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Kowalik A, Roberts E, Harris AH, Sund M, Wird S, Kvist O, Hjelte L. Clinical outcomes of two infants with cystic fibrosis, including presence of the vas deferens, born to a woman with cystic fibrosis taking CFTR modulators during both pregnancies. J Cyst Fibros 2024:S1569-1993(24)00080-8. [PMID: 38876833 DOI: 10.1016/j.jcf.2024.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Revised: 05/22/2024] [Accepted: 06/03/2024] [Indexed: 06/16/2024]
Affiliation(s)
- Aleksandra Kowalik
- Stockholm CF Centre, Karolinska University Hospital, Karolinska Institute, Stockholm, Sweden.
| | - Emma Roberts
- Stockholm CF Centre, Karolinska University Hospital, Karolinska Institute, Stockholm, Sweden
| | - Anna Hedborg Harris
- Stockholm CF Centre, Karolinska University Hospital, Karolinska Institute, Stockholm, Sweden
| | - Marie Sund
- Department of Pediatric Radiology, Karolinska University Hospital, Stockholm, Sweden
| | - Sara Wird
- Department of Pediatric Radiology, Karolinska University Hospital, Stockholm, Sweden
| | - Ola Kvist
- Department of Pediatric Radiology, Karolinska University Hospital, Stockholm, Sweden; Department of Women's and Children's Health, Karolinska Institute, Stockholm, Sweden
| | - Lena Hjelte
- Stockholm CF Centre, Karolinska University Hospital, Karolinska Institute, Stockholm, Sweden
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2
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Syunyaeva Z, Mall MA, Stahl M. [Cystic fibrosis in childhood and adulthood]. INNERE MEDIZIN (HEIDELBERG, GERMANY) 2024; 65:538-544. [PMID: 38714556 DOI: 10.1007/s00108-024-01717-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/24/2024] [Indexed: 05/10/2024]
Abstract
BACKGROUND Cystic fibrosis (CF, or mucoviscidosis) is one of the rare diseases with a fatal course and with the highest prevalence. Formerly known as a purely childhood disease, this multisystemic disease follows an autosomal recessive inheritance pattern and results in a malfunction of the cystic fibrosis transmembrane conductance regulator (CFTR) channel, leading to the production of viscous secretions. The prognosis and outcome of CF are determined by the severity of the involvement of the lungs. Other typically affected organs include the pancreas, liver and intestines. OBJECTIVE This article reviews the clinical presentation and evolution of CF with a focus on the new era of the highly effective CFTR modulator treatment. MATERIAL AND METHODS An overview of the current state of knowledge on the care for CF patients is presented. RESULTS AND DISCUSSION The introduction of the CF newborn screening, the increased understanding of the disease and the development of novel treatment options have substantially increased the quality of life and life expectancy of people with CF. As a result, more than half of CF patients in Germany are now older than 18 years of age and the complications of a chronic disease as well as organ damage due to the intensive treatment are gaining in importance. The highly effective CFTR modulator treatment results in a significant improvement in CFTR function, lung function, body mass index and quality of life and is available to approximately 90% of patients in Germany, based on the genotype. Nevertheless, further research including the development of causal treatment, e.g., gene therapy, targeting the underlying defect in the remaining 10% of CF patients, is urgently needed. Even in adult patients, CF with a mild course or a CFTR-related disease should be considered, e.g., in cases of bronchiectasis and/or recurrent abdominal complaints.
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Affiliation(s)
- Zulfiya Syunyaeva
- Klinik für Pädiatrie m. S. Pneumologie, Immunologie und Intensivmedizin, Sektion Mukoviszidose, Campus Virchow Klinikum, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Deutschland.
| | - Marcus A Mall
- Klinik für Pädiatrie m. S. Pneumologie, Immunologie und Intensivmedizin, Sektion Mukoviszidose, Campus Virchow Klinikum, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Deutschland
- Deutsches Zentrum für Lungenforschung (DZL), assoziierter Partnerstandort, Berlin, Deutschland
- Berlin Institute of Health (BIH), Charité - Universitätsmedizin Berlin, Berlin, Deutschland
| | - Mirjam Stahl
- Klinik für Pädiatrie m. S. Pneumologie, Immunologie und Intensivmedizin, Sektion Mukoviszidose, Campus Virchow Klinikum, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Deutschland
- Deutsches Zentrum für Lungenforschung (DZL), assoziierter Partnerstandort, Berlin, Deutschland
- Berlin Institute of Health (BIH), Charité - Universitätsmedizin Berlin, Berlin, Deutschland
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3
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Ciobanu DZ, Liessi N, Tomati V, Capurro V, Bertozzi SM, Summa M, Bertorelli R, Loberto N, Dobi D, Aureli M, Nobbio L, Bandiera T, Pedemonte N, Bassi R, Armirotti A. Tezacaftor is a direct inhibitor of sphingolipid delta-4 desaturase enzyme (DEGS). J Cyst Fibros 2024:S1569-1993(24)00067-5. [PMID: 38789319 DOI: 10.1016/j.jcf.2024.05.004] [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: 02/28/2024] [Revised: 04/20/2024] [Accepted: 05/13/2024] [Indexed: 05/26/2024]
Abstract
BACKGROUND We recently demonstrated that 48 h exposure of primary human bronchial epithelial (hBE) cells, obtained from both CF (F508del homozygous) and non-CF subjects, to the triple drug combination Elexacaftor/Tezacaftor/Ivacaftor (ETI) results in a CFTR genotype-independent modulation of the de novo synthethic pathway of sphingolipids, with an accumulation of dihydroceramides (dHCer). Since dHCer are converted into ceramides (Cer) by the action of a delta-4 sphingolipid desaturase (DEGS) enzyme, we aimed to better understand this off-target effect of ETI (i.e., not related to CFTR rescue) METHODS: hBE cells, both F508del and wild-type, were cultured to create fully differentiated bronchial epithelia. We analyzed Cer and dHCer using an LC-MS based method previously developed by our lab. DEGS expression levels in differentiated hBE cells lysates were quantified by western blot analysis. RESULTS We demonstrated that 1) dHCer accumulate in hBE with time following prolonged ETI exposure, that 2) similar inhibition occurs in wild-type primary human hepatocytes and that 3) this does not result in an alteration of DEGS expression. We then proved that 4) ETI is a direct inhibitor of DEGS, that 5) Tezacaftor is the molecule responsible for this effect, that 6) the inhibition is concentration dependent. Finally, after repeated oral administration of ETI to naïve, non-CF, mice, we observed a slight accumulation of dHCer in the brain. CONCLUSIONS We believe that further investigations on Tezacaftor should be envisaged, particularly for the use of ETI during pregnancy, breastfeeding and in the early stages of development. DEGS dysfunction and dHCer accumulation causes impairment in the development of the nervous system, due to a derangement in myelin formation and maintenance.
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Affiliation(s)
- Dinu Zinovie Ciobanu
- Analytical Chemistry Facility, Istituto Italiano di Tecnologia, Via Morego 30, 16163, Genova, Italy
| | - Nara Liessi
- Analytical Chemistry Facility, Istituto Italiano di Tecnologia, Via Morego 30, 16163, Genova, Italy
| | - Valeria Tomati
- UOC Genetica Medica, IRCCS Istituto Giannina Gaslini, Via Gerolamo Gaslini 5, 16147, Genova, Italy
| | - Valeria Capurro
- UOC Genetica Medica, IRCCS Istituto Giannina Gaslini, Via Gerolamo Gaslini 5, 16147, Genova, Italy
| | - Sine Mandrup Bertozzi
- Analytical Chemistry Facility, Istituto Italiano di Tecnologia, Via Morego 30, 16163, Genova, Italy
| | - Maria Summa
- Translational Pharmacology Facility, Istituto Italiano di Tecnologia, Via Morego 30, 16163, Genova, Italy
| | - Rosalia Bertorelli
- Translational Pharmacology Facility, Istituto Italiano di Tecnologia, Via Morego 30, 16163, Genova, Italy
| | - Nicoletta Loberto
- Dipartimento di Biotecnologie Mediche e Medicina Traslazionale, Università degli Studi di Milano, Via F.lli Cervi 93, 20054, Segrate, Milano, Italy
| | - Dorina Dobi
- Dipartimento di Biotecnologie Mediche e Medicina Traslazionale, Università degli Studi di Milano, Via F.lli Cervi 93, 20054, Segrate, Milano, Italy
| | - Massimo Aureli
- Dipartimento di Biotecnologie Mediche e Medicina Traslazionale, Università degli Studi di Milano, Via F.lli Cervi 93, 20054, Segrate, Milano, Italy
| | - Lucilla Nobbio
- IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genova, Italy
| | - Tiziano Bandiera
- D3 PharmaChemistry, Istituto Italiano di Tecnologia, Via Morego 30, 16163, Genova, Italy
| | - Nicoletta Pedemonte
- UOC Genetica Medica, IRCCS Istituto Giannina Gaslini, Via Gerolamo Gaslini 5, 16147, Genova, Italy
| | - Rosaria Bassi
- Dipartimento di Biotecnologie Mediche e Medicina Traslazionale, Università degli Studi di Milano, Via F.lli Cervi 93, 20054, Segrate, Milano, Italy
| | - Andrea Armirotti
- Analytical Chemistry Facility, Istituto Italiano di Tecnologia, Via Morego 30, 16163, Genova, Italy.
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Li D, Donnelley M, Parsons D, Habgood MD, Schneider-Futschik EK. Extent of foetal exposure to maternal elexacaftor/tezacaftor/ivacaftor during pregnancy. Br J Pharmacol 2024. [PMID: 38770951 DOI: 10.1111/bph.16417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 03/28/2024] [Accepted: 03/28/2024] [Indexed: 05/22/2024] Open
Abstract
BACKGROUND AND PURPOSE Cystic fibrosis (CF) patients are living longer and healthier due to improved treatments, e.g. cystic fibrosis transmembrane conductance regulator (CFTR) modulator therapy elexacaftor/tezacaftor/ivacaftor (ETI), with treatment possibly occurring in pregnancy. The risk of ETI to foetuses remain unknown. Thus the effect of maternally administered ETI on foetal genetic and structural development was investigated. EXPERIMENTAL APPROACH Pregnant Sprague Dawley rats were orally treated with ETI (6.7 mg·kg-1·day-1 elexacaftor + 3.5 mg·kg-1·day-1 tezacaftor + 25 mg·kg-1·day-1 ivacaftor) for 7 days from E12 to E19. Tissue samples collected at E19 were analysed using histology and RNA sequencing. Histological changes and differentially expressed genes (DEG) were assessed. KEY RESULTS No overt structural abnormalities were found in foetal pancreas, liver, lung and small intestine after 7-day ETI exposure. Very few non-functionally associated DEG in foetal liver, lung and small intestine were identified using RNA-seq. 29 DEG were identified in thymus (27 up-regulated and two down-regulated) and most were functionally linked to each other. Gene ontology enrichment analysis revealed that multiple muscle-related terms were significantly enriched. Many more DEG were identified in cortex (44 up-regulated and four down-regulated) and a group of these were involved in central nervous system and brain development. CONCLUSION AND IMPLICATION Sub-chronic ETI treatment in late pregnancy does not appear to pose a significant risk to the genetic and structural development of many foetal tissues. However, significant gene changes in foetal thymic myoid cells and cortical neuronal development requires future follow-up studies to assess the risk to these organs.
