laboratory QIMR Berghofer Medical Research InstituteBrisbane, Australiaand
- Faculty of MedicineUniversity of QueenslandBrisbane, Australia
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182
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Association of High-Dose Ibuprofen Use, Lung Function Decline, and Long-Term Survival in Children with Cystic Fibrosis. Ann Am Thorac Soc 2018; 15:485-493. [DOI: 10.1513/annalsats.201706-486oc] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
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183
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Dasenbrook EC, Sawicki GS. Cystic fibrosis patient registries: A valuable source for clinical research. J Cyst Fibros 2018; 17:433-440. [PMID: 29555479 DOI: 10.1016/j.jcf.2018.03.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 02/26/2018] [Accepted: 03/01/2018] [Indexed: 02/08/2023]
Abstract
Cystic Fibrosis (CF) patient registries are valuable data sources for researchers studying the natural history, treatment paradigms, and long-term health outcomes of individuals with CF. In this review, we discuss the role of CF patient registries in facilitating comparative effectiveness research, particularly evaluating therapies and variation in health care delivery. We also discuss the limitations of registry-based research, particularly indication bias, as well as statistical methods that can be used to address these issues.
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Affiliation(s)
| | - Gregory S Sawicki
- Division of Respiratory Diseases, Boston Children's Hospital, Boston, MA, United States.
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184
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Taylor-Cousar JL, Jain M, Barto TL, Haddad T, Atkinson J, Tian S, Tang R, Marigowda G, Waltz D, Pilewski J. Lumacaftor/ivacaftor in patients with cystic fibrosis and advanced lung disease homozygous for F508del-CFTR. J Cyst Fibros 2018; 17:228-235. [DOI: 10.1016/j.jcf.2017.09.012] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Revised: 09/27/2017] [Accepted: 09/28/2017] [Indexed: 10/18/2022]
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Abstract
The majority of rare diseases affect children, most of whom have an underlying genetic cause for their condition. However, making a molecular diagnosis with current technologies and knowledge is often still a challenge. Paediatric genomics is an immature but rapidly evolving field that tackles this issue by incorporating next-generation sequencing technologies, especially whole-exome sequencing and whole-genome sequencing, into research and clinical workflows. This complex multidisciplinary approach, coupled with the increasing availability of population genetic variation data, has already resulted in an increased discovery rate of causative genes and in improved diagnosis of rare paediatric disease. Importantly, for affected families, a better understanding of the genetic basis of rare disease translates to more accurate prognosis, management, surveillance and genetic advice; stimulates research into new therapies; and enables provision of better support.
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186
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Abstract
INTRODUCTION Cystic fibrosis (CF) is a genetic disorder that results in a multi-organ disease with progressive respiratory decline that ultimately leads to premature death. CF is caused by mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) gene, which codes for the CFTR anion channel. Established CF treatments target downstream manifestations of the primary genetic defect, including pulmonary and nutritional interventions. Areas covered: CFTR modulators are novel therapies that improve the function of CFTR, and have been approved in the past five years to mitigate the effects of several CF-disease causing mutations. This review summarizes currently approved CFTR modulators and discusses emerging modulator therapies in phase II and III clinical trials described on clinical trials.gov as of April, 2017. Results of relevant trials reported in peer-reviewed journals in Pubmed, scientific conference abstracts and sponsor press releases available as of November, 2017 are included. Expert opinion: The current scope of CF therapeutic development is robust and CFTR modulators have demonstrated significant benefit to patients with specific CFTR mutations. We anticipate that in the future healthcare providers will be faced with a different treatment paradigm, initiating CFTR-directed therapies well before the onset of progressive lung disease.
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Affiliation(s)
- Kristin M Hudock
- a Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine , University of Cincinnati , Cincinnati , OH , USA.,b Division of Pulmonary Biology, Department of Pediatrics , Cincinnati Children's Hospital Medical Center , Cincinnati , OH , USA
| | - John Paul Clancy
- c Division of Pulmonary Medicine, Department of Pediatrics , Cincinnati Children's Hospital Medical Center , Cincinnati , OH , USA
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187
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Epidemiology of CF: How registries can be used to advance our understanding of the CF population. J Cyst Fibros 2017; 17:297-305. [PMID: 29275954 DOI: 10.1016/j.jcf.2017.11.013] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Revised: 11/23/2017] [Accepted: 11/24/2017] [Indexed: 02/08/2023]
Abstract
Cystic fibrosis (CF) registries work by bringing patient data together from specialist CF centres and accumulating data on a relatively rare condition over patients' lifetimes. In this review, we examine the origin of national CF registries, the use of registries for monitoring the health of the population, the power of conducting longitudinal analysis of registry data, knowledge gleaned from changing demographics, the evolving area of international comparisons of registries, strategies for sustaining registries and CF registries of the future. Examples of research undertaken using registry data and routinely reported CF registry statistics from across the world are provided. The application, utility and challenges facing CF registries in the future are discussed.
