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Li Y, Zhang N, Jiang T, Gan L, Su H, Wu Y, Yang X, Xiang G, Ni R, Xu J, Li C, Liu Y. Disproportionality Analysis of Nusinersen in the Food and Drug Administration Adverse Event Reporting System: A Real-World Postmarketing Pharmacovigilance Assessment. Pediatr Neurol 2024; 158:71-78. [PMID: 38981277 DOI: 10.1016/j.pediatrneurol.2024.06.005] [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: 10/09/2023] [Revised: 05/10/2024] [Accepted: 06/09/2024] [Indexed: 07/11/2024]
Abstract
BACKGROUND Nusinersen is the first drug for precise targeted therapy of spinal muscular atrophy, a rare disease that occurs in one of 10,000 to 20,000 live births. Therefore, thorough and comprehensive reports on the safety of nusinersen in large, real-world populations are necessary. This study aimed to mine the adverse event (AE) signals related to nusinersen through the Food and Drug Administration Adverse Event Reporting System (FAERS) database. METHODS We extracted reports of AEs with nusinersen as the primary suspect from FAERS between December 2016 and March 2023. Reporting odds ratio (ROR) and Bayesian confidence propagation neural network (BCPNN) were used for AE signal detection. RESULTS We extracted a total of 4807 suspected AE cases with nusinersen as the primary suspect from the FAERS database. Among them, 106 positive signals were obtained using the ROR and BCPNN. The highest frequency reported systemic organ class was general disorders and administration site conditions. Common clinical AEs of nusinersen were detected in the FAERS database, such as pneumonia, vomiting, back pain, headache, pyrexia, and post-lumbar puncture syndrome. In addition, we identified potential unexpected serious AEs through disproportionality analysis, including sepsis, seizure, epilepsy, brain injury, cardiorespiratory arrest, and cardiac arrest. CONCLUSIONS Analyzing large amounts of real-world data from the FAERS database, we identified potential new AEs of nusinersen by disproportionate analysis. It is advantageous for health care professionals and pharmacists to concentrate on effectively managing high-risk AEs of nusinersen, improve medication levels in clinical settings, and uphold patient medication safety.
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Affiliation(s)
- Yanping Li
- Department of Pharmacy, Daping Hospital, Army Medical University, Chongqing, China
| | - Ni Zhang
- Department of Pharmacy, Daping Hospital, Army Medical University, Chongqing, China
| | - Tingting Jiang
- Department of Pharmacy, Daping Hospital, Army Medical University, Chongqing, China
| | - Lanlan Gan
- Department of Pharmacy, Daping Hospital, Army Medical University, Chongqing, China
| | - Hui Su
- Department of Pharmacy, Daping Hospital, Army Medical University, Chongqing, China
| | - Yuanlin Wu
- Department of Pharmacy, Daping Hospital, Army Medical University, Chongqing, China
| | - Xue Yang
- Department of Pharmacy, Daping Hospital, Army Medical University, Chongqing, China
| | - Guiyuan Xiang
- Department of Pharmacy, Daping Hospital, Army Medical University, Chongqing, China
| | - Rui Ni
- Department of Pharmacy, Daping Hospital, Army Medical University, Chongqing, China
| | - Jing Xu
- Department of Pharmacy, Daping Hospital, Army Medical University, Chongqing, China
| | - Chen Li
- Department of Pharmacy, Daping Hospital, Army Medical University, Chongqing, China
| | - Yao Liu
- Department of Pharmacy, Daping Hospital, Army Medical University, Chongqing, China.
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2
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Herrero-Vicente J, Black DL, Valcárcel J. Splice-modifying drug mechanisms. Nat Chem Biol 2024:10.1038/s41589-024-01678-2. [PMID: 39060391 DOI: 10.1038/s41589-024-01678-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2024]
Affiliation(s)
- Jorge Herrero-Vicente
- Centre for Genomic Regulation (CRG), The Barcelona Institute of Science and Technology, Barcelona, Spain
- Universitat Pompeu Fabra (UPF), Barcelona, Spain
| | - Douglas L Black
- Department of Microbiology, Immunology and Molecular Genetics, University of California Los Angeles, Los Angeles, CA, USA
| | - Juan Valcárcel
- Centre for Genomic Regulation (CRG), The Barcelona Institute of Science and Technology, Barcelona, Spain.
- Universitat Pompeu Fabra (UPF), Barcelona, Spain.
- Institució Catalana de Recerca i Estudis Avançats (ICREA), Barcelona, Spain.
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3
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Qassem S, Breier D, Naidu GS, Hazan-Halevy I, Peer D. Unlocking the therapeutic potential of locked nucleic acids through lipid nanoparticle delivery. MOLECULAR THERAPY. NUCLEIC ACIDS 2024; 35:102224. [PMID: 38933259 PMCID: PMC11201112 DOI: 10.1016/j.omtn.2024.102224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/28/2024]
Abstract
Locked nucleic acids (LNAs) are a subtype of antisense oligonucleotides (ASOs) that are characterized by a bridge within the sugar moiety. LNAs owe their robustness to this chemical modification, which as the name suggests, locks it in one conformation. This perspective includes two components: a general overview on ASOs from one side and on delivery issues focusing on lipid nanoparticles (LNPs) on the other side. Throughout, a screening of the ongoing clinical trials involving ASOs is given, as well as a take on the versatility and challenges of using LNAs. Finally, we highlight the potential of LNPs as carriers for the successful delivery of LNAs.