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Affiliation(s)
- Danni Li
- Department of Biochemistry & Pharmacology, School of Biomedical Sciences, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, VIC, Australia
| | - Martin Donnelley
- Robinson Research Institute, University of Adelaide, Adelaide, South Australia, Australia
- Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
- Department of Respiratory and Sleep Medicine, Women's and Children's Hospital, North Adelaide, South Australia, Australia
| | - David Parsons
- Robinson Research Institute, University of Adelaide, Adelaide, South Australia, Australia
- Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
- Department of Respiratory and Sleep Medicine, Women's and Children's Hospital, North Adelaide, South Australia, Australia
| | - Mark D Habgood
- Department of Biochemistry & Pharmacology, School of Biomedical Sciences, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, VIC, Australia
| | - Elena K Schneider-Futschik
- Department of Biochemistry & Pharmacology, School of Biomedical Sciences, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, VIC, Australia
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Cohen-Cymberknoh M, Ariel Dabby M, Gindi Reiss B, Melo Tanner J, Pérez G, Lechtzin N, Polverino E, Perez Miranda J, Gramegna A, Aliberti S, Levine H, Mussaffi H, Blau H, Prais D, Mei-Zahav M, Shteinberg M, Livnat G, Gur M, Bentur L, Downey DG, Dagan A, Golan-Tripto I, Aviram M, Mondejar-Lopez P, Picard E, Schwarz C, Jakubec P, Kazmerski TM, Amsalem H, Hochner Celnikier D, Kerem E, Reiter J. Maternal and fetal outcomes in multiparous women with Cystic Fibrosis. Respir Med 2024; 228:107654. [PMID: 38735372 DOI: 10.1016/j.rmed.2024.107654] [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: 10/29/2023] [Revised: 04/21/2024] [Accepted: 04/25/2024] [Indexed: 05/14/2024]
Abstract
BACKGROUND Quality of life and survival in Cystic Fibrosis (CF) have improved dramatically, making family planning a feasible option. Maternal and perinatal outcomes in women with CF (wwCF) are similar to those seen in the general population. However, the effect of undergoing multiple pregnancies is unknown. METHODS A multinational-multicenter retrospective cohort study. Data was obtained from 18 centers worldwide, anonymously, on wwCF 18-45 years old, including disease severity and outcome, as well as obstetric and newborn complications. Data were analyzed, within each individual patient to compare the outcomes of an initial pregnancy (1st or 2nd) with a multigravid pregnancy (≥3) as well as secondary analysis of grouped data to identify risk factors for disease progression or adverse neonatal outcomes. Three time periods were assessed - before, during, and after pregnancy. RESULTS The study population included 141 wwCF of whom 41 (29%) had ≥3 pregnancies, "multiparous". Data were collected on 246 pregnancies, between 1973 and 2020, 69 (28%) were multiparous. A greater decline in ppFEV1 was seen in multiparous women, primarily in pancreatic insufficient (PI) wwCF and those with two severe (class I-III) mutations. Multigravid pregnancies were shorter, especially in wwCF over 30 years old, who had high rates of prematurity and newborn complications. There was no effect on pulmonary exacerbations or disease-related complications. CONCLUSIONS Multiple pregnancies in wwCF are associated with accelerated respiratory deterioration and higher rates of preterm births. Therefore, strict follow-up by a multidisciplinary CF and obstetric team is needed in women who desire to carry multiple pregnancies.
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Affiliation(s)
- Malena Cohen-Cymberknoh
- Pediatric Pulmonary Unit and Cystic Fibrosis Center, Hadassah Medical Center, Jerusalem, Israel; Faculty of Medicine, Hebrew University of Jerusalem, Israel.
| | | | | | | | - Gema Pérez
- Pediatric Pulmonology and Cystic Fibrosis Unit, Hospital Exequiel González Cortés, Chile
| | - Noah Lechtzin
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Eva Polverino
- Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | | | - Andrea Gramegna
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Respiratory Unit and Cystic Fibrosis Center, Italy; Department Pathophysiology and Transplantation University of Milan, Italy
| | - Stefano Aliberti
- Department of Biomedical Sciences, Humanitas University, Milan, Italy; IRCCS Humanitas Research Hospital, Respiratory Unit, Milan, Italy
| | - Hagit Levine
- Graub CF Center, Schneider Children's Medical Center, Petach-Tikva and Sackler School of Medicine, Tel-Aviv University, Israel
| | - Huda Mussaffi
- Graub CF Center, Schneider Children's Medical Center, Petach-Tikva and Sackler School of Medicine, Tel-Aviv University, Israel
| | - Hanna Blau
- Graub CF Center, Schneider Children's Medical Center, Petach-Tikva and Sackler School of Medicine, Tel-Aviv University, Israel
| | - Dario Prais
- Graub CF Center, Schneider Children's Medical Center, Petach-Tikva and Sackler School of Medicine, Tel-Aviv University, Israel
| | - Meir Mei-Zahav
- Graub CF Center, Schneider Children's Medical Center, Petach-Tikva and Sackler School of Medicine, Tel-Aviv University, Israel
| | - Michal Shteinberg
- Pulmonology Institute and CF Center, Carmel Medical Center and the Technion- Israel Institute of Technology, Haifa, Israel
| | - Galit Livnat
- Pulmonology Institute and CF Center, Carmel Medical Center and the Technion- Israel Institute of Technology, Haifa, Israel
| | - Michal Gur
- Pediatric Pulmonary Institute and CF Center, Ruth Rappaport Children's Hospital, Rambam Medical Center and the Technion- Israel Institute of Technology, Haifa, Israel
| | - Lea Bentur
- Pediatric Pulmonary Institute and CF Center, Ruth Rappaport Children's Hospital, Rambam Medical Center and the Technion- Israel Institute of Technology, Haifa, Israel
| | - Damian G Downey
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University, Belfast, Ireland
| | - Adi Dagan
- Safra Sheba Medical Center, Ramat-Gan, Israel
| | - Inbal Golan-Tripto
- Pediatric Pulmonary Unit, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Micha Aviram
- Pediatric Pulmonary Unit, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Pedro Mondejar-Lopez
- Pediatric Pulmonology and Cystic Fibrosis Unit, Hospital Clinico Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Elie Picard
- Pediatric Pulmonary Unit, Shaare Zedek Medical Center, Jerusalem, Israel
| | | | - Petr Jakubec
- CF Center, University Hospital Olomouc and Faculty of Medicine, Palacky University, Olomouc, Czech Republic
| | - Traci M Kazmerski
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, USA; Center for Innovative Research on Gender Health Equity (CONVERGE), University of Pittsburgh, Pittsburgh, PA, USA
| | - Hagai Amsalem
- Department of Obstetrics and Gynecology, Mount Scopus, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Drorit Hochner Celnikier
- Department of Obstetrics and Gynecology, Mount Scopus, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Eitan Kerem
- Pediatric Pulmonary Unit and Cystic Fibrosis Center, Hadassah Medical Center, Jerusalem, Israel; Faculty of Medicine, Hebrew University of Jerusalem, Israel
| | - Joel Reiter
- Pediatric Pulmonary Unit and Cystic Fibrosis Center, Hadassah Medical Center, Jerusalem, Israel; Faculty of Medicine, Hebrew University of Jerusalem, Israel
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Taylor-Cousar JL, Janney R, Middleton PG, Jain R, Nightingale J, West NE, Shteinberg M, Velez D, Kazmerski TM. A provider survey assessing fetal impact of CFTR modulator use in males with CF during assisted and unassisted reproduction and partner pregnancy. J Cyst Fibros 2024; 23:412-416. [PMID: 37953181 DOI: 10.1016/j.jcf.2023.10.022] [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: 08/15/2023] [Revised: 10/22/2023] [Accepted: 10/31/2023] [Indexed: 11/14/2023]
Abstract
BACKGROUND Most males with cystic fibrosis (mwCF) are infertile but with CF transmembrane conductance regulator (CFTR) modulator-conferred benefits, more are utilizing assisted reproductive technologies (ART). Administration of normal human doses of modulators in animal reproductive models caused no genotoxicity; no human data exists. Potential health decline following modulator discontinuation makes the decision to withhold therapy during reproduction challenging. METHODS From August-October 2021, international CF clinicians completed an anonymous questionnaire regarding mwCF who used modulators during reproduction. RESULTS We received 42 surveys for mwCF with partner pregnancies. Forty of 42 mwCF utilized ART; 35 continued modulators during sperm retrieval and 40/42 during partner pregnancy. One of four males who discontinued modulators experienced clinical deterioration. First trimester miscarriages occurred in 11.9 % of partner pregnancies. No congenital anomalies were reported. CONCLUSIONS Use of CFTR modulators during reproduction and partner pregnancy in mwCF did not result in a higher-than-expected miscarriage rate nor congenital anomalies.
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Affiliation(s)
- Jennifer L Taylor-Cousar
- National Jewish Health, Departments of Medicine and Pediatrics; University of Colorado Anschutz Medical Campus, Departments of Medicine and Pediatrics.
| | | | | | - Raksha Jain
- University of Texas Southwestern, Department of Medicine
| | | | | | - Michal Shteinberg
- Pulmonology institute and CF center, Carmel Medical center, Haifa, Israel; Technion-Israel institute of technology, the B. Rappaport school of medicine
| | - Danielle Velez
- Rutgers Robert Wood Johnson Medical School, Division of Urology
| | - Traci M Kazmerski
- University of Pittsburgh, Department of Pediatrics; Center for Innovative Research on Gender Health Equity (CONVERGE)
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7
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Gramegna A, Addy C, Allen L, Bakkeheim E, Brown C, Daniels T, Davies G, Davies JC, De Marie K, Downey D, Felton I, Hafkemeyer S, Hamouda S, Kendall V, Lindberg U, Macek M, Mayell S, Pearlsman O, Schechter MS, Salvatori L, Sands D, Schwarz C, Shteinberg M, Taylor J, Taylor-Cousar JL, Taylor-Robinson D, Watkins B, Verkleij M, Bevan A, Castellani C, Drevinek P, Gartner S, Lammertyn E, Landau EEC, Middleton PG, Plant BJ, Smyth AR, van Koningsbruggen-Rietschel S, Burgel PR, Southern KW. Standards for the care of people with cystic fibrosis (CF); Planning for a longer life. J Cyst Fibros 2024; 23:375-387. [PMID: 38789317 DOI: 10.1016/j.jcf.2024.05.007] [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: 02/12/2024] [Revised: 05/13/2024] [Accepted: 05/16/2024] [Indexed: 05/26/2024]
Abstract
This is the final of four papers updating standards for the care of people with CF. That this paper "Planning a longer life" was considered necessary, highlights how much CF care has progressed over the past decade. Several factors underpin this progress, notably increased numbers of people with CF with access to CFTR modulator therapy. As the landscape for CF changes, so do the hopes and aspirations of people with CF and their families. This paper reflects the need to consider people with CF not as a "problem" to be solved, but as a success, a potential and a voice to be heard. People with CF and the wider CF community have driven this approach, reflecting many of the topics in this paper. This exercise involved wide stakeholder engagement. People with CF are keen to contribute to research priorities and be involved in all stages of research. People with CF want healthcare professionals to respect them as individuals and consider the impact of our actions on the world around us. Navigating life presents challenges to all, but for people with CF these challenges are heightened and complex. In this paper we highlight the concerns and life moments that impact people with CF, and events that the CF team should aim to support, including the challenges around having a family. People with CF and their care teams must embrace the updated standards outlined in these four papers to enjoy the full potential for a healthier life.
