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Fuenzalida K, Leal-Witt MJ, Guerrero P, Hamilton V, Salazar MF, Peñaloza F, Arias C, Cornejo V. NTBC Treatment Monitoring in Chilean Patients with Tyrosinemia Type 1 and Its Association with Biochemical Parameters and Liver Biomarkers. J Clin Med 2021; 10:jcm10245832. [PMID: 34945128 PMCID: PMC8706240 DOI: 10.3390/jcm10245832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 11/27/2021] [Accepted: 12/08/2021] [Indexed: 11/16/2022] Open
Abstract
Treatment and follow-up in Hereditary Tyrosinemia type 1 (HT-1) patients require comprehensive clinical and dietary management, which involves drug therapy with NTBC and the laboratory monitoring of parameters, including NTBC levels, succinylacetone (SA), amino acids, and various biomarkers of liver and kidney function. Good adherence to treatment and optimal adjustment of the NTBC dose, according to clinical manifestations and laboratory parameters, can prevent severe liver complications such as hepatocarcinogenesis (HCC). We analyzed several laboratory parameters for 15 HT-1 patients over one year of follow-up in a cohort that included long-term NTBC-treated patients (more than 20 years), as well as short-term patients (one year). Based on this analysis, we described the overall adherence by our cohort of 70% adherence to drug and dietary treatment. A positive correlation was found between blood and plasma NTBC concentration with a conversion factor of 2.57. Nonetheless, there was no correlation of the NTBC level with SA levels, αFP, liver biomarkers, and amino acids in paired samples analysis. By separating according to the range of the NTBC concentration, we therefore determined the mean concentration of each biochemical marker, for NTBC ranges above 15–25 μmol/L. SA in urine and αFP showed mean levels within controlled parameters in our group of patients. Future studies analyzing a longer follow-up period, as well as SA determination in the blood, are encouraged to confirm the present findings.
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Bärhold F, Meyer U, Neugebauer AK, Thimm EM, Lier D, Rosenbaum-Fabian S, Och U, Fekete A, Möslinger D, Rohde C, Beblo S, Hochuli M, Bogovic N, Korpel V, vom Dahl S, Mayorandan S, Fischer A, Freisinger P, Dokoupil K, Heddrich-Ellerbrok M, Jörg-Streller M, van Teeffelen-Heithoff A, Lahl J, Das AM. Hepatorenal Tyrosinaemia: Impact of a Simplified Diet on Metabolic Control and Clinical Outcome. Nutrients 2020; 13:nu13010134. [PMID: 33396520 PMCID: PMC7824011 DOI: 10.3390/nu13010134] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 12/16/2020] [Accepted: 12/30/2020] [Indexed: 12/17/2022] Open
Abstract
Background: Tyrosinaemia type 1 is a rare inherited metabolic disease caused by an enzyme defect in the tyrosine degradation pathway. It is treated using nitisinone and a low-protein diet. In a workshop in 2013, a group of nutritional specialists from Germany, Switzerland and Austria agreed to advocate a simplified low-protein diet and to allow more natural protein intake in patients with tyrosinaemia type 1. This retrospective study evaluates the recommendations made at different treatment centers and their impact on clinical symptoms and metabolic control. Methods: For this multicenter study, questionnaires were sent to nine participating treatment centers to collect data on the general therapeutic approach and data of 47 individual patients treated by those centers. Results: Dietary simplification allocating food to 3 categories led to increased tyrosine and phenylalanine blood concentrations without weighing food. Phenylalanine levels were significantly higher in comparison to a strict dietary regimen whereas tyrosine levels in plasma did not change. Non-inferiority was shown for the simplification and liberalization of the diet. Compliance with dietary recommendations was higher using the simplified diet in comparison to the stricter approach. Age correlates negatively with compliance. Conclusions: Simplification of the diet with increased natural protein intake based on three categories of food may be implemented in the diet of patients with tyrosinaemia type 1 without significantly altering metabolic control. Patient compliance is strongly influencing tyrosine blood concentrations. A subsequent prospective study with a larger sample size is necessary to get a better insight into the effect of dietary recommendations on metabolic control.
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Affiliation(s)
- Friederike Bärhold
- Department of Paediatrics, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany; (F.B.); (U.M.); (S.M.)
| | - Uta Meyer
- Department of Paediatrics, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany; (F.B.); (U.M.); (S.M.)
| | - Anne-Kathrin Neugebauer
- Klinik für Allgemeine Pädiatrie, Universitätsklinikum Düsseldorf, Moorenstraße 5, 40225 Düsseldorf, Germany; (A.-K.N.); (E.M.T.)
| | - Eva Maria Thimm
- Klinik für Allgemeine Pädiatrie, Universitätsklinikum Düsseldorf, Moorenstraße 5, 40225 Düsseldorf, Germany; (A.-K.N.); (E.M.T.)