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Affiliation(s)
- Shahd Qassem
- Laboratory of Precision NanoMedicine, Shmunis School for Biomedicine and Cancer Research, George S. Wise Faculty of Life Sciences, Tel Aviv University, Tel Aviv 69978, Israel
- Center for Nanoscience and Nanotechnology, Tel Aviv University, Tel Aviv 69978, Israel
- Department of Materials Sciences and Engineering, Iby and Aladar Fleischman Faculty of Engineering, Tel Aviv University, Tel Aviv 69978, Israel
- Cancer Biology Research Center, Tel Aviv University, Tel Aviv 69978, Israel
| | - Dor Breier
- Laboratory of Precision NanoMedicine, Shmunis School for Biomedicine and Cancer Research, George S. Wise Faculty of Life Sciences, Tel Aviv University, Tel Aviv 69978, Israel
- Center for Nanoscience and Nanotechnology, Tel Aviv University, Tel Aviv 69978, Israel
- Department of Materials Sciences and Engineering, Iby and Aladar Fleischman Faculty of Engineering, Tel Aviv University, Tel Aviv 69978, Israel
- Cancer Biology Research Center, Tel Aviv University, Tel Aviv 69978, Israel
| | - Gonna Somu Naidu
- Laboratory of Precision NanoMedicine, Shmunis School for Biomedicine and Cancer Research, George S. Wise Faculty of Life Sciences, Tel Aviv University, Tel Aviv 69978, Israel
- Center for Nanoscience and Nanotechnology, Tel Aviv University, Tel Aviv 69978, Israel
- Department of Materials Sciences and Engineering, Iby and Aladar Fleischman Faculty of Engineering, Tel Aviv University, Tel Aviv 69978, Israel
- Cancer Biology Research Center, Tel Aviv University, Tel Aviv 69978, Israel
| | - Inbal Hazan-Halevy
- Laboratory of Precision NanoMedicine, Shmunis School for Biomedicine and Cancer Research, George S. Wise Faculty of Life Sciences, Tel Aviv University, Tel Aviv 69978, Israel
- Center for Nanoscience and Nanotechnology, Tel Aviv University, Tel Aviv 69978, Israel
- Department of Materials Sciences and Engineering, Iby and Aladar Fleischman Faculty of Engineering, Tel Aviv University, Tel Aviv 69978, Israel
- Cancer Biology Research Center, Tel Aviv University, Tel Aviv 69978, Israel
| | - Dan Peer
- Laboratory of Precision NanoMedicine, Shmunis School for Biomedicine and Cancer Research, George S. Wise Faculty of Life Sciences, Tel Aviv University, Tel Aviv 69978, Israel
- Center for Nanoscience and Nanotechnology, Tel Aviv University, Tel Aviv 69978, Israel
- Department of Materials Sciences and Engineering, Iby and Aladar Fleischman Faculty of Engineering, Tel Aviv University, Tel Aviv 69978, Israel
- Cancer Biology Research Center, Tel Aviv University, Tel Aviv 69978, Israel
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4
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Brkušanin M, Kosać A, Branković-Srećković V, Jovanović K, Perić S, Karanović J, Matijašević Joković S, Garai N, Pešović J, Nikolić D, Stević Z, Brajušković G, Milić-Rašić V, Savić-Pavićević D. Phosphorylated neurofilament heavy chain in cerebrospinal fluid and plasma as a Nusinersen treatment response marker in childhood-onset SMA individuals from Serbia. Front Neurol 2024; 15:1394001. [PMID: 38756215 PMCID: PMC11097956 DOI: 10.3389/fneur.2024.1394001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 04/17/2024] [Indexed: 05/18/2024] Open
Abstract
Introduction Biomarkers capable of reflecting disease onset and short- and long-term therapeutic effects in individuals with spinal muscular atrophy (SMA) are still an unmet need and phosphorylated neurofilament heavy chain (pNF-H) holds significant promise. Methods We conducted a longitudinal prospective study to evaluate pNF-H levels in the cerebrospinal fluid (CSF) and plasma of 29 individuals with childhood-onset SMA treated with Nuinersen (SMA type 1: n = 6, 2: n = 17, 3: n = 6). pNF-H levels before and during treatment were compared with the levels of controls (n = 22), patients with Duchenne muscular dystrophy (n = 17), myotonic dystrophy type 1 (n = 11), untreated SMA individuals with chronic type 3 disease (n = 8), and children with presymptomatic SMA (n = 3). Results SMA type 1 showed the highest mean CSF pNF-H levels before treatment initiation. All Nusinersen-treated individuals (types 1, 2, and 3) showed significantly elevated mean baseline CSF pNF-H compared to controls, which inversely correlated with age at disease onset, age at first dose, disease duration and the initial CHOP INTEND result (SMA type 1 and 2). During 22 months of treatment, CSF pNF-H levels declined during loading doses, stabilizing at reduced levels from the initial maintenance dose in all individuals. Baseline plasma pNF-H levels in type 1 and 2 SMA were significantly increased compared to other cohorts and decreased notably in type 1 after 2 months of treatment and type 2 after 14 months. Conversely, SMA type 3, characterized by lower baseline pNF-H levels, did not show significant fluctuations in plasma pNF-H levels after 14 months of treatment. Conclusion Our findings suggest that CSF pNF-H levels in untreated SMA individuals are significantly higher than in controls and that monitoring of CSF pNF-H levels may serve as an indicator of rapid short-term treatment response in childhood-onset SMA individuals, irrespective of the subtype of the disease, while also suggesting its potential for assessing long-term suppression of neurodegeneration. Plasma pNF-H may serve as an appropriate outcome measure for disease progression and/or response to treatment in types 1 and 2 but not in type 3. Presymptomatic infants with SMA may show elevated pNF-H levels, confirming early neuronal degeneration.