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Affiliation(s)
- Andrea Gramegna
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Respiratory Unit; Respiratory Unit and Adult Cystic Fibrosis Center, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Charlotte Addy
- All Wales Adult Cystic Fibrosis Centre, University Hospital Llandough, Cardiff and Vale University Health Board, Cardiff, UK
| | - Lorna Allen
- Cystic Fibrosis Trust (UK), 2nd Floor, One Aldgate, London, UK
| | - Egil Bakkeheim
- Norwegian Resource Centre for Cystic Fibrosis, Oslo University Hospital, Oslo, Norway
| | | | - Thomas Daniels
- NIHR Biomedical Research Centre, School of Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Wessex Adult Cystic Fibrosis Service, University Hospital Southampton NHSFT, Southampton, UK
| | - Gwyneth Davies
- Population, Policy and Practice Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, Great Ormond Street Hospital for Children, London, UK
| | - Jane C Davies
- National Heart & Lung Institute, Imperial College London, Imperial Biomedical Research Centre, Royal Brompton Hospital, London, UK
| | | | - Damian Downey
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, Northern Ireland
| | - Imogen Felton
- Adult Cystic Fibrosis Centre, Royal Brompton Hospital, Guys and St Thomas' Hospital NHS Foundation Trust, London UK, National Heart & Lung Institute, Imperial College London, Imperial Biomedical Research Centre
| | - Sylvia Hafkemeyer
- Mukoviszidose Institut GmbH, subsidiary of the German Cystic Fibrosis association Mukoviszidose e. V., Bonn, Germany
| | - Samia Hamouda
- Bechir Hamza Children's Hospital of Tunis, Faculty of Medicine of Tunis, University Al Manar, Tunis, Tunisia
| | - Victoria Kendall
- Manchester Adult Cystic Fibrosis Centre, Manchester University NHS Foundation Trust, Manchester, UK
| | - Ulrika Lindberg
- Skane University Hospital, Department of clinical sciences, Lund, Respiratory medicine and Allergology, Lund, Sweden
| | - Milan Macek
- Department of Biology and Medical Genetics, 2nd Faculty of Medicine Charles University and Motol University Hospital, Prague, Czech Republic
| | - Sarah Mayell
- Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | | | - Michael S Schechter
- Division of Pulmonary and Sleep Medicine, Virginia Commonwealth University, Children's Hospital of Richmond at VCU, USA
| | | | - Dorota Sands
- Cystic Fibrosis Department, Institute of Mother and Child, Warsaw, Poland
| | - Carsten Schwarz
- HMU-Health and Medical University, Division Cystic Fibrosis, CF Center, Clinic Westbrandenburg, Potsdam, Germany
| | - Michal Shteinberg
- Pulmonologuy institute and CF center, Carmel medical center and the Technion- Israel Institute of Technology, Haifa, Israel
| | - Julia Taylor
- Manchester Adult Cystic Fibrosis Centre, Manchester University NHS Foundation Trust, Manchester, UK
| | - Jennifer L Taylor-Cousar
- Divisions of Pulmonary, Critical Care and Sleep Medicine and Pediatric Pulmonary Medicine, National Jewish Health, Denver, CO, USA, Division of Pulmonary Sciences and Critical Care Medicine, Anschutz Medical Campus, University of Colorado, Aurora, CO, USA
| | - David Taylor-Robinson
- Department of Public Health, Policy and Systems, Waterhouse Building Block F, University of Liverpool, Liverpool, L69 3GB, UK
| | - Bethan Watkins
- All Wales Adult Cystic Fibrosis Centre, University Hospital Llandough, Cardiff and Vale University Health Board, Cardiff, UK
| | - Marieke Verkleij
- Amsterdam UMC location University of Amsterdam, Emma Children's Hospital, Child and Adolescent Psychiatry & Psychosocial Care, Amsterdam, the Netherlands
| | - Amanda Bevan
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Carlo Castellani
- IRCCS Istituto Giannina Gaslini, Via Gerolamo Gaslini 5, 16147 Genova, Italy
| | - Pavel Drevinek
- Department of Medical Microbiology, Second Faculty of Medicine, Motol University Hospital, Charles University, Prague, Czech Republic
| | - Silvia Gartner
- Cystic Fibrosis Unit and Pediatric Pulmonology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Elise Lammertyn
- Cystic Fibrosis Europe, the Belgian CF Association, Brussels, Belgium
| | - Eddie Edwina C Landau
- The Graub CF Center, Pulmonary Institute, Schneider Children's Medical Center, Petah Tikva, Israel
| | - Peter G Middleton
- Westmead Clinical School, University of Sydney and CITRICA, Dept Respiratory & Sleep Medicine, Westmead Hospital, Westmead, Australia
| | - Barry J Plant
- Cork Centre for Cystic Fibrosis (3CF), Cork University Hospital, University College Cork, Cork, Ireland
| | - Alan R Smyth
- School of Medicine, Dentistry and Biomedical Sciences, Queens University Belfast, Belfast and NIHR Nottingham Biomedical Research Centre, Nottingham, UK
| | | | - Pierre-Régis Burgel
- Respiratory Medicine and Cystic Fibrosis National Reference Center, Cochin Hospital, Assistance Publique Hôpitaux de Paris (AP-HP) and Université Paris-Cité, Institut Cochin, Inserm U1016, Paris, France
| | - Kevin W Southern
- Department of Women's and Children's Health, University of Liverpool, Liverpool, UK.
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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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9
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Li D, Zhu Y, Donnelley M, Parsons D, Habgood MD, Schneider-Futschik EK. Fetal drug exposure after maternally administered CFTR modulators Elexacaftor/Tezacaftor/Ivacaftor in a rat model. Biomed Pharmacother 2024; 171:116155. [PMID: 38232663 DOI: 10.1016/j.biopha.2024.116155] [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: 11/20/2023] [Revised: 01/04/2024] [Accepted: 01/10/2024] [Indexed: 01/19/2024] Open
Abstract
BACKGROUND The potential effects of the very effective cystic fibrosis triple combination drug, Elexacaftor/Tezacaftor/Ivacaftor (ETI) in pregnancy on prenatal development of offspring remain largely unknown. RESEARCH QUESTION We aimed to investigate the fetal tissue distribution pattern of maternally administered ETI by placental transfer in the rat fetuses. STUDY DESIGN AND METHODS Sprague Dawley pregnant rats were administered ETI (6.7 mg/kg/d elexacaftor + 3.5 mg/kg/d tezacaftor + 25 mg/kg/d ivacaftor) traced with [3 H]-ivacaftor in single dose acute experiments (intraperitoneal injection) or treated orally with ETI (the same dose) for 7 days in sub-chronic experiments. Fetal tissue samples were collected at embryonic day (E) 19 and analyzed using liquid scintillation counting for acute experiments or liquid chromatography-mass spectrometry for sub-chronic experiments. RESULTS On day E19, after acute exposure, the entry of ivacaftor into fetal brain (brain/plasma concentration ratios <50%) was significantly lower than to other tissues (>100%). However, after sub-chronic exposure, the entry of all 3 components into the developing brain was comparably extensive as into other tissues (tissue/plasma ratios, 260 - 1000%). Each component of ETI accumulated in different fetal tissues to approximately equal extent. Inter-litter differences on fetal drug distribution were found in cortex for ivacaftor, muscle for tezacaftor and cortex and mid/hindbrain for elexacaftor. Fetal plasma concentrations of ETI (ng/mL) were variable between litters. The entry of ivacaftor and tezacaftor into adult brain appeared to be restricted (<100%). INTERPRETATION Fetal rats are exposed to maternally ingested ETI after sub-chronic exposure, potentially impacting fetal development. The brain entry data highlights the need for attention be paid to any long-term potential effects ETI exposure could have on normal brain development.
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Affiliation(s)
- Danni Li
- Department of Biochemistry & Pharmacology, School of Biomedical Sciences, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, VIC 3010, Australia
| | - Yimin Zhu
- Department of Biochemistry & Pharmacology, School of Biomedical Sciences, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, VIC 3010, Australia
| | - Martin Donnelley
- Robinson Research Institute, University of Adelaide, Adelaide, South Australia, Australia; Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia; Department of Respiratory and Sleep Medicine, Women's and Children's Hospital, 72 King William Rd, North Adelaide, South Australia 5006, Australia
| | - David Parsons
- Robinson Research Institute, University of Adelaide, Adelaide, South Australia, Australia; Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia; Department of Respiratory and Sleep Medicine, Women's and Children's Hospital, 72 King William Rd, North Adelaide, South Australia 5006, Australia
| | - Mark D Habgood
- Department of Biochemistry & Pharmacology, School of Biomedical Sciences, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, VIC 3010, Australia
| | - Elena K Schneider-Futschik
- Department of Biochemistry & Pharmacology, School of Biomedical Sciences, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, VIC 3010, Australia.
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10
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Cimino G, Sorrenti S, Murciano M, Galoppi P, Ascenzioni F, Botta B, Brunelli R. Use of elexacaftor/tezacaftor/ivacaftor combination in pregnancy. Arch Gynecol Obstet 2024; 309:9-15. [PMID: 36907900 DOI: 10.1007/s00404-023-06962-5] [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: 10/12/2022] [Accepted: 02/01/2023] [Indexed: 03/14/2023]
Abstract
INTRODUCTION Management of cystic fibrosis has recently stepped forward with the introduction of cystic fibrosis transmembrane conductance regulator (CFTR) modulators, although data on potential adverse effects are lacking for many categories of patients, such as pregnant women. METHODS We report one of the first reports on the outcome of pregnancy in a woman treated with Elexacaftor/Tezacaftor/Ivacaftor during the second and third trimester of pregnancy, showing a significant improvement of respiratory status, compared with the first trimester when the medication was discontinued due to unknown and, therefore, potential teratogenic effects. Also, we performed the review of the existing literature on the topic. RESULTS The course of pregnancy was uneventful, with reference to major obstetric complications, and the patient delivered a healthy neonate. These results were similar to those coming from other short series of pregnant women affected by cystic fibrosis and treated with CFTR modulators during pregnancy. CONCLUSIONS Thus, despite the lack of evidence on the topic, the use of Elexacaftor/Tezacaftor/Ivacaftor in pregnancy seems to be apparently not associated with major adverse events, thus opening optimistic scenarios in terms of management of these patients.