| | - Dinah Lier
- Klinik für Kinder- und Jugendmedizin, Stoffwechselzentrum, Klinikum am Steinenberg, Steinenbergstraße 31, 72764 Reutlingen, Germany; (D.L.); (A.F.); (P.F.)
| | - Stefanie Rosenbaum-Fabian
- Zentrum für Kinder- u. Jugendmedizin, Universitätsklinikum Freiburg, Mathildenstraße 1, 79106 Freiburg, Germany;
| | - Ulrike Och
- Klinik für Kinder- und Jugendmedizin, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany; (U.O.); (A.v.T.-H.)
| | - Anna Fekete
- Kinder- und Jugendheilkunde, AKH Universitätsklinikum Wien, Währinger Gürtel 18-20, 1090 Wien, Austria; (A.F.); (D.M.)
| | - Dorothea Möslinger
- Kinder- und Jugendheilkunde, AKH Universitätsklinikum Wien, Währinger Gürtel 18-20, 1090 Wien, Austria; (A.F.); (D.M.)
| | - Carmen Rohde
- Universitätsklinik für Kinder und Jugendliche, Universitätsklinikum Leipzig, Liebigstraße 20 a, 04103 Leipzig, Germany; (C.R.); (S.B.)
| | - Skadi Beblo
- Universitätsklinik für Kinder und Jugendliche, Universitätsklinikum Leipzig, Liebigstraße 20 a, 04103 Leipzig, Germany; (C.R.); (S.B.)
| | - Michel Hochuli
- Klinik für Endokrinologie, Diabetologie und Klinische Ernährung, Universitätsspital Zürich, Rämistraße 100, 8091 Zürich, Switzerland;
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism Inselspital Bern, University Hospital and University of Bern, Freiburgstrasse 15, 3010 Bern, Switzerland
| | - Nina Bogovic
- Klinik für Gastroenterologie, Hepatologie und Infektiologie, Universitätsklinikum Düsseldorf, Moorenstraße 5, 40225 Düsseldorf, Germany; (N.B.); (V.K.); (S.v.D.)
| | - Vanessa Korpel
- Klinik für Gastroenterologie, Hepatologie und Infektiologie, Universitätsklinikum Düsseldorf, Moorenstraße 5, 40225 Düsseldorf, Germany; (N.B.); (V.K.); (S.v.D.)
| | - Stephan vom Dahl
- Klinik für Gastroenterologie, Hepatologie und Infektiologie, Universitätsklinikum Düsseldorf, Moorenstraße 5, 40225 Düsseldorf, Germany; (N.B.); (V.K.); (S.v.D.)
| | - Sebene Mayorandan
- Department of Paediatrics, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany; (F.B.); (U.M.); (S.M.)
- Klinik für Kinder- und Jugendmedizin, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany; (U.O.); (A.v.T.-H.)
| | - Aleksandra Fischer
- Klinik für Kinder- und Jugendmedizin, Stoffwechselzentrum, Klinikum am Steinenberg, Steinenbergstraße 31, 72764 Reutlingen, Germany; (D.L.); (A.F.); (P.F.)
| | - Peter Freisinger
- Klinik für Kinder- und Jugendmedizin, Stoffwechselzentrum, Klinikum am Steinenberg, Steinenbergstraße 31, 72764 Reutlingen, Germany; (D.L.); (A.F.); (P.F.)
| | - Katharina Dokoupil
- Dr. von Haunersches Kinderspital, Lindwurmstraße 4, 80337 München, Germany;
| | - Margret Heddrich-Ellerbrok
- Klinik für Kinder- und Jugendmedizin, Universitätsklinikum Hamburg Eppendorf, Martinistraße 52, 20246 Hamburg, Germany;
| | - Monika Jörg-Streller
- Department für Kinder- und Jugendheilkunde, Medizinische Universität Innsbruck, Anichstraße 35, 6020 Innsbruck, Austria;
| | - Agnes van Teeffelen-Heithoff
- Klinik für Kinder- und Jugendmedizin, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany; (U.O.); (A.v.T.-H.)
| | - Janina Lahl
- Nutricia GmbH, Metabolics Expert Centre, Am Hauptbahnhof 18, 60329 Frankfurt, Germany;
| | - Anibh Martin Das
- Department of Paediatrics, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany; (F.B.); (U.M.); (S.M.)