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Affiliation(s)
- Miloš Brkušanin
- Faculty of Biology, Centre for Human Molecular Genetics, University of Belgrade, Belgrade, Serbia
| | - Ana Kosać
- Clinic for Neurology and Psychiatry for Children and Youth, Belgrade, Serbia
| | | | - Kristina Jovanović
- University Children's Hospital Tirsova, University Clinical Centre of Serbia, Belgrade, Serbia
| | - Stojan Perić
- Neurology Clinic, University Clinical Centre of Serbia, Belgrade, Serbia
| | - Jelena Karanović
- Faculty of Biology, Centre for Human Molecular Genetics, University of Belgrade, Belgrade, Serbia
| | | | - Nemanja Garai
- Faculty of Biology, Centre for Human Molecular Genetics, University of Belgrade, Belgrade, Serbia
| | - Jovan Pešović
- Faculty of Biology, Centre for Human Molecular Genetics, University of Belgrade, Belgrade, Serbia
| | - Dimitrije Nikolić
- University Children's Hospital Tirsova, University Clinical Centre of Serbia, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Zorica Stević
- Neurology Clinic, University Clinical Centre of Serbia, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Goran Brajušković
- Faculty of Biology, Centre for Human Molecular Genetics, University of Belgrade, Belgrade, Serbia
| | - Vedrana Milić-Rašić
- Clinic for Neurology and Psychiatry for Children and Youth, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Dušanka Savić-Pavićević
- Faculty of Biology, Centre for Human Molecular Genetics, University of Belgrade, Belgrade, Serbia
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Voight S, Arya K. Considerations for Treatment in Clinical Care of Spinal Muscular Atrophy Patients. CHILDREN (BASEL, SWITZERLAND) 2024; 11:495. [PMID: 38671712 PMCID: PMC11049032 DOI: 10.3390/children11040495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Revised: 04/09/2024] [Accepted: 04/13/2024] [Indexed: 04/28/2024]
Abstract
Spinal Muscular Atrophy is a neurodegenerative disease which can lead to muscle weakness, paralysis, and in some cases death. There are many factors that contribute to the severity of symptoms and those factors can be used to determine the best course of treatment for the patients. We looked through published literature to create a set of considerations for treatment in patients with Spinal Muscular Atrophy including age, type, SMN2 copies, and any familial considerations. This can serve as a guide for what to consider in the treatment of SMA patients clinically.
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Affiliation(s)
- Stephanie Voight
- Department of Neuroscience, College of Natural Sciences, The University of Texas at Austin, Austin, TX 78712, USA;
| | - Kapil Arya
- Division of Pediatric Neurology, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR 72202, USA
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Kiel K, Król SK, Bronisz A, Godlewski J. MiR-128-3p - a gray eminence of the human central nervous system. MOLECULAR THERAPY. NUCLEIC ACIDS 2024; 35:102141. [PMID: 38419943 PMCID: PMC10899074 DOI: 10.1016/j.omtn.2024.102141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
MicroRNA-128-3p (miR-128-3p) is a versatile molecule with multiple functions in the physiopathology of the human central nervous system. Perturbations of miR-128-3p, which is enriched in the brain, contribute to a plethora of neurodegenerative disorders, brain injuries, and malignancies, as this miRNA is a crucial regulator of gene expression in the brain, playing an essential role in the maintenance and function of cells stemming from neuronal lineage. However, the differential expression of miR-128-3p in pathologies underscores the importance of the balance between its high and low levels. Significantly, numerous reports pointed to miR-128-3p as one of the most depleted in glioblastoma, implying it is a critical player in the disease's pathogenesis and thus may serve as a therapeutic agent for this most aggressive form of brain tumor. In this review, we summarize the current knowledge of the diverse roles of miR-128-3p. We focus on its involvement in the neurogenesis and pathophysiology of malignant and neurodegenerative diseases. We also highlight the promising potential of miR-128-3p as an antitumor agent for the future therapy of human cancers, including glioblastoma, and as the linchpin of brain development and function, potentially leading to the development of new therapies for neurological conditions.
