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Newland DM, Palmer MM, Knorr LR, Pak JL, Albers EL, Friedland-Little JM, Hong BJ, Law YM, Spencer KL, Kemna MS. Analysis of Platelet Function Testing in Children Receiving Aspirin for Antiplatelet Effects. Pediatr Cardiol 2024; 45:614-622. [PMID: 38153548 DOI: 10.1007/s00246-023-03377-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Accepted: 12/06/2023] [Indexed: 12/29/2023]
Abstract
Aspirin (ASA) remains the most common antiplatelet agent used in children. VerifyNow Aspirin Test® (VN) assesses platelet response to ASA, with therapeutic effect defined by the manufacturer as ≤ 549 aspirin reaction units (ARU). Single-center, observational, analysis of 195 children (< 18 years-old) who underwent first VN between 2015 and 2020. Primary outcome was proportion of patients with ASA biochemical resistance (> 549 ARU). Secondary outcomes included incidence of new clinical thrombotic and bleeding events during ≤ 6 months from VN in those who received ASA monotherapy (n = 113). Median age was 1.8 years. Common indications for ASA included cardiac anomalies or dysfunction (74.8%) and ischemic stroke (22.6%). Median ASA dose before VN was 4.6 mg/kg/day. Mean VN was 471 ARU. ASA biochemical resistance was detected in 14.4% (n = 28). Of 113 patients receiving ASA monotherapy, 14 (12.4%) had a thrombotic event and 2 (1.8%) had a bleeding event. Mean VN was significantly higher at initial testing in patients experiencing thrombotic event compared to those without thrombosis (516 vs 465 ARU, [95% CI: 9.8, 92.2], p = 0.02). Multivariable analysis identified initial VN ASA result ≥ 500 ARU at initial testing as the only significant independent risk factor for thrombosis (p < 0.01). VN testing identifies ASA biochemical resistance in 14.4% of children. VN ASA ≥ 500 ARU rather than ≥ 550 ARU at initial testing was independently associated with increased odds of thrombosis. Designated cut-off of 550 ARU for detecting platelet dysfunction by ASA may need reconsideration in children.
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Affiliation(s)
- David M Newland
- Department of Pharmacy, Seattle Children's Hospital, 4800 Sandpoint Way NE, Mailstop MB.5.420, Seattle, WA, 98105, USA.
- School of Pharmacy, University of Washington, Seattle, WA, USA.
| | - Michelle M Palmer
- Department of Pharmacy, Seattle Children's Hospital, 4800 Sandpoint Way NE, Mailstop MB.5.420, Seattle, WA, 98105, USA
- School of Pharmacy, University of Washington, Seattle, WA, USA
| | - Lisa R Knorr
- Department of Pharmacy, Seattle Children's Hospital, 4800 Sandpoint Way NE, Mailstop MB.5.420, Seattle, WA, 98105, USA
- School of Pharmacy, University of Washington, Seattle, WA, USA
| | - Jennifer L Pak
- Department of Pharmacy, Seattle Children's Hospital, 4800 Sandpoint Way NE, Mailstop MB.5.420, Seattle, WA, 98105, USA
- School of Pharmacy, University of Washington, Seattle, WA, USA
| | - Erin L Albers
- Pediatric Cardiology, Seattle Children's Hospital, Seattle, WA, USA
- School of Medicine, University of Washington, Seattle, WA, USA
| | - Joshua M Friedland-Little
- Pediatric Cardiology, Seattle Children's Hospital, Seattle, WA, USA
- School of Medicine, University of Washington, Seattle, WA, USA
| | - Borah J Hong
- Pediatric Cardiology, Seattle Children's Hospital, Seattle, WA, USA
- School of Medicine, University of Washington, Seattle, WA, USA
| | - Yuk M Law
- Pediatric Cardiology, Seattle Children's Hospital, Seattle, WA, USA
- School of Medicine, University of Washington, Seattle, WA, USA