- Correspondence: ; Tel.: +49-511-532-3220; Fax: +49-511-532-18516
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Yeo M, Turner C, Dalton NR, Rahman Y, Vara R. Clinical utilization of dried blood spot nitisinone (NTBC) and succinylacetone (SA) concentrations in hereditary tyrosinaemia type 1 - A UK centre experience. Ann Clin Biochem 2020; 57:412-419. [PMID: 32936663 DOI: 10.1177/0004563220961760] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Dried blood spot monitoring of nitisinone and succinylacetone in hereditary tyrosinaemia type 1 patients is not widely available in the United Kingdom. Currently, biochemical monitoring utilizes urinary succinylacetone, blood spot tyrosine and phenylalanine monitoring, which can lack in convenience and accuracy, respectively. METHODS We report the development of a dried blood spot assay for nitisinone and succinylacetone and analysed retrospective clinical and biochemical data for hereditary tyrosinaemia type 1 patients from a single UK centre. RESULTS A total of 13 hereditary tyrosinaemia type 1 patients were evaluated. Eleven presented with liver dysfunction (two with associated renal tubulopathy) and two were detected by early sibling screening. All patients (age 0.03-22 months) were commenced on a tyrosine-/phenylalanine-restricted diet and nitisinone at diagnosis. Ten patients were on twice daily dosing and three were on single daily dosing at the start of monitoring. One patient from each dosing group swapped between dosing regimens at 20 years of age and 8 months of age, respectively. A total of 684 dried blood spot samples were analysed; 80% of nitisinone concentrations were between 9.2 and 27 µmol/L when succinylacetone was <0.3 µmol/L. Patients on twice daily dosing regimens had significantly higher nitisinone concentration compared with those on once daily dosing (P < 0.0001). The median dose required in the twice daily doing group was significantly lower when compared with once daily dosing. CONCLUSIONS Dried blood spot monitoring for nitisinone and succinylacetone concentrations in hereditary tyrosinaemia type 1 patients is a rapid and convenient method which allows physicians to individualize treatment plans and observe adherence to treatment.
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Affiliation(s)
- Mildrid Yeo
- Department of Paediatric Inherited Metabolic Disease, Evelina London Children's Hospital, London, UK
| | - Charles Turner
- WellChild Laboratory, Evelina London Children's Hospital, London, UK
| | - Neil R Dalton
- WellChild Laboratory, Evelina London Children's Hospital, London, UK
| | - Yusof Rahman
- Department of Adult Inherited Metabolic Disease, St Thomas' Hospital, London, UK
| | - Roshni Vara
- Department of Paediatric Inherited Metabolic Disease, Evelina London Children's Hospital, London, UK
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van Ginkel WG, Rodenburg IL, Harding CO, Hollak CEM, Heiner-Fokkema MR, van Spronsen FJ. Long-Term Outcomes and Practical Considerations in the Pharmacological Management of Tyrosinemia Type 1. Paediatr Drugs 2019; 21:413-426. [PMID: 31667718 PMCID: PMC6885500 DOI: 10.1007/s40272-019-00364-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Tyrosinemia type 1 (TT1) is a rare metabolic disease caused by a defect in tyrosine catabolism. TT1 is clinically characterized by acute liver failure, development of hepatocellular carcinoma, renal and neurological problems, and consequently an extremely poor outcome. This review showed that the introduction of 2-(2-nitro-4-trifluoromethylbenzoyl)-1,3-cyclohexanedione (NTBC) in 1992 has revolutionized the outcome of TT1 patients, especially when started pre-clinically. If started early, NTBC can prevent liver failure, renal problems, and neurological attacks and decrease the risk for hepatocellular carcinoma. NTBC has been shown to be safe and well tolerated, although the long-term effectiveness of treatment with NTBC needs to be awaited. The high tyrosine concentrations caused by treatment with NTBC could result in ophthalmological and skin problems and requires life-long dietary restriction of tyrosine and its precursor phenylalanine, which could be strenuous to adhere to. In addition, neurocognitive problems have been reported since the introduction of NTBC, with hypothesized but as yet unproven pathophysiological mechanisms. Further research should be done to investigate the possible relationship between important clinical outcomes and blood concentrations of biochemical parameters such as phenylalanine, tyrosine, succinylacetone, and NTBC, and to develop clear guidelines for treatment and follow-up with reliable measurements. This all in order to ultimately improve the combined NTBC and dietary treatment and limit possible complications such as hepatocellular carcinoma development, neurocognitive problems, and impaired quality of life.
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Affiliation(s)
- Willem G van Ginkel
- Department of Metabolic Diseases, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands
| | - Iris L Rodenburg
- Department of Dietetics, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Cary O Harding
- Department of Molecular and Medical Genetics, Oregon Health & Science University, Portland, USA
| | - Carla E M Hollak
- Deparment of Endocrinology and Metabolism, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - M Rebecca Heiner-Fokkema
- Department of Laboratory Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Francjan J van Spronsen
- Department of Metabolic Diseases, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands.