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188
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Taylor-Cousar JL, Munck A, McKone EF, van der Ent CK, Moeller A, Simard C, Wang LT, Ingenito EP, McKee C, Lu Y, Lekstrom-Himes J, Elborn JS. Tezacaftor-Ivacaftor in Patients with Cystic Fibrosis Homozygous for Phe508del. N Engl J Med 2017; 377:2013-2023. [PMID: 29099344 DOI: 10.1056/nejmoa1709846] [Citation(s) in RCA: 531] [Impact Index Per Article: 75.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Combination treatment with the cystic fibrosis transmembrane conductance regulator (CFTR) modulators tezacaftor (VX-661) and ivacaftor (VX-770) was designed to target the underlying cause of disease in patients with cystic fibrosis. METHODS In this phase 3, randomized, double-blind, multicenter, placebo-controlled, parallel-group trial, we evaluated combination therapy with tezacaftor and ivacaftor in patients 12 years of age or older who had cystic fibrosis and were homozygous for the CFTR Phe508del mutation. Patients were randomly assigned in a 1:1 ratio to receive either 100 mg of tezacaftor once daily and 150 mg of ivacaftor twice daily or matched placebo for 24 weeks. The primary end point was the absolute change in the percentage of the predicted forced expiratory volume in 1 second (FEV1) through week 24 (calculated in percentage points); relative change in the percentage of the predicted FEV1 through week 24 (calculated as a percentage) was a key secondary end point. RESULTS Of the 510 patients who underwent randomization, 509 received tezacaftor-ivacaftor or placebo, and 475 completed 24 weeks of the trial regimen. The mean FEV1 at baseline was 60.0% of the predicted value. The effects on the absolute and relative changes in the percentage of the predicted FEV1 in favor of tezacaftor-ivacaftor over placebo were 4.0 percentage points and 6.8%, respectively (P<0.001 for both comparisons). The rate of pulmonary exacerbation was 35% lower in the tezacaftor-ivacaftor group than in the placebo group (P=0.005). The incidence of adverse events was similar in the two groups. Most adverse events were of mild severity (in 41.8% of patients overall) or moderate severity (in 40.9% overall), and serious adverse events were less frequent with tezacaftor-ivacaftor (12.4%) than with placebo (18.2%). A total of 2.9% of patients discontinued the assigned regimen owing to adverse events. Fewer patients in the tezacaftor-ivacaftor group than in the placebo group had respiratory adverse events, none of which led to discontinuation. CONCLUSIONS The combination of tezacaftor and ivacaftor was efficacious and safe in patients 12 years of age or older who had cystic fibrosis and were homozygous for the CFTR Phe508del mutation. (Funded by Vertex Pharmaceuticals; EVOLVE ClinicalTrials.gov number, NCT02347657 .).
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Affiliation(s)
- Jennifer L Taylor-Cousar
- From National Jewish Health, Denver (J.L.T.-C.); Hôpital Robert Debré, Assistance Publique-Hopitaux de Paris, Paris (A. Munck); University College Dublin School of Medicine, St. Vincent's University Hospital, Dublin (E.F.M.); University Medical Center, Utrecht, the Netherlands (C.K.E.); University Children's Hospital Zurich, Zurich, Switzerland (A. Moeller); Vertex Pharmaceuticals, Boston (C.S., L.T.W., E.P.I., C.M., Y.L., J.L.-H.); and Imperial College and Royal Brompton Hospital and Harefield NHS Foundation Trust, London, and Queens University, Belfast - all in the United Kingdom (J.S.E.)
| | - Anne Munck
- From National Jewish Health, Denver (J.L.T.-C.); Hôpital Robert Debré, Assistance Publique-Hopitaux de Paris, Paris (A. Munck); University College Dublin School of Medicine, St. Vincent's University Hospital, Dublin (E.F.M.); University Medical Center, Utrecht, the Netherlands (C.K.E.); University Children's Hospital Zurich, Zurich, Switzerland (A. Moeller); Vertex Pharmaceuticals, Boston (C.S., L.T.W., E.P.I., C.M., Y.L., J.L.-H.); and Imperial College and Royal Brompton Hospital and Harefield NHS Foundation Trust, London, and Queens University, Belfast - all in the United Kingdom (J.S.E.)
