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Sanville J, O'Toole GA, Madan J, Coker M. Premodulator microbiome alterations associated with postmodulator growth outcomes in pediatric cystic fibrosis: Can we predict outcomes? J Pediatr Gastroenterol Nutr 2024. [PMID: 39118488 DOI: 10.1002/jpn3.12350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 07/11/2024] [Accepted: 07/16/2024] [Indexed: 08/10/2024]
Abstract
OBJECTIVES The gut microbiota plays an important role in childhood growth. Our longitudinal cohort includes children with children with cystic fibrosis (CwCF) treated with highly effective modulator therapy. We aimed to elucidate early premodulator microbial signatures associated with postmodulator weight for CwCF later in childhood. METHODS Stool samples were collected from CwCF at 13 days to 60 months. Metagenomic sequencing determined differentially abundant taxa. Children with body mass index or weight for length Z-scores within 1 standard deviation of the mean (SD) were considered normal weight, those >1 SD were classified as risk of overweight while children <1 SD were considered undernourished, although no CwCF met this latter criterion here. Multivariate regression models were applied to identify significant associations between metadata and microbial taxonomic relative abundances. RESULTS One hundred and eighty-nine stool samples were analyzed from 39 CwCF. We identified statistically significant differences in early microbiome patterns among those at risk of being overweight compared to those who were normal weight when adjusted for age, sex, CF mutation, and early feeding method. Early microbiome was a stronger driver of growth status than current modulator use. Among those at risk of overweight, several taxa that were consistently in lower abundance included Eggerthella lentha, Ruminococcus, Bacteroides, with increase in abundance of Bacteroides stercoris. CONCLUSIONS The early microbiome strongly predicts growth in the setting of modulator use for CwCF and we identify microbiome signatures associated with risk of being overweight. We highlight the possibility for interventions or early alternations to nutritional guidance for prevention of comorbid complications.
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Affiliation(s)
- Julie Sanville
- Department of Pediatrics, Division of Pediatric Gastroenterology, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - George A O'Toole
- Department of Microbiology and Immunology, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Juliette Madan
- Departments of Pediatrics and Psychiatry, Division of Child and Adolescent Psychiatry, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire, USA
- Department of Epidemiology, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
- Department of Quantitative Biomedical Data Science, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Modupe Coker
- Department of Epidemiology, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
- Department of Quantitative Biomedical Data Science, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
- Department of Oral Biology, Rutgers School of Dental Medicine, Newark, New Jersey, USA
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2
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Bardin E, Pranke I, Hinzpeter A, Sermet-Gaudelus I. [Therapeutics in cystic fibrosis: Clinical revolution and new challenges]. Med Sci (Paris) 2024; 40:258-267. [PMID: 38520101 DOI: 10.1051/medsci/2024014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/25/2024] Open
Abstract
Over time, cystic fibrosis has become a model of synergy between research in pathophysiology and cell biology, and clinical advances. Therapies targeting the CFTR protein, in particular CFTR modulators, have transformed the prognosis of patients, bringing the hope of a normal life with the possibility of starting a family and growing old, challenging established statistics. However, patients are not yet cured, and side effects remain insufficiently documented. Epidemiological changes create new challenges for the management of cystic fibrosis. Approximately 10 % of patients still lack a therapeutic option. The community of researchers, pharmaceutical industries, patient associations, and health authorities remains committed to monitor the long-term effects of these still poorly characterised treatments, and to explore new pharmacological approaches, such as gene therapies.
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Affiliation(s)
- Emmanuelle Bardin
- Université Paris Cité, Inserm U1151, Institut Necker Enfants Malades, Paris, France
| | - Iwona Pranke
- Université Paris Cité, Inserm U1151, Institut Necker Enfants Malades, Paris, France
| | - Alexandre Hinzpeter
- Université Paris Cité, Inserm U1151, Institut Necker Enfants Malades, Paris, France
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3
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Mailhot G, Denis MH, Beauchamp-Parent C, Jomphe V. Nutritional management of people living with cystic fibrosis throughout life and disease continuum: Changing times, new challenges. J Hum Nutr Diet 2023; 36:1675-1691. [PMID: 37515397 DOI: 10.1111/jhn.13214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 07/07/2023] [Accepted: 07/10/2023] [Indexed: 07/30/2023]
Abstract
Cystic fibrosis (CF) is a genetic disease caused by mutations in the gene encoding for the ion channel cystic fibrosis transmembrane conductance regulator (CFTR). The management of CF disease has evolved in recent decades from treating downstream disease manifestations affecting the airways, the lungs and the gastrointestinal system to addressing the CFTR gene defect. The advent of CFTR modulators, which correct the functionality of the defective CFTR, contributes to reshaping the landscape of CF demographics, prognosis and therapies, including nutritional management. A spectrum of clinical manifestations is emerging within the same patient population where undernutrition and nutritional deficiencies coexist with excessive weight gain and metabolic derangements. Such contrasting presentations challenge current practices, require adjustments to traditional approaches, and involve more individualised interventions. This narrative review examines the current state of knowledge on the nutritional management of people living with cystic fibrosis from early life to adulthood in the era of CFTR modulation.
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Affiliation(s)
- Geneviève Mailhot
- Department of Nutrition, Faculty of Medicine, Montreal, QC, Canada
- CHU Sainte-Justine Research Center, Montreal, QC, Canada
| | | | | | - Valérie Jomphe
- Lung Transplant Program, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, QC, Canada
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4
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Regard L, Martin C, Da Silva J, Burgel PR. CFTR Modulators: Current Status and Evolving Knowledge. Semin Respir Crit Care Med 2023; 44:186-195. [PMID: 36535667 DOI: 10.1055/s-0042-1758851] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
In the past decade, the medical management of people with cystic fibrosis (pwCF) has changed with the development of small molecules that partially restore the function of the defective CF transmembrane conductance regulator (CFTR) protein and are called CFTR modulators. Ivacaftor (IVA), a CFTR potentiator with a large effect on epithelial ion transport, was the first modulator approved in pwCF carrying gating mutations. Because IVA was unable to restore sufficient CFTR function in pwCF with other mutations, two CFTR correctors (lumacaftor and tezacaftor) were developed and used in combination with IVA in pwCF homozygous for F508del, the most common CFTR variant. However, LUM/IVA and TEZ/IVA were only moderately effective in F508del homozygous pwCF and had no efficacy in those with F508del and minimal function mutations. Elexacaftor, a second-generation corrector, was thus developed and combined to tezacaftor and ivacaftor (ELX/TEZ/IVA) to target pwCF with at least one F508del variant, corresponding to approximately 85% of pwCF. Both IVA and ELX/TEZ/IVA are considered highly effective modulator therapies (HEMTs) in eligible pwCF and are now approved for nearly 90% of the CF population over 6 years of age. HEMTs are responsible for rapid improvement in respiratory manifestations, including improvement in symptoms and lung function, and reduction in the rate of pulmonary exacerbations. The impact of HEMT on extrapulmonary manifestations of CF is less well established, although significant weight gain and improvement in quality of life have been demonstrated. Recent clinical trials and real-world studies suggest that benefits of HEMT could even prove greater when used earlier in life (i.e., in younger children and infants). This article shortly reviews the past 10 years of development and use of CFTR modulators. Effects of HEMT on extrapulmonary manifestations and on CF demographics are also discussed.
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Affiliation(s)
- Lucile Regard
- Department of Respiratory Medicine and French Cystic Fibrosis National Reference Center, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Paris, France.,Institut Cochin and Université de Paris, INSERM U1016, Paris, France.,ERN Lung Cystic Fibrosis Network, Frankfurt, Germany
| | - Clémence Martin
- Department of Respiratory Medicine and French Cystic Fibrosis National Reference Center, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Paris, France.,Institut Cochin and Université de Paris, INSERM U1016, Paris, France.,ERN Lung Cystic Fibrosis Network, Frankfurt, Germany
| | - Jennifer Da Silva
- Department of Respiratory Medicine and French Cystic Fibrosis National Reference Center, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Paris, France.,ERN Lung Cystic Fibrosis Network, Frankfurt, Germany
| | - Pierre-Régis Burgel
- Department of Respiratory Medicine and French Cystic Fibrosis National Reference Center, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Paris, France.,Institut Cochin and Université de Paris, INSERM U1016, Paris, France.,ERN Lung Cystic Fibrosis Network, Frankfurt, Germany
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5
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Athanazio RA, Tanni SE, Ferreira J, Dalcin PDTR, Fuccio MBD, Esposito C, Canan MGM, Coelho LS, Firmida MDC, Almeida MBD, Marostica PJC, Monte LDFV, Souza EL, Pinto LA, Rached SZ, Oliveira VSBD, Riedi CA, Silva Filho LVRFD. Brazilian guidelines for the pharmacological treatment of the pulmonary symptoms of cystic fibrosis. Official document of the Sociedade Brasileira de Pneumologia e Tisiologia (SBPT, Brazilian Thoracic Association). J Bras Pneumol 2023; 49:e20230040. [PMID: 37194817 DOI: 10.36416/1806-3756/e20230040] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Accepted: 03/31/2023] [Indexed: 05/18/2023] Open
Abstract
Cystic fibrosis (CF) is a genetic disease that results in dysfunction of the CF transmembrane conductance regulator (CFTR) protein, which is a chloride and bicarbonate channel expressed in the apical portion of epithelial cells of various organs. Dysfunction of that protein results in diverse clinical manifestations, primarily involving the respiratory and gastrointestinal systems, impairing quality of life and reducing life expectancy. Although CF is still an incurable pathology, the therapeutic and prognostic perspectives are now totally different and much more favorable. The purpose of these guidelines is to define evidence-based recommendations regarding the use of pharmacological agents in the treatment of the pulmonary symptoms of CF in Brazil. Questions in the Patients of interest, Intervention to be studied, Comparison of interventions, and Outcome of interest (PICO) format were employed to address aspects related to the use of modulators of this protein (ivacaftor, lumacaftor+ivacaftor, and tezacaftor+ivacaftor), use of dornase alfa, eradication therapy and chronic suppression of Pseudomonas aeruginosa, and eradication of methicillin-resistant Staphylococcus aureus and Burkholderia cepacia complex. To formulate the PICO questions, a group of Brazilian specialists was assembled and a systematic review was carried out on the themes, with meta-analysis when applicable. The results obtained were analyzed in terms of the strength of the evidence compiled, the recommendations being devised by employing the GRADE approach. We believe that these guidelines represent a major advance to be incorporated into the approach to patients with CF, mainly aiming to favor the management of the disease, and could become an auxiliary tool in the definition of public policies related to CF.