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Schuller Y, Gispen-de Wied C, Hollak CEM, Leufkens HGM, Stoyanova-Beninska V. Dose-Finding Studies Among Orphan Drugs Approved in the EU: A Retrospective Analysis. J Clin Pharmacol 2018; 59:229-244. [PMID: 30192386 PMCID: PMC6585723 DOI: 10.1002/jcph.1304] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 07/22/2018] [Indexed: 11/21/2022]
Abstract
In the development process for new drugs, dose‐finding studies are of major importance. Absence of these studies may lead to failed phase 3 trials and delayed marketing authorization. In our study we investigated to what extent dose‐finding studies are performed in the case of orphan drugs for metabolic and oncologic indications. We identified all orphan drugs that were authorized until August 1, 2017. European Public Assessment Reports were used to extract the final dose used in the summary of product characteristics, involvement of healthy volunteers, study type, end points used, number of patients, number of doses, studies in special populations, and dose used for phase 3 studies. Each drug was checked for major objections and dose changes postmarketing. We included 49 orphan drugs, of which 28 were indicated for metabolic disorders and 21 for oncologic indications. Dose‐finding studies were performed in 32 orphan drugs, and studies in healthy volunteers in 26. The absence of dose‐finding studies was mostly due to the rarity of the disease. In this case the dose was determined based on factors such as animal studies or clinical experience. Dose‐related major objections were raised for 9 orphan drugs. Postmarketing dose‐finding studies were conducted in 18 orphan drugs, but dose changes were applied in only 2 drugs. In conclusion, dose‐finding studies in the case of metabolic and oncologic orphan drugs were conducted in the development programs of two thirds of orphan drugs. Dose‐finding studies performed postmarketing suggest that registered doses are not always optimal. It is thus important to perform more robust dose‐finding studies both pre‐ and postmarketing.
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Affiliation(s)
- Yvonne Schuller
- Department of Endocrinology and Metabolism, Academic Medical Center, Meibergdreef, Amsterdam, The Netherlands
| | - Christine Gispen-de Wied
- College ter Beoordeling Geneesmiddelen/Medicines Evaluation Board, Graadt van Roggenweg, Utrecht, The Netherlands
| | - Carla E M Hollak
- Department of Endocrinology and Metabolism, Academic Medical Center, Meibergdreef, Amsterdam, The Netherlands
| | - Hubertus G M Leufkens
- Division of Pharmacoepidemiology and Clinical Pharmacology, Department of Pharmaceutical Sciences, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Universiteitsweg, Utrecht, The Netherlands
| | - Violeta Stoyanova-Beninska
- College ter Beoordeling Geneesmiddelen/Medicines Evaluation Board, Graadt van Roggenweg, Utrecht, The Netherlands
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Kienstra NS, van Reemst HE, van Ginkel WG, Daly A, van Dam E, MacDonald A, Burgerhof JGM, de Blaauw P, McKiernan PJ, Heiner-Fokkema MR, van Spronsen FJ. Daily variation of NTBC and its relation to succinylacetone in tyrosinemia type 1 patients comparing a single dose to two doses a day. J Inherit Metab Dis 2018; 41:181-186. [PMID: 29170874 PMCID: PMC5830494 DOI: 10.1007/s10545-017-0112-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 10/25/2017] [Accepted: 10/29/2017] [Indexed: 12/17/2022]
Abstract
INTRODUCTION In hereditary tyrosinemia type 1 (HT1) patients, the dose of NTBC that leads to the absence of toxic metabolites such as succinylacetone (SA) is still unknown. Therefore, the aims of this study were to investigate the variation and concentrations of 2-(2-nitro-4-trifluormethyl-benzyl)-1,3-cyclohexanedione (NTBC) during the day in relation to the detection of SA, while comparing different dosing regimens. METHODS All patients were treated with NTBC (mean 1.08 ± 0.34 mg/kg/day) and a low phenylalanine-tyrosine diet. Thirteen patients received a single dose of NTBC and five patients twice daily. Home bloodspots were collected four times daily for three consecutive days measuring NTBC and SA concentrations. Statistical analyses were performed by using mixed model analyses and generalized linear mixed model analyses to study variation and differences in NTBC concentrations and the correlation with SA, respectively. RESULTS NTBC concentrations varied significantly during the day especially if NTBC was taken at breakfast only (p = 0.026), although no significant difference in NTBC concentrations between different dosing regimens could be found (p = 0.289). Momentary NTBC concentrations were negatively correlated with SA (p < 0.001). Quantitatively detectable SA was only found in subjects with once daily administration of NTBC and associated with momentary NTBC concentrations <44.3 μmol/l. DISCUSSION NTBC could be less stable than previously considered, thus dosing NTBC once daily and lower concentrations may be less adequate. Further research including more data is necessary to establish the optimal dosing of NTBC.