| | - Edward F McKone
- From National Jewish Health, Denver (J.L.T.-C.); Hôpital Robert Debré, Assistance Publique-Hopitaux de Paris, Paris (A. Munck); University College Dublin School of Medicine, St. Vincent's University Hospital, Dublin (E.F.M.); University Medical Center, Utrecht, the Netherlands (C.K.E.); University Children's Hospital Zurich, Zurich, Switzerland (A. Moeller); Vertex Pharmaceuticals, Boston (C.S., L.T.W., E.P.I., C.M., Y.L., J.L.-H.); and Imperial College and Royal Brompton Hospital and Harefield NHS Foundation Trust, London, and Queens University, Belfast - all in the United Kingdom (J.S.E.)
| | - Cornelis K van der Ent
- From National Jewish Health, Denver (J.L.T.-C.); Hôpital Robert Debré, Assistance Publique-Hopitaux de Paris, Paris (A. Munck); University College Dublin School of Medicine, St. Vincent's University Hospital, Dublin (E.F.M.); University Medical Center, Utrecht, the Netherlands (C.K.E.); University Children's Hospital Zurich, Zurich, Switzerland (A. Moeller); Vertex Pharmaceuticals, Boston (C.S., L.T.W., E.P.I., C.M., Y.L., J.L.-H.); and Imperial College and Royal Brompton Hospital and Harefield NHS Foundation Trust, London, and Queens University, Belfast - all in the United Kingdom (J.S.E.)
| | - Alexander Moeller
- From National Jewish Health, Denver (J.L.T.-C.); Hôpital Robert Debré, Assistance Publique-Hopitaux de Paris, Paris (A. Munck); University College Dublin School of Medicine, St. Vincent's University Hospital, Dublin (E.F.M.); University Medical Center, Utrecht, the Netherlands (C.K.E.); University Children's Hospital Zurich, Zurich, Switzerland (A. Moeller); Vertex Pharmaceuticals, Boston (C.S., L.T.W., E.P.I., C.M., Y.L., J.L.-H.); and Imperial College and Royal Brompton Hospital and Harefield NHS Foundation Trust, London, and Queens University, Belfast - all in the United Kingdom (J.S.E.)
| | - Christopher Simard
- From National Jewish Health, Denver (J.L.T.-C.); Hôpital Robert Debré, Assistance Publique-Hopitaux de Paris, Paris (A. Munck); University College Dublin School of Medicine, St. Vincent's University Hospital, Dublin (E.F.M.); University Medical Center, Utrecht, the Netherlands (C.K.E.); University Children's Hospital Zurich, Zurich, Switzerland (A. Moeller); Vertex Pharmaceuticals, Boston (C.S., L.T.W., E.P.I., C.M., Y.L., J.L.-H.); and Imperial College and Royal Brompton Hospital and Harefield NHS Foundation Trust, London, and Queens University, Belfast - all in the United Kingdom (J.S.E.)
| | - Linda T Wang
- From National Jewish Health, Denver (J.L.T.-C.); Hôpital Robert Debré, Assistance Publique-Hopitaux de Paris, Paris (A. Munck); University College Dublin School of Medicine, St. Vincent's University Hospital, Dublin (E.F.M.); University Medical Center, Utrecht, the Netherlands (C.K.E.); University Children's Hospital Zurich, Zurich, Switzerland (A. Moeller); Vertex Pharmaceuticals, Boston (C.S., L.T.W., E.P.I., C.M., Y.L., J.L.-H.); and Imperial College and Royal Brompton Hospital and Harefield NHS Foundation Trust, London, and Queens University, Belfast - all in the United Kingdom (J.S.E.)
| | - Edward P Ingenito
- From National Jewish Health, Denver (J.L.T.-C.); Hôpital Robert Debré, Assistance Publique-Hopitaux de Paris, Paris (A. Munck); University College Dublin School of Medicine, St. Vincent's University Hospital, Dublin (E.F.M.); University Medical Center, Utrecht, the Netherlands (C.K.E.); University Children's Hospital Zurich, Zurich, Switzerland (A. Moeller); Vertex Pharmaceuticals, Boston (C.S., L.T.W., E.P.I., C.M., Y.L., J.L.-H.); and Imperial College and Royal Brompton Hospital and Harefield NHS Foundation Trust, London, and Queens University, Belfast - all in the United Kingdom (J.S.E.)