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Affiliation(s)
- Klaudia Kiel
- Tumor Microenvironment Laboratory, Mossakowski Medical Research Institute, Polish Academy of Sciences, 5 Pawińskiego Street, Warsaw, Poland
| | - Sylwia Katarzyna Król
- Department of Neurooncology, Mossakowski Medical Research Institute, Polish Academy of Sciences, 5 Pawińskiego Street, Warsaw, Poland
| | - Agnieszka Bronisz
- Tumor Microenvironment Laboratory, Mossakowski Medical Research Institute, Polish Academy of Sciences, 5 Pawińskiego Street, Warsaw, Poland
| | - Jakub Godlewski
- Department of Neurooncology, Mossakowski Medical Research Institute, Polish Academy of Sciences, 5 Pawińskiego Street, Warsaw, Poland
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7
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Servais L, Day JW, De Vivo DC, Kirschner J, Mercuri E, Muntoni F, Proud CM, Shieh PB, Tizzano EF, Quijano-Roy S, Desguerre I, Saito K, Faulkner E, Benguerba KM, Raju D, LaMarca N, Sun R, Anderson FA, Finkel RS. Real-World Outcomes in Patients with Spinal Muscular Atrophy Treated with Onasemnogene Abeparvovec Monotherapy: Findings from the RESTORE Registry. J Neuromuscul Dis 2024; 11:425-442. [PMID: 38250783 DOI: 10.3233/jnd-230122] [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] [Indexed: 01/23/2024]
Abstract
Background Long-term, real-world effectiveness and safety data of disease-modifying treatments for spinal muscular atrophy (SMA) are important for assessing outcomes and providing information for a larger number and broader range of SMA patients than included in clinical trials. Objective We sought to describe patients with SMA treated with onasemnogene abeparvovec monotherapy in the real-world setting. Methods RESTORE is a prospective, multicenter, multinational, observational registry that captures data from a variety of sources. Results Recruitment started in September 2018. As of May 23, 2022, data were available for 168 patients treated with onasemnogene abeparvovec monotherapy. Median (IQR) age at initial SMA diagnosis was 1 (0-6) month and at onasemnogene abeparvovec infusion was 3 (1-10) months. Eighty patients (47.6%) had two and 70 (41.7%) had three copies of SMN2, and 98 (58.3%) were identified by newborn screening. Infants identified by newborn screening had a lower age at final assessment (mean age 11.5 months) and greater mean final (SD) CHOP INTEND score (57.0 [10.0] points) compared with clinically diagnosed patients (23.1 months; 52.1 [8.0] points). All patients maintained/achieved motor milestones. 48.5% (n = 81/167) experienced at least one treatment-emergent adverse event (AE), and 31/167 patients (18.6%) experienced at least one serious AE, of which 8/31 were considered treatment-related. Conclusion These real-world outcomes support findings from the interventional trial program and demonstrate effectiveness of onasemnogene abeparvovec over a large patient population, which was consistent with initial clinical data and published 5-year follow-up data. Observed AEs were consistent with the established safety profile of onasemnogene abeparvovec.
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Affiliation(s)
- Laurent Servais
- MDUK Oxford Neuromuscular Centre & NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
- Neuromuscular Reference Center, Department of Paediatrics, University and University Hospital of Liège, Liège, Belgium
| | - John W Day
- Department of Neurology, Stanford University Medical Center, Stanford, CA, USA
| | - Darryl C De Vivo
- Departments of Neurology and Pediatrics, Columbia University Irving Medical Center, New York, NY, USA
| | - Janbernd Kirschner
- Department for Neuropediatrics and Muscle Disease, Medical Center - University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Eugenio Mercuri
- Department of Paediatric Neurology and Nemo Clinical Centre, Catholic University, Rome, Italy
| | - Francesco Muntoni
- The Dubowitz Neuromuscular Centre, University College London, Great Ormond Street Institute of Child Health & Great Ormond Street Hospital, London, UK
- National Institute of Health Research, Great Ormond Street Hospital Biomedical Research Centre, London, UK
| | - Crystal M Proud
- Children's Hospital of The King's Daughters, Norfolk, VA, USA
| | - Perry B Shieh
- Department of Neurology, David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, CA, USA
| | - Eduardo F Tizzano
- Department of Clinical and Molecular Genetics, Hospital Vall d'Hebron, Barcelona, Spain
| | - Susana Quijano-Roy
- Garches Neuromuscular Reference Center, Child Neurology and ICU Department, APHP Raymond Poincare University Hospital (UVSQ Paris Saclay), Garches, France
| | | | - Kayoko Saito
- Institute of Medical Genetics, Tokyo Women's Medical University, Tokyo, Japan
| | - Eric Faulkner
- Novartis Gene Therapies, Inc., Bannockburn, IL, USA
- Institute for Precision and Individualized Therapy, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, IL, USA
- Genomics, Biotech and Emerging Medical Technology Institute, National Association of Managed Care Physicians, Richmond, VA, USA
| | | | - Dheeraj Raju
- Novartis Gene Therapies, Inc., Bannockburn, IL, USA
| | | | - Rui Sun
- Novartis Gene Therapies, Inc., Bannockburn, IL, USA
| | - Frederick A Anderson
- Center for Outcomes Research, University of Massachusetts Medical School, Worcester, MA, USA
| | - Richard S Finkel
- Center for Experimental Neurotherapeutics, St. Jude Children's Research Hospital, Memphis, TN, USA
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8
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Audic F. Gene therapy in spinal muscular atrophy. Arch Pediatr 2023; 30:8S12-8S17. [PMID: 38043977 DOI: 10.1016/s0929-693x(23)00222-1] [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] [Indexed: 12/05/2023]
Abstract
Infantile SMA is a neuromuscular disease caused by the motor neuron degeneration, depending on the age of appearance of clinical signs and the evolution of the disease, three types of decreasing severity have been defined. SMA is caused by mutations or deletions of the SMN1 gene and disease. Various therapies aimed at increasing SMN protein levels have been developed. Gene therapy is part of the therapeutic arsenal now available for the treatment of SMA under certain conditions. It uses the scAAV9 vector carrying a functional copy of SMN1 to restore SMN protein expression at the cellular level. Because the adeno-associated virus genome is maintained as it is an episome, a single intravenous administration is sufficient to producing a long-lasting therapeutic effect. The effectiveness of gene replacement therapy in patients with SMA has been demonstrated in various studies. It is now clear that treatment as early as possible provides better clinical results. However, this treatment must be carried out in a suitable medical environment, with close monitoring initially due to potentially serious side effects. In France, this treatment has been available since 2019. A national committee of experts involved in the treatment of pediatric SMA patients has established that pediatric patients with SMA decide on the indications for disease-modifying therapies (DMT) in children. The French Spinal Muscular Atrophy Registry (SMA France Registry) was established in January 2020. The registry includes all patients with genetically confirmed SMN1-related SMA. All patients treated with GT are systematically included in the registry. As of July 21, 2023: 72 patients with SMA have been treated with GT in France since June 2019. The arrival of new treatments reveals new clinical phenotypes of SMA which constitute a new management challenge. Treatment as early as possible is also a very important factor for a favorable outcome and calls for presymptomatic screening. However, the arrival of these new treatments, extremely expensive raises other socio-economic questions. © 2023 Published by Elsevier Masson SAS on behalf of French Society of Pediatrics.