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Affiliation(s)
- Nienke S Kienstra
- Department of Metabolic Diseases, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands
| | - Hannah E van Reemst
- Department of Metabolic Diseases, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands
| | - Willem G van Ginkel
- Department of Metabolic Diseases, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands
| | - Anne Daly
- Department of Metabolic Diseases, Birmingham Children's Hospital, Birmingham, UK
| | - Esther van Dam
- Department of Dietetics, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Anita MacDonald
- Department of Metabolic Diseases, Birmingham Children's Hospital, Birmingham, UK
| | - Johannes G M Burgerhof
- Department of Epidemiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Pim de Blaauw
- Department of Laboratory Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Patrick J McKiernan
- Department of Metabolic Diseases, Birmingham Children's Hospital, Birmingham, UK
| | - M Rebecca Heiner-Fokkema
- Department of Laboratory Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Francjan J van Spronsen
- Department of Metabolic Diseases, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands.
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Diagnosis and treatment of tyrosinemia type I: a US and Canadian consensus group review and recommendations. Genet Med 2017; 19:S1098-3600(21)04765-1. [PMID: 28771246 PMCID: PMC5729346 DOI: 10.1038/gim.2017.101] [Citation(s) in RCA: 116] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Accepted: 04/28/2017] [Indexed: 12/19/2022] Open
Abstract
Tyrosinemia type I (hepatorenal tyrosinemia, HT-1) is an autosomal recessive condition resulting in hepatic failure with comorbidities involving the renal and neurologic systems and long term risks for hepatocellular carcinoma. An effective medical treatment with 2-[2-nitro-4-trifluoromethylbenzoyl]-1,3-cyclohexanedione (NTBC) exists but requires early identification of affected children for optimal long-term results. Newborn screening (NBS) utilizing blood succinylacetone as the NBS marker is superior to observing tyrosine levels as a way of identifying neonates with HT-1. If identified early and treated appropriately, the majority of affected infants can remain asymptomatic. A clinical management scheme is needed for infants with HT-1 identified by NBS or clinical symptoms. To this end, a group of 11 clinical practitioners, including eight biochemical genetics physicians, two metabolic dietitian nutritionists, and a clinical psychologist, from the United States and Canada, with experience in providing care for patients with HT-1, initiated an evidence- and consensus-based process to establish uniform recommendations for identification and treatment of HT-1. Recommendations were developed from a literature review, practitioner management survey, and nominal group process involving two face-to-face meetings. There was strong consensus in favor of NBS for HT-1, using blood succinylacetone as a marker, followed by diagnostic confirmation and early treatment with NTBC and diet. Consensus recommendations for both immediate and long-term clinical follow-up of positive diagnoses via both newborn screening and clinical symptomatic presentation are provided.
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Das AM. Clinical utility of nitisinone for the treatment of hereditary tyrosinemia type-1 (HT-1). APPLICATION OF CLINICAL GENETICS 2017; 10:43-48. [PMID: 28769581 PMCID: PMC5533484 DOI: 10.2147/tacg.s113310] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Medical therapy for hereditary hepatorenal tyrosinemia (hereditary tyrosinemia type 1, HT-1) with nitisinone was discovered incidentally, and is a by-product of agrochemistry. It blocks the catabolic pathway of tyrosine, thereby leading to a reduction in the accumulation of toxic metabolites in HT-1. It has to be combined with a low-protein diet supplemented with amino acid mixtures devoid of tyrosine and phenylalanine. This treatment option has completely changed the clinical course of patients suffering from HT-1 who used to die in the first few months to years of life from liver failure, renal dysfunction, and/or hepatocellular carcinoma (HCC). It is essential to start nitisinone therapy early in life to avoid sequelae; beginning treatment in the newborn period is ideal. As initial clinical symptoms of HT-1 are often atypical and because there is a clinically latent phase during the first few months of life in many patients, newborn screening is required to secure early diagnosis. Succinylacetone in blood is a reliable screening parameter whereas tyrosine is neither specific nor sensitive. Especially HCC, but also liver and kidney dysfunction, rickets, and neurological crises can be prevented in most patients if nitisinone therapy is started in the newborn period. It is essential to adhere to a low-protein diet to avoid tyrosine toxicity. Reversible eye symptoms may occur as a side-effect of nitisinone, but other side effects are rare. Neurocognitive development is impaired in some patients, and the reason for this is unclear. Metabolic monitoring includes measurement of tyrosine, succinylacetone, and nitisinone concentrations in blood.