| | - Charlotte McKee
- From National Jewish Health, Denver (J.L.T.-C.); Hôpital Robert Debré, Assistance Publique-Hopitaux de Paris, Paris (A. Munck); University College Dublin School of Medicine, St. Vincent's University Hospital, Dublin (E.F.M.); University Medical Center, Utrecht, the Netherlands (C.K.E.); University Children's Hospital Zurich, Zurich, Switzerland (A. Moeller); Vertex Pharmaceuticals, Boston (C.S., L.T.W., E.P.I., C.M., Y.L., J.L.-H.); and Imperial College and Royal Brompton Hospital and Harefield NHS Foundation Trust, London, and Queens University, Belfast - all in the United Kingdom (J.S.E.)
| | - Yimeng Lu
- From National Jewish Health, Denver (J.L.T.-C.); Hôpital Robert Debré, Assistance Publique-Hopitaux de Paris, Paris (A. Munck); University College Dublin School of Medicine, St. Vincent's University Hospital, Dublin (E.F.M.); University Medical Center, Utrecht, the Netherlands (C.K.E.); University Children's Hospital Zurich, Zurich, Switzerland (A. Moeller); Vertex Pharmaceuticals, Boston (C.S., L.T.W., E.P.I., C.M., Y.L., J.L.-H.); and Imperial College and Royal Brompton Hospital and Harefield NHS Foundation Trust, London, and Queens University, Belfast - all in the United Kingdom (J.S.E.)
| | - Julie Lekstrom-Himes
- From National Jewish Health, Denver (J.L.T.-C.); Hôpital Robert Debré, Assistance Publique-Hopitaux de Paris, Paris (A. Munck); University College Dublin School of Medicine, St. Vincent's University Hospital, Dublin (E.F.M.); University Medical Center, Utrecht, the Netherlands (C.K.E.); University Children's Hospital Zurich, Zurich, Switzerland (A. Moeller); Vertex Pharmaceuticals, Boston (C.S., L.T.W., E.P.I., C.M., Y.L., J.L.-H.); and Imperial College and Royal Brompton Hospital and Harefield NHS Foundation Trust, London, and Queens University, Belfast - all in the United Kingdom (J.S.E.)
| | - J Stuart Elborn
- From National Jewish Health, Denver (J.L.T.-C.); Hôpital Robert Debré, Assistance Publique-Hopitaux de Paris, Paris (A. Munck); University College Dublin School of Medicine, St. Vincent's University Hospital, Dublin (E.F.M.); University Medical Center, Utrecht, the Netherlands (C.K.E.); University Children's Hospital Zurich, Zurich, Switzerland (A. Moeller); Vertex Pharmaceuticals, Boston (C.S., L.T.W., E.P.I., C.M., Y.L., J.L.-H.); and Imperial College and Royal Brompton Hospital and Harefield NHS Foundation Trust, London, and Queens University, Belfast - all in the United Kingdom (J.S.E.)
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189
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Rowe S, Daines C, Ringshausen F, Kerem E, Wilson J, Tullis E, Nair N, Simard C, Han L, Ingenito E, McKee C, Lekstrom-Himes J, Davies J. Tezacaftor-Ivacaftor in Residual-Function Heterozygotes with Cystic Fibrosis. N Engl J Med 2017; 377:2024-2035. [PMID: 29099333 PMCID: PMC6472479 DOI: 10.1056/nejmoa1709847] [Citation(s) in RCA: 354] [Impact Index Per Article: 50.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Cystic fibrosis is an autosomal recessive disease caused by mutations in the CFTR gene that lead to progressive respiratory decline. Some mutant CFTR proteins show residual function and respond to the CFTR potentiator ivacaftor in vitro, whereas ivacaftor alone does not restore activity to Phe508del mutant CFTR. METHODS We conducted a randomized, double-blind, placebo-controlled, phase 3, crossover trial to evaluate the efficacy and safety of ivacaftor alone or in combination with tezacaftor, a CFTR corrector, in 248 patients 12 years of age or older who had cystic fibrosis and were heterozygous for the Phe508del mutation and a CFTR mutation associated with residual CFTR function. Patients were randomly assigned to one of six sequences, each involving two 8-week intervention periods separated by an 8-week washout period. They received tezacaftor-ivacaftor, ivacaftor monotherapy, or placebo. The primary end point was the absolute change in the percentage of predicted forced expiratory volume in 1 second (FEV1) from the baseline value to the average of the week 4 and week 8 measurements in each intervention period. RESULTS The number of analyzed intervention periods was 162 for tezacaftor-ivacaftor, 157 for ivacaftor alone, and 162 for placebo. The least-squares mean difference versus placebo with respect to the absolute change in the percentage of predicted FEV1 was 6.8 percentage points for tezacaftor-ivacaftor and 4.7 percentage points for ivacaftor alone (P<0.001 for both comparisons). Scores on the respiratory domain of the Cystic Fibrosis Questionnaire-Revised, a quality-of-life measure, also significantly favored the active-treatment groups. The incidence of adverse events was similar across intervention groups; most events were mild or moderate in severity, with no discontinuations of the trial regimen due to adverse events for tezacaftor-ivacaftor and few for ivacaftor alone (1% of patients) and placebo (<1%). CONCLUSIONS CFTR modulator therapy with tezacaftor-ivacaftor or ivacaftor alone was efficacious in patients with cystic fibrosis who were heterozygous for the Phe508del deletion and a CFTR residual-function mutation. (Funded by Vertex Pharmaceuticals and others; EXPAND ClinicalTrials.gov number, NCT02392234 .).