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Affiliation(s)
- Rodrigo Abensur Athanazio
- . Divisão de Pneumologia, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | - Suzana Erico Tanni
- . Faculdade de Medicina de Botucatu, Universidade Estadual Paulista Julio de Mesquita Filho - UNESP - Botucatu (SP) Brasil
| | - Juliana Ferreira
- . Divisão de Pneumologia, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | - Paulo de Tarso Roth Dalcin
- . Programa de Pós-Graduação em Ciências Pneumológicas, Universidade Federal do Rio Grande do Sul - UFRGS - Porto Alegre (RS) Brasil
- . Serviço de Pneumologia, Hospital de Clínicas de Porto Alegre - HCPA - Universidade Federal do Rio Grande do Sul - UFRGS - Porto Alegre (RS) Brasil
| | - Marcelo B de Fuccio
- . Hospital Júlia Kubitschek, Fundação Hospitalar do Estado de Minas Gerais - FHEMIG - Belo Horizonte (MG) Brasil
| | | | | | - Liana Sousa Coelho
- . Faculdade de Medicina de Botucatu, Universidade Estadual Paulista Julio de Mesquita Filho - UNESP - Botucatu (SP) Brasil
| | | | - Marina Buarque de Almeida
- . Unidade de Pneumologia, Instituto da Criança, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | - Paulo José Cauduro Marostica
- . Unidade de Pneumologia Infantil, Hospital de Clínicas de Porto Alegre - HCPA - Universidade Federal do Rio Grande do Sul - UFRGS - Porto Alegre (RS) Brasil
| | | | - Edna Lúcia Souza
- . Faculdade de Medicina da Bahia, Universidade Federal da Bahia, Salvador (BA) Brasil
| | | | - Samia Zahi Rached
- . Divisão de Pneumologia, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | - Verônica Stasiak Bednarczuk de Oliveira
- . Hospital de Clínicas, Universidade Federal do Paraná, Curitiba (PR) Brasil
- . Unidos Pela Vida - Instituto Brasileiro de Atenção à Fibrose Cística, Curitiba (PR) Brasil
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Foucaud P, Mercier JC. CFTR pharmacological modulators: A great advance in cystic fibrosis management. Arch Pediatr 2023; 30:1-9. [PMID: 36509624 DOI: 10.1016/j.arcped.2022.11.019] [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: 03/08/2022] [Revised: 09/16/2022] [Accepted: 11/11/2022] [Indexed: 12/13/2022]
Abstract
Cystic fibrosis is a severe monogenic disease that affects around 7400 patients in France. More than 2100 mutations in the cystic fibrosis conductance transmembrane regulator (CFTR), the gene encoding for an epithelial ion channel that normally transports chloride and bicarbonate, lead to mucus dehydration and impaired bronchial clearance. Systematic neonatal screening in France since 2002 has enabled early diagnosis of cystic fibrosis. Although highly demanding, supportive treatments including daily chest physiotherapy, inhaled aerosol therapy, frequent antibiotic courses, nutritional and pancreatic extracts have improved the prognosis. Median age at death is now beyond 30 years. Ivacaftor was the first CFTR modulator found to both reduce sweat chloride concentration and improve pulmonary function in the rare CFTR gating mutations. Combinations of modulators such as lumacaftor + ivacaftor or tezacaftor + ivacaftor were found to improve pulmonary function both in patients homozygous for the F508del mutation characterized by the lack of CFTR protein and those heterozygous for F508del with minimal CFTR activity. The triple combination of ivacaftor + tezacaftor + elexacaftor was recently shown to significantly improve pulmonary function and quality of life, to normalize sweat chloride concentration, and to reduce the need for antibiotic therapy in patients with at least one F508del mutation (83% in France). These impressive data, however, need to be confirmed in the long term. Nevertheless, it is encouraging to hear treated patients testify about their markedly improved quality of life and to observe that the number of lung transplants for cystic fibrosis decreased dramatically in France after 2020, despite the COVID pandemic, with no increase in deaths without lung transplant.
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Affiliation(s)
- P Foucaud
- Vice-Président de l'Association Vaincre la Mucoviscidose, 181 Rue de Tolbiac, Paris 75013, France.
| | - J C Mercier
- Membre de la Commission de Transparence, Haute Autorité de Santé, 5 avenue du Stade de France, Saint Denis 93210, France
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7
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Thangaraju P, Velmurugan H, N K. Current Status of Pharmacokinetic Research in Children: A Systematic Review of Clinical Trial Records. Curr Rev Clin Exp Pharmacol 2022; 19:CRCEP-EPUB-128427. [PMID: 36573054 DOI: 10.2174/2772432818666221223155455] [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: 06/04/2022] [Revised: 09/05/2022] [Accepted: 10/18/2022] [Indexed: 12/28/2022]
Abstract
BACKGROUND Many medications have different pharmacokinetics in children than in adults. Knowledge about the safety and efficacy of medications in children requires research into the pharmacokinetic profiles of children's medicines. By analysing registered clinical trial records, this study determined how frequently pharmacokinetic data is gathered in paediatric drug trials. METHODS We searched for the pharmacokinetic data from clinical trial records for preterm infants and children up to the age of 16 from January 2011 to April 2022. The records of trials involving one or more drugs in preterm infants and children up to the age of 16 were examined for evidence that pharmacokinetic data would be collected. RESULTS In a total of 1483 records of interventional clinical trials, 136 (9.17%) pharmacokinetic data involved adults. Of those 136 records, 60 (44.1%) records were pharmacokinetics trials involving one or more medicines in children up to the age of 16. 20 (33.3 %) in America, followed by 19 (31.6 %) in Europe. Most trials researched medicines in the field of infection or parasitic diseases 20 (33.3%). 27 (48.2%) and 26 (46.4%) trials investigated medicines that were indicated as essential medicine. CONCLUSION The pharmacokinetic characteristics of children's drugs need to be better understood. The current state of pharmacokinetic research appears to address the knowledge gap in this area adequately. Despite slow progress, paediatric clinical trials have experienced a renaissance as the significance of paediatric trials has gained international attention. The outcome of paediatric trials will have an impact on children's health in the future. In recent years, the need for greater availability and access to safe child-size pharmaceuticals has received a lot of attention.
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Affiliation(s)
- Pugazhenthan Thangaraju
- Department of Pharmacology, All India institute of medical sciences, Raipur, Chhattisgarh, India
| | - Hemasri Velmurugan
- Department of Pharmacology, All India institute of medical sciences, Raipur, Chhattisgarh, India
| | - Krishnapriya N
- Department of Pharmacology, All India institute of medical sciences, Raipur, Chhattisgarh, India
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8
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Prentice B, Nicholson M, Lam GY. Cystic fibrosis related diabetes (CFRD) in the era of modulators: A scoping review. Paediatr Respir Rev 2022:S1526-0542(22)00086-0. [PMID: 36581478 DOI: 10.1016/j.prrv.2022.11.005] [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: 08/24/2022] [Accepted: 11/30/2022] [Indexed: 12/12/2022]
Abstract
Cystic fibrosis-related diabetes (CFRD) is a common complication of CF that increases in incidence as patients age. Poor glycemic control has been shown to negatively impact lung function and weight, resulting in higher risk of recurrent pulmonary exacerbations. With the advent of highly effective modulator therapies (HEMT), patients with CF are living longer and healthier lives. Consequently, CFRD and its microvascular complications are rising in prominence, becoming one of the most urgent clinical concerns. As HEMT were developed with the primary focus of improving pulmonary outcomes, it is not clear from the original phase III studies what the short- or long-term benefits of modulators might be on CFRD development and trajectory. In this review, we will examine the pathophysiology of CFRD, summarize and synthesize the available evidence of HEMT impact on CFRD and describe the emerging research needs in this field.
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Affiliation(s)
- Bernadette Prentice
- Department of Respiratory Medicine, Sydney Children's Hospital, Randwick Australia; Molecular and Integrative Cystic Fibrosis (miCF) Research Centre, Randwick, Australia; Discipline of Paediatrics and Child Health, School of Clinical Medicine, University of New South Wales, Randwick, Australia
| | - Mike Nicholson
- Division of Respirology, Department of Medicine, Western University, Ontario, Canada
| | - Grace Y Lam
- Division of Pulmonary Medicine, Department of Medicine, University of Alberta, Alberta, Canada.
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Cornet M, Robin G, Ciciriello F, Bihouee T, Marguet C, Roy V, Lebourgeois M, Chedevergne F, Bonnel AS, Kelly M, Reix P, Lucidi V, Stoven V, Sermet-Gaudelus I. Profiling the response to lumacaftor-ivacaftor in children with cystic between fibrosis and new insight from a French-Italian real-life cohort. Pediatr Pulmonol 2022; 57:2992-2999. [PMID: 35996214 PMCID: PMC9826158 DOI: 10.1002/ppul.26123] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 08/11/2022] [Accepted: 08/21/2022] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Clinical trials for CFTR modulators consider mean changes of clinical status at the cohort level, and thus fail to assess the heterogeneity of the response. We aimed to study the different response profiles to lumacaftor-ivacaftor according to age in children with cystic fibrosis (CF). METHODS A mathematical framework, including principal component analysis, data clustering, and data completion, was applied to a multicenter cohort of 112 children aged 6-18 years, treated with lumacaftor-ivacaftor. Studied parameters at baseline and 6 months included body mass index (BMI), number of days of antibiotics (ATB), Sweat test (ST), forced expiratory volume in 1 s expressed in percentage predicted (ppFEV1 ), forced vital capacity (ppFVC), and forced expiratory flow at 25%-75% of FVC (ppFEF25-75 ). RESULTS Change in ppFEV1 was the most significant parameter in characterizing response heterogeneity among the 12-18-year-old patients. Patients with minimal changes in ppFEV1 were further separated by change in BMI and ATB course. In the 6-12-year-old children both BMI and ppFEV1 evolution were the most relevant. ST change was not associated with a clinical response. CONCLUSIONS Change in ppFEV1 , BMI, and ATB course are the most relevant outcomes to discriminate clinical response profiles in children treated with lumacaftor-ivacaftor. Prepubertal and pubertal children display different response profiles.
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Affiliation(s)
| | - Geneviève Robin
- Laboratoire de Mathematiques et Modelisation d'Evry, Evry, France
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10
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Current state of CFTR modulators for treatment of Cystic Fibrosis. Curr Opin Pharmacol 2022; 65:102239. [DOI: 10.1016/j.coph.2022.102239] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 03/31/2022] [Accepted: 04/13/2022] [Indexed: 12/23/2022]
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Abstract
Over the past decade there have been significant developments in the field of Cystic Fibrosis Transmembrane Regulator modulator drugs. Following treatment in patients with cystic fibrosis with common gating mutations using the potentiator drug ivacaftor, successive development of corrector drugs used in combination has led to highly effective modulator therapy being available to more than 85% of the cystic fibrosis population over 12 years of age in the form of elexacaftor/tezacaftor/ivacaftor. In this article, we review the evidence from clinical trials and mounting real-world observational and registry data that demonstrates the impact highly effective modulators have on both pulmonary and extra-pulmonary manifestations of cystic fibrosis. As clinical trials progress to younger patient groups, we discuss the challenges to demonstrating drug efficacy in early life, and also consider practicalities of drug development in an ever-shrinking modulator-naïve population. Drug-drug interactions are an important consideration in people with cystic fibrosis, where polypharmacy is commonplace, but also as the modulated population look to remain healthier for longer, we identify trials that aim to address treatment burden too. Inequity of care, through drug cost or ineligibility for modulators by genotype, is widening without apparent strategies to address this; however, we present evidence of hopeful early-stage drug development for non-modulatable genes and summarise the current state of gene-therapy development.