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Affiliation(s)
- Giuseppe Cimino
- Cystic Fibrosis Regional Reference Center, A.O.U. Policlinico Umberto I, Rome, Italy
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Via del Policlinico, 155, 00161, Rome, Italy
| | - Sara Sorrenti
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Via del Policlinico, 155, 00161, Rome, Italy.
| | - Manuel Murciano
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Via del Policlinico, 155, 00161, Rome, Italy
- Emergency and General Pediatrics Department, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Paola Galoppi
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Via del Policlinico, 155, 00161, Rome, Italy
| | - Fiorentina Ascenzioni
- Department of Biology and Biotechnology "C. Darwin", Sapienza University of Rome, Rome, Italy
| | - Bruno Botta
- Department of Chemistry and Technology of Drugs, "Department of Excellence 2018-2022", Sapienza University of Rome, Rome, Italy
| | - Roberto Brunelli
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Via del Policlinico, 155, 00161, Rome, Italy
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11
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Miravitlles M, Criner GJ, Mall MA, Rowe SM, Vogelmeier CF, Hederer B, Schoenberger M, Altman P. Potential systemic effects of acquired CFTR dysfunction in COPD. Respir Med 2024; 221:107499. [PMID: 38104786 DOI: 10.1016/j.rmed.2023.107499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 11/25/2023] [Accepted: 12/10/2023] [Indexed: 12/19/2023]
Abstract
Chronic obstructive pulmonary disease (COPD) is characterized by airflow limitation, respiratory symptoms, inflammation of the airways, and systemic manifestations of the disease. Genetic susceptibility and environmental factors are important in the development of the disease, particularly exposure to cigarette smoke which is the most notable risk factor. Mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) gene are the cause of cystic fibrosis (CF), which shares several pathophysiological pulmonary features with COPD, including airway obstruction, chronic airway inflammation and bacterial colonization; in addition, both diseases also present systemic defects leading to comorbidities such as pancreatic, gastrointestinal, and bone-related diseases. In patients with COPD, systemic CFTR dysfunction can be acquired by cigarette smoking, inflammation, and infection. This dysfunction is, on average, about half of that found in CF. Herein we review the literature focusing on acquired CFTR dysfunction and the potential role in the pathogenesis of comorbidities associated with COPD and chronic bronchitis.
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Affiliation(s)
- Marc Miravitlles
- Pneumology Department Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Hospital Campus, Barcelona, Spain.
| | - Gerard J Criner
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, USA
| | - Marcus A Mall
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine, Charité-Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; Berlin Institute of Health at the Charité - Universitätsmedizin Berlin, Berlin, Germany; German Centre for Lung Research, Berlin, Germany
| | - Steven M Rowe
- Univeristy of Alabama at Birmingham, Birmingham, USA
| | - Claus F Vogelmeier
- Department of Medicine, Pulmonary and Critical Care Medicine, University Hospital Marburg UKGM, German Centre for Lung Research (DZL), Marburg, Germany
| | | | | | - Pablo Altman
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey, USA
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12
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Ripani P, Mucci M, Pantano S, Di Sabatino M, Collini F, Ferri G, Romano M, Recchiuti A. Maternal, newborn and breast milk concentrations of elexacaftor/tezacaftor/ivacaftor in a F508del heterozygous woman with cystic fibrosis following successful pregnancy. Front Med (Lausanne) 2023; 10:1274303. [PMID: 38131041 PMCID: PMC10734635 DOI: 10.3389/fmed.2023.1274303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 11/07/2023] [Indexed: 12/23/2023] Open
Abstract
With the introduction of elexacaftor/tezacaftor/ivacaftor (ETI), more women with cystic fibrosis (CF) are likely to grow families. Hence, an understanding long-term safety and effects of CFTR modulators on fertile women and children while monitoring their concentrations is crucial. Here, we report on the development of an improved LC-MS/MS methodology to measure ETI concentrations in maternal and child blood and breastmilk, applied in one case of successful pregnancy of a 30-year-old woman with CF (F508del/R334W). We observed that ETI remains stable in breastmilk, is absorbed by the infant and can be detected in child plasma. Our results confirm accumulating evidence of a successful pregnancy in women treated with CFTR modulators without significant side effects on the child and provide valuable analytical procedures suitable for the post-marketing evaluation of CFTR modulators in pregnant and lactating women, as well as in their infants.
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Affiliation(s)
- Pietro Ripani
- Unità Operativa Semplice a valenza Dipartimentale Centro Regionale di Riferimento per la Fibrosi Cistica, Teramo, Italy
| | - Matteo Mucci
- Department of Medical, Oral, and Biotechnology Science (DSMOB), Center of Advanced Studies and Technology, Università “G. d’Annunzio”, Chieti, Italy
| | - Stefano Pantano
- Unità Operativa Semplice a valenza Dipartimentale Centro Regionale di Riferimento per la Fibrosi Cistica, Teramo, Italy
| | - Maria Di Sabatino
- Unità Operativa Semplice a valenza Dipartimentale Centro Regionale di Riferimento per la Fibrosi Cistica, Teramo, Italy
| | - Francesca Collini
- Unità Operativa Semplice a valenza Dipartimentale Centro Regionale di Riferimento per la Fibrosi Cistica, Teramo, Italy
| | - Giulia Ferri
- Department of Medical, Oral, and Biotechnology Science (DSMOB), Center of Advanced Studies and Technology, Università “G. d’Annunzio”, Chieti, Italy
| | - Mario Romano
- Department of Medical, Oral, and Biotechnology Science (DSMOB), Center of Advanced Studies and Technology, Università “G. d’Annunzio”, Chieti, Italy
| | - Antonio Recchiuti
- Department of Medical, Oral, and Biotechnology Science (DSMOB), Center of Advanced Studies and Technology, Università “G. d’Annunzio”, Chieti, Italy
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13
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Elijah J, Fitzgerald LJ, Phan H. Use of CFTR modulators in special populations, part 1: Pregnancy and lactation. Pediatr Pulmonol 2023; 58:3377-3385. [PMID: 37787417 DOI: 10.1002/ppul.26706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Revised: 08/22/2023] [Accepted: 09/13/2023] [Indexed: 10/04/2023]
Abstract
Safety and efficacy data regarding cystic fibrosis transmembrane conductance regulator (CFTR) modulator use in the setting of pregnancy or breastfeeding remains lacking due to exclusion from key trials and lack of multicenter prospective and retrospective studies in the post-CFTR modulator era. A scoping review of English articles from the period of January 1, 2012, to July 31, 2023, was conducted utilizing PubMed and EmBase databases with the following terms: "special population (pregnancy, lactation, breastfeeding)" AND "ivacaftor OR lumacaftor OR tezacaftor OR elexacaftor"; "cystic fibrosis transmembrane conductance regulator" AND "off label drug use." Search results were reviewed by title and abstract for duplications and relevance. Relative to pregnancy or breastfeeding, a total of 18 publications were included for review. Majority of case reports and surveys concluded maternal and infant health were preserved throughout gestation. Likewise, breastfeeding infant case reports show possible changes in liver function and lens opacities, though risk may be increased with both in-utero and breastfeeding exposure. Ivacaftor (IVA) and lumacaftor (LUM) concentrations in fetal cord blood and maternal blood were found to be equivalent. Yet, low concentrations of IVA and LUM were detectable in breastmilk and infant plasma. Current safety data surrounding CFTR modulator use in the setting of pregnancy and lactation is relatively reassuring; however, long-term safety remains unclear, necessitating ongoing observation, and reporting by care teams. As such, treatment decisions should be individualized and coproduced.
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Affiliation(s)
- Joseph Elijah
- Department of Pharmacy Services, Michigan Medicine, Ann Arbor, Michigan, USA
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
- School of Pharmacy and Pharmaceutical Sciences, Bouve College of Health Sciences, Northeastern University, Boston, United States
| | - Linda J Fitzgerald
- Department of Pharmacy Services, Michigan Medicine, Ann Arbor, Michigan, USA
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
- Sanofi Medical Affairs, Bridgewater, New Jersey, USA
| | - Hanna Phan
- Department of Pharmacy Services, Michigan Medicine, Ann Arbor, Michigan, USA
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
- Susan B. Meister Child Health Evaluation and Research (CHEAR) Center, University of Michigan, Ann Arbor, Michigan, USA
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14
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Lieu N, Prentice BJ, Field P, Fitzgerald DA. Trials and tribulations of highly effective modulator therapies in cystic fibrosis. Paediatr Respir Rev 2023; 48:10-19. [PMID: 37914566 DOI: 10.1016/j.prrv.2023.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 09/13/2023] [Indexed: 11/03/2023]
Abstract
Highly effective modulator therapies (HEMTs) have revolutionised the management approach of most patients living with cystic fibrosis (CF) who have access to these therapies. Clinical trials have reported significant improvements across multiorgan systems, with patients surviving longer. However, there are accumulating case reports and observational data describing various adverse events following initiation of HEMTs including drug-to-drug interactions, drug induced liver injury, Stevens-Johnson syndrome, and neurocognitive symptoms including psychosis and depression, which have required discontinuation of therapy. Current clinical trials are assessing efficacy in younger patients with CF, yet long-term studies are also required to better understand the safety profile in the real-world setting across all ages and the impact of HEMT dose alteration or discontinuation.
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Affiliation(s)
- Nathan Lieu
- Department of Respiratory Medicine, The Children's Hospital at Westmead, Sydney, New South Wales, Australia, 2145; Discipline of Paediatrics and Child Health, University of Sydney, Sydney, New South Wales, Australia.
| | - Bernadette J Prentice
- Department of Respiratory Medicine, Sydney Children's Hospital, Randwick, Sydney, New South Wales, Australia, 2031; Discipline of Paediatrics and Child Health, UNSW, Sydney, New South Wales, Australia
| | - Penelope Field
- Department of Respiratory Medicine, The Children's Hospital at Westmead, Sydney, New South Wales, Australia, 2145; Department of Respiratory Medicine, Sydney Children's Hospital, Randwick, Sydney, New South Wales, Australia, 2031; Discipline of Paediatrics and Child Health, UNSW, Sydney, New South Wales, Australia
| | - Dominic A Fitzgerald
- Department of Respiratory Medicine, The Children's Hospital at Westmead, Sydney, New South Wales, Australia, 2145; Discipline of Paediatrics and Child Health, University of Sydney, Sydney, New South Wales, Australia
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15
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Jain R, Kazmerski TM, Taylor-Cousar JL. The modern landscape of fertility, pregnancy, and parenthood in people with cystic fibrosis. Curr Opin Pulm Med 2023; 29:595-602. [PMID: 37789771 PMCID: PMC10629848 DOI: 10.1097/mcp.0000000000001009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/05/2023]
Abstract
PURPOSE OF REVIEW With improved long-term survival and the expanding availability of cystic fibrosis transmembrane conductance regulator (CFTR) modulator therapies that treat the underlying genetic defect in cystic fibrosis, more people are interested in parenthood. Cystic fibrosis care centers and people with cystic fibrosis need more information to guide decisions related to parenting. RECENT FINDINGS Here we present currently available data on fertility, pregnancy, and parenthood in the modern era of cystic fibrosis care. Fertility may be improving in female individuals with cystic fibrosis with the use of CFTR modulator therapies, and there is an associated increase in annual pregnancies. Infertility in male individuals with cystic fibrosis remains approximately 97-98% and is unchanged with CFTR modulators in those already born with cystic fibrosis. As more female individuals with cystic fibrosis experience pregnancy, questions remain about the impact of pregnancy on their health and that of their child. Fortunately, there are multiple routes to becoming a parent; however, more work is needed to understand the impact of pregnancy and parenthood in the context of CF as some previous data suggests potential challenges to the health of parents with cystic fibrosis. SUMMARY We encourage cystic fibrosis care teams to have knowledge and resources available to support the reproductive goals of all individuals with cystic fibrosis.