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Affiliation(s)
- Frédérique Audic
- Centre de Référence des Maladies Neuromusculaires de l'enfant PACARARE, Service de Neuropédiatrie, Hôpital Timone Enfants, 264 rue Saint Pierre, 14 13385 Marseille Cedex 5, France.
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9
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Pessano S, Romantsik O, Olsson E, Hedayati E, Bruschettini M. Pharmacological interventions for the management of pain and discomfort during lumbar puncture in newborn infants. Cochrane Database Syst Rev 2023; 9:CD015594. [PMID: 37767875 PMCID: PMC10535798 DOI: 10.1002/14651858.cd015594.pub2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/29/2023]
Abstract
BACKGROUND Lumbar puncture (LP) is a common invasive procedure, most frequently performed to diagnose infection. Physicians perform LP in newborn infants with the help of an assistant using a strict aseptic technique; it is important to monitor the infant during all the steps of the procedure. Without adequate analgesia, LP can cause considerable pain and discomfort. As newborns have increased sensitivity to pain, it is crucial to adequately manage the procedural pain of LP in this population. OBJECTIVES To assess the benefits and harms, including pain, discomfort, and success rate, of any pharmacological intervention during lumbar puncture in newborn infants, compared to placebo, no intervention, non-pharmacological interventions, or other pharmacological interventions. SEARCH METHODS We searched CENTRAL, PubMed, Embase, and three trial registries in December 2022. We also screened the reference lists of included studies and related systematic reviews for studies not identified by the database searches. SELECTION CRITERIA We included randomized controlled trials (RCTs) and quasi-RCTs comparing drugs used for pain management, sedation, or both, during LP. We considered the following drugs suitable for inclusion. • Topical anesthetics (e.g. eutectic mixture of local anesthetics [EMLA], lidocaine) • Opioids (e.g. morphine, fentanyl) • Alpha-2 agonists (e.g. clonidine, dexmedetomidine) • N-Methyl-D-aspartate (NMDA) receptor antagonists (e.g. ketamine) • Other analgesics (e.g. paracetamol) • Sedatives (e.g. benzodiazepines such as midazolam) DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. We used the fixed-effect model with risk ratio (RR) for dichotomous data and mean difference (MD) or standardized mean difference (SMD) for continuous data, with their 95% confidence intervals (CIs). Our main outcomes were successful LP on first attempt, total number of LP attempts, episodes of bradycardia, pain assessed with validated scales, episodes of desaturation, number of episodes of apnea, and number of infants with one or more episodes of apnea. We used the GRADE approach to evaluate the certainty of the evidence. MAIN RESULTS We included three studies (two RCTs and one quasi-RCT) that enrolled 206 newborns. One study included only term infants. All studies assessed topical treatment versus placebo or no intervention. The topical anesthetics were lidocaine 4%, lidocaine 1%, and EMLA. We identified no completed studies on opioids, non-steroidal anti-inflammatory drugs, alpha-2 agonists, NMDA receptor antagonists, other analgesics, sedatives, or head-to-head comparisons (drug A versus drug B). Based on very low-certainty evidence from one quasi-RCT of 100 LPs in 76 infants, we are unsure if topical anesthetics (lidocaine), compared to no anesthesia, has an effect on the following outcomes. • Successful LP on first attempt (first-attempts success in 48% of LPs in the lidocaine group and 42% of LPs in the control group) • Number of attempts per LP (mean 1.9 attempts, [standard error of the mean 0.2] in the lidocaine group, and mean 2.1 attempts [standard error of the mean 2.1] in the control group) • Episodes of bradycardia (0% of LPs in the lidocaine group and 4% of LPs in the control group) • Episodes of desaturation (0% of LPs in the lidocaine group and 8% of LPs in the control group) • Occurrence of apnea (RR 3.24, 95% CI 0.14 to 77.79; risk difference [RD] 0.02, 95% CI -0.03 to 0.08). Topical anesthetics compared to placebo may reduce pain assessed with the Neonatal Facial Coding System (NFCS) score (SMD -1.00 standard deviation (SD), 95% CI -1.47 to -0.53; I² = 98%; 2 RCTs, 112 infants; low-certainty evidence). No studies in this comparison reported total number of episodes of apnea. We identified three ongoing studies, which will assess the effects of EMLA, lidocaine, and fentanyl. Three studies are awaiting classification. AUTHORS' CONCLUSIONS The evidence is very uncertain about the effect of topical anesthetics (lidocaine) compared to no anesthesia on successful lumbar puncture on first attempt, the number of attempts per lumbar puncture, episodes of bradycardia, episodes of desaturation, and occurrence of apnea. Compared to placebo, topical anesthetics (lidocaine or EMLA) may reduce pain assessed with the NFCS score. One ongoing study will assess the effects of systemic treatment.