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Affiliation(s)
- Anibh Martin Das
- Department of Pediatrics, Hannover Medical School, Hannover, Germany
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Alobaidy H, Barkaoui E. Experience of a Single Center in NTBC Use in Management of Hereditary Tyrosinemia Type I in Libya. IRANIAN JOURNAL OF PEDIATRICS 2015; 25:e3608. [PMID: 26495099 PMCID: PMC4610339 DOI: 10.5812/ijp.3608] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Accepted: 08/16/2015] [Indexed: 11/20/2022]
Abstract
Background: Hereditary Tyrosinemia type I (HTI) is a metabolic disease caused by deficiency of fumarylacetoacetate hydrolase enzyme. Objectives: This study reports beside its clinical and biochemical presentation, the outcome of NTBC [2- (2-nitro-4-trifloro-methylbenzoyl)-1, 3-cyclohexanedion] treatment of the disease and evaluates its biochemical markers in 16 pediatric Libyan patients. Patients and Methods: The diagnosis was based on presence of high tyrosine levels in blood and succinylacetone in urine. Results: The consanguinity rate was 81.2%, the median age at onset, at diagnosis and at starting treatment were 4.5, 8, and 9.5 months respectively. At presentation hepatomegaly, jaundice, rickets and high gamma glutamyl transferase (GGT) were observed in 87.5% of patients. All patients had extremely high alpha fetoprotein (AFP) and high alkaline phosphatase (ALP) levels. Fifteen patients were treated with NTBC, normalization of PT (Prothrombine time) was achieved in average in 14 days. The other biochemical parameters of liver function (transaminases, GGT, ALP, bilirubin and albumin) took longer to improve and several months to be normalized. Survival rate with NTBC was 86.6%. Patients who started treatment in a median of 3 months post onset observed a fast drop of AFP in 90.6% of patients (P = 0.003). Abnormal liver function and rickets were the common presentations, GGT was an early cholestatic sensitive test. ALP was constantly high even in asymptomatic patients. Conclusions: In HT1 a faster dropping of AFP is a marker of good prognosis.
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Affiliation(s)
- Hanna Alobaidy
- Department of Pediatrics, Faculty of Medicine, Elkhadra Hospital, Tripoli University, Tripoli, Libya
- Corresponding author: Hanna Alobaidy, Department of Pediatrics, Faculty of Medicine, Elkhadra Hospital, Tripoli University, Tripoli, Libya. Tel: +218-4900753, Fax: +218-4906030, E-mail:
| | - Emna Barkaoui
- Pasteur Institute, Children’s Hospital, Tunis, Tunisia
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Zeybek ACA, Kiykim E, Soyucen E, Cansever S, Altay S, Zubarioglu T, Erkan T, Aydin A. Hereditary tyrosinemia type 1 in Turkey: twenty year single-center experience. Pediatr Int 2015; 57:281-9. [PMID: 25223216 DOI: 10.1111/ped.12503] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Revised: 08/28/2014] [Accepted: 09/09/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND Hereditary tyrosinemia type 1(HT1) is a chronic disorder leading to severe hepatic, renal and peripheral nerve damage if left untreated. Despite nitisinone treatment HT1 still carries the risks of hepatocellular carcinoma (HCC) and neuropsychological outcome. METHODS A retrospective single center study was carried out based on the phenotype, therapy and outcome in 38 Turkish patients with HT1 diagnosed during the last 20 years. RESULTS None of the patients was diagnosed on newborn screening. The patients were grouped according to acute, subacute and chronic forms of the disorder. The main clinical manifestations were hepatosplenomegaly, liver and renal tubular dysfunction. Thirty-six patients were treated with nitisinone. The mean duration of nitisinone treatment was 64 months and the mean dosage was 1.2 mg/kg/day. Dietary compliance problems were frequent. Eleven patients had cognitive evaluation (mean total IQ, 84 points). Six patients had living donor liver transplantation despite nitisinone treatment: three due to suspected HCC, two for non-compliance to diet, and one for both, at a median age of 90 months. CONCLUSION Nitisinone treatment is effective and improves both short- and long-term prognosis of HT1. Early diagnosis on newborn screening is needed because delay in treatment increases the risk of the persistence of hepatic disease and HCC. Interruption of the drug can lead to re-occurrence of hepatocellular damage and neurological crisis. Increased α-fetoprotein and new hypoechoic nodule formation are the warning signs for HCC.
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Affiliation(s)
- A Cigdem Aktuglu Zeybek
- Department of Pediatrics, Division of Nutrition and Metabolism, Istanbul University, Istanbul, Turkey
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Gertsman I, Barshop BA, Panyard-Davis J, Gangoiti JA, Nyhan WL. Metabolic Effects of Increasing Doses of Nitisinone in the Treatment of Alkaptonuria. JIMD Rep 2015; 24:13-20. [PMID: 25665838 DOI: 10.1007/8904_2014_403] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Revised: 12/12/2014] [Accepted: 12/23/2014] [Indexed: 12/26/2022] Open
Abstract
Alkaptonuria is an autosomal recessive disease involving a deficiency of the enzyme homogentisate dioxygenase, which is involved in the tyrosine degradation pathway. The enzymatic deficiency results in high concentrations of homogentisic acid (HGA), which results in orthopedic and cardiac complications, among other symptoms. Nitisinone (NTBC) has been shown to effectively treat alkaptonuria by blocking the conversion of 4-hydroxyphenylpyruvate to HGA, but there have been concerns that using doses higher than about 2 mg/day could cause excessively high levels of tyrosine, resulting in crystal deposition and corneal pathology. We have enrolled seven patients in a study to determine whether higher doses of NTBC were effective at further reducing HGA levels while maintaining tyrosine at acceptable levels. Patients were given varying doses of NTBC (ranging from 2 to 8 mg/day) over the course of between 0.5 and 3.5 years. Urine HGA, plasma tyrosine levels, and plasma NTBC were then measured longitudinally at various doses. We found that tyrosine concentrations plateaued and did not reach significantly higher levels as NTBC doses were increased above 2 mg/day, while a significant drop in HGA continued from 2 to 4 mg/day, with no significant changes at higher doses. We also demonstrated using untargeted metabolomics that elevations in tyrosine from treatment resulted in proportional elevations in alternative tyrosine metabolic products, that of N-acetyltyrosine and γ-glutamyltyrosine.