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12
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McGarry ME, Gibb ER, Oates GR, Schechter MS. Left behind: The potential impact of CFTR modulators on racial and ethnic disparities in cystic fibrosis. Paediatr Respir Rev 2022; 42:35-42. [PMID: 35277357 PMCID: PMC9356388 DOI: 10.1016/j.prrv.2021.12.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 12/16/2021] [Indexed: 12/16/2022]
Abstract
The advent of CFTR modulators, a genomic specific medication, revolutionized the treatment of CF for many patients. However, given that these therapeutics were only developed for specific CFTR mutations, not all people with CF have access to such disease-modifying drugs. Racial and ethnic minority groups are less likely to have CFTR mutations that are approved for CFTR modulators. This exclusion has the potential to widen existing health disparities.
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Affiliation(s)
- Meghan E. McGarry
- Division of Pulmonary Medicine, Department of Pediatrics, University of California San Francisco, San Francisco, CA
| | - Elizabeth R. Gibb
- Division of Pulmonary Medicine, Department of Pediatrics, University of California San Francisco, San Francisco, CA
| | - Gabriela R. Oates
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL
| | - Michael S. Schechter
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, Virginia Commonwealth University and Children’s Hospital of Richmond at VCU, Richmond, VA
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13
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Changing paradigms in the treatment of gastrointestinal complications of cystic fibrosis in the era of cystic fibrosis transmembrane conductance regulator modulators. Paediatr Respir Rev 2022; 42:9-16. [PMID: 33485777 DOI: 10.1016/j.prrv.2020.12.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 12/17/2020] [Indexed: 12/17/2022]
Abstract
Cystic fibrosis (CF) - although primarily a lung disease - also causes a variety of gastrointestinal manifestations which are important for diagnosis, prognosis and quality of life. All parts of the gastrointestinal tract can be affected by CF. Besides the well-known pancreatic insufficiency, gastroesophageal reflux disease, liver disease and diseases of the large intestine are important pathologies that impact on prognosis and also impair quality of life. Diagnosis and management of gastrointestinal manifestations will be discussed in this review. Since optimisation of CF therapy is associated with a significantly longer life-span of CF patients nowadays, also gastrointestinal malignancies, which are more common in CF than in the non-CF population need to be considered. Furthermore, novel evidence on the role of the gut microbiome in CF is emerging. The introduction of cystic fibrosis transmembrane conductance regulator (CFTR) protein modulators gives hope for symptom alleviation and even cure of gastrointestinal manifestations of CF.
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14
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Gabel ME, Fox CK, Grimes RA, Lowman JD, McDonald CM, Stallings VA, Michel SH. Overweight and cystic fibrosis: An unexpected challenge. Pediatr Pulmonol 2022; 57 Suppl 1:S40-S49. [PMID: 34738328 DOI: 10.1002/ppul.25748] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 10/06/2021] [Accepted: 10/18/2021] [Indexed: 02/06/2023]
Abstract
Achieving a healthy weight balance has been a central focus of care for people who have cystic fibrosis (CF). Over the years, the emphasis has primarily been on promoting weight gain to optimize pulmonary outcomes. With continued improvements in CF care, including highly effective CF modulators available for many people, the CF community is now experiencing a new challenge: addressing the concern that some people are gaining weight excessively. While at this time, we do not know to what extent overweight and obesity will affect health outcomes for people with CF, it is likely that excessive weight gain may have negative health impacts similar to those seen in the general population. In this paper, we review the history of nutritional guidelines for people with CF, as well as more recent trends toward overweight and obesity for some. A multidisciplinary approach is needed to collaboratively start the oftentimes difficult conversation regarding excessive weight gain, and to identify resources to help people achieve and maintain a healthy weight through diet, exercise, and behavioral modification.
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Affiliation(s)
- Megan E Gabel
- Department of Pediatrics, University of Rochester Medical Center, Rochester, New York, USA
| | - Claudia K Fox
- Department of Pediatrics, Center for Pediatric Obesity Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Rachel A Grimes
- Department of Psychiatry, Cook Children's Medical Center, Fort Worth, Texas, USA
| | - John D Lowman
- Department of Physical Therapy, Gregory Fleming James Cystic Fibrosis Research Center, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Catherine M McDonald
- Department of Clinical Nutrition, Primary Children's Hospital, Salt Lake City, Utah, USA
| | - Virginia A Stallings
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Suzanne H Michel
- Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
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15
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Sawicki GS, Chilvers M, McNamara J, Naehrlich L, Saunders C, Sermet-Gaudelus I, Wainwright CE, Ahluwalia N, Campbell D, Harris RS, Paz-Diaz H, Shih JL, Davies JC. A Phase 3, open-label, 96-week trial to study the safety, tolerability, and efficacy of tezacaftor/ivacaftor in children ≥ 6 years of age homozygous for F508del or heterozygous for F508del and a residual function CFTR variant. J Cyst Fibros 2022; 21:675-683. [DOI: 10.1016/j.jcf.2022.02.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 01/26/2022] [Accepted: 02/05/2022] [Indexed: 01/03/2023]
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16
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Li Q, Liu S, Ma X, Yu J. Effectiveness and Safety of Cystic Fibrosis Transmembrane Conductance Regulator Modulators in Children With Cystic Fibrosis: A Meta-Analysis. Front Pediatr 2022; 10:937250. [PMID: 35844763 PMCID: PMC9276987 DOI: 10.3389/fped.2022.937250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 05/27/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND AND AIM Cystic fibrosis (CF) is a genetic disease that is difficult to treat and caused by dysfunction of the cystic fibrosis transmembrane conductance regulator (CFTR) protein. Small molecules have been used to treat the symptom caused by CFTR mutations by restoring CFTR protein function. However, the data on children with CF are scarce. This meta-analysis aimed to evaluate the effectiveness and safety of this therapy in children diagnosed with CF. MATERIALS AND METHODS Relevant studies were identified through searching medical databases before April 1, 2022. The primary outcomes of ppFEV1, lung clearance index2.5 (LCI2.5), sweat chloride concentration (SwCI), and Cystic Fibrosis Questionnaire-Revised (CFQ-R) score were pooled and analyzed. The secondary outcomes were nutritional status (weight, BMI, stature, and their z-score) and adverse events under therapy. RESULTS A total of twelve studies were included. Compared with the placebo group, the pooled outcome of the ppFEV1, LCI2.5, SwCI, and CFQ-R score were improved by 7.91 {[95% confidence interval (CI), 3.71-12.12], -1.00 (95% CI, -1.38 to -0.63), -35.22 (95% CI, -55.51 to -14.92), and 4.45 (95% CI, 2.31-6.59), respectively}. Compared with the placebo group, the pooled result of the change in weight was improved by 1.53 (95% CI, 0.42-2.63). All the aforementioned results were also improved in single-arm studies. No clear differences in adverse events were found between CFTR modulator therapy and the placebo group. CONCLUSION CFTR modulators could improve multiaspect function in children with CF and result in comparable adverse events.
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Affiliation(s)
- Qiyu Li
- Department of Pediatrics, General Hospital of Northern Theater Command, Shenyang, China
| | - Siyuan Liu
- Department of Pediatrics, General Hospital of Northern Theater Command, Shenyang, China
| | - Xuemei Ma
- Department of Pediatrics, General Hospital of Northern Theater Command, Shenyang, China
| | - Jiaping Yu
- Department of Pediatrics, General Hospital of Northern Theater Command, Shenyang, China
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17
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Medicina de precisión en fibrosis quística. REVISTA MÉDICA CLÍNICA LAS CONDES 2022. [DOI: 10.1016/j.rmclc.2021.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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18
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Kunovský L, Dítě P, Jabandžiev P, Eid M, Poredská K, Vaculová J, Sochorová D, Janeček P, Tesaříková P, Blaho M, Trna J, Hlavsa J, Kala Z. Causes of Exocrine Pancreatic Insufficiency Other Than Chronic Pancreatitis. J Clin Med 2021; 10:jcm10245779. [PMID: 34945075 PMCID: PMC8708123 DOI: 10.3390/jcm10245779] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 11/30/2021] [Accepted: 12/02/2021] [Indexed: 12/12/2022] Open
Abstract
Exocrine pancreatic insufficiency (EPI), an important cause of maldigestion and malnutrition, results from primary pancreatic disease or is secondary to impaired exocrine pancreatic function. Although chronic pancreatitis is the most common cause of EPI, several additional causes exist. These include pancreatic tumors, pancreatic resection procedures, and cystic fibrosis. Other diseases and conditions, such as diabetes mellitus, celiac disease, inflammatory bowel disease, and advanced patient age, have also been shown to be associated with EPI, but the exact etiology of EPI has not been clearly elucidated in these cases. The causes of EPI can be divided into loss of pancreatic parenchyma, inhibition or inactivation of pancreatic secretion, and postcibal pancreatic asynchrony. Pancreatic enzyme replacement therapy (PERT) is indicated for the conditions described above presenting with clinically clear steatorrhea, weight loss, or symptoms related to maldigestion and malabsorption. This review summarizes the current literature concerning those etiologies of EPI less common than chronic pancreatitis, the pathophysiology of the mechanisms of EPI associated with each diagnosis, and treatment recommendations.
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Affiliation(s)
- Lumír Kunovský
- Department of Gastroenterology and Internal Medicine, University Hospital Brno, Faculty of Medicine, Masaryk University, 62500 Brno, Czech Republic; (L.K.); (P.D.); (K.P.); (J.V.)
- Department of Surgery, University Hospital Brno, Faculty of Medicine, Masaryk University, 62500 Brno, Czech Republic; (D.S.); (P.J.); (Z.K.)
| | - Petr Dítě
- Department of Gastroenterology and Internal Medicine, University Hospital Brno, Faculty of Medicine, Masaryk University, 62500 Brno, Czech Republic; (L.K.); (P.D.); (K.P.); (J.V.)