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Affiliation(s)
- S.M. Rowe
- Division of Pulmonary, Allergy & Critical Care Medicine, University of Alabama at Birmingham, Birmingham, Alabama, United States
| | - C. Daines
- Arizona Respiratory Center, University of Arizona, Tucson, AZ, United States
| | - F.C. Ringshausen
- Department of Respiratory Medicine, Hannover Medical School, and German Center for Lung Research (DZL), Hannover, Germany
| | - E. Kerem
- Hadassah Hebrew University Medical Center, Israel
| | | | - E. Tullis
- St. Michael’s Hospital, Toronto, ON, Canada
| | - N. Nair
- Vertex Pharmaceuticals Incorporated, Boston, MA, United States
| | - C. Simard
- Vertex Pharmaceuticals Incorporated, Boston, MA, United States
| | - L. Han
- Vertex Pharmaceuticals Incorporated, Boston, MA, United States
| | - E.P. Ingenito
- Vertex Pharmaceuticals Incorporated, Boston, MA, United States
| | - C. McKee
- Vertex Pharmaceuticals Incorporated, Boston, MA, United States
| | | | - J.C. Davies
- Royal Brompton & Harefield NHS Foundation Trust, Royal Brompton Hospital, London, United Kingdom
- Imperial College London, London, United Kingdom
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190
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Barnaby R, Koeppen K, Nymon A, Hampton TH, Berwin B, Ashare A, Stanton BA. Lumacaftor (VX-809) restores the ability of CF macrophages to phagocytose and kill Pseudomonas aeruginosa. Am J Physiol Lung Cell Mol Physiol 2017; 314:L432-L438. [PMID: 29146575 DOI: 10.1152/ajplung.00461.2017] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Cystic fibrosis (CF), the most common lethal genetic disease in Caucasians, is characterized by chronic bacterial lung infection and excessive inflammation, which lead to progressive loss of lung function and premature death. Although ivacaftor (VX-770) alone and ivacaftor in combination with lumacaftor (VX-809) improve lung function in CF patients with the Gly551Asp and del508Phe mutations, respectively, the effects of these drugs on the function of human CF macrophages are unknown. Thus studies were conducted to examine the effects of lumacaftor alone and lumacaftor in combination with ivacaftor (i.e., ORKAMBI) on the ability of human CF ( del508Phe/ del508Phe) monocyte-derived macrophages (MDMs) to phagocytose and kill Pseudomonas aeruginosa. Lumacaftor alone restored the ability of CF MDMs to phagocytose and kill P. aeruginosa to levels observed in MDMs obtained from non-CF (WT-CFTR) donors. This effect contrasts with the partial (~15%) correction of del508Phe Cl- secretion of airway epithelial cells by lumacaftor. Ivacaftor reduced the ability of lumacaftor to stimulate phagocytosis and killing of P. aeruginosa. Lumacaftor had no effect on P. aeruginosa-stimulated cytokine secretion by CF MDMs. Ivacaftor (5 µM) alone and ivacaftor in combination with lumacaftor reduced secretion of several proinflammatory cytokines. The clinical efficacy of ORKAMBI may be related in part to the ability of lumacaftor to stimulate phagocytosis and killing of P. aeruginosa by macrophages.