| | | | - Mariska S Kemna
- Pediatric Cardiology, Seattle Children's Hospital, Seattle, WA, USA
- School of Medicine, University of Washington, Seattle, WA, USA
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Regan IE, Cox D, Kelleher ST, Nolan B, Shaw K, Smith OP, McMahon CJ. Towards a greater understanding of reduced response to aspirin in children with congenital heart disease post-cardiac surgery using immature platelet fraction. Thromb Res 2024; 233:101-108. [PMID: 38039722 DOI: 10.1016/j.thromres.2023.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 10/10/2023] [Accepted: 11/13/2023] [Indexed: 12/03/2023]
Abstract
OBJECTIVE A high platelet turnover rate may produce a population of platelets that confers an inadequate response to aspirin. We aimed to investigate the relationship between residual platelet aggregation and platelet turnover in paediatric cardiology patients on aspirin monotherapy by evaluating the fraction of immature platelets as a marker for turnover and secondly to test the predictive value of the immature platelet fraction (IPF) to classify patients as responsive or non-responsive to aspirin. METHODS Sixty patients divided into two age categories (≤90 days, >90 days of age) were included in this prospective observational study. Patients were then stratified into tertiles using their IPF level. Platelet studies included thromboelastography with platelet mapping (TEGPM). RESULTS The overall incidence of 'inadequate response to aspirin' was 38 % in our patient cohort recently post-cardiac surgery a consequence that warrants further study. The frequency of inadequate response to aspirin was higher in the upper tertile of IPF when compared to the lower tertile, (88 %) versus (4 %) respectively (p < 0.05). The 'cut off' for IPF was determined to be 3.9 % with a sensitivity of 95.7 %, and a specificity of 92.9 % (area under the curve of 0.955 [CI 0.896-1.014, p < 0.05]). CONCLUSION This study demonstrates that inadequate response to aspirin occurs in approximately 38 % of patients undergoing specific high-risk congenital cardiac procedures using the dosing practice of a national centre. This study supports the hypothesis that an elevated platelet turnover may result in aspirin being less effective in patients who are recently post cardiac surgery. These data are of direct translational relevance.
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Affiliation(s)
- Irene E Regan
- Department of Coagulation/Haematology, Children's Health Ireland at Crumlin, Dublin, Ireland; School of Medicine, University College Dublin, Belfield, Dublin 4, Ireland; National Children's Research Centre, Children's Health Ireland, Dublin, Ireland
| | - Dermot Cox
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons Ireland, Dublin, Ireland
| | - Sean T Kelleher
- Department of Paediatric Cardiology, Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Beatrice Nolan
- Department of Coagulation/Haematology, Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Kathryn Shaw
- Department of Paediatric Pharmacy, Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Owen P Smith
- Department of Coagulation/Haematology, Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Colin J McMahon
- Department of Paediatric Cardiology, Children's Health Ireland at Crumlin, Dublin, Ireland; School of Medicine, University College Dublin, Belfield, Dublin 4, Ireland; School of Health Professions Education (SHE), Maastricht University, Maastricht, Netherlands; National Children's Research Centre, Children's Health Ireland, Dublin, Ireland.