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Affiliation(s)
- Raksha Jain
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Traci M Kazmerski
- University of Pittsburgh School of Medicine, Department of Pediatrics, Pittsburgh, PA, USA
- Center for Innovative Research on Gender Health Equity (CONVERGE), University of Pittsburgh, Pittsburgh, PA, USA
| | - Jennifer L Taylor-Cousar
- National Jewish Health, Departments of Internal Medicine and Pediatrics Denver, CO, USA
- University of Colorado Anschutz Medical Campus, Departments of Internal Medicine and Pediatrics, Aurora, CO, USA
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16
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Martín Hernández AS, Rodrigo-García M, Peláez A, Gómez Punter RM, Ancochea J, Girón Moreno RM. Evolution of Lung Function in Pregnant Women With Cystic Fibrosis. Arch Bronconeumol 2023; 59:685-687. [PMID: 37507276 DOI: 10.1016/j.arbres.2023.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 07/08/2023] [Accepted: 07/10/2023] [Indexed: 07/30/2023]
Affiliation(s)
| | - María Rodrigo-García
- Instituto de Investigación Sanitaria del Hospital Universitario de La Princesa, Madrid, Spain
| | - Adrián Peláez
- Instituto de Investigación Sanitaria del Hospital Universitario de La Princesa, Madrid, Spain; CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain.
| | - Rosa Mar Gómez Punter
- Instituto de Investigación Sanitaria del Hospital Universitario de La Princesa, Madrid, Spain
| | - Julio Ancochea
- Instituto de Investigación Sanitaria del Hospital Universitario de La Princesa, Madrid, Spain; CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Rosa María Girón Moreno
- Instituto de Investigación Sanitaria del Hospital Universitario de La Princesa, Madrid, Spain
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17
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Hisert KB, Birket SE, Clancy JP, Downey DG, Engelhardt JF, Fajac I, Gray RD, Lachowicz-Scroggins ME, Mayer-Hamblett N, Thibodeau P, Tuggle KL, Wainwright CE, De Boeck K. Understanding and addressing the needs of people with cystic fibrosis in the era of CFTR modulator therapy. THE LANCET. RESPIRATORY MEDICINE 2023; 11:916-931. [PMID: 37699420 DOI: 10.1016/s2213-2600(23)00324-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 08/07/2023] [Accepted: 08/20/2023] [Indexed: 09/14/2023]
Abstract
Cystic fibrosis is a multiorgan disease caused by impaired function of the cystic fibrosis transmembrane conductance regulator (CFTR). Since the introduction of the CFTR modulator combination elexacaftor-tezacaftor-ivacaftor (ETI), which acts directly on mutant CFTR to enhance its activity, most people with cystic fibrosis (pwCF) have seen pronounced reductions in symptoms, and studies project marked increases in life expectancy for pwCF who are eligible for ETI. However, modulator therapy has not cured cystic fibrosis and the success of CFTR modulators has resulted in immediate questions about the new state of cystic fibrosis disease and clinical challenges in the care of pwCF. In this Series paper, we summarise key questions about cystic fibrosis disease in the era of modulator therapy, highlighting state-of-the-art research and clinical practices, knowledge gaps, new challenges faced by pwCF and the potential for future health-care challenges, and the pressing need for additional therapies to treat the underlying genetic or molecular causes of cystic fibrosis.
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Affiliation(s)
| | - Susan E Birket
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - Damian G Downey
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, Northern Ireland
| | - John F Engelhardt
- Department of Anatomy and Cell Biology, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Isabelle Fajac
- Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Paris, France
| | - Robert D Gray
- Institution of Regeneration and Repair, Centre for Inflammation Research, The University of Edinburgh, Edinburgh, UK
| | | | - Nicole Mayer-Hamblett
- Department of Pediatrics, Department of Biostatistics, Seattle Children's Research Institute, University of Washington, Seattle, WA, USA
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18
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Taylor-Cousar JL, Robinson PD, Shteinberg M, Downey DG. CFTR modulator therapy: transforming the landscape of clinical care in cystic fibrosis. Lancet 2023; 402:1171-1184. [PMID: 37699418 DOI: 10.1016/s0140-6736(23)01609-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 07/17/2023] [Accepted: 07/31/2023] [Indexed: 09/14/2023]
Abstract
Following discovery of the cystic fibrosis transmembrane conductance regulator (CFTR) gene in 1989 and subsequent elucidation of the varied CFTR protein abnormalities that result, a new era of cystic fibrosis management has emerged-one in which scientific principles translated from the bench to the bedside have enabled us to potentially treat the basic defect in the majority of children and adults with cystic fibrosis, with a resultant burgeoning adult cystic fibrosis population. However, the long-term effects of these therapies on the multiple manifestations of cystic fibrosis are still under investigation. Understanding the effects of modulators in populations excluded from clinical trials is also crucial. Furthermore, establishing appropriate disease measures to assess efficacy in the youngest potential trial participants and in those whose post-modulator lung function is in the typical range for people without chronic lung disease is essential for continued drug development. Finally, recognising that a health outcome gap has been created for some people and widened for others who are not eligible for, cannot tolerate, or do not have access to modulators is important.
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Affiliation(s)
- Jennifer L Taylor-Cousar
- Division of Pulmonary, Critical Care and Sleep Medicine, National Jewish Health, Denver, CO, USA; Division of Pediatric Pulmonary Medicine, National Jewish Health, Denver, CO, USA; Division of Pulmonary Sciences and Critical Care Medicine, Anschutz Medical Campus, University of Colorado, Aurora, CO, USA.
| | - Paul D Robinson
- Department of Respiratory Medicine, Queensland Children's Hospital, Brisbane, QLD, Australia; Children's Health and Environment Program, Child Health Research Centre, University of Queensland, Brisbane, QLD, Australia
| | - Michal Shteinberg
- Pulmonology Institute and CF Center, Carmel Medical Center, Haifa, Israel; B Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Damian G Downey
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
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19
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Zhu Y, Li D, Reyes-Ortega F, Chinnery HR, Schneider-Futschik EK. Ocular development after highly effective modulator treatment early in life. Front Pharmacol 2023; 14:1265138. [PMID: 37795027 PMCID: PMC10547496 DOI: 10.3389/fphar.2023.1265138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Accepted: 09/06/2023] [Indexed: 10/06/2023] Open
Abstract
Highly effective cystic fibrosis (CF) transmembrane conductance regulator (CFTR) modulator therapies (HEMT), including elexacaftor-tezacaftor-ivacaftor, correct the underlying molecular defect causing CF. HEMT decreases general symptom burden by improving clinical metrics and quality of life for most people with CF (PwCF) with eligible CFTR variants. This has resulted in more pregnancies in women living with CF. All HEMT are known to be able pass through the placenta and into breast milk in mothers who continue on this therapy while pregnant and breast feeding. Toxicity studies of HEMT in young rats demonstrated infant cataracts, and case reports have reported the presence of congenital cataracts in early life exposure to HEMT. This article reviews the evidence for how HEMT influences the dynamic and interdependent processes of healthy and abnormal lens development in the context of HEMT exposure during pregnancy and breastfeeding, and raises questions that remain unanswered.
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Affiliation(s)
- Yimin Zhu
- Department of Biochemistry and Pharmacology, School of Biomedical Sciences, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, VIC, Australia
| | - Danni Li
- Department of Biochemistry and Pharmacology, School of Biomedical Sciences, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, VIC, Australia
| | - Felisa Reyes-Ortega
- Department of Biochemistry and Pharmacology, School of Biomedical Sciences, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, VIC, Australia
- Department of Ophthalmology, Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Reina Sofia University Hospital and University of Cordoba, Cordoba, Spain
| | - Holly R. Chinnery
- Department of Optometry and Vision Sciences, The University of Melbourne, Parkville, VIC, Australia
| | - Elena K. Schneider-Futschik
- Department of Biochemistry and Pharmacology, School of Biomedical Sciences, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, VIC, Australia
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20
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McGlynn J, DeCelie-Germana JK, Kier C, Langfelder-Schwind E. Reproductive Counseling and Care in Cystic Fibrosis: A Multidisciplinary Approach for a New Therapeutic Era. Life (Basel) 2023; 13:1545. [PMID: 37511919 PMCID: PMC10381247 DOI: 10.3390/life13071545] [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: 05/19/2023] [Revised: 07/01/2023] [Accepted: 07/02/2023] [Indexed: 07/30/2023] Open
Abstract
With the advent of highly effective modulator therapies, many people with cystic fibrosis (CF) are living longer, healthier lives. Pregnancy rates for women with CF more than doubled between 2019 and 2021, reflecting increases in both planned and unplanned pregnancies. For men with CF, CF-associated infertility can be mitigated with assistive reproductive technology, yet patient knowledge of these challenges and options is variable. Preconception and prenatal counseling for individuals with CF and for parents of children with CF who wish to expand their families requires nuanced discussions to promote informed reproductive decisions, drawing from a combination of standard practice recommendations and CF-specific assessments. This review article synthesizes the current literature and practice recommendations regarding reproductive counseling and care in CF, outlining the role of genetic counseling, carrier screening, teratogen counseling, in vitro fertilization and pre-implantation genetic diagnosis, and careful assessment and management of cystic fibrosis-related diabetes when present. Via a multidisciplinary, patient-centered approach, clinicians can support adults with CF and parents of children with CF as they make informed reproductive decisions and embark on family planning.
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Affiliation(s)
- Julie McGlynn
- Gynecology and Reproductive Sciences, Department of Obstetrics, Yale School of Medicine, New Haven, CT 06510, USA
| | - Joan K DeCelie-Germana
- Zucker School of Medicine at Northwell Division of Pediatric Pulmonary, and Cystic Fibrosis Center, Cohen Children's Medical Center, New Hyde Park, NY 11040, USA
| | - Catherine Kier
- Renaissance School of Medicine at Stony Brook, Department of Pediatrics, Stony Brook, NY 11794, USA
| | - Elinor Langfelder-Schwind
- The Cystic Fibrosis Center, Department of Pulmonary Medicine, Lenox Hill Hospital, Northwell Health, New York, NY 10075, USA
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21
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Mulrennan S, Sapru K, Tewkesbury D, Jones AM. Beyond the Lungs-Emerging Challenges in Adult Cystic Fibrosis Care. Semin Respir Crit Care Med 2023; 44:307-314. [PMID: 36535664 DOI: 10.1055/s-0042-1758734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Cystic fibrosis (CF) is a multisystem disease. This article provides an up-to-date review of many of the nonrespiratory complications of CF, including mental health issues, nutritional and gastrointestinal problems, fertility issues, diabetes mellitus, bone health and musculoskeletal problems, liver disease, renal problems, and risk of malignancy. It highlights the recent impact of new therapies, including CF transmembrane conductance regulator modulators, on the nonrespiratory complications of CF and provides insights into the potential challenges faced by an aging population of adults with CF and their caregivers, including the potential future risk for cardiovascular disease.
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Affiliation(s)
- Siobhain Mulrennan
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Australia.,Faculty of Health and Medical Sciences, University of Western Australia, Australia
| | - Karuna Sapru
- Manchester Adult Cystic Fibrosis Centre, Wythenshawe Hospital, Manchester, United Kingdom
| | - Daniel Tewkesbury
- Manchester Adult Cystic Fibrosis Centre, Wythenshawe Hospital, Manchester, United Kingdom
| | - Andrew M Jones
- Manchester Adult Cystic Fibrosis Centre, Wythenshawe Hospital, Manchester, United Kingdom
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22
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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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23
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Tümmler B. Post-approval studies with the CFTR modulators Elexacaftor-Tezacaftor—Ivacaftor. Front Pharmacol 2023; 14:1158207. [PMID: 37025483 PMCID: PMC10072268 DOI: 10.3389/fphar.2023.1158207] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 03/07/2023] [Indexed: 03/31/2023] Open
Abstract
Triple combination therapy with the CFTR modulators elexacaftor (ELX), tezacaftor (TEZ) and ivacaftor (IVA) has been qualified as a game changer in cystic fibrosis (CF). We provide an overview of the body of literature on ELX/TEZ/IVA published between November 2019 and February 2023 after approval by the regulators. Recombinant ELX/TEZ/IVA-bound Phe508del CFTR exhibits a wild type conformationin vitro, but in patient’s tissue a CFTR glyoisoform is synthesized that is distinct from the wild type and Phe508del isoforms. ELX/TEZ/IVA therapy improved the quality of life of people with CF in the real-life setting irrespective of their anthropometry and lung function at baseline. ELX/TEZ/IVA improved sinonasal and abdominal disease, lung function and morphology, airway microbiology and the basic defect of impaired epithelial chloride and bicarbonate transport. Pregnancy rates were increasing in women with CF. Side effects of mental status changes deserve particular attention in the future.