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Affiliation(s)
- Sara Pessano
- Neonatal Intensive Care Unit, Department Mother and Child, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Olga Romantsik
- Paediatrics, Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
| | - Emma Olsson
- Department of Pediatrics, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
- Faculty of Medicine and Health, School of Health Sciences, Örebro University, Örebro, Sweden
| | - Ehsan Hedayati
- Nezam Mafi Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Matteo Bruschettini
- Paediatrics, Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
- Cochrane Sweden, Department of Research and Education, Lund University, Skåne University Hospital, Lund, Sweden
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10
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Yaksh TL, Santos GGD, Borges Paes Lemes J, Malange K. Neuraxial drug delivery in pain management: An overview of past, present, and future. Best Pract Res Clin Anaesthesiol 2023; 37:243-265. [PMID: 37321769 DOI: 10.1016/j.bpa.2023.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 04/11/2023] [Indexed: 06/17/2023]
Abstract
Activation of neuraxial nociceptive linkages leads to a high level of encoding of the message that is transmitted to the brain and that can initiate a pain state with its attendant emotive covariates. As we review here, the encoding of this message is subject to a profound regulation by pharmacological targeting of dorsal root ganglion and dorsal horn systems. Though first shown with the robust and selective modulation by spinal opiates, subsequent work has revealed the pharmacological and biological complexity of these neuraxial systems and points to several regulatory targets. Novel therapeutic delivery platforms, such as viral transfection, antisense and targeted neurotoxins, point to disease-modifying approaches that can selectively address the acute and chronic pain phenotype. Further developments are called for in delivery devices to enhance local distribution and to minimize concentration gradients, as frequently occurs with the poorly mixed intrathecal space. The field has advanced remarkably since the mid-1970s, but these advances must always address the issues of safety and tolerability of neuraxial therapy.
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Affiliation(s)
- Tony L Yaksh
- Department of Anesthesiology University of California, San Diego, San Diego CA, 92103, USA.
| | | | | | - Kaue Malange
- Department of Anesthesiology University of California, San Diego, San Diego CA, 92103, USA
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11
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Machetanz G, Grziwotz M, Semmler L, Maier M, Maegerlein C, Deschauer M. Symptomatic intracranial hypertension in an adult patient with spinal muscular atrophy and arachnoid cysts receiving nusinersen. J Neuromuscul Dis 2023:JND230032. [PMID: 37248913 DOI: 10.3233/jnd-230032] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
In patients with spinal muscular atrophy (SMA) headache after intrathecal administration of nusinersen is usually attributed to post-lumbar puncture syndrome. However, lumbar puncture opening pressure (LOP) has also been reported to be increased in children with SMA, both before and after treatment with nusinersen, although symptoms associated with increased LOP were not observed. We report to our knowledge the first case of symptomatic intracranial hypertension in an adult SMA patient. This 21-year-old man suffered from headache and vomiting followed by visual disturbances after the 12th injection of nusinersen. Bilateral papilledema was recognized ophthalmologically. MRI of the head showed signs of intracranial hypertension and additionally arachnoid cysts but not hydrocephalus. Symptoms resolved after 8 weeks of treatment with repeated lumbar punctures and acetazolamide. This case raises the possibility of intracranial hypertension as a complication of nusinersen therapy although arachnoid cysts represent another risk factor for intracranial hypertension. We recommend that patients suffering from headache after nusinersen injections should not only be questioned and examined for symptoms suggestive of post-lumbar puncture syndrome, but also intracranial hypertension.
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Affiliation(s)
- Gerrit Machetanz
- Department of Neurology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Marc Grziwotz
- Department of Neurology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Luisa Semmler
- Department of Neurology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Mathias Maier
- Department of Ophthalmology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Christian Maegerlein
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Marcus Deschauer
- Department of Neurology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
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Shimizu-Motohashi Y, Chiba E, Mizuno K, Yajima H, Ishiyama A, Takeshita E, Sato N, Oba M, Sasaki M, Ito S, Komaki H. Muscle impairment in MRI affect variability in treatment response to nusinersen in patients with spinal muscular atrophy type 2 and 3: A retrospective cohort study. Brain Dev 2023; 45:161-170. [PMID: 36460551 DOI: 10.1016/j.braindev.2022.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 11/08/2022] [Accepted: 11/09/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Real-world data have shown variability in treatment responses to nusinersen in spinal muscular atrophy (SMA). We investigated whether the magnitude of muscle impairment assessed by magnetic resonance imaging (MRI) at baseline can predict the treatment response. METHODS We retrospectively assessed the clinical data in relevance to the thigh and pelvic MRI taken before the nusinersen treatment. A total of 16 patients with SMA types 2 and 3 (age = mean [SD]; 9.2 [4.6] year) receiving nusinersen treatment were enrolled. The T1-weighted MRI images of the pelvis and thigh were scored for muscle fatty infiltration and atrophy. The minimally clinically important difference (MCID) was considered as gaining at least 3 points of Hammersmith Functional Motor Scale-Expanded (HFMSE) from baseline. RESULTS Of these 16 individuals, 14 had been treated for at least 15 months with baseline data. At 15 months, seven individuals obtained MCID in HFMSE. Baseline muscle MRI score could not differentiate the two groups; however, individuals who obtained MCID had significantly less severe scoliosis. In addition, there was a significant and negative relationship between baseline MRI score and the change of score in HFMSE after 15 months of treatment. Further, baseline Cobb angle along with MRI score also indicated the correlation to the degree of change in motor function. CONCLUSION The degree of muscle damage may confer the variability in response to nusinersen in SMA types 2 and 3. Muscle MRI score along with the severity of scoliosis assessed at baseline may help to predict the motor function change.