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Ziesenitz VC, Welzel T, van Dyk M, Saur P, Gorenflo M, van den Anker JN. Efficacy and Safety of NSAIDs in Infants: A Comprehensive Review of the Literature of the Past 20 Years. Paediatr Drugs 2022; 24:603-655. [PMID: 36053397 PMCID: PMC9592650 DOI: 10.1007/s40272-022-00514-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/25/2022] [Indexed: 11/29/2022]
Abstract
Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used in infants, children, and adolescents worldwide; however, despite sufficient evidence of the beneficial effects of NSAIDs in children and adolescents, there is a lack of comprehensive data in infants. The present review summarizes the current knowledge on the safety and efficacy of various NSAIDs used in infants for which data are available, and includes ibuprofen, dexibuprofen, ketoprofen, flurbiprofen, naproxen, diclofenac, ketorolac, indomethacin, niflumic acid, meloxicam, celecoxib, parecoxib, rofecoxib, acetylsalicylic acid, and nimesulide. The efficacy of NSAIDs has been documented for a variety of conditions, such as fever and pain. NSAIDs are also the main pillars of anti-inflammatory treatment, such as in pediatric inflammatory rheumatic diseases. Limited data are available on the safety of most NSAIDs in infants. Adverse drug reactions may be renal, gastrointestinal, hematological, or immunologic. Since NSAIDs are among the most frequently used drugs in the pediatric population, safety and efficacy studies can be performed as part of normal clinical routine, even in young infants. Available data sources, such as (electronic) medical records, should be used for safety and efficacy analyses. On a larger scale, existing data sources, e.g. adverse drug reaction programs/networks, spontaneous national reporting systems, and electronic medical records should be assessed with child-specific methods in order to detect safety signals pertinent to certain pediatric age groups or disease entities. To improve the safety of NSAIDs in infants, treatment needs to be initiated with the lowest age-appropriate or weight-based dose. Duration of treatment and amount of drug used should be regularly evaluated and maximum dose limits and other recommendations by the manufacturer or expert committees should be followed. Treatment for non-chronic conditions such as fever and acute (postoperative) pain should be kept as short as possible. Patients with chronic conditions should be regularly monitored for possible adverse effects of NSAIDs.
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Affiliation(s)
- Victoria C Ziesenitz
- Pediatric Cardiology and Congenital Heart Diseases, Centre for Child and Adolescent Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany.
- Pediatric Pharmacology and Pharmacometrics, University Children's Hospital Basel, University of Basel, Basel, Switzerland.
| | - Tatjana Welzel
- Pediatric Pharmacology and Pharmacometrics, University Children's Hospital Basel, University of Basel, Basel, Switzerland
- Pediatric Rheumatology and Autoinflammatory Reference Center, University Hospital Tuebingen, Tuebingen, Germany
| | - Madelé van Dyk
- Flinders Centre for Innovation in Cancer, College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - Patrick Saur
- Pediatric Cardiology and Congenital Heart Diseases, Centre for Child and Adolescent Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany
| | - Matthias Gorenflo
- Pediatric Cardiology and Congenital Heart Diseases, Centre for Child and Adolescent Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany
| | - Johannes N van den Anker
- Pediatric Pharmacology and Pharmacometrics, University Children's Hospital Basel, University of Basel, Basel, Switzerland
- Division of Clinical Pharmacology, Children's National Hospital, Washington DC, USA
- Intensive Care and Department of Pediatric Surgery, Sophia Children's Hospital, Rotterdam, The Netherlands
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4
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Bonilla-Velez J, Whitlock KB, Ganti S, Zenner K, Cheng CV, Jensen DM, Pham MHM, Mitchell RM, Dobyns W, Bly RA, Bennett JT, Dahl JP, Perkins JA. Acetylsalicylic acid suppression of the PI3K pathway as a novel medical therapy for head and neck lymphatic malformations. Int J Pediatr Otorhinolaryngol 2021; 151:110869. [PMID: 34537546 PMCID: PMC9632366 DOI: 10.1016/j.ijporl.2021.110869] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 07/21/2021] [Accepted: 08/04/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Head and neck lymphatic malformations (HNLM) are caused by gain-of-function somatic mutations in PIK3CA. Acetylsalicylic acid (ASA/aspirin) is thought to limit growth in PIK3CA-mutated neoplasms through PI3K pathway suppression. We sought to determine if ASA could be beneficial for HNLM. METHODS Retrospective case series of patients (0-18 years) offered ASA (3-5 mg/kg/day) for HNLM treatment (2010-2018). Clinical and treatment characteristics, patient-reported symptom improvement, medication tolerance, compliance, and complications were recorded. Treatment response was determined by change in patient/caregiver-reported symptoms, or HNLM size [complete (resolved), partial (decreased), or stable]. RESULTS Fifty-three patients were offered ASA, 23 (43%) accepted (median age 10 years, IQR 6-14). Compared to patients who declined, patients receiving ASA were more likely to have extensive malformations: ex-utero intrapartum treatment procedure, bilateral malformations, oral cavity location, ≥2 invasive treatments, or tracheotomy (p < 0.05). All patients with tissue available had PIK3CA mutations (13/23). Treatment indications included oral pain/blebs (12, 52%), recurrent pain/swelling (6, 26%), or sudden/persistent swelling (5, 22%). Treatment plan was commonly one 81 mg tablet daily (19, 83%) for 3-12 months (8, 42%). Therapeutic adherence was reported by 18 patients (78%). Symptoms improved in 18 patients [78%; decreased pain (9, 39%) and swelling (8, 35%)]. Treatment resulted in partial (14, 61%) or complete response (4, 17%). Three patients developed oral bleb bleeding, which resolved with medication discontinuation. CONCLUSION ASA seems to be a well-tolerated, low-risk medication for HNLM treatment. This pilot study suggests that it often improves symptoms and reduces HNLM size. Further prospective, randomized studies are warranted to comprehensively assess indications, safety, and efficacy. LEVEL OF EVIDENCE Level 4.