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Affiliation(s)
- Roxanna Barnaby
- Department of Microbiology and Immunology, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Katja Koeppen
- Department of Microbiology and Immunology, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Amanda Nymon
- Department of Microbiology and Immunology, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire.,Section of Pulmonary and Critical Care Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Thomas H Hampton
- Department of Microbiology and Immunology, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Brent Berwin
- Department of Microbiology and Immunology, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Alix Ashare
- Department of Microbiology and Immunology, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire.,Section of Pulmonary and Critical Care Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Bruce A Stanton
- Department of Microbiology and Immunology, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
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191
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Guimbellot JS, Leach JM, Chaudhry IG, Quinney NL, Boyles SE, Chua M, Aban I, Jaspers I, Gentzsch M. Nasospheroids permit measurements of CFTR-dependent fluid transport. JCI Insight 2017; 2:95734. [PMID: 29202459 DOI: 10.1172/jci.insight.95734] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Accepted: 10/11/2017] [Indexed: 12/19/2022] Open
Abstract
Expansion of novel therapeutics to all patients with cystic fibrosis (CF) requires personalized CFTR modulator therapy. We have developed nasospheroids, a primary cell culture-based model derived from individual CF patients and healthy subjects by a minimally invasive nasal biopsy. Confocal microscopy was utilized to measure CFTR activity by analyzing changes in cross-sectional area over time that resulted from CFTR-mediated ion and fluid movement. Both the rate of change over time and AUC were calculated. Non-CF nasospheroids with active CFTR-mediated ion and fluid movement showed a reduction in cross-sectional area, whereas no changes were observed in CF spheroids. Non-CF spheroids treated with CFTR inhibitor lost responsiveness for CFTR activation. However, nasospheroids from F508del CF homozygotes that were treated with lumacaftor and ivacaftor showed a significant reduction in cross-sectional area, indicating pharmacologic rescue of CFTR function. This model employs a simple measurement of size corresponding to changes in CFTR activity and is applicable for detection of small changes in CFTR activity from individual patients in vitro. Advancements of this technique will provide a robust model for individualized prediction of CFTR modulator efficacy.
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Affiliation(s)
| | - Justin M Leach
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | | | | | | | - Michael Chua
- Marsico Lung Institute/Cystic Fibrosis Research Center
| | - Inmaculada Aban
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Ilona Jaspers
- Center for Environmental Medicine, Asthma, and Lung Biology, and
| | - Martina Gentzsch
- Marsico Lung Institute/Cystic Fibrosis Research Center.,Department of Cell Biology and Physiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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192
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Effects of new and emerging therapies on gastrointestinal outcomes in cystic fibrosis. Curr Opin Pulm Med 2017; 23:551-555. [DOI: 10.1097/mcp.0000000000000423] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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193
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Guimbellot J, Sharma J, Rowe SM. Toward inclusive therapy with CFTR modulators: Progress and challenges. Pediatr Pulmonol 2017; 52:S4-S14. [PMID: 28881097 PMCID: PMC6208153 DOI: 10.1002/ppul.23773] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Accepted: 06/29/2017] [Indexed: 12/29/2022]
Abstract
Cystic fibrosis is caused by gene mutations that result in an abnormal Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) protein on the surface of cells. CFTR modulators are a novel class of drugs that directly target the molecular defect. CFTR modulators include potentiators that result in improved activity of the channel; correctors that help the protein traffic to the cell surface properly; and readthrough agents that restore full-length CFTR by suppression of premature termination codons, among other novel classes more recently established. While some of these drugs, CFTR potentiators in particular, have provided remarkable improvements for CF patients, others have yet to achieve profoundly improved outcomes, and many CF patients are not yet impacted by CFTR modulators due to lack of knowledge regarding susceptibility of their mutations to treatment. One limitation to expanding these types of therapies to the maximum number of patients with CF is the lack of rigorously validated clinical biomarkers that can determine efficacy on an individual basis, as well as few pre-clinical tools that can predict whether an individual with a rare combination of mutant alleles will respond to a particular CFTR modulator regimen. In this review, we discuss the various groups of CFTR modulators and their status in clinical development, as well as address the current literature on biomarkers, pre-clinical cell-based tools, and the role of pharmacometrics in creating therapeutic strategies to improve the lives of all patients with cystic fibrosis, regardless of their specific mutation.