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Affiliation(s)
- Yuko Shimizu-Motohashi
- Department of Child Neurology, National Center Hospital, National Center of Neurology and Psychiatry, 4-1-1 Ogawahigashi-cho, Kodaira, Tokyo 187-8551, Japan
| | - Emiko Chiba
- Department of Radiology, National Center Hospital, National Center of Neurology and Psychiatry, 4-1-1 Ogawahigashi-cho, Kodaira, Tokyo 187-8551, Japan
| | - Katsuhiro Mizuno
- Department of Rehabilitation Medicine, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa 259-1193, Japan; Department of Physical Rehabilitation, National Center Hospital, National Center of Neurology and Psychiatry, 4-1-1 Ogawahigashi-cho, Kodaira, Tokyo 187-8551, Japan
| | - Hiroyuki Yajima
- Translational Medical Center, National Center of Neurology and Psychiatry, 4-1-1 Ogawahigashi-cho, Kodaira, Tokyo 187-8551, Japan
| | - Akihiko Ishiyama
- Department of Neuropediatrics, Tokyo Metropolitan Neurological Hospital, 2-6-1 Musashidai, Fuchu-shi, Tokyo 183-0042, Japan
| | - Eri Takeshita
- Department of Child Neurology, National Center Hospital, National Center of Neurology and Psychiatry, 4-1-1 Ogawahigashi-cho, Kodaira, Tokyo 187-8551, Japan
| | - Noriko Sato
- Department of Radiology, National Center Hospital, National Center of Neurology and Psychiatry, 4-1-1 Ogawahigashi-cho, Kodaira, Tokyo 187-8551, Japan
| | - Mari Oba
- Translational Medical Center, National Center of Neurology and Psychiatry, 4-1-1 Ogawahigashi-cho, Kodaira, Tokyo 187-8551, Japan; Clinical Research & Education Promotion Division, National Center of Neurology and Psychiatry, 4-1-1 Ogawahigashi-cho, Kodaira, Tokyo 187-8551, Japan
| | - Masayuki Sasaki
- Department of Child Neurology, National Center Hospital, National Center of Neurology and Psychiatry, 4-1-1 Ogawahigashi-cho, Kodaira, Tokyo 187-8551, Japan
| | - Shuichi Ito
- Department of Pediatrics, Graduate School of Medicine, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa 236-0004, Japan
| | - Hirofumi Komaki
- Department of Child Neurology, National Center Hospital, National Center of Neurology and Psychiatry, 4-1-1 Ogawahigashi-cho, Kodaira, Tokyo 187-8551, Japan; Translational Medical Center, National Center of Neurology and Psychiatry, 4-1-1 Ogawahigashi-cho, Kodaira, Tokyo 187-8551, Japan; Clinical Research & Education Promotion Division, National Center of Neurology and Psychiatry, 4-1-1 Ogawahigashi-cho, Kodaira, Tokyo 187-8551, Japan.
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Pan M, Shi J, Miao H, Zhang Q. Successful weaning from the invasive respiratory support after nusinersen treatment in a child with SMA type 1: A case report. Front Pediatr 2023; 11:1097063. [PMID: 36873628 PMCID: PMC9975261 DOI: 10.3389/fped.2023.1097063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Accepted: 01/23/2023] [Indexed: 02/17/2023] Open
Abstract
BACKGROUND Spinal muscular atrophy (SMA) is an autosomal recessive disease, which can be classified into 4 types according to the symptom onset age and the highest physical developmental milestone. Among them, type 1 SMA is the most severe form that affects infants younger than 6 months. Permanent assisted ventilation is usually needed for infants with type 1 SMA before the age of 2 years due to the rapid progression of disease. Nusinersen can improve the motor function of SMA patients, but its effect on respiratory function varies. In the present study, we reported a case of child with type 1 SMA who was successfully weaned from the invasive respiratory support after nusinersen treatment. CASE PRESENTATION A girl aged 6 years and 5 months was admitted for SMA in the Children's Hospital of Nanjing Medical University for 18 times. She received the first administration of nusinersen in November 2020 at the age of 5 years and 1 month. At the age of 6 years and 1 month following 6 loading doses, we tried to wean the child from the invasive ventilation for non-invasive respiratory support using a nasal mask. At present, the patient shows oxygen saturation (SpO2) above 95% without ventilator support during the daytime, and no signs of dyspnea. A non-invasive home ventilator was used at nighttime for the sake of safety. The CHOP INTEND score increased by 11 points from the first loading dose to the sixth. She can now move her limbs against gravity, take in food orally and perform partial vocal function. CONCLUSIONS We reported a child with type 1 SMA who was successfully weaned from the 2-years invasive ventilation after 6 loading doses, and now only need non-invasive ventilation 12 h per day. It is suggested that even a late nusinersen treatment can improve respiratory and motor function in SMA patients, and wean them from mechanical ventilation, thus improve the quality of life and reduce the medical cost.