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Affiliation(s)
- Burkhard Tümmler
- Department of Pediatric Pneumology, Allergology and Neonatology, Hannover Medical School, Hannover, Germany
- Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), German Center for Lung Research, Hannover Medical School, Hannover, Germany
- *Correspondence: Burkhard Tümmler,
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24
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Taylor-Cousar JL, Shteinberg M, Cohen-Cymberknoh M, Jain R. The Impact of Highly Effective Cystic Fibrosis Transmembrane Conductance Regulator Modulators on the Health of Female Subjects With CF. Clin Ther 2023; 45:278-289. [PMID: 36841738 DOI: 10.1016/j.clinthera.2023.01.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 12/28/2022] [Accepted: 01/31/2023] [Indexed: 02/26/2023]
Abstract
Cystic fibrosis (CF) is a genetic disorder that occurs in people of all genetic ancestries. CF is caused by variants in the CF transmembrane conductance regulator (CFTR) gene that result in decreased, absent, or nonfunctional CFTR protein at the cell surface of the mucous membranes. Clinical manifestations include chronic respiratory disease, malabsorption, and decreased fertility. Historically, therapies for CF were focused on the signs and symptoms of the disease. However, more recently, CFTR modulators, therapies directed at the basic defect, are improving the quality and duration of the lives of people with CF. The predicted survival of people with CF in the United States is now 53 years of age. With the hope of longer, healthier lives, female individuals with CF (fwCF) are expressing the desire to discuss fertility, pregnancy, and parenthood. Furthermore, pregnancy rates are increasing substantially. Understanding the impact of use or discontinuation of highly effective modulator therapy on the reproductive health of fwCF is critical. Finally, fwCF and their providers must consider preventative cancer screening. (Clin Ther. 2023;45:XXX-XXX) © 2023 Elsevier HS Journals, Inc.
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Affiliation(s)
- Jennifer L Taylor-Cousar
- Division of Pulmonary, Critical Care and Sleep Medicine and of Pediatric Pulmonary Medicine, National Jewish Health, Denver, CO, USA.
| | - Michal Shteinberg
- Technion-Israel Institute of Technology and the B. Rappaport Faculty of Medicine, Haifa, Israel; Pulmonology Institute and CF Center, Carmel Medical Center, Haifa, Israel
| | - Malena Cohen-Cymberknoh
- Pediatric Pulmonology Unit and Cystic Fibrosis Center, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Raksha Jain
- University of Texas Southwestern Medical Center, Dallas, TX, USA
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25
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Patel P, Yeley J, Brown C, Wesson M, Lesko BG, Slaven JE, Chmiel JF, Jain R, Sanders DB. Immunoreactive Trypsinogen in Infants Born to Women with Cystic Fibrosis Taking Elexacaftor–Tezacaftor–Ivacaftor. Int J Neonatal Screen 2023; 9:ijns9010010. [PMID: 36975847 PMCID: PMC10056483 DOI: 10.3390/ijns9010010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Revised: 02/05/2023] [Accepted: 02/16/2023] [Indexed: 02/25/2023] Open
Abstract
Most people with cystic fibrosis (CF) are diagnosed following abnormal newborn screening (NBS), which begins with measurement of immunoreactive trypsinogen (IRT) values. A case report found low concentrations of IRT in an infant with CF exposed to the CF transmembrane conductance regulator (CFTR) modulator, elexacaftor–tezacaftor–ivacaftor (ETI), in utero. However, IRT values in infants born to mothers taking ETI have not been systematically assessed. We hypothesized that ETI-exposed infants have lower IRT values than newborns with CF, CFTR-related metabolic syndrome/CF screen positive, inconclusive diagnosis (CRMS/CFSPID), or CF carriers. IRT values were collected from infants born in Indiana between 1 January 2020, and 2 June 2022, with ≥1 CFTR mutation. IRT values were compared to infants born to mothers with CF taking ETI followed at our institution. Compared to infants identified with CF (n = 51), CRMS/CFSPID (n = 21), and CF carriers (n = 489), ETI-exposed infants (n = 19) had lower IRT values (p < 0.001). Infants with normal NBS results for CF had similar median (interquartile range) IRT values, 22.5 (16.8, 30.6) ng/mL, as ETI-exposed infants, 18.9 (15.2, 26.5). IRT values from ETI-exposed infants were lower than for infants with abnormal NBS for CF. We recommend that NBS programs consider performing CFTR variant analysis for all ETI-exposed infants.
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Affiliation(s)
- Payal Patel
- Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Jana Yeley
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Cynthia Brown
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Melissa Wesson
- Department of Molecular Genetics, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Barbara G. Lesko
- Department of Pathology, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - James E. Slaven
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - James F. Chmiel
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Raksha Jain
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
| | - Don B. Sanders
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN 46202, USA
- Correspondence:
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26
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Gur M, Pollak M, Bar-Yoseph R, Bentur L. Pregnancy in Cystic Fibrosis-Past, Present, and Future. J Clin Med 2023; 12:jcm12041468. [PMID: 36836003 PMCID: PMC9963833 DOI: 10.3390/jcm12041468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 02/09/2023] [Accepted: 02/10/2023] [Indexed: 02/15/2023] Open
Abstract
The introduction of mutation-specific therapy led to a revolution in cystic fibrosis (CF) care. These advances in CF therapies have changed the disease profile from a severe incurable disease with limited survival to a treatable disease with improved quality of life and survival into adulthood. CF patients are now able to plan their future, including marriage and parenthood. Side by side with the optimism, new issues and concerns are arising, including fertility and preparation for pregnancy, maternal and fetal care during pregnancy, and post-partum care. While cystic fibrosis transmembrane regulator (CFTR) modulators show promising results for improving CF lung disease, data on their safety in pregnancy are still limited. We performed a literature review on pregnancy in CF from the past, with the first described pregnancy in 1960, through the current fascinating changes in the era of CFTR modulators, to ongoing studies and future directions. Current advances in knowledge give hope for improved outcomes of pregnancy, towards the best possible prognosis for the mother and for the baby.
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Affiliation(s)
- Michal Gur
- Pediatric Pulmonary Institute and CF Center, Rappaport Children’s Hospital, Rambam Health Care Campus, Haifa 3109601, Israel
- Rappaport Faculty of Medicine, Technion–Israel Institute of Technology, Haifa 3525422, Israel
- Correspondence: ; Tel.: +972-4-7774360; Fax: +972-4-7774395
| | - Mordechai Pollak
- Pediatric Pulmonary Institute and CF Center, Rappaport Children’s Hospital, Rambam Health Care Campus, Haifa 3109601, Israel
- Rappaport Faculty of Medicine, Technion–Israel Institute of Technology, Haifa 3525422, Israel
| | - Ronen Bar-Yoseph
- Pediatric Pulmonary Institute and CF Center, Rappaport Children’s Hospital, Rambam Health Care Campus, Haifa 3109601, Israel
- Rappaport Faculty of Medicine, Technion–Israel Institute of Technology, Haifa 3525422, Israel
| | - Lea Bentur
- Pediatric Pulmonary Institute and CF Center, Rappaport Children’s Hospital, Rambam Health Care Campus, Haifa 3109601, Israel
- Rappaport Faculty of Medicine, Technion–Israel Institute of Technology, Haifa 3525422, Israel
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27
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Jordan KD, Zemanick ET, Taylor-Cousar JL, Hoppe JE. Managing cystic fibrosis in children aged 6-11yrs: a critical review of elexacaftor/tezacaftor/ivacaftor combination therapy. Expert Rev Respir Med 2023; 17:97-108. [PMID: 36803356 DOI: 10.1080/17476348.2023.2179989] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
INTRODUCTION Cystic fibrosis is a life-limiting, autosomal recessive genetic disorder resulting in multi-organ disease due to CF transmembrane conductance regulator (CFTR) protein dysfunction. CF treatment previously focused on mitigation of disease signs and symptoms. The recent introduction of highly effective CFTR modulators, for which ~90% of people with CF are CFTR variant-eligible, has resulted in substantial health improvements. AREAS COVERED In this review, we will describe the clinical trials leading to approval of the highly effective CFTR modulator, elexacaftor-tezacaftor-ivacaftor (ETI), with a focus on the safety and efficacy of this treatment in children aged 6-11 years. EXPERT OPINION The use of ETI in variant-eligible children aged 6-11 is associated with marked clinical improvements with a favorable safety profile. We anticipate that introduction of ETI in early childhood may result in the prevention of pulmonary, gastrointestinal, and endocrine complications from CF, consequently leading to previously unimaginable gains in the quality and quantity of life. However, there is an urgent need to develop effective treatments for the remaining 10% of people with CF who are not eligible or unable to tolerate ETI treatment, and to increase access of ETI to more pwCF across the world.
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Affiliation(s)
- Kamyron D Jordan
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.,Breathing Institute, Children's Hospital Colorado, Aurora, CO, USA
| | - Edith T Zemanick
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.,Breathing Institute, Children's Hospital Colorado, Aurora, CO, USA
| | | | - Jordana E Hoppe
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.,Breathing Institute, Children's Hospital Colorado, Aurora, CO, USA
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28
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Abstract
Cystic fibrosis (CF) is an inherited multisystemic disease that can cause progressive bronchiectasis, pancreatic endocrine and exocrine insufficiency, distal intestinal obstruction syndrome, liver dysfunction, and other disorders. Traditional therapies focused on the treatment or prevention of damage to each organ system with incremental modalities such as nebulized medications for the lungs, insulin for diabetes, and supplementation with pancreatic enzymes. However, the advent of highly effective modulator therapies that target specific cystic fibrosis transmembrane conductance regulator protein malformations resulting from individual genetic mutations has transformed the lives and prognosis for persons with CF.
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Affiliation(s)
- Shijing Jia
- Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, Michigan, USA;
| | - Jennifer L Taylor-Cousar
- Divisions of Pulmonary Sciences and Critical Care Medicine and Pediatric Pulmonology, National Jewish Health, Denver, Colorado, USA;
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29
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Standards of care for CFTR variant-specific therapy (including modulators) for people with cystic fibrosis. J Cyst Fibros 2023; 22:17-30. [PMID: 36916675 DOI: 10.1016/j.jcf.2022.10.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 10/06/2022] [Accepted: 10/10/2022] [Indexed: 11/11/2022]
Abstract
Cystic fibrosis (CF) has entered the era of variant-specific therapy, tailored to the genetic variants in the Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) gene. CFTR modulators, the first variant-specific therapy available, have transformed the management of CF. The latest standards of care from the European CF Society (2018) did not include guidance on variant-specific therapy, as CFTR modulators were becoming established as a novel therapy. We have produced interim standards to guide healthcare professionals in the provision of variant-specific therapy for people with CF. Here we provide evidence-based guidance covering the spectrum of care, established using evidence from systematic reviews and expert opinion. Statements were reviewed by key stakeholders using Delphi methodology, with agreement (≥80%) achieved for all statements after one round of consultation. Issues around accessibility are discussed and there is clear consensus that all eligible people with CF should have access to variant-specific therapy.