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Affiliation(s)
- Jennifer Guimbellot
- Departments of Pediatrics, The University of Alabama at Birmingham, Birmingham, Alabama
- Gregory Fleming James Cystic Fibrosis Research Center, The University of Alabama at Birmingham, Birmingham, Alabama
| | - Jyoti Sharma
- Gregory Fleming James Cystic Fibrosis Research Center, The University of Alabama at Birmingham, Birmingham, Alabama
- Cell Developmental and Integrative Biology, The University of Alabama at Birmingham, Birmingham, Alabama
| | - Steven M. Rowe
- Departments of Pediatrics, The University of Alabama at Birmingham, Birmingham, Alabama
- Gregory Fleming James Cystic Fibrosis Research Center, The University of Alabama at Birmingham, Birmingham, Alabama
- Cell Developmental and Integrative Biology, The University of Alabama at Birmingham, Birmingham, Alabama
- Departments of Medicine, The University of Alabama at Birmingham, Birmingham, Alabama
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194
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195
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Fink AK, Loeffler DR, Marshall BC, Goss CH, Morgan WJ. Data that empower: The success and promise of CF patient registries. Pediatr Pulmonol 2017; 52:S44-S51. [PMID: 28910520 DOI: 10.1002/ppul.23790] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Accepted: 07/30/2017] [Indexed: 12/17/2022]
Abstract
In this article, we describe existing CF registries with a focus on US registry data collected through the CF Foundation Patient Registry (CFFPR) and the Epidemiologic Study of CF (ESCF); highlight what registries have taught us regarding epidemiology of CF; showcase the impact of registries on research and clinical care; and discuss future directions. This manuscript complements the plenary address given by Dr Wayne Morgan at the 2016 North American CF Conference by summarizing the key points from the presentation and providing additional detail and information.
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Affiliation(s)
| | | | | | - Christopher H Goss
- Department of Medicine and Pediatrics, University of Washington, Seattle, Washington
| | - Wayne J Morgan
- Department of Pediatrics, University of Arizona, Tucson, Arizona
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196
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Strategies for the etiological therapy of cystic fibrosis. Cell Death Differ 2017; 24:1825-1844. [PMID: 28937684 PMCID: PMC5635223 DOI: 10.1038/cdd.2017.126] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Revised: 06/22/2017] [Accepted: 06/23/2017] [Indexed: 12/14/2022] Open
Abstract
Etiological therapies aim at repairing the underlying cause of cystic fibrosis (CF), which is the functional defect of the cystic fibrosis transmembrane conductance regulator (CFTR) protein owing to mutations in the CFTR gene. Among these, the F508del CFTR mutation accounts for more than two thirds of CF cases worldwide. Two somehow antinomic schools of thought conceive CFTR repair in a different manner. According to one vision, drugs should directly target the mutated CFTR protein to increase its plasma membrane expression (correctors) or improve its ion transport function (potentiators). An alternative strategy consists in modulating the cellular environment and proteostasis networks in which the mutated CFTR protein is synthesized, traffics to its final destination, the plasma membrane, and is turned over. We will analyze distinctive advantages and drawbacks of these strategies in terms of their scientific and clinical dimensions, and we will propose a global strategy for CF research and development based on a reconciliatory approach. Moreover, we will discuss the utility of preclinical biomarkers that may guide the personalized, patient-specific implementation of CF therapies.
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197
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Bulloch MN, Hanna C, Giovane R. Lumacaftor/ivacaftor, a novel agent for the treatment of cystic fibrosis patients who are homozygous for the F580del CFTR mutation. Expert Rev Clin Pharmacol 2017; 10:1055-1072. [PMID: 28891346 DOI: 10.1080/17512433.2017.1378094] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Cystic Fibrosis (CF) is an autosomal recessive disease affecting up to 90,000 people worldwide. Approximately 73% of patients are homozygous for the F508del cystic fibrosis transmembrane conductance regulator [CFTR] mutation. Traditionally treatment has only included supportive care. Therefore, there is a need for safe and effective novel therapies targeting the underlying molecular defects seen with CF. Areas covered: In 2016, the Food and Drug Administration and the European Commission approved LUM/IVA (Orkambi), a CFTR modulator that includes both a CFTR corrector and potentiator, for CF patients homozygous for the F508del CFTR mutation. This article reviews the pharmacologic features, clinical efficacy, and safety of LUM/IVA and summarize the available pre-clinical and clinical data of LUM/IVA use. Expert commentary: LUM/IVA showed modest, but significant improvements from baseline in percent predicted FEV1 (ppFEV1) as well as a reduction in pulmonary exacerbations by 35% It was shown to be safe for short- and long-term use. Currently, LUM/IVA is the only oral agent in its class available and represents a milestone the development of therapies for the management of CF. Nonetheless, pharmacoeconomic data are necessary to justify its high cost before is use becomes standard of care.