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Affiliation(s)
- Juliana Bonilla-Velez
- Division of Pediatric Otolaryngology, Seattle Children's Hospital, Seattle, WA, USA; Department of Otolaryngology-Head and Neck Surgery, University of Washington School of Medicine, Seattle, WA, USA.
| | - Kathryn B. Whitlock
- Division of Pediatric Otolaryngology, Seattle Children’s Hospital, Seattle, WA, USA,Center for Clinical and Translational Research, Seattle Children’s Research Institute, Seattle, WA, USA
| | - Sheila Ganti
- Division of Pediatric Otolaryngology, Seattle Children’s Hospital, Seattle, WA, USA,Center for Clinical and Translational Research, Seattle Children’s Research Institute, Seattle, WA, USA
| | - Kaitlyn Zenner
- Division of Pediatric Otolaryngology, Seattle Children’s Hospital, Seattle, WA, USA,Department of Otolaryngology–Head and Neck Surgery, University of Washington School of Medicine, Seattle, WA, USA
| | - Chi Vicky Cheng
- Center for Integrative Brain Research, Seattle Children’s Research Institute, Seattle, WA, USA
| | - Dana M. Jensen
- Center for Developmental Biology and Regenerative Medicine, Seattle Children’s Research Institute, Seattle, WA, USA
| | - Minh-Hang M. Pham
- Center for Integrative Brain Research, Seattle Children’s Research Institute, Seattle, WA, USA
| | - Ryan M. Mitchell
- Division of Pediatric Otolaryngology, Seattle Children’s Hospital, Seattle, WA, USA,Department of Otolaryngology–Head and Neck Surgery, Indiana University, Indianapolis, IN, USA
| | - William Dobyns
- Center for Integrative Brain Research, Seattle Children’s Research Institute, Seattle, WA, USA
| | - Randall A. Bly
- Division of Pediatric Otolaryngology, Seattle Children’s Hospital, Seattle, WA, USA,Department of Otolaryngology–Head and Neck Surgery, University of Washington School of Medicine, Seattle, WA, USA
| | - James T. Bennett
- Center for Developmental Biology and Regenerative Medicine, Seattle Children’s Research Institute, Seattle, WA, USA,Division of Genetic Medicine, Department of Pediatrics, Seattle Children’s Hospital, University of Washington, Seattle, WA, USA
| | - John P. Dahl
- Division of Pediatric Otolaryngology, Seattle Children’s Hospital, Seattle, WA, USA,Department of Otolaryngology–Head and Neck Surgery, University of Washington School of Medicine, Seattle, WA, USA
| | - Jonathan A. Perkins
- Division of Pediatric Otolaryngology, Seattle Children’s Hospital, Seattle, WA, USA,Department of Otolaryngology–Head and Neck Surgery, University of Washington School of Medicine, Seattle, WA, USA,Center for Clinical and Translational Research, Seattle Children’s Research Institute, Seattle, WA, USA
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5
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Abstract
Neonatal megakaryopoiesis and platelet turnover form a developmentally unique pattern by generating a pool of newly released reticulated platelets from the bone marrow into the circulation. Reticulated platelets are more reactive and hyperaggregable compared to mature platelets, due to their high residual mRNA content, large size, increased expression of platelet surface receptors, and degranulation. The proportion of reticulated platelets in neonates is higher compared to that in adults. Due to the emergence of an uninhibited platelet subpopulation, the newly formed reticulated platelet pool is inherently hyporesponsive to antiplatelets. An elevated population of reticulated platelets is often associated with increased platelet reactivity and is inversely related to high on-treatment platelet reactivity, which can contribute to ischemia. Measurements of the reticulated platelet subpopulation could be a useful indicator of increased tendency for platelet aggregation. Future research is anticipated to define the distinct functional properties of newly formed reticulated or immature platelets in neonates, as well as determine the impact of enhanced platelet turnover and high residual platelet reactivity on the response to antiplatelet agents.