- Department of Gastroenterology and Internal Medicine, University Hospital Ostrava, Faculty of Medicine, University of Ostrava, 70852 Ostrava, Czech Republic;
| | - Petr Jabandžiev
- Department of Pediatrics, University Hospital Brno, Faculty of Medicine, Masaryk University, 61300 Brno, Czech Republic;
- Central European Institute of Technology, Masaryk University, 62500 Brno, Czech Republic
| | - Michal Eid
- Department of Hematology, Oncology and Internal Medicine, University Hospital Brno, Faculty of Medicine, Masaryk University, 62500 Brno, Czech Republic;
| | - Karolina Poredská
- Department of Gastroenterology and Internal Medicine, University Hospital Brno, Faculty of Medicine, Masaryk University, 62500 Brno, Czech Republic; (L.K.); (P.D.); (K.P.); (J.V.)
| | - Jitka Vaculová
- Department of Gastroenterology and Internal Medicine, University Hospital Brno, Faculty of Medicine, Masaryk University, 62500 Brno, Czech Republic; (L.K.); (P.D.); (K.P.); (J.V.)
| | - Dana Sochorová
- Department of Surgery, University Hospital Brno, Faculty of Medicine, Masaryk University, 62500 Brno, Czech Republic; (D.S.); (P.J.); (Z.K.)
| | - Pavel Janeček
- Department of Surgery, University Hospital Brno, Faculty of Medicine, Masaryk University, 62500 Brno, Czech Republic; (D.S.); (P.J.); (Z.K.)
| | - Pavla Tesaříková
- Department of Internal Medicine, Hospital Boskovice, 68001 Boskovice, Czech Republic;
| | - Martin Blaho
- Department of Gastroenterology and Internal Medicine, University Hospital Ostrava, Faculty of Medicine, University of Ostrava, 70852 Ostrava, Czech Republic;
| | - Jan Trna
- Department of Gastroenterology and Internal Medicine, University Hospital Brno, Faculty of Medicine, Masaryk University, 62500 Brno, Czech Republic; (L.K.); (P.D.); (K.P.); (J.V.)
- Department of Internal Medicine, Hospital Boskovice, 68001 Boskovice, Czech Republic;
- Department of Gastroenterology and Digestive Endoscopy, Masaryk Memorial Cancer Institute Brno, 60200 Brno, Czech Republic
- Correspondence: (J.T.); (J.H.)
| | - Jan Hlavsa
- Department of Surgery, University Hospital Brno, Faculty of Medicine, Masaryk University, 62500 Brno, Czech Republic; (D.S.); (P.J.); (Z.K.)
- Correspondence: (J.T.); (J.H.)
| | - Zdeněk Kala
- Department of Surgery, University Hospital Brno, Faculty of Medicine, Masaryk University, 62500 Brno, Czech Republic; (D.S.); (P.J.); (Z.K.)
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19
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Shaughnessy CA, Zeitlin PL, Bratcher PE. Elexacaftor is a CFTR potentiator and acts synergistically with ivacaftor during acute and chronic treatment. Sci Rep 2021; 11:19810. [PMID: 34615919 PMCID: PMC8494914 DOI: 10.1038/s41598-021-99184-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 09/03/2021] [Indexed: 02/07/2023] Open
Abstract
Cystic fibrosis (CF) is caused by mutations in the cystic fibrosis transmembrane conductance regulator (CFTR), which lead to early death due to progressive lung disease. The development of small-molecule modulators that directly interact with CFTR to aid in protein folding (“correctors”) and/or increase channel function (“potentiators”) have proven to be highly effective in the therapeutic treatment of CF. Notably, incorporation of the next-generation CFTR corrector, elexacaftor, into a triple combination therapeutic (marketed as Trikafta) has shown tremendous clinical promise in treating CF caused by F508del-CFTR. Here, we report on a newly-described role of elexacaftor as a CFTR potentiator. We explore the acute and chronic actions, pharmacology, and efficacy of elexacaftor as a CFTR potentiator in restoring function to multiple classes of CFTR mutations. We demonstrate that the potentiating action of elexacaftor exhibits multiplicative synergy with the established CFTR potentiator ivacaftor in rescuing multiple CFTR class defects, indicating that a new combination therapeutic of ivacaftor and elexacaftor could have broad impact on CF therapies.
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Affiliation(s)
| | - Pamela L Zeitlin
- Department of Pediatrics, National Jewish Health, Denver, CO, USA.,Department of Pediatrics, University of Colorado Anschutz Medical Center, Aurora, CO, USA
| | - Preston E Bratcher
- Department of Pediatrics, National Jewish Health, Denver, CO, USA.,Department of Pediatrics, University of Colorado Anschutz Medical Center, Aurora, CO, USA
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20
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Meoli A, Fainardi V, Deolmi M, Chiopris G, Marinelli F, Caminiti C, Esposito S, Pisi G. State of the Art on Approved Cystic Fibrosis Transmembrane Conductance Regulator ( CFTR) Modulators and Triple-Combination Therapy. Pharmaceuticals (Basel) 2021; 14:ph14090928. [PMID: 34577628 PMCID: PMC8471029 DOI: 10.3390/ph14090928] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 09/09/2021] [Accepted: 09/10/2021] [Indexed: 11/23/2022] Open
Abstract
Cystic fibrosis (CF) is the most common life-limiting inherited disease in Caucasian populations, affecting approximately 80,000 people worldwide. CF is a complex multi-organ monogenic autosomal recessive disorder caused by a mutation in cystic fibrosis transmembrane conductance regulator (CFTR) gene. Since the discovery of the CFTR gene in 1989, more than 2000 mutations have been identified so far and about 240 can cause CF. Until recently, the treatment for CF was aimed to prevent and manage the manifestations of CFTR dysfunction, primarily recurrent pulmonary infections and pancreatic exocrine failure. Over the past few decades, the therapeutic approach to CF has been revolutionized by the development of a new class of small molecules called CFTR modulators that target specific defects caused by mutations in the CFTR gene. CFTR modulators have been shown to change profoundly the clinical course of the CF, leading to meaningful improvements in the lives of a large proportion of people of CF heterozygous for F508del, especially if started in young children. Further studies are needed to extend the use of triple CFTR modulation therapy also for young children in order to prevent the irreversible effects of the disease and for patients with very rare mutations with a personalized approach to treatment.
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Affiliation(s)
- Aniello Meoli
- Paediatric Clinic, Department of Medicine and Surgery, University Hospital of Parma, Via Gramsci 14, 43126 Parma, Italy; (A.M.); (V.F.); (M.D.); (G.C.); (F.M.); (G.P.)
| | - Valentina Fainardi
- Paediatric Clinic, Department of Medicine and Surgery, University Hospital of Parma, Via Gramsci 14, 43126 Parma, Italy; (A.M.); (V.F.); (M.D.); (G.C.); (F.M.); (G.P.)
| | - Michela Deolmi
- Paediatric Clinic, Department of Medicine and Surgery, University Hospital of Parma, Via Gramsci 14, 43126 Parma, Italy; (A.M.); (V.F.); (M.D.); (G.C.); (F.M.); (G.P.)
| | - Giulia Chiopris
- Paediatric Clinic, Department of Medicine and Surgery, University Hospital of Parma, Via Gramsci 14, 43126 Parma, Italy; (A.M.); (V.F.); (M.D.); (G.C.); (F.M.); (G.P.)
| | - Francesca Marinelli
- Paediatric Clinic, Department of Medicine and Surgery, University Hospital of Parma, Via Gramsci 14, 43126 Parma, Italy; (A.M.); (V.F.); (M.D.); (G.C.); (F.M.); (G.P.)
| | - Caterina Caminiti
- Research and Innovation Unit, University Hospital of Parma, Via Gramsci 14, 43126 Parma, Italy;
| | - Susanna Esposito
- Paediatric Clinic, Department of Medicine and Surgery, University Hospital of Parma, Via Gramsci 14, 43126 Parma, Italy; (A.M.); (V.F.); (M.D.); (G.C.); (F.M.); (G.P.)
- Correspondence:
| | - Giovanna Pisi
- Paediatric Clinic, Department of Medicine and Surgery, University Hospital of Parma, Via Gramsci 14, 43126 Parma, Italy; (A.M.); (V.F.); (M.D.); (G.C.); (F.M.); (G.P.)
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21
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Zemanick ET, Taylor-Cousar JL, Davies J, Gibson RL, Mall MA, McKone EF, McNally P, Ramsey BW, Rayment JH, Rowe SM, Tullis E, Ahluwalia N, Chu C, Ho T, Moskowitz SM, Noel S, Tian S, Waltz D, Weinstock TG, Xuan F, Wainwright CE, McColley SA. A Phase 3 Open-Label Study of Elexacaftor/Tezacaftor/Ivacaftor in Children 6 through 11 Years of Age with Cystic Fibrosis and at Least One F508del Allele. Am J Respir Crit Care Med 2021; 203:1522-1532. [PMID: 33734030 PMCID: PMC8483230 DOI: 10.1164/rccm.202102-0509oc] [Citation(s) in RCA: 139] [Impact Index Per Article: 46.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Rationale: Elexacaftor/tezacaftor/ivacaftor (ELX/TEZ/IVA) was shown to be efficacious and safe in patients ≥12 years of age with cystic fibrosis and at least one F508del-CFTR (cystic fibrosis transmembrane conductance regulator) allele, but it has not been evaluated in children <12 years of age. Objectives: To assess the safety, pharmacokinetics, and efficacy of ELX/TEZ/IVA in children 6 through 11 years of age with F508del–minimal function or F508del-F508del genotypes. Methods: In this 24-week open-label phase 3 study, children (N = 66) weighing <30 kg received 50% of the ELX/TEZ/IVA adult daily dose (ELX 100 mg once daily, TEZ 50 mg once daily, and IVA 75 mg every 12 h) whereas children weighing ⩾30 kg received the full adult daily dose (ELX 200 mg once daily, TEZ 100 mg once daily, and IVA 150 mg every 12 h). Measurements and Main Results: The primary endpoint was safety and tolerability. The safety and pharmacokinetic profiles of ELX/TEZ/IVA were generally consistent with those observed in older patients. The most commonly reported adverse events included cough, headache, and pyrexia; in most of the children who had adverse events, these were mild or moderate in severity. Through Week 24, ELX/TEZ/IVA treatment improved the percentage of predicted FEV1 (10.2 percentage points; 95% confidence interval [CI], 7.9 to 12.6), Cystic Fibrosis Questionnaire–Revised respiratory domain score (7.0 points; 95% CI, 4.7 to 9.2), lung clearance index2.5 (−1.71 units; 95% CI, −2.11 to −1.30), and sweat chloride (−60.9 mmol/L; 95% CI, −63.7 to −58.2); body mass index-for-age z-score increased over the 24-week treatment period when compared with the pretreatment baseline. Conclusions: Our results show ELX/TEZ/IVA is safe and efficacious in children 6 through 11 years of age with at least one F508del-CFTR allele, supporting its use in this patient population. Clinical trial registered with www.clinicaltrials.gov (NCT03691779).