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30
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Davidson SJ, France M, Callaway LK, Lust K, Chambers D, Hopkins P, Bell SC, Burr L, Keating R, Barrett HL. Pregnancy in women with cystic fibrosis and diabetes: An audit of outcomes at two tertiary obstetric hospitals in Australia in the pre-cystic fibrosis transmembrane conductance regulator modulator era. Obstet Med 2022. [DOI: 10.1177/1753495x221146342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Background Pregnancy in women with cystic fibrosis (CF) is becoming more common. Long-term metabolic issues such as diabetes are also becoming more common and have potentially important impacts on pregnancy outcomes. This study aimed to assess the impact of diabetes on pregnancy outcomes for women with CF. Methods We undertook a retrospective chart audit of pregnancies to women with CF at the two tertiary obstetric hospitals in Southeast Queensland associated with CF and transplant management clinics between 2006 and 2016. Results A total of 38 pregnancies among 26 women were identified. Four women (five pregnancies) had cystic fibrosis-related diabetes (CFRD) diagnosed prior to pregnancy, and 12 women (15 pregnancies) developed gestational diabetes (GDM) complicating pregnancy. CFRD and GDM were associated with higher rates of delivery complications, prematurity, and the need for neonatal intensive care unit admission. Conclusion Diabetes is common during pregnancy in women with CF and impacts pregnancy outcomes.
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Affiliation(s)
- Sarah J Davidson
- Women's & Newborn Services, Royal Brisbane & Women's Hospital, Herston, Australia
- Duke University School of Medicine, Durham, NC, USA
| | - Megan France
- Thoracic Medicine, The Prince Charles Hospital, Chermside, Australia
| | - Leonie K Callaway
- Women's & Newborn Services, Royal Brisbane & Women's Hospital, Herston, Australia
- Faculty of Medicine, The University of Queensland, Herston, Australia
| | - Karin Lust
- Women's & Newborn Services, Royal Brisbane & Women's Hospital, Herston, Australia
- Faculty of Medicine, The University of Queensland, Herston, Australia
| | - Daniel Chambers
- Faculty of Medicine, The University of Queensland, Herston, Australia
- Queensland Lung Transplant Program, The Prince Charles Hospital, Chermside, Australia
| | - Peter Hopkins
- Faculty of Medicine, The University of Queensland, Herston, Australia
- Queensland Lung Transplant Program, The Prince Charles Hospital, Chermside, Australia
| | - Scott C Bell
- Thoracic Medicine, The Prince Charles Hospital, Chermside, Australia
- Faculty of Medicine, The University of Queensland, Herston, Australia
- Translational Research Institute, Woolloongabba, Australia
| | - Lucy Burr
- Faculty of Medicine, The University of Queensland, Herston, Australia
- Department of Respiratory Medicine, Mater Health Services, South Brisbane, Australia
- Mater Research Institute – The University of Queensland, South Brisbane, Australia
| | - Rebecca Keating
- Department of Respiratory Medicine, Mater Health Services, South Brisbane, Australia
| | - Helen L Barrett
- Mater Research Institute – The University of Queensland, South Brisbane, Australia
- Departments of Endocrinology and Obstetric Medicine, Mater Health Services, South Brisbane, Australia
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31
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Meiss LN, Jain R, Kazmerski TM. Family Planning and Reproductive Health in Cystic Fibrosis. Clin Chest Med 2022; 43:811-820. [PMID: 36344082 DOI: 10.1016/j.ccm.2022.06.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Family planning in cystic fibrosis (CF) is an increasingly important aspect of care, as improvements in care and outcomes lead to a rise in the number of pregnancies and parenthood in people with CF. This article highlights: (1) Health considerations for people with CF related to pregnancy, contraception, and parenthood. (2) Facets of reproductive planning, fertility, and preconception counseling. (3) Relationship-centered reproductive health discussions.
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Affiliation(s)
- Lauren N Meiss
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, 20 York Street, New Haven, CT 06510, USA
| | - Raksha Jain
- Department of Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390-8558, USA
| | - Traci M Kazmerski
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Center for Innovative Research on Gender Health Equity (CONVERGE), University of Pittsburgh, Pittsburgh, PA, USA.
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32
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Pulmonary disorders in pregnancy: Bronchiectasis, cystic fibrosis, sarcoidosis and interstitial diseases. Best Pract Res Clin Obstet Gynaecol 2022; 85:114-126. [PMID: 36244873 DOI: 10.1016/j.bpobgyn.2022.09.001] [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: 08/19/2022] [Revised: 09/03/2022] [Accepted: 09/05/2022] [Indexed: 12/14/2022]
Abstract
This chapter aims to provide expert guidance to obstetricians, general practitioners, allied health staff and women with lung disease about the interactions between pregnancy and different lung diseases. This chapter will cover other airway diseases such as bronchiectasis and cystic fibrosis (CF) together with sarcoidosis and interstitial lung disease (ILD), noting that another chapter covers asthma. The physiological changes which occur in pregnancy, such as the changes in airway physiology, resting ventilation and sleep, are summarised in another chapter. This chapter extends the evidence-based approach and clinical expertise of the recent European Respiratory Society/Thoracic Society of Australia and New Zealand (ERS/TSANZ) taskforce. The papers selected were based on the population (pregnant women with lung disease other than asthma) and the effects of these diseases on risks of pregnancy-associated complications and miscarriages, breastfeeding, nutritional considerations, lung function, long-term maternal outcomes and management considerations during pregnancy. As there are very few randomised control trials in the area, the majority of the literature consists of observational studies (prospective or retrospective), cross-sectional surveys and case series. Other guidelines have also recently been published, which may be helpful to the reader.
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33
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Guimbellot JS, Nichols DP, Brewington JJ. Novel Applications of Biomarkers and Personalized Medicine in Cystic Fibrosis. Clin Chest Med 2022; 43:617-630. [PMID: 36344070 DOI: 10.1016/j.ccm.2022.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
As routine care in cystic fibrosis (CF) becomes increasingly personalized, new opportunities to further focus care on the individual have emerged. These opportunities are increasingly filled through research in tools aiding drug selection, drug monitoring and titration, disease-relevant biomarkers, and evaluation of therapeutic benefits. Herein, we will discuss such research tools presently being translated into the clinic to improve the personalization of care in CF.
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Affiliation(s)
- Jennifer S Guimbellot
- Department of Pediatrics, Division of Pulmonary and Sleep Medicine, Gregory Fleming James Cystic Fibrosis Research Center, University of Alabama at Birmingham; 1600 7th Avenue South, ACC 620, Birmingham, AL 35233, USA
| | - David P Nichols
- Department of Pediatrics, Division of Pulmonary Medicine, Seattle Children's Hospital, University of Washington School of Medicine, Building Cure, 1920 Terry Avenue, Office 4-209, Seattle, WA 98109, USA
| | - John J Brewington
- Department of Pediatrics, University of Cincinnati College of Medicine, 3230 Eden Avenue, Cincinnati, OH 45267, USA; Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2021, Cincinnati, OH 45229, USA.
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Gifford AH, Taylor-Cousar JL, Davies JC, McNally P. Update on Clinical Outcomes of Highly Effective Modulator Therapy. Clin Chest Med 2022; 43:677-695. [PMID: 36344074 DOI: 10.1016/j.ccm.2022.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Based on the cystic fibrosis transmembrane conductance regulator (CFTR) genotype, approximately 90% of people with cystic fibrosis (CF) are candidates for highly effective modulator therapy (HEMT). Clinical trials conducted over the last 11 years have shown that these oral therapies substantially restore CFTR function, leading to improvements in lung function, nutritional status, and health-related quality of life. Here, we review safety and efficacy data from phase 3 clinical trials and observational studies which support the use of HEMT in most adults and children with CF. We also discuss opportunities for additional investigation in groups underrepresented or excluded from phase 3 clinical trials, and challenges in the evaluation of the safety and efficacy of HEMT at increasingly earlier stages of CFTR-mediated pathophysiology.
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Affiliation(s)
- Alex H Gifford
- Division of Pulmonary, Critical Care, and Sleep Medicine, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Bolwell Building 6174, Cleveland, OH 44106, USA; Rainbow Babies and Children's Hospital, Cleveland, OH, USA.
| | - Jennifer L Taylor-Cousar
- Department of Internal Medicine, National Jewish Medical Center, Denver, CO, USA; Department of Pediatrics, National Jewish Medical Center, Denver, CO, USA
| | - Jane C Davies
- National Heart and Lung Institute, Imperial College London, England, United Kingdom; Royal Brompton & Harefield Hospital, Guys & St Thomas' Trust, London, United Kingdom
| | - Paul McNally
- Department of Paediatrics, RCSI University of Medicine and Health Sciences, Dublin, Ireland; Cystic Fibrosis Center, Children's Health Ireland, Dublin, Ireland
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Balmpouzis Z, Faure van Rossum A, Baud D, Panchaud A, Mitropoulou G, Mazza Stalder J, Koutsokera A. Successful pregnancy in a cystic fibrosis patient with a severe impairment of lung function receiving Elexacaftor-Tezacaftor-Ivacaftor. Respir Med Case Rep 2022; 40:101776. [PMID: 36386288 PMCID: PMC9664010 DOI: 10.1016/j.rmcr.2022.101776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Accepted: 11/06/2022] [Indexed: 11/09/2022] Open
Abstract
Before the arrival of Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) modulators women with CF and impaired lung function were experiencing a high risk of complications and mortality during and the years after pregnancy. The arrival of the highly efficient CFTR modulator, Elexacaftor-Tezacaftor-Ivacaftor (ETI) resulted in an improvement of lung function, quality of life and fertility. Here we report a case of successful pregnancy and uncomplicated delivery for a CF patient with severely impaired lung function receiving ETI prior to conception.
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Congenital bilateral cataracts in newborns exposed to elexacaftor-tezacaftor-ivacaftor in utero and while breast feeding. J Cyst Fibros 2022; 21:1074-1076. [PMID: 36266182 DOI: 10.1016/j.jcf.2022.10.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 10/11/2022] [Accepted: 10/11/2022] [Indexed: 11/07/2022]
Abstract
Elexacaftor-tezacaftor-ivacaftor (ETI) is known to pass through the placenta and into breast milk in mothers who continue on this therapy while pregnant and breast feeding. Toxicity studies of ivacaftor in rats demonstrated infant cataracts, but cataracts were not reported in human infants exposed to ivacaftor. We describe 3 cases of infants exposed to elexacaftor-tezacaftor-ivacaftor (ETI) in utero and while breast feeding who were found to have bilateral congenital cataracts within six months of birth. None of the infants had significant visual impairment from the cataracts nor any report of elevated liver function testing. These data highlight the need to counsel females who continue ETI throughout pregnancy and while breast feeding to consider cataract screen for their infants.