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Affiliation(s)
- Belay Tesfamariam
- Division of Pharmacology and Toxicology, 372792Center for Drug Evaluation and Research, Silver Spring, MD, USA
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6
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Smitka M, Bruck N, Engellandt K, Hahn G, Knoefler R, von der Hagen M. Clinical Perspective on Primary Angiitis of the Central Nervous System in Childhood (cPACNS). Front Pediatr 2020; 8:281. [PMID: 32719754 PMCID: PMC7349935 DOI: 10.3389/fped.2020.00281] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 05/04/2020] [Indexed: 12/21/2022] Open
Abstract
Non-arteriosclerotic arteriopathies have emerged as important underlying pathomechanism in pediatric arterial ischemic stroke (AIS). The pathogenesis and classification of cerebral arteriopathies in childhood are heterogeneous. Different classifications base on (i) the anatomic site; (ii) the distribution and size of the affected vessel; (iii) the time course, for example, transient vs. progressive, monophasic vs. recurrent; (iv) the putative pathogenesis; (v) the magnetic resonance imaging morphology of the vasculopathies. Inflammation affecting the cerebral vessels is increasingly recognized as common cause of pediatric AIS. Primary cerebral vasculitis or primary angiitis of the central nervous system (CNS) in childhood (cPACNS) is an important differential diagnosis in pediatric AIS. Primary angiitis of the CNS is a rare disorder, and the pathogenesis is poorly understood so far. The current classification of cPACNS is based on the affected cerebral vessel size, the disease course, and angiographic pattern. Two large subtypes are currently recognized comprising large- and medium-sized vessel CNS vasculitis referred to as angiography-positive cPACNS and angiography-negative small vessel cPACNS. As the clinical manifestations of cPACNS are rather diverse, precise diagnosis can be challenging for the treating pediatrician because of the lack of vital laboratory tests or imaging features. Initial misdiagnosis is common because of overlapping phenotypes and pediatric AIS mimics. As untreated cPACNS is associated with a high morbidity and mortality, timely diagnosis, and induction of immunomodulatory and symptomatic therapy are essential. Survival and neurological outcome depend on early diagnosis and prompt therapy. Primary angiitis of the central nervous system in childhood differs in several aspects from primary cerebral angiitis in adults. The aim of this article is to give a brief comprehensive summary on pediatric primary cerebral vasculitis focusing on the clinical perspective regarding the classification, the putative pathogenesis, the disease course, the diagnostic tools, and emerging treatment options. A modified terminology for clinical practice is discussed.