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Affiliation(s)
- Edith T Zemanick
- Department of Pediatrics, University of Colorado Anschutz Medical Campus and Children's Hospital Colorado, Aurora, Colorado
| | | | - Jane Davies
- National Heart and Lung Institute, Imperial College London, National Institute for Health Research Imperial Biomedical Research Centre and Royal Brompton and Harefield National Health Service Foundation Trust, London, United Kingdom
| | - Ronald L Gibson
- University of Washington/Seattle Children's Hospital, Seattle, Washington
| | - Marcus A Mall
- Department of Pediatric Pulmonology, Immunology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health, Berlin, Germany.,German Center for Lung Research, Berlin, Germany
| | - Edward F McKone
- St. Vincent's University Hospital and University College, Dublin, Ireland
| | - Paul McNally
- Children's Health Ireland and Royal College of Surgeons in Ireland University of Medicine and Health Sciences, Dublin, Ireland
| | - Bonnie W Ramsey
- University of Washington/Seattle Children's Hospital, Seattle, Washington
| | - Jonathan H Rayment
- British Columbia Children's Hospital, Vancouver, British Columbia, Canada
| | - Steven M Rowe
- University of Alabama at Birmingham, Birmingham, Alabama
| | | | - Neil Ahluwalia
- Vertex Pharmaceuticals Incorporated, Boston, Massachusetts
| | - Chenghao Chu
- Vertex Pharmaceuticals Incorporated, Boston, Massachusetts
| | - Thang Ho
- Vertex Pharmaceuticals Incorporated, Boston, Massachusetts
| | | | - Sabrina Noel
- Vertex Pharmaceuticals Incorporated, Boston, Massachusetts
| | - Simon Tian
- Vertex Pharmaceuticals Incorporated, Boston, Massachusetts
| | - David Waltz
- Vertex Pharmaceuticals Incorporated, Boston, Massachusetts
| | | | - Fengjuan Xuan
- Vertex Pharmaceuticals Incorporated, Boston, Massachusetts
| | | | - Susanna A McColley
- Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois; and.,Northwestern University Feinberg School of Medicine, Chicago, Illinois
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22
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Calucho M, Gartner S, Barranco P, Fernández-Álvarez P, Pérez RG, Tizzano EF. Validation of nasospheroids to assay CFTR functionality and modulator responses in cystic fibrosis. Sci Rep 2021; 11:15511. [PMID: 34330959 PMCID: PMC8324871 DOI: 10.1038/s41598-021-94798-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 07/05/2021] [Indexed: 02/07/2023] Open
Abstract
The availability of a simple, robust and non-invasive in vitro airway model would be useful to study the functionality of the cystic fibrosis transmembrane regulator (CFTR) protein and to personalize modulator therapy for cystic fibrosis (CF) patients. Our aim was to validate a CFTR functional study using nasospheroids, a patient-derived nasal cell 3D-culture. We performed live-cell experiments in nasospheroids obtained from wild-type individuals and CF patients with different genotypes and phenotypes. We extended the existing method and expanded the analysis to upgrade measurements of CFTR activity using forskolin-induced shrinking. We also tested modulator drugs in CF samples. Immobilizing suspended-nasospheroids provided a high number of samples for live-cell imaging. The diversity observed in basal sizes of nasospheroids did not affect the functional analysis of CFTR. Statistical analysis with our method was simple, making this protocol easy to reproduce. Moreover, we implemented the measurement of inner fluid reservoir areas to further differentiate CFTR functionality. In summary, this rapid methodology is helpful to analyse response to modulators in CF samples to allow individualized treatment for CF patients.
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Affiliation(s)
- Maite Calucho
- Medicine Genetics Group, Vall D'Hebron Research Institute, 08035, Barcelona, Spain.,Department of Clinical and Molecular Genetics, Hospital Universitari Vall d'Hebron , 08035, Barcelona, Spain
| | - Silvia Gartner
- Cystic Fibrosis Unit, Hospital Universitari Vall d'Hebron, 08035, Barcelona, Spain
| | - Paula Barranco
- Medicine Genetics Group, Vall D'Hebron Research Institute, 08035, Barcelona, Spain.,Department of Clinical and Molecular Genetics, Hospital Universitari Vall d'Hebron , 08035, Barcelona, Spain
| | - Paula Fernández-Álvarez
- Medicine Genetics Group, Vall D'Hebron Research Institute, 08035, Barcelona, Spain.,Department of Clinical and Molecular Genetics, Hospital Universitari Vall d'Hebron , 08035, Barcelona, Spain
| | | | - Eduardo F Tizzano
- Medicine Genetics Group, Vall D'Hebron Research Institute, 08035, Barcelona, Spain. .,Department of Clinical and Molecular Genetics, Hospital Universitari Vall d'Hebron , 08035, Barcelona, Spain.
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23
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Daines CL, Morgan WJ. The Future of Highly Effective Modulator Therapy in Cystic Fibrosis. Am J Respir Crit Care Med 2021; 203:1453-1455. [PMID: 33901406 PMCID: PMC8483216 DOI: 10.1164/rccm.202104-0850ed] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Cori L Daines
- Department of Pediatrics University of Arizona Tucson, Arizona
| | - Wayne J Morgan
- Department of Pediatrics University of Arizona Tucson, Arizona
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24
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Bergeron C, Cantin AM. New Therapies to Correct the Cystic Fibrosis Basic Defect. Int J Mol Sci 2021; 22:ijms22126193. [PMID: 34201249 PMCID: PMC8227161 DOI: 10.3390/ijms22126193] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 05/31/2021] [Accepted: 06/04/2021] [Indexed: 12/24/2022] Open
Abstract
Rare diseases affect 400 million individuals worldwide and cause significant morbidity and mortality. Finding solutions for rare diseases can be very challenging for physicians and researchers. Cystic fibrosis (CF), a genetic, autosomal recessive, multisystemic, life-limiting disease does not escape this sad reality. Despite phenomenal progress in our understanding of this disease, treatment remains difficult. Until recently, therapies for CF individuals were focused on symptom management. The discovery of the cystic fibrosis transmembrane conductance regulator (CFTR) gene and its product, a protein present at the apical surface of epithelial cells regulating ion transport, allowed the scientific community to learn about the basic defect in CF and to study potential therapies targeting the dysfunctional protein. In the past few years, promising therapies with the goal to restore CFTR function became available and changed the lives of several CF patients. These medications, called CFTR modulators, aim to correct, potentialize, stabilize or amplify CFTR function. Furthermore, research is ongoing to develop other targeted therapies that could be more efficient and benefit a larger proportion of the CF community. The purpose of this review is to summarize our current knowledge of CF genetics and therapies restoring CFTR function, particularly CFTR modulators and gene therapy.
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Affiliation(s)
- Christelle Bergeron
- Department of Medicine, Respiratory Division, Faculty of Medicine and Health Sciences, University of Sherbrooke, Sherbrooke, QC J1H 5N4, Canada;
| | - André M. Cantin
- Department of Medicine, Respiratory Division, Faculty of Medicine and Health Sciences, University of Sherbrooke, Sherbrooke, QC J1H 5N4, Canada;
- Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Respiratory Division, Faculty of Medicine, University of Sherbrooke, 3001, 12e Avenue Nord, Sherbrooke, QC J1H 5N4, Canada
- Correspondence: ; Tel.: +1-819-346-1110 (ext. 14893); Fax: +1-819-564-5377
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25
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Eschenhagen P, Schwarz C. [Many patients with cystic fibrosis have a better quality of life now]. MMW Fortschr Med 2021; 163:74-81. [PMID: 33950452 DOI: 10.1007/s15006-021-9804-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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26
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Dave K, Dobra R, Scott S, Saunders C, Matthews J, Simmonds NJ, Davies JC. Entering the era of highly effective modulator therapies. Pediatr Pulmonol 2021; 56 Suppl 1:S79-S89. [PMID: 33434412 DOI: 10.1002/ppul.24968] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 06/04/2020] [Indexed: 12/25/2022]
Abstract
Since the discovery of the gene responsible for cystic fibrosis (CF) in 1989, hopes have been pinned on a future with novel therapies tackling the basis of the disease rather than its symptoms. These have become a reality over the last decade with the development through to the clinic of CF transmembrane conductance regulator (CFTR) modulators. These are oral drugs which improve CFTR protein function through either increasing the time the channel pore is open (potentiators) or facilitating its trafficking through the cell to its location on the cell membrane (correctors). The first potentiator, ivacaftor, is now licensed and available clinically in many parts of the world. It is highly effective with impressive clinical impact in the lungs and gastrointestinal tract; longer-term data from patient registries show fewer exacerbations, a slower rate of lung function loss and reduced need for transplantation in patients receiving ivacaftor. However, as a single drug, it is suitable for only a small minority of patients. The commonest CFTR mutation, F508del, requires both correction and potentiation for clinical efficacy. Two dual-agent drugs (lumacaftor/ivacaftor and tezacaftor/ivacaftor) have progressed through to licensing, although their short term impact is more modest than that of ivacaftor; this is likely due to only partial correction of protein misfolding and trafficking. Most recently, triple compounds have been developed: two different corrector molecules (elexacaftor and tezacaftor) which, by addressing different regions in the misfolded F508del protein, more effectively improve trafficking. In addition to large improvements in clinical outcomes in people with two copies of F508del, the combination is sufficiently effective that it works in patients with only one copy of F508del and a second, nonmodulator responsive mutation. For the first time, we thus have a drug suitable for around 85% of people with CF. Even more gains are likely to be possible when these drugs can be used in younger children, although more sensitive outcome measures are needed for this age group. Special consideration is needed for people with very rare mutations; those with nonmodulatable mutation combinations will likely require gene or messenger RNA-based therapeutic approaches, many of which are being explored. Although this progress is hugely to be celebrated, we still have more work to do. The international collaboration between trials networks, pharma, patient organizations, registries, and people with CF is something we are all rightly proud of, but innovative trial design and implementation will be needed if we are to continue to build on this progress and further develop drugs for people with CF.
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Affiliation(s)
- Kavita Dave
- Departments of Cystic Fibrosis and Paediatric Respiratory Medicine, Royal Brompton & Harefield Foundation Trust, London, UK
| | - Rebecca Dobra
- Departments of Cystic Fibrosis and Paediatric Respiratory Medicine, Royal Brompton & Harefield Foundation Trust, London, UK.,Cystic Fibrosis and Chronic Lung Infection Research Group, National Heart & Lung Institute, Imperial College London, London, UK
| | - Sandra Scott
- Departments of Cystic Fibrosis and Paediatric Respiratory Medicine, Royal Brompton & Harefield Foundation Trust, London, UK.,Cystic Fibrosis and Chronic Lung Infection Research Group, National Heart & Lung Institute, Imperial College London, London, UK
| | - Clare Saunders
- Departments of Cystic Fibrosis and Paediatric Respiratory Medicine, Royal Brompton & Harefield Foundation Trust, London, UK.,Cystic Fibrosis and Chronic Lung Infection Research Group, National Heart & Lung Institute, Imperial College London, London, UK
| | - Jess Matthews
- Departments of Cystic Fibrosis and Paediatric Respiratory Medicine, Royal Brompton & Harefield Foundation Trust, London, UK
| | - Nicholas J Simmonds
- Departments of Cystic Fibrosis and Paediatric Respiratory Medicine, Royal Brompton & Harefield Foundation Trust, London, UK.,Cystic Fibrosis and Chronic Lung Infection Research Group, National Heart & Lung Institute, Imperial College London, London, UK
| | - Jane C Davies
- Departments of Cystic Fibrosis and Paediatric Respiratory Medicine, Royal Brompton & Harefield Foundation Trust, London, UK.,Cystic Fibrosis and Chronic Lung Infection Research Group, National Heart & Lung Institute, Imperial College London, London, UK
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Bardin E, Pastor A, Semeraro M, Golec A, Hayes K, Chevalier B, Berhal F, Prestat G, Hinzpeter A, Gravier-Pelletier C, Pranke I, Sermet-Gaudelus I. Modulators of CFTR. Updates on clinical development and future directions. Eur J Med Chem 2021; 213:113195. [PMID: 33524685 DOI: 10.1016/j.ejmech.2021.113195] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 01/08/2021] [Accepted: 01/11/2021] [Indexed: 12/19/2022]
Abstract
Cystic fibrosis (CF) is the most frequent life-limiting autosomal recessive disorder in the Caucasian population. It is due to mutations in the Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) gene. Current symptomatic CF therapies, which treat the downstream consequences of CFTR mutations, have increased survival. Better knowledge of the CFTR protein has enabled pharmacologic therapy aiming to restore mutated CFTR expression and function. These CFTR "modulators" have revolutionised the CF therapeutic landscape, with the potential to transform prognosis for a considerable number of patients. This review provides a brief summary of their mechanism of action and presents a thorough review of the results obtained from clinical trials of CFTR modulators.