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Affiliation(s)
- Ilya Gertsman
- Biochemical Genetics and Metabolomics Laboratory, University of California, San Diego, 9500 Gilman Drive, La Jolla, CA, 92093, USA
| | - Bruce A Barshop
- Biochemical Genetics and Metabolomics Laboratory, University of California, San Diego, 9500 Gilman Drive, La Jolla, CA, 92093, USA.
| | - Jan Panyard-Davis
- Biochemical Genetics and Metabolomics Laboratory, University of California, San Diego, 9500 Gilman Drive, La Jolla, CA, 92093, USA
| | - Jon A Gangoiti
- Biochemical Genetics and Metabolomics Laboratory, University of California, San Diego, 9500 Gilman Drive, La Jolla, CA, 92093, USA
| | - William L Nyhan
- Biochemical Genetics and Metabolomics Laboratory, University of California, San Diego, 9500 Gilman Drive, La Jolla, CA, 92093, USA
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Maiorana A, Malamisura M, Emma F, Boenzi S, Di Ciommo VM, Dionisi-Vici C. Early effect of NTBC on renal tubular dysfunction in hereditary tyrosinemia type 1. Mol Genet Metab 2014; 113:188-93. [PMID: 25172236 DOI: 10.1016/j.ymgme.2014.07.021] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Revised: 07/24/2014] [Accepted: 07/24/2014] [Indexed: 12/22/2022]
Abstract
BACKGROUND Hereditary tyrosinemia type 1 (HT1) is characterized by severe progressive liver disease and renal tubular dysfunction. NTBC therapy has revolutionized the management of HT1 but its effect on renal tubular function has so far been poorly investigated. The aim of this study was to describe the early effect of NTBC on renal tubular disease in patients with HT1. METHODS Five HT1 patients (age between 5 and 53 months) with different types of presentation were evaluated before and during the first 2 weeks of therapy with NTBC in a retrospective case analysis for phosphate metabolism and renal tubular function. RESULTS Before starting NTBC therapy, all children manifested signs of renal dysfunction which included hypophosphatemia, acidosis, reduced phosphate reabsorption, aminoaciduria, glycosuria (Fanconi syndrome), and variable degree of proteinuria. Some patients also presented increased urinary calcium/creatinine ratio and raised fractional excretion of sodium. Starting of NTBC therapy resulted in the rapid normalization of plasma phosphate within one week from its initiation in majority of patients and in all patients during the second week of therapy. TmP/GFR normalized in 48h, while the other markers of renal dysfunction showed an improving trend over 2 weeks. CONCLUSIONS NTBC is an efficient treatment for renal tubular dysfunction in HT1, allowing the return to normal function within a few weeks. Its early effect on renal tubular cells appeared to be very rapid, particularly in normalizing plasma phosphate and TmP/GFR. In our series of patients, the TmP/GFR resulted as the most reliable index of tubular function.
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Affiliation(s)
- A Maiorana
- Department of Pediatric Medicine, Division of Metabolism and Research Unit of Metabolic Biochemistry.
| | - M Malamisura
- Department of Pediatric Medicine, Division of Metabolism and Research Unit of Metabolic Biochemistry.
| | - F Emma
- Department of Nephrology & Urology, Division of Nephrology and Dialysis.
| | - S Boenzi
- Department of Pediatric Medicine, Division of Metabolism and Research Unit of Metabolic Biochemistry.
| | - V M Di Ciommo
- Department of Health, Unit of Epidemiology, Bambino Gesù Children's Hospital and Research Institute, Piazza S. Onofrio 4, 00165 Rome, Italy.
| | - C Dionisi-Vici
- Department of Pediatric Medicine, Division of Metabolism and Research Unit of Metabolic Biochemistry.