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Affiliation(s)
- Martin Smitka
- Abteilung Neuropädiatrie, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Normi Bruck
- Klinik für Kinder und Jugendmedizin, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Kay Engellandt
- Department of Neuroradiology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Gabriele Hahn
- Bereich Kinderradiologie, Medizinische Fakultät Carl Gustav Carus, Institut und Poliklinik für Radiologische Diagnostik, Technische Universität Dresden, Dresden, Germany
| | - Ralf Knoefler
- Klinik für Kinder und Jugendmedizin, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Maja von der Hagen
- Abteilung Neuropädiatrie, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
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7
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Prevalence of aspirin resistance by thromboelastography plus platelet mapping in children with CHD: a single-centre experience. Cardiol Young 2019; 29:24-29. [PMID: 30501653 DOI: 10.1017/s1047951118000021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
RationaleAspirin resistance has been reported in up to 80% of children with cardiovascular defects undergoing surgery. Because of a patient who had embolic stroke while on therapeutic aspirin dose but in whom aspirin resistance was present on his thromboelastography platelet mapping, we chose to obtain thromboelastography platelet mapping on cardiac patients on aspirin to assess their risk. OBJECTIVES: This study evaluates aspirin resistance noted in these patients and their characteristics.Methods and resultsThis is a retrospective study of 25 patients taking aspirin for a month at therapeutic dose. In total, 11 female patients were enrolled. Ages in all subjects were 5 months to 27 years. A total of 19 patients had a Fontan surgery. Three had a cavopulomanary anastomosis, one had a hybrid procedure, and two had coronary anomalies. Compliance was assessed at the time of the clinic visit. Aspirin resistance was defined as platelet inhibition below 50%. Variables evaluated were level of platelet inhibition, age, body mass index, and gender.
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9
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Leenders EKSM, Westdorp H, Brüggemann RJ, Loeffen J, Kratz C, Burn J, Hoogerbrugge N, Jongmans MCJ. Cancer prevention by aspirin in children with Constitutional Mismatch Repair Deficiency (CMMRD). Eur J Hum Genet 2018; 26:1417-1423. [PMID: 29904176 DOI: 10.1038/s41431-018-0197-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Revised: 05/18/2018] [Accepted: 05/22/2018] [Indexed: 12/16/2022] Open
Abstract
Constitutional MisMatch Repair Deficiency (CMMRD) is caused by homozygous or compound heterozygous germline variants in one of the mismatch repair (MMR) genes (MSH2, MSH6, PMS2, MLH1). This syndrome results in early onset colorectal cancer, leukemia and lymphoma, brain tumors and other malignancies. Children with CMMRD are at high risk of developing multiple cancers and cancer surveillance does not guarantee detection of cancer at a curable stage. The development of a preventive treatment strategy would be a major step forward. Long-term daily use of acetylsalicylic acid (ASA) has been shown to reduce cancer risk in individuals with Lynch syndrome (LS). LS is caused by heterozygous germline variants of MSH2, MSH6, PMS2 and MLH1 and characterized by an increased risk of developing colorectal and endometrial cancer at adult age. Here we discuss the potential use of ASA for cancer prevention in patients with CMMRD.
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Affiliation(s)
- Erika K S M Leenders
- Department of Human Genetics, Radboud University Medical Center, Radboud Institute for Molecular Life Sciences, Nijmegen, The Netherlands
| | - Harm Westdorp
- Department of Tumor Immunology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Medical Oncology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Roger J Brüggemann
- Department of Pharmacy, Radboud University Nijmegen Medical Centre, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Jan Loeffen
- Department of Pediatric Oncology, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands.,Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Christian Kratz
- Pediatric Hematology and Oncology, Hannover Medical School, Hannover, Germany
| | - John Burn
- Institute of Genetic Medicine Newcastle University, Newcastle upon Tyne, UK
| | - Nicoline Hoogerbrugge
- Department of Human Genetics, Radboud University Medical Center, Radboud Institute for Molecular Life Sciences, Nijmegen, The Netherlands
| | - Marjolijn C J Jongmans
- Department of Human Genetics, Radboud University Medical Center, Radboud Institute for Molecular Life Sciences, Nijmegen, The Netherlands. .,Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands. .,Department of Medical Genetics, University Medical Center Utrecht, Utrecht, The Netherlands.