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Nuytten A, Prevotat A, Le Rouzic O, Dekemp J, Gilliot S, Gautier S, Le Duc K, Garabedian C. Pulmonary hemorrhage in a neonate born to a woman with cystic fibrosis treated with targeted cystic fibrosis transmembrane conductance regulator modulator elexacaftor-tezacaftor-ivacaftor during pregnancy. Therapie 2022; 77:743-745. [PMID: 35606190 DOI: 10.1016/j.therap.2022.01.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 12/07/2021] [Accepted: 01/31/2022] [Indexed: 01/13/2023]
Affiliation(s)
- Alexandra Nuytten
- Department of neonatology, CHU de Lille, 59000 Lille, France; ULR 2694 - METRICS: évaluation des technologies de santé et des pratiques médicales, University Lille, CHU de Lille, 59000 Lille, France.
| | - Anne Prevotat
- Cystic fibrosis center for adults, service de pneumologie et immuno-allergologie, CHU de Lille, 59000 Lille, France
| | - Olivier Le Rouzic
- Cystic fibrosis center for adults, service de pneumologie et immuno-allergologie, CHU de Lille, 59000 Lille, France
| | - Joëlle Dekemp
- Pharmacology department, centre régional de pharmacovigilance, Université Lille, CHU de Lille, 59000 Lille, France
| | - Sixtine Gilliot
- ULR 7365-GRITA-Groupe de recherche sur les formes injectables et les technologies associées, University Lille, CHU de Lille, 59000 Lille, France
| | - Sophie Gautier
- Pharmacology department, centre régional de pharmacovigilance, Université Lille, CHU de Lille, 59000 Lille, France
| | - Kévin Le Duc
- Department of neonatology, CHU de Lille, 59000 Lille, France; ULR 2694 - METRICS: évaluation des technologies de santé et des pratiques médicales, University Lille, CHU de Lille, 59000 Lille, France
| | - Charles Garabedian
- ULR 2694 - METRICS: évaluation des technologies de santé et des pratiques médicales, University Lille, CHU de Lille, 59000 Lille, France; Department of obstetrics, CHU de Lille, 59000 Lille, France
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Chamagne M, Farabet C, Grenet D, Ayoubi JM. Comparison of two pregnancies with and without elexacaftor-tezacaftor-ivacaftor in a woman with cystic fibrosis. Respir Med Res 2022; 83:100953. [PMID: 36563551 DOI: 10.1016/j.resmer.2022.100953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 08/03/2022] [Accepted: 08/30/2022] [Indexed: 12/25/2022]
Affiliation(s)
- Matthieu Chamagne
- Département de Gynécologie Obstétrique, hôpital Foch, 92151 Suresnes, France.
| | - Clémence Farabet
- Département de Gynécologie Obstétrique, hôpital Foch, 92151 Suresnes, France
| | | | - Jean Marc Ayoubi
- Département de Gynécologie Obstétrique, Faculté de Médecine Paris Ouest, hôpital Foch. 92151 Suresnes, France
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Pregnancies and Gynecological Follow-Up after Solid Organ Transplantation: Experience of a Decade. J Clin Med 2022; 11:jcm11164792. [PMID: 36013030 PMCID: PMC9409658 DOI: 10.3390/jcm11164792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 08/09/2022] [Accepted: 08/13/2022] [Indexed: 11/17/2022] Open
Abstract
In recent years, solid organ transplantations, such as kidney or lung grafts, have been performed worldwide with an improvement of quality of life under immunosuppressive therapy and an increase in life expectancy, allowing young women to consider childbearing. In the current study, we conduct a retrospective study in two French centers for kidney and lung transplantations to evaluate the rate and outcomes of pregnancies, contraception and gynecological monitoring for women under 40 years old who underwent solid organ transplantation. Among 210 women, progestin was the most widely used contraceptive method. Of the 210 women, 24 (11.4%) conceived 33 pregnancies of which 25 (75.8%) were planned with an immunosuppressant therapy switch. Of the 33 pregnancies, 7 miscarried (21.2%) and 21 (63.7%) resulted in a live birth with a high rate of pre-eclampsia (50%). No graft rejections were observed during pregnancies. Among the deliveries, 19 were premature (90.5%, mostly due to induced delivery) and the C-section rate was high (52.4%). No particular pathology was identified among newborns. We conclude that pregnancies following solid organ transplantation are feasible, and while they are at an increased risk of pre-eclampsia and prematurity, they should still be permitted with close surveillance by a multidisciplinary care team.
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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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Regard L, Martin C, Burgel PR. Cystic Fibrosis in 2021: "The Times They Are A-Changin". Arch Bronconeumol 2022; 58:536-538. [PMID: 35312571 DOI: 10.1016/j.arbres.2021.09.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Revised: 09/14/2021] [Accepted: 09/16/2021] [Indexed: 11/18/2022]
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
| | - 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
| | - 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.
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42
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Savant AP. Cystic fibrosis year in review 2021. Pediatr Pulmonol 2022; 57:1590-1599. [PMID: 35501666 DOI: 10.1002/ppul.25948] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 04/13/2022] [Accepted: 04/28/2022] [Indexed: 11/06/2022]
Abstract
People with cystic fibrosis (CF) have an amazing outlook with the treatment availability of highly effective modulators. Unfortunately, not all people with CF are eligible for modulators leading to continued pulmonary exacerbations and advanced lung disease. Additionally, optimizing diagnosis and evaluation for CF in the newborn period continues to be an area of focus for research. This review article will work to cover articles published in 2021 with high clinical relevance related to the above topics; however, due to the extensive body of research published, this review will not be comprehensive.
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Affiliation(s)
- Adrienne P Savant
- Department of Pediatrics, Children's Hospital of New Orleans, New Orleans, Louisiana, USA.,Department of Pediatrics, Tulane University, New Orleans, Louisiana, USA
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43
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Montemayor K, Tullis E, Jain R, Taylor-Cousar JL. Management of pregnancy in cystic fibrosis. Breathe (Sheff) 2022; 18:220005. [DOI: 10.1183/20734735.0005-2022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 03/22/2022] [Indexed: 12/12/2022] Open
Abstract
With recent therapeutic advances in care, people with cystic fibrosis (CF) are living longer and healthier lives. Development of the cystic fibrosis transmembrane conductance regulator (CFTR) modulator therapies has led to improved function of the CFTR protein resulting in improved lung function, decreased rates of pulmonary exacerbations and improved nutritional status for the majority of people with CF. Given improved quality and quantity of life, more people with CF are considering becoming pregnant than ever before. Since the first reported pregnancy in a woman with CF in 1960, the management of pregnancy in CF has been of increased interest and is an active field of research.In this review, we aim to discuss the management of pregnancy in CF. We discuss the optimisation of preconception health, management of maintenance CF therapies, and use of CFTR modulators during pregnancy and lactation. We also describe the management of pulmonary exacerbations during pregnancy as well as the unique management of pregnancy in a post-transplant patient with CF.Educational aimsTo describe considerations for optimisation of preconception health.To describe the management of chronic CF therapies including CFTR modulators during pregnancy and lactation.To describe treatment of an acute pulmonary exacerbation during pregnancy.To describe the management of pregnancy in individuals with CF following organ transplantation.
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Jain R, Magaret A, Vu PT, VanDalfsen JM, Keller A, Wilson A, Putman MS, Mayer-Hamblett N, Esther CR, Taylor-Cousar JL. Prospectively evaluating maternal and fetal outcomes in the era of CFTR modulators: the MAYFLOWERS observational clinical trial study design. BMJ Open Respir Res 2022; 9:9/1/e001289. [PMID: 35710144 PMCID: PMC9204448 DOI: 10.1136/bmjresp-2022-001289] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Accepted: 06/06/2022] [Indexed: 11/12/2022] Open
Abstract
Introduction Therapeutic advances have markedly increased life expectancy for those with cystic fibrosis (CF), resulting in a median predicted survival over 50 years. Consequently, people with CF (pwCF) are living through their reproductive years and the rate of pregnancy is rapidly rising. Despite the increased relevance of this topic, multicentre studies investigating the association between maternal health and choices made during pregnancy on maternal and fetal outcomes do not exist. Furthermore, there are very limited data on the outcomes following CF transmembrane conductance regulator (CFTR) modulator use during pregnancy and lactation. Methods and analysis Maternal and Fetal Outcomes in the Era of Modulators (MAYFLOWERS) is a prospective, multicentre observational clinical trial which will enrol approximately 285 pregnant pwCF including those who are modulator ineligible and those who choose to continue or discontinue CFTR modulator therapy during pregnancy and lactation. The primary aim of this 35-month study is to assess whether lung function changes during pregnancy differ based on the continued use of modulators or other factors such as pre-existing comorbid conditions. Secondary objectives include evaluation of pregnancy related and obstetrical complications and changes in mental health. Ethics and dissemination The design of this study required special consideration of study burden on pregnant and lactating people with chronic illness in the setting of a substantial number of unanswered questions under these conditions. MAYFLOWERS is the first prospective clinical trial examining pregnancy in CF; the outcomes will guide providers on pregnancy management in pwCF and others with chronic respiratory disease.
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Affiliation(s)
- Raksha Jain
- Department of Medicine, University of Texas Southwestern, Dallas, Texas, USA
| | - Amalia Magaret
- Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children's Hospital, Seattle, Washington, USA.,Department of Biostatistics, University of Washington, Seattle, Texas, USA
| | - Phuong T Vu
- Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children's Hospital, Seattle, Washington, USA
| | - Jill M VanDalfsen
- Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children's Hospital, Seattle, Washington, USA
| | - Ashley Keller
- Department of Medicine, University of Texas Southwestern, Dallas, Texas, USA
| | - Alexandra Wilson
- Clinical Research Services, National Jewish Health, Denver, Colorado, USA
| | - Melissa S Putman
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA.,Division of Endocrinology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Nicole Mayer-Hamblett
- Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children's Hospital, Seattle, Washington, USA.,Department of Biostatistics, University of Washington, Seattle, Texas, USA.,Department of Pediatrics, University of Washington, Seattle, Washington, USA
| | - Charles R Esther
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Szentpetery S, Foil K, Hendrix S, Gray S, Mingora C, Head B, Johnson D, Flume PA. A case report of CFTR modulator administration via carrier mother to treat meconium ileus in a F508del homozygous fetus. J Cyst Fibros 2022; 21:721-724. [DOI: 10.1016/j.jcf.2022.04.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 03/16/2022] [Accepted: 04/04/2022] [Indexed: 10/18/2022]
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Kazmerski TM, West NE, Jain R, Uluer A, Georgiopoulos AM, Aitken ML, Taylor-Cousar JL. Family-building and parenting considerations for people with cystic fibrosis. Pediatr Pulmonol 2022; 57 Suppl 1:S75-S88. [PMID: 34407321 PMCID: PMC9292426 DOI: 10.1002/ppul.25620] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 08/03/2021] [Accepted: 08/04/2021] [Indexed: 01/24/2023]
Abstract
As people with cystic fibrosis (CF) live longer and healthier lives, increasing numbers are considering the full range of reproductive options for their futures, including parenthood, pregnancy, or pregnancy prevention. As the face of CF changes, the CF care model must adapt to meet the reproductive health needs of both parents and nonparents with CF. This article summarizes the reproductive goals and family-building concerns faced by people with CF, including fertility, pregnancy, and alternative paths to parenthood, the impact of parenthood on mental and physical health, and important future research.
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Affiliation(s)
- Traci M Kazmerski
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Center for Women's Health Research and Innovation (CWHRI), University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Natalie E West
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Raksha Jain
- Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Ahmet Uluer
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Anna M Georgiopoulos
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Moira L Aitken
- Department of Medicine, University