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Affiliation(s)
| | - Alexandra Pastor
- LCBPT, UMR CNRS 8601, Paris, France; Université de Paris, Paris, France
| | - Michaela Semeraro
- Centre d'Investigation Clinique, Unité de Recherche Clinique-CIC P1419, Hôpital Necker Enfants Malades, Université de Paris, Paris, France
| | - Anita Golec
- Institut Necker Enfants Malades. INSERM U1151, Paris, France
| | - Kate Hayes
- Clinical Trial Network, European Cystic Fibrosis Society, Belfast, Ireland
| | | | - Farouk Berhal
- LCBPT, UMR CNRS 8601, Paris, France; Université de Paris, Paris, France
| | - Guillaume Prestat
- LCBPT, UMR CNRS 8601, Paris, France; Université de Paris, Paris, France
| | | | | | - Iwona Pranke
- Institut Necker Enfants Malades. INSERM U1151, Paris, France
| | - Isabelle Sermet-Gaudelus
- Institut Necker Enfants Malades. INSERM U1151, Paris, France; Université de Paris, Paris, France; Clinical Trial Network, European Cystic Fibrosis Society, Belfast, Ireland; Centre de Référence Maladies Rares, Mucoviscidose et Maladies de CFTR, Hôpital Necker Enfants Malades, Paris, France; European Respiratory Network Lung, Paris, France.
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McKone EF, DiMango EA, Sutharsan S, Barto TL, Campbell D, Ahluwalia N, Higgins M, Owen CA, Tullis E. A phase 3, randomized, double-blind, parallel-group study to evaluate tezacaftor/ivacaftor in people with cystic fibrosis heterozygous for F508del-CFTR and a gating mutation. J Cyst Fibros 2020; 20:234-242. [PMID: 33339768 DOI: 10.1016/j.jcf.2020.11.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 10/30/2020] [Accepted: 11/03/2020] [Indexed: 01/29/2023]
Abstract
BACKGROUND Tezacaftor (TEZ)/ivacaftor (IVA) is an approved CFTR modulator shown to be efficacious and generally safe and well tolerated in people ≥12 years of age with cystic fibrosis (CF) homozygous for the F508del-CFTR mutation or heterozygous for the F508del-CFTR mutation and a residual function mutation. Although previous studies with IVA alone showed clinical benefits in people with CFTR gating mutations, TEZ/IVA has not yet been evaluated in a Phase 3 study of participants heterozygous for F508del-CFTR and a gating mutation (F/gating genotypes). Here, we present results from a randomized, double-blind, IVA-controlled, parallel-group, Phase 3 study assessing the efficacy, safety, and pharmacokinetics (PK) of TEZ/IVA in participants ≥12 years of age with F/gating genotypes. METHODS Enrolled participants entered a 4-week IVA run-in period to create a stable IVA baseline. Participants were then randomized to receive IVA or TEZ/IVA for 8 weeks in an active comparator treatment period (ACTP). The primary endpoint was absolute change in percent predicted forced expiratory volume in 1 second (ppFEV1). Key secondary endpoints were relative change in ppFEV1 and absolute change in CF Questionnaire-Revised respiratory domain score. Secondary endpoints included absolute change in sweat chloride (SwCl) concentration, PK parameters, and safety. All endpoints except PK parameters and safety were assessed from baseline through Week 8. RESULTS Sixty-nine participants (92.0%) in the IVA group and 75 participants (98.7%) in the TEZ/IVA group completed treatment. No improvements were seen in efficacy endpoints from baseline at the end of the IVA run-in period through the end of the ACTP in the IVA group. No significant differences in ppFEV1 or any key secondary endpoint were observed between the IVA and TEZ/IVA groups. SwCl concentrations decreased more in the TEZ/IVA versus IVA group during the ACTP. The safety profile and PK parameters of TEZ/IVA were consistent with those of previous studies in participants ≥12 years of age with CF. CONCLUSIONS This Phase 3 study showed that the dual-combination regimen of TEZ/IVA demonstrated clinical efficacy but did not have significantly greater clinical efficacy than IVA alone in participants ≥12 years of age with F/gating genotypes. However, as reported in other studies, TEZ/IVA was generally safe and well tolerated (NCT02412111).
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Affiliation(s)
- Edward F McKone
- St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland.
| | - Emily A DiMango
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University, 622 West 168 Street, PH 8 East, Room 101, New York, NY 10032, United States.
| | - Sivagurunathan Sutharsan
- Division of Cystic Fibrosis, Department of Pulmonary Medicine, University Medicine Essen-Ruhrlandklinik, University of Duisburg-Essen, Essen, Germany.
| | - Tara Lynn Barto
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Baylor College of Medicine, 7200 Cambridge Street, Houston, TX 77030.
| | - Daniel Campbell
- Vertex Pharmaceuticals Incorporated, 50 Northern Avenue, Boston, MA 02210, United States.
| | - Neil Ahluwalia
- Vertex Pharmaceuticals Incorporated, 50 Northern Avenue, Boston, MA 02210, United States.
| | - Mark Higgins
- Vertex Pharmaceuticals (Europe) Limited, Level 9, Paddington Central, 2 Kingdom Street, London W2 6BD, United Kingdom.
| | - Caroline A Owen
- Vertex Pharmaceuticals Incorporated, 50 Northern Avenue, Boston, MA 02210, United States.
| | - Elizabeth Tullis
- Division of Respirology, Department of Medicine, St. Michael's Hospital, University of Toronto, 30 Bond Street, Toronto, Ontario M5B 1W8, Canada.
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Tsai A, Wu SP, Haseltine E, Kumar S, Moskowitz SM, Panorchan P, Shah K. Physiologically Based Pharmacokinetic Modeling of CFTR Modulation in People with Cystic Fibrosis Transitioning from Mono or Dual Regimens to Triple-Combination Elexacaftor/Tezacaftor/Ivacaftor. Pulm Ther 2020; 6:275-286. [PMID: 32734574 PMCID: PMC7672136 DOI: 10.1007/s41030-020-00124-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Indexed: 11/06/2022] Open
Abstract
INTRODUCTION The triple-combination (TC) cystic fibrosis transmembrane conductance regulator (CFTR) modulator regimen elexacaftor, tezacaftor, and ivacaftor was shown to be safe and efficacious in phase 3 trials of people with cystic fibrosis (pwCF) ≥ 12 years of age with ≥ 1 F508del-CFTR allele. Here, a simulation study predicted ivacaftor, tezacaftor, and elexacaftor exposures and impacts on CFTR modulation following transition from ivacaftor [a cytochrome P450 3A (CYP3A) substrate], lumacaftor (a CYP3A inducer)/ivacaftor, or tezacaftor/ivacaftor to TC. METHODS Physiologically based pharmacokinetic (PBPK) modeling was used to evaluate plasma exposures during transition from mono- or dual-combination CFTR modulator regimens to TC. PBPK models were parameterized using data from human hepatocytes to account for CYP3A induction by lumacaftor and validated to match clinical data from healthy volunteers and pwCF. Using dosing regimens for pwCF ≥ 12 years of age, simulations were performed for ivacaftor, lumacaftor/ivacaftor, and tezacaftor/ivacaftor dosing for 14 days followed by immediate transition to elexacaftor/tezacaftor/ivacaftor dosing for 14 days. Drug exposures during transitions were compared with respective half-maximal effective concentrations (EC50) estimated from efficacy endpoint data from clinical studies. RESULTS In simulations of immediate transition from ivacaftor or tezacaftor/ivacaftor to TC, the preceding treatment had no impact on ivacaftor, tezacaftor, or elexacaftor exposures. In simulations of immediate transition from lumacaftor/ivacaftor to TC, ivacaftor exposure decreased to 64% of maximum effective concentration (EC), due to reduction in ivacaftor dose and residual CYP3A4 induction, then returned to 90-95% of maximum EC. Lumacaftor-mediated CYP3A induction resolved within approximately 2 weeks. In all simulations, ivacaftor, tezacaftor, and elexacaftor exposures approached steady state within 2 weeks following transition and, at all times, ivacaftor and ≥ 1 CFTR corrector remained above EC50. CONCLUSION PBPK modeling indicates that immediate transition to the elexacaftor/tezacaftor/ivacaftor regimen from an ivacaftor, lumacaftor/ivacaftor, or tezacaftor/ivacaftor regimen results in sustained CFTR modulation in pwCF ≥ 12 years of age.
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Affiliation(s)
- Alice Tsai
- Vertex Pharmaceuticals Incorporated, Boston, MA, USA.
| | - Shu-Pei Wu
- Vertex Pharmaceuticals Incorporated, Boston, MA, USA
| | | | - Sanjeev Kumar
- Vertex Pharmaceuticals Incorporated, Boston, MA, USA
| | | | | | - Kushal Shah
- Vertex Pharmaceuticals Incorporated, Boston, MA, USA
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Savant AP, McColley SA. Cystic fibrosis year in review 2019: Section 1 CFTR modulators. Pediatr Pulmonol 2020; 55:3236-3242. [PMID: 32833326 DOI: 10.1002/ppul.25039] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 08/18/2020] [Indexed: 12/12/2022]
Abstract
During the year 2019, research and case reports/series in the field of cystic fibrosis (CF) were in abundance. To adequately address the large body of CF research published during 2019, the CF year in review will be divided into three sections. This report is the first section, focusing specifically on new research related to cystic fibrosis transmembrane conductance regulator modulator therapy. Additional sections will concentrate on pulmonary and infections research and the multisystem effects of CF. It is an exciting time to be providing care for patients and their families with CF with all the exciting new discoveries that will be shared in these reviews.