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France M, Rees A, Datta D, Thompson G, Capps N, Ferns G, Ramaswami U, Seed M, Neely D, Cramb R, Shoulders C, Barbir M, Pottle A, Eatough R, Martin S, Bayly G, Simpson B, Halcox J, Edwards R, Main L, Payne J, Soran H. HEART UK statement on the management of homozygous familial hypercholesterolaemia in the United Kingdom. Atherosclerosis 2016; 255:128-139. [DOI: 10.1016/j.atherosclerosis.2016.10.017] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 08/03/2016] [Accepted: 10/07/2016] [Indexed: 12/16/2022]
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Abstract
Homozygous familial hypercholesterolaemia (HoFH) is an inherited disease causing an approximately fourfold increase in blood low-density lipoprotein cholesterol (LDLC) from birth compared with the age-matched normal population owing to reduced low-density lipoprotein receptor (LDLR) activity. Such elevated cholesterol is associated with accelerated atheromatous disease, particularly of the aortic root and coronary arteries. However, HoFH is clinically heterogeneous, reflecting residual low-density lipoprotein receptor (LDLR) activity. The main objective in treating children may be stated to be the avoidance of irreversible cardiac damage requiring heart transplantation by sufficient lowering of blood cholesterol. Lipoprotein apheresis or plasmapheresis are safe means of lowering cholesterol but may be insufficient on their own. Statin drugs, PCSK9 inhibitors ezetimibe and bile acid sequestrants are relatively ineffective if LDLR activity is lacking, but should be used if effective. Two new drugs, lomitapide and mipomersen, have been licensed specifically for HoFH by some regulatory authorities. They work by reducing LDL production rate. They have been associated with fatty liver in adults. Evidence of safety in children is lacking. An alternative is liver transplantation, which replaces the missing LDLR and normalises cholesterol. Clinicians are faced with a dilemma in choosing between these options or deferring such treatment associated with potential harm. Individual case descriptions are an important means of informing clinical judgement. Management of the two cases described in this issue is discussed in the light of modern developments in transplantation and pharmacotherapy.
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Key Words
- ADH, autosomal dominant hypercholesterolaemia, refers to hypercholesterolaemia owing to a single mutation of an allele of a gene affecting LDLR activity
- APOB, apolipoprotein B, is the main protein component of LDL and is the ligand for LDL receptors in the liver
- ARH, autosomal recessive hypercholesterolaemia, refers to hypercholesterolaemia owing to a mutation of both alleles of a single gene affecting LDLR activity
- Evolucomab
- FH, familial hypercholesterolaemia, is an inherited condition causing reduced LDLR activity with consequent hypercholesterolaemia
- HeFH, heterozygous familial hypercholesterolaemia, is caused by one mutant allele of genes affecting LDLR activity
- HoFH, homozygous familial hypercholesterolaemia is caused by two mutant alleles of genes affecting LDLR activity
- Homozygous familial hypercholesterolaemia
- LDL, low-density lipoprotein, is a complex of cholesterol attached to a lipoprotein particle which is removed from blood mainly by the liver
- LDLC, LDL cholesterol, refers to the cholesterol component of LDL
- LDLR, LDL receptors, mediate LDL uptake by the liver
- LDLRAP1, a protein called LDLR adaptor protein 1, facilitates LDLR function
- Lipoprotein apheresis
- Liver transplantation
- Lomitapide
- Microsomal triglyceride transfer protein is an enzyme involved in the hepatic assembly of triglyceride, cholesterol and APOB into triglyceride-rich particles which are secreted by the liver. These particles are metabolised to LDL
- PCSK9
- PCSK9, a protein called proprotein convertase subtilisin/kexin type 9, increases the rate of degradation of LDLR
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Affiliation(s)
- Michael France
- a Cardiovascular Trials Unit , Central Manchester University Hospitals Foundation Trust and Cardiovascular Research Group, University of Manchester , Manchester , UK
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