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Cross-sectional study of 168 patients with hepatorenal tyrosinaemia and implications for clinical practice. Orphanet J Rare Dis 2014; 9:107. [PMID: 25081276 PMCID: PMC4347563 DOI: 10.1186/s13023-014-0107-7] [Citation(s) in RCA: 83] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Accepted: 07/01/2014] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Hepatorenal tyrosinaemia (Tyr 1) is a rare inborn error of tyrosine metabolism. Without treatment, patients are at high risk of developing acute liver failure, renal dysfunction and in the long run hepatocellular carcinoma. The aim of our study was to collect cross-sectional data. METHODS Via questionnaires we collected retrospective data of 168 patients with Tyr 1 from 21 centres (Europe, Turkey and Israel) about diagnosis, treatment, monitoring and outcome. In a subsequent consensus workshop, we discussed data and clinical implications. RESULTS Early treatment by NTBC accompanied by diet is essential to prevent serious complications such as liver failure, hepatocellular carcinoma and renal disease. As patients may remain initially asymptomatic or develop uncharacteristic clinical symptoms in the first months of life newborn mass screening using succinylacetone (SA) as a screening parameter in dried blood is mandatory for early diagnosis. NTBC-treatment has to be combined with natural protein restriction supplemented with essential amino acids. NTBC dosage should be reduced to the minimal dose allowing metabolic control, once daily dosing may be an option in older children and adults in order to increase compliance. Metabolic control is judged by SA (below detection limit) in dried blood or urine, plasma tyrosine (<400 μM) and NTBC-levels in the therapeutic range (20-40 μM). Side effects of NTBC are mild and often transient. Indications for liver transplantation are hepatocellular carcinoma or failure to respond to NTBC. Follow-up procedures should include liver and kidney function tests, tumor markers and imaging, ophthalmological examination, blood count, psychomotor and intelligence testing as well as therapeutic monitoring (SA, tyrosine, NTBC in blood). CONCLUSION Based on the data from 21 centres treating 168 patients we were able to characterize current practice and clinical experience in Tyr 1. This information could form the basis for clinical practice recommendations, however further prospective data are required to underpin some of the recommendations.
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de Laet C, Dionisi-Vici C, Leonard JV, McKiernan P, Mitchell G, Monti L, de Baulny HO, Pintos-Morell G, Spiekerkötter U. Recommendations for the management of tyrosinaemia type 1. Orphanet J Rare Dis 2013. [DOI: 10.1186/1750-1172-8-8 10.1186/1750-1172-8-188] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
The management of tyrosinaemia type 1 (HT1, fumarylacetoacetase deficiency) has been revolutionised by the introduction of nitisinone but dietary treatment remains essential and the management is not easy. In this review detailed recommendations for the management are made based on expert opinion, published case reports and investigational studies as the evidence base is limited and there are no prospective controlled studies.
The added value of this paper is that it summarises in detail current clinical knowledge about HT1 and makes recommendations for the management.
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de Laet C, Dionisi-Vici C, Leonard JV, McKiernan P, Mitchell G, Monti L, de Baulny HO, Pintos-Morell G, Spiekerkötter U. Recommendations for the management of tyrosinaemia type 1. Orphanet J Rare Dis 2013; 8:8. [PMID: 23311542 PMCID: PMC3558375 DOI: 10.1186/1750-1172-8-8] [Citation(s) in RCA: 135] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2012] [Accepted: 12/27/2012] [Indexed: 01/11/2023] Open
Abstract
The management of tyrosinaemia type 1 (HT1, fumarylacetoacetase deficiency) has been revolutionised by the introduction of nitisinone but dietary treatment remains essential and the management is not easy. In this review detailed recommendations for the management are made based on expert opinion, published case reports and investigational studies as the evidence base is limited and there are no prospective controlled studies.The added value of this paper is that it summarises in detail current clinical knowledge about HT1 and makes recommendations for the management.
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Affiliation(s)
- Corinne de Laet
- Nutrition and Metabolism Unit, Department of Pediatrics, University Children’s Hospital Queen Fabiola, Brussels, Belgium
| | - Carlo Dionisi-Vici
- Division of Metabolism, Department of Pediatric Medicine, Bambino Gesù Children’s Hospital IRCCS, Rome, Italy
| | - James V Leonard
- UCL Institute of Child Health, 30 Guilford Street, LONDON WC1N 1EH, UK
| | - Patrick McKiernan
- The Liver Unit, Birmingham Children’s Hospital, Birmingham, B4 6NH, UK
| | - Grant Mitchell
- Pediatrics Department, CHU Sainte-Justine, 3175 Cote St Catherine, Montreal Quebec, H3T 1C5, Canada
| | - Lidia Monti
- Unit of Hepatobiliary Imaging, Department of Radiology, Bambino Gesù Children’s Hospital IRCCS, Rome, Italy
| | | | - Guillem Pintos-Morell
- Department of Paediatrics, Section of Paediatric Nephrology, Genetics and Metabolism, University Hospital “Germans Trias i Pujol”, Badalona. Universitat Autònoma de Barcelona, Catalonia, Spain
| | - Ute Spiekerkötter
- Ute Spiekerkoetter, Department of Pediatric and Adolescent Medicine, University Children’s Hospital, 79106, Freiburg, Germany
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