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Affiliation(s)
- Adrienne P Savant
- Children's Hospital of New Orleans, New Orleans, Louisiana.,Department of Pediatrics, Division of Pulmonary Medicine, Tulane University School of Medicine, New Orleans, Illinois
| | - Susanna A McColley
- Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.,Stanley Manne Children's Research Institute, Chicago, Illinois.,Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
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31
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Davies JC, Sermet-Gaudelus I, Naehrlich L, Harris RS, Campbell D, Ahluwalia N, Short C, Haseltine E, Panorchan P, Saunders C, Owen CA, Wainwright CE. A phase 3, double-blind, parallel-group study to evaluate the efficacy and safety of tezacaftor in combination with ivacaftor in participants 6 through 11 years of age with cystic fibrosis homozygous for F508del or heterozygous for the F508del-CFTR mutation and a residual function mutation. J Cyst Fibros 2020; 20:68-77. [PMID: 32967799 DOI: 10.1016/j.jcf.2020.07.023] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 07/24/2020] [Accepted: 07/26/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND The CFTR modulator tezacaftor/ivacaftor was efficacious and generally safe and well tolerated in Phase 3 studies in participants ≥12 years of age with cystic fibrosis (CF) homozygous for the F508del-CFTR mutation or heterozygous with a residual function-CFTR mutation (F/F or F/RF respectively). We evaluated tezacaftor/ivacaftor's efficacy and safety over 8 weeks in participants 6 through 11 years of age with these mutations. METHODS Participants were randomized 4:1 to tezacaftor/ivacaftor or a blinding group (placebo for F/F, ivacaftor for F/RF). The primary endpoint was within-group change from baseline in the lung clearance index 2·5 (LCI2·5) through Week 8. Secondary endpoints were change from baseline in sweat chloride (SwCl), cystic fibrosis questionnaire-revised (CFQ-R) respiratory domain score, and safety. RESULTS Sixty-seven participants received at least one study drug dose. Of those, 54 received tezacaftor/ivacaftor (F/F, 42; F/RF, 12), 10 placebo, and 3 ivacaftor; 66 completed the study. The within-group change in LCI2·5 was significantly reduced (improved) by -0·51 (95% CI: -0·74, -0·29). SwCl concentration decreased (improved) by -12·3 mmol/L and CFQ-R respiratory domain score increased (improved, nonsignificantly) by 2·3 points. There were no serious adverse events (AEs) or AEs leading to tezacaftor/ivacaftor discontinuation or interruption. The most common AEs (≥10%) in participants receiving tezacaftor/ivacaftor were cough, headache, and productive cough. CONCLUSIONS Tezacaftor/ivacaftor improved lung function (assessed using LCI) and CFTR function (measured by SwCl concentration) in participants 6 through 11 years of age with F/F or F/RF genotypes. Tezacaftor/ivacaftor was safe and well tolerated; no new safety concerns were identified.
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Affiliation(s)
- Jane C Davies
- National Heart and Lung Institute, Imperial College London, London, United Kingdom; Royal Brompton & Harefield NHS Foundation Trust, London, United Kingdom.
| | - Isabelle Sermet-Gaudelus
- INSERM U1151, Institut Necker Enfants Malades, Université Paris Sorbonne, Paris, France, Hôpital Necker-Enfants malades, Paris, France
| | - Lutz Naehrlich
- Department of Pediatrics, Justus Liebig University Giessen, Giessen, Germany; Universities of Giessen and Marburg Lung Center, The German Center for Lung Research, Giessen, Germany
| | - R Scott Harris
- Vertex Pharmaceuticals Incorporated, Boston, MA, United States
| | - Daniel Campbell
- Vertex Pharmaceuticals Incorporated, Boston, MA, United States
| | - Neil Ahluwalia
- Vertex Pharmaceuticals Incorporated, Boston, MA, United States
| | - Christopher Short
- National Heart and Lung Institute, Imperial College London, London, United Kingdom; Royal Brompton & Harefield NHS Foundation Trust, London, United Kingdom
| | - Eric Haseltine
- Vertex Pharmaceuticals Incorporated, Boston, MA, United States
| | - Paul Panorchan
- Vertex Pharmaceuticals Incorporated, Boston, MA, United States
| | - Clare Saunders
- National Heart and Lung Institute, Imperial College London, London, United Kingdom; Royal Brompton & Harefield NHS Foundation Trust, London, United Kingdom
| | - Caroline A Owen
- Vertex Pharmaceuticals Incorporated, Boston, MA, United States
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Gramegna A, Contarini M, Aliberti S, Casciaro R, Blasi F, Castellani C. From Ivacaftor to Triple Combination: A Systematic Review of Efficacy and Safety of CFTR Modulators in People with Cystic Fibrosis. Int J Mol Sci 2020; 21:E5882. [PMID: 32824306 PMCID: PMC7461566 DOI: 10.3390/ijms21165882] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 08/11/2020] [Accepted: 08/12/2020] [Indexed: 12/15/2022] Open
Abstract
Over the last years CFTR (cystic fibrosis transmembrane conductance regulator) modulators have shown the ability to improve relevant clinical outcomes in patients with cystic fibrosis (CF). This review aims at a systematic research of the current evidence on efficacy and tolerability of CFTR modulators for different genetic subsets of patients with CF. Two investigators independently performed the search on PubMed and included phase 2 and 3 clinical trials published in the study period 1 January 2005-31 January 2020. A final pool of 23 papers was included in the systematic review for a total of 4219 patients. For each paper data of interest were extracted and reported in table. In terms of lung function, patients who had the most beneficial effects from CFTR modulation were those patients with one gating mutation receiving IVA (ivacaftor) and patients with p.Phe508del mutation, both homozygous and heterozygous, receiving ELX/TEZ/IVA (elexacaftor/tezacaftor/ivacaftor) had the most relevant beneficial effects in term of lung function, pulmonary exacerbation decrease, and symptom improvement. CFTR modulators showed an overall favorable safety profile. Next steps should aim to systematize our comprehension of scientific data of efficacy and safety coming from real life observational studies.
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Affiliation(s)
- Andrea Gramegna
- Department of Pathophysiology and Transplantation, University of Milano, 20129 Milano, Italy; (S.A.); (F.B.)
- Respiratory Disease and Adult Cystic Fibrosis Center, Internal Medicine Department, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore, Policlinico, 20129 Milano, Italy;
| | - Martina Contarini
- Respiratory Disease and Adult Cystic Fibrosis Center, Internal Medicine Department, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore, Policlinico, 20129 Milano, Italy;
| | - Stefano Aliberti
- Department of Pathophysiology and Transplantation, University of Milano, 20129 Milano, Italy; (S.A.); (F.B.)
- Respiratory Disease and Adult Cystic Fibrosis Center, Internal Medicine Department, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore, Policlinico, 20129 Milano, Italy;
| | - Rosaria Casciaro
- IRCCS Istituto Giannina Gaslini, Cystic Fibrosis Center, 16147 Genoa, Italy; (R.C.); (C.C.)
| | - Francesco Blasi
- Department of Pathophysiology and Transplantation, University of Milano, 20129 Milano, Italy; (S.A.); (F.B.)
- Respiratory Disease and Adult Cystic Fibrosis Center, Internal Medicine Department, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore, Policlinico, 20129 Milano, Italy;
| | - Carlo Castellani
- IRCCS Istituto Giannina Gaslini, Cystic Fibrosis Center, 16147 Genoa, Italy; (R.C.); (C.C.)
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Abstract
PURPOSE OF REVIEW Cystic fibrosis transmembrane conductance receptor (CFTR) modulators are a new class of drugs that treat the underlying cause of cystic fibrosis. To date, there are four approved medications, which are mutation-specific. Although the number of mutations that respond to these agents is expanding, effective CFTR modulators are not available to all cystic fibrosis patients. The purpose of this article is to review the approved CFTR modulators and discuss the mutations that can be treated with these agents, as well as, review the long-term benefits of modulator therapy. RECENT FINDINGS More people with cystic fibrosis can be effectively treated with CFTR modulators. The new, highly effective triple therapy, elexacaftor/tezacaftor/ivacaftor is indicated for more than 90% of patients with cystic fibrosis and ivacaftor is now approved for children as young as 6 months of age with 1 of 30 CFTR mutations. Long-term use of modulator therapy is associated with fewer pulmonary exacerbations, maintenance of lung function, improved weight gain, and quality of life. SUMMARY CFTR modulators are the first therapies developed to treat the underlying defect in cystic fibrosis. Their use is associated with preserved lung function and improved health in patients with cystic fibrosis.
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Rang C, Keating D, Wilson J, Kotsimbos T. Re-imagining cystic fibrosis care: next generation thinking. Eur Respir J 2020; 55:13993003.02443-2019. [PMID: 32139465 DOI: 10.1183/13993003.02443-2019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 02/20/2020] [Indexed: 12/26/2022]
Abstract
Cystic fibrosis (CF) is a common multi-system genetically inherited condition, predominately found in individuals of Caucasian decent. Since the identification of the cystic fibrosis (CF) transmembrane conductance regulator (CFTR) gene in 1989, and the subsequent improvement in understanding of CF pathophysiology, significant increases in life-expectancy have followed. Initially this was related to improvements in the management and systems of care for treating the various affected organ systems. These cornerstone treatments are still essential for CF patients born today. However, over the last decade, the major advance has been in therapies that target the resultant genetic defect: the dysfunctional CFTR protein. Small molecule agents that target this dysfunctional protein via a variety of mechanisms have led to lung function improvements, reductions in pulmonary exacerbation rates and increases in weight and quality-of-life indices. As more patients receive these agents earlier and earlier in life, it is likely that general CF care will increasingly pivot around these specific therapies, although it is also likely that effects other than those identified in the initial trials will be discovered and need to be managed. Despite great excitement for modulator therapies, they are unlikely to be suitable or available for all; whether this is due to a lack of availability for specific CFTR mutations, drug-reactions or the health economic set-up in certain countries. Nevertheless, the CF community must be applauded for its ongoing focus on research and development for this life-limiting disease. With time, personalised individualised therapy would ideally be the mainstay of CF care.