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Affiliation(s)
- Marilyn N Bulloch
- a Harrison School of Pharmacy , Auburn University , Auburn , AL , USA.,b College of Community Health Sciences , University of Alabama , Tuscaloosa , AL , USA
| | - Cameron Hanna
- a Harrison School of Pharmacy , Auburn University , Auburn , AL , USA
| | - Richard Giovane
- c Harrison School of Pharmacy , Auburn University , Tuscaloosa , AL , USA
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198
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Talamo Guevara M, McColley SA. The safety of lumacaftor and ivacaftor for the treatment of cystic fibrosis. Expert Opin Drug Saf 2017; 16:1305-1311. [PMID: 28846049 DOI: 10.1080/14740338.2017.1372419] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Lumacaftor-ivacaftor is indicated for treatment of cystic fibrosis (CF) in patients homozygous for the Phe-508del cystic fibrosis transmembrane conductance regulator (CFTR) gene mutations. In clinical trials, treated patients showed improved pulmonary function, reduced pulmonary exacerbations, and other benefits. This article reviews safety of this therapy. Areas covered: Safety findings in ivacaftor, lumacaftor and combined therapy trials, and reported subsequently through post-approval evaluation, were accessed by PubMed and Google searches using key words 'VX-770', 'ivacaftor', 'VX-809', and 'lumacaftor'. Transaminitis was seen in ivacaftor and combination trials. Non-congenital cataracts were seen in pre-clinical animal studies and in children taking ivacaftor and combined therapy. Dyspnea occurs in some patients taking lumacaftor and combined therapy and usually resolves without stopping treatment. Lumacaftor is a strong inducer of CYP3A while ivacaftor is a CYP3A sensitive substrate. Combination therapy can decrease systemic exposure of medications that are substrates of CYP3A, decreasing therapeutic effect. Co-administration of lumacaftor-ivacaftor with sensitive CYP3A substrates or CYP3A substrates with narrow therapeutic index is not recommended. Expert opinion: Lumacaftor-ivacaftor therapy may be associated with ocular and hepatic side effects. Specific recommendations for monitoring are available. Dyspnea occurs, especially during initiation of treatment. Potential drug interactions should be evaluated in patients taking combination therapy. The risk benefit ratio of lumacaftor-ivacaftor favors therapy.
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Affiliation(s)
- Maria Talamo Guevara
- a Department of Pediatrics , Northwestern University Feinberg School of Medicine and Ann & Robert H. Lurie Children's Hospital of Chicago
| | - Susanna A McColley
- b Department of Pediatrics , Northwestern University Feinberg School of Medicine.,c Stanley Manne Children's Research Institute , Ann & Robert H. Lurie Children's Hospital of Chicago
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199
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Kazmerski TM, Sawicki GS. Early Lung Function Decline in Cystic Fibrosis. Can Registry Data Explain Divergent Phenotypes? Am J Respir Crit Care Med 2017; 196:407-409. [DOI: 10.1164/rccm.201704-0813ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Traci M. Kazmerski
- Department of MedicineBoston Children’s HospitalBoston, Massachusettsand
- Institute for Healthcare ImprovementCambridge, Massachusetts
| | - Gregory S. Sawicki
- Department of MedicineBoston Children’s HospitalBoston, Massachusettsand
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200
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Zemanick ET, Daines CL, Dellon EP, Esther CR, Kinghorn B, Ong T, Muhlebach MS. Highlights from the 2016 North American Cystic Fibrosis Conference. Pediatr Pulmonol 2017; 52:1103-1110. [PMID: 28696526 PMCID: PMC5963883 DOI: 10.1002/ppul.23707] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Accepted: 03/23/2017] [Indexed: 01/25/2023]
Abstract
The 30th annual North American Cystic Fibrosis Conference (NACFC) was held in Orlando, FL, on October 27-29, 2016. Abstracts were published in a supplement to Pediatric Pulmonology. This review summarizes several major topic areas addressed at the conference: the pathophysiology of cystic fibrosis (CF) lung disease, clinical trials, clinical management issues, and quality improvement. We sought to provide an overview of emerging concepts in several areas of CF research and care, rather than a comprehensive review of the conference. Citations from the conference are by first author and abstract number or symposium number, as designated in the supplement.
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Affiliation(s)
- Edith T Zemanick
- Department of Pediatrics, University of Colorado Denver Anschutz Medical Campus, Aurora, Colorado
| | - Cori L Daines
- Department of Pediatrics, University of Arizona College of Medicine, Tucson, Arizona
| | - Elisabeth P Dellon
- Division of Pulmonology, Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Charles R Esther
- Division of Pulmonology, Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - BreAnna Kinghorn
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, Washington
| | - Thida Ong
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, Washington
| | - Marianne S Muhlebach
- Division of Pulmonology, Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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