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Affiliation(s)
- Meiling Pan
- Department of Emergency and Critical Care Medicine, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Jun Shi
- Department of Emergency and Critical Care Medicine, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Hongjun Miao
- Department of Emergency and Critical Care Medicine, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Qin Zhang
- Department of Emergency and Critical Care Medicine, Children's Hospital of Nanjing Medical University, Nanjing, China
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Pessano S, Romantsik O, Hedayati E, Olsson E, Bruschettini M. Pharmacological interventions for the management of pain and discomfort during lumbar puncture in newborn infants. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2022; 2022:CD015594. [PMCID: PMC9749080 DOI: 10.1002/14651858.cd015594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To assess the benefits and harms, including pain, discomfort, and success rate, of any pharmacological intervention during lumbar puncture in newborn infants, compared to placebo, no intervention, non‐pharmacological interventions, or other pharmacological interventions.
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Affiliation(s)
| | - Sara Pessano
- Neonatal Intensive Care Unit, Department Mother and ChildIRCCS Istituto Giannina GasliniGenoaItaly
| | - Olga Romantsik
- Department of Clinical Sciences Lund, PaediatricsLund University, Skåne University HospitalLundSweden
| | - Ehsan Hedayati
- Nezam Mafi HospitalAhvaz Jundishapur University of Medical SciencesAhvazIran
| | | | - Matteo Bruschettini
- Department of Clinical Sciences Lund, Paediatrics, Lund University, Skåne University HospitalLundSweden,Cochrane Sweden, Lund University, Skåne University HospitalLundSweden
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Abstract
Onasemnogene abeparvovec (Zolgensma®) is a gene therapy approved for the treatment of spinal muscular atrophy (SMA). Administered as a one-time intravenous infusion, onasemnogene abeparvovec uses the adeno-associated virus vector to deliver a functional copy of the human survival motor neuron (SMN) gene to motor neuron cells. SMN1 encodes survival motor neuron protein, which is responsible for the maintenance and function of motor neurons. In clinical trials, onasemnogene abeparvovec improved event-free survival, motor function and motor milestone outcomes in patients with SMA, with these improvements maintained over the longer term (up to a median of ≈ 5 years). Onasemnogene abeparvovec was also associated with rapid age-appropriate achievement of motor milestones and improvements in motor function in children with pre-symptomatic SMA, indicating the benefit of early treatment. Onasemnogene abeparvovec was generally well tolerated. Hepatotoxicity is a known risk that can generally be mitigated with prophylactic prednisolone. In conclusion, onasemnogene abeparvovec represents an important treatment option for patients with SMA, particularly when initiated early in the course of the disease.
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Affiliation(s)
- Hannah A Blair
- Springer Nature, Private Bag 65901, Mairangi Bay, Auckland, 0754, New Zealand.
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De Andres J, Hayek S, Perruchoud C, Lawrence MM, Reina MA, De Andres-Serrano C, Rubio-Haro R, Hunt M, Yaksh TL. Intrathecal Drug Delivery: Advances and Applications in the Management of Chronic Pain Patient. FRONTIERS IN PAIN RESEARCH 2022; 3:900566. [PMID: 35782225 PMCID: PMC9246706 DOI: 10.3389/fpain.2022.900566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Accepted: 05/02/2022] [Indexed: 11/19/2022] Open
Abstract
Advances in our understanding of the biology of spinal systems in organizing and defining the content of exteroceptive information upon which higher centers define the state of the organism and its role in the regulation of somatic and automatic output, defining the motor response of the organism, along with the unique biology and spatial organization of this space, have resulted in an increased focus on therapeutics targeted at this extracranial neuraxial space. Intrathecal (IT) drug delivery systems (IDDS) are well-established as an effective therapeutic approach to patients with chronic non-malignant or malignant pain and as a tool for management of patients with severe spasticity and to deliver therapeutics that address a myriad of spinal pathologies. The risk to benefit ratio of IDD makes it a useful interventional approach. While not without risks, this approach has a significant therapeutic safety margin when employed using drugs with a validated safety profile and by skilled practioners. The present review addresses current advances in our understanding of the biology and dynamics of the intrathecal space, therapeutic platforms, novel therapeutics, delivery technology, issues of safety and rational implementation of its therapy, with a particular emphasis upon the management of pain.
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Affiliation(s)
- Jose De Andres
- Surgical Specialties Department, Valencia University Medical School, Valencia, Spain
- Anesthesia Critical Care and Pain Management Department, Valencia, Spain
- *Correspondence: Jose De Andres
| | - Salim Hayek
- Department of Anesthesiology, University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - Christophe Perruchoud
- Pain Center and Department of Anesthesia, La Tour Hospital, Geneva, Switzerland
- Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Melinda M. Lawrence
- Department of Anesthesiology, University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - Miguel Angel Reina
- Department of Anesthesiology, Montepríncipe University Hospital, Madrid, Spain
- CEU-San-Pablo University School of Medicine, Madrid, Spain
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL, United States
- Facultad de Ciencias de la Salud Universidad Francisco de Vitoria, Madrid, Spain
| | | | - Ruben Rubio-Haro
- Anesthesia and Pain Management Department, Provincial Hospital, Castellon, Spain
- Multidisciplinary Pain Clinic, Vithas Virgen del Consuelo Hospital, Valencia, Spain
| | - Mathew Hunt
- Department of Physiology, Karolinska Institute, Stockholm, Sweden
| | - Tony L. Yaksh
- Departments of Anesthesiology and Pharmacology, University of California, San Diego, San Diego, CA, United States
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