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Affiliation(s)
- Catherine Rang
- Cystic Fibrosis Service, Dept of Respiratory Medicine, Alfred Health, Melbourne, Australia
| | - Dominic Keating
- Cystic Fibrosis Service, Dept of Respiratory Medicine, Alfred Health, Melbourne, Australia.,Dept of Medicine, Monash University, Alfred Campus, Melbourne, Australia
| | - John Wilson
- Cystic Fibrosis Service, Dept of Respiratory Medicine, Alfred Health, Melbourne, Australia.,Dept of Medicine, Monash University, Alfred Campus, Melbourne, Australia
| | - Tom Kotsimbos
- Cystic Fibrosis Service, Dept of Respiratory Medicine, Alfred Health, Melbourne, Australia.,Dept of Medicine, Monash University, Alfred Campus, Melbourne, Australia
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35
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Sharma J, Keeling KM, Rowe SM. Pharmacological approaches for targeting cystic fibrosis nonsense mutations. Eur J Med Chem 2020; 200:112436. [PMID: 32512483 DOI: 10.1016/j.ejmech.2020.112436] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 05/04/2020] [Accepted: 05/06/2020] [Indexed: 12/11/2022]
Abstract
Cystic fibrosis (CF) is a monogenic autosomal recessive disorder. The clinical manifestations of the disease are caused by ∼2,000 mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) protein. It is unlikely that any one approach will be efficient in correcting all defects. The recent approvals of ivacaftor, lumacaftor/ivacaftor and elexacaftor/tezacaftor/ivacaftor represent the genesis of a new era of precision combination medicine for the CF patient population. In this review, we discuss targeted translational readthrough approaches as mono and combination therapies for CFTR nonsense mutations. We examine the current status of efficacy of translational readthrough/nonsense suppression therapies and their limitations, including non-native amino acid incorporation at PTCs and nonsense-mediated mRNA decay (NMD), along with approaches to tackle these limitations. We further elaborate on combining various therapies such as readthrough agents, NMD inhibitors, and corrector/potentiators to improve the efficacy and safety of suppression therapy. These mutation specific strategies that are directed towards the basic CF defects should positively impact CF patients bearing nonsense mutations.
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Affiliation(s)
- Jyoti Sharma
- Department of Medicine, University of Alabama at Birmingham (UAB), USA; Department of Gregory Fleming James Cystic Fibrosis Research Center, University of Alabama at Birmingham (UAB), USA
| | - Kim M Keeling
- Department of Biochemistry and Molecular Genetics, University of Alabama at Birmingham (UAB), USA; Department of Gregory Fleming James Cystic Fibrosis Research Center, University of Alabama at Birmingham (UAB), USA
| | - Steven M Rowe
- Department of Medicine, University of Alabama at Birmingham (UAB), USA; Department of Pediatrics, University of Alabama at Birmingham (UAB), USA; Department of Gregory Fleming James Cystic Fibrosis Research Center, University of Alabama at Birmingham (UAB), USA.
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36
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Guerra L, Favia M, Di Gioia S, Laselva O, Bisogno A, Casavola V, Colombo C, Conese M. The preclinical discovery and development of the combination of ivacaftor + tezacaftor used to treat cystic fibrosis. Expert Opin Drug Discov 2020; 15:873-891. [PMID: 32290721 DOI: 10.1080/17460441.2020.1750592] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Cystic Fibrosis (CF) is caused by mutations in the Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) gene. The most common mutation, F508del, induces protein misprocessing and loss of CFTR function. The discovery through in vitro studies of the CFTR correctors (i.e. lumacaftor, tezacaftor) that partially rescue the misprocessing of F508del-CFTR with the potentiator ivacaftor is promising in giving an unprecedented clinical benefit in affected patients. AREAS COVERED Online databases were searched using key phrases for CF and CFTR modulators. Tezacaftor-ivacaftor treatment has proved to be safer than lumacaftor-ivacaftor, although clinical efficacy is similar. Further clinical efficacy has ensued with the introduction of triple therapy, i.e. applying second-generation correctors, such as VX-569 and VX-445 (elexacaftor) to tezacaftor-ivacaftor. The triple combinations will herald the availability of etiologic therapies for patients for whom no CFTR modulators are currently applied (i.e. F508del/minimal function mutations) and enhance CFTR modulator therapy for patients homozygous for F508del. EXPERT OPINION CF patient-derived tissue models are being explored to determine donor-specific response to current approved and future novel CFTR modulators for F508del and other rare mutations. The discovery and validation of biomarkers of CFTR modulation will complement these studies in the long term and in real-life world.
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Affiliation(s)
- Lorenzo Guerra
- Department of Biosciences, Biotechnologies and Biopharmaceutics, University of Bari , Bari, Italy
| | - Maria Favia
- Department of Biosciences, Biotechnologies and Biopharmaceutics, University of Bari , Bari, Italy
| | - Sante Di Gioia
- Department of Medical and Surgical Sciences, University of Foggia , Foggia, Italy
| | - Onofrio Laselva
- Programme in Molecular Medicine, Research Institute, Hospital for Sick Children , Toronto, Ontario, Canada.,Department of Physiology, University of Toronto , Toronto, Ontario, Canada
| | - Arianna Bisogno
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Centro Regionale di Riferimento per la Fibrosi Cistica, Università degli Studi di Milano , Milan, Italy
| | - Valeria Casavola
- Department of Biosciences, Biotechnologies and Biopharmaceutics, University of Bari , Bari, Italy
| | - Carla Colombo
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Centro Regionale di Riferimento per la Fibrosi Cistica, Università degli Studi di Milano , Milan, Italy
| | - Massimo Conese
- Department of Medical and Surgical Sciences, University of Foggia , Foggia, Italy
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Lopes-Pacheco M. CFTR Modulators: The Changing Face of Cystic Fibrosis in the Era of Precision Medicine. Front Pharmacol 2020; 10:1662. [PMID: 32153386 PMCID: PMC7046560 DOI: 10.3389/fphar.2019.01662] [Citation(s) in RCA: 269] [Impact Index Per Article: 67.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 12/19/2019] [Indexed: 12/22/2022] Open
Abstract
Cystic fibrosis (CF) is a lethal inherited disease caused by mutations in the CF transmembrane conductance regulator (CFTR) gene, which result in impairment of CFTR mRNA and protein expression, function, stability or a combination of these. Although CF leads to multifaceted clinical manifestations, the respiratory disorder represents the major cause of morbidity and mortality of these patients. The life expectancy of CF patients has substantially lengthened due to early diagnosis and improvements in symptomatic therapeutic regimens. Quality of life remains nevertheless limited, as these individuals are subjected to considerable clinical, psychosocial and economic burdens. Since the discovery of the CFTR gene in 1989, tremendous efforts have been made to develop therapies acting more upstream on the pathogenesis cascade, thereby overcoming the underlying dysfunctions caused by CFTR mutations. In this line, the advances in cell-based high-throughput screenings have been facilitating the fast-tracking of CFTR modulators. These modulator drugs have the ability to enhance or even restore the functional expression of specific CF-causing mutations, and they have been classified into five main groups depending on their effects on CFTR mutations: potentiators, correctors, stabilizers, read-through agents, and amplifiers. To date, four CFTR modulators have reached the market, and these pharmaceutical therapies are transforming patients' lives with short- and long-term improvements in clinical outcomes. Such breakthroughs have paved the way for the development of novel CFTR modulators, which are currently under experimental and clinical investigations. Furthermore, recent insights into the CFTR structure will be useful for the rational design of next-generation modulator drugs. This review aims to provide a summary of recent developments in CFTR-directed therapeutics. Barriers and future directions are also discussed in order to optimize treatment adherence, identify feasible and sustainable solutions for equitable access to these therapies, and continue to expand the pipeline of novel modulators that may result in effective precision medicine for all individuals with CF.
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Affiliation(s)
- Miquéias Lopes-Pacheco
- Biosystems & Integrative Sciences Institute, Faculty of Sciences, University of Lisbon, Lisbon, Portugal
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Jaques R, Shakeel A, Hoyle C. Novel therapeutic approaches for the management of cystic fibrosis. Multidiscip Respir Med 2020; 15:690. [PMID: 33282281 PMCID: PMC7706361 DOI: 10.4081/mrm.2020.690] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 11/06/2020] [Indexed: 12/19/2022] Open
Abstract
Cystic fibrosis (CF) is a genetic condition characterised by the build-up of thick, sticky mucus that can damage many of the body's organs. It is a life-long disease that results in a shortened life expectancy, often due to the progression of advanced lung disease. Treatment has previously targeted the downstream symptoms such as diminished mucus clearance and recurrent infection. More recently, significant advances have been made in treating the cause of the disease by targeting the faulty gene responsible. Hope for the development of potential therapies lies with ongoing research into new pharmacological agents and gene therapy. This review gives an overview of CF, and summarises the current evidence regarding the disease management and upcoming strategies aimed at treating or potentially curing this condition.
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Affiliation(s)
- Ryan Jaques
- Centre for Atherothrombosis and Metabolic Disease, Hull York Medical School, University of Hull, UK
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Paterson SL, Barry PJ, Horsley AR. Tezacaftor and ivacaftor for the treatment of cystic fibrosis. Expert Rev Respir Med 2019; 14:15-30. [PMID: 31626570 DOI: 10.1080/17476348.2020.1682998] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Introduction: Cystic fibrosis (CF) is a complex, multi-system, genetic disease affecting over 70,000 people worldwide. The underlying defect is a mutation in the CFTR gene. Dysfunctional CFTR protein results in abnormal anion movement across epithelial membranes in affected organs. There has been a paradigm shift in CF treatment over the last decade with the advent of CFTR modulation, treatments which target this underlying genetic defect and have the potential to change the course of CF clinical disease.Areas covered: Available CFTR modulators in current clinical practice are reviewed in this article, with a direct comparison and summary of relevant pivotal clinical trials. The approval of ivacaftor and subsequent development of lumacaftor and tezacaftor dual combinations represents an exciting development in CF management in recent years.Expert opinion: Tezacaftor/ivacaftor (tez/iva) appears to have a more favorable adverse event and drug-drug interaction profile than lumacaftor/ivacaftor. Tez/iva has been approved, alongside Phe508del, for a large number of 'residual function' CFTR mutations, with some based on response to in vitro culture. Dual therapy with tez/iva has paved the way for triple CFTR modulation currently in clinical trials with an ultimate view to provide modulation therapy to the majority of CF genotypes in the future.
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Affiliation(s)
- Sarah L Paterson
- Manchester Adult Cystic Fibrosis Centre, Manchester NHS Foundation Trust, Wythenshawe Hospital, Wythenshawe, UK.,Division of Infection Immunity & Respiratory Medicine, Faculty of Biology Medicine and Health, University of Manchester, Manchester, UK
| | - Peter J Barry
- Manchester Adult Cystic Fibrosis Centre, Manchester NHS Foundation Trust, Wythenshawe Hospital, Wythenshawe, UK.,Division of Infection Immunity & Respiratory Medicine, Faculty of Biology Medicine and Health, University of Manchester, Manchester, UK
| | - Alexander R Horsley
- Manchester Adult Cystic Fibrosis Centre, Manchester NHS Foundation Trust, Wythenshawe Hospital, Wythenshawe, UK.,Division of Infection Immunity & Respiratory Medicine, Faculty of Biology Medicine and Health, University of Manchester, Manchester, UK
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VanDevanter DR, Mayer-Hamblett N. Important steps in the journey to highly effective CFTR modulator access for people with CF. J Cyst Fibros 2019; 18:577-578. [PMID: 31500809 DOI: 10.1016/j.jcf.2019.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- D R VanDevanter
- Case Western Reserve University School of Medicine, Cleveland, OH, USA.
| | - N Mayer-Hamblett
- University of Washington and Seattle Children's Hospital, Seattle, WA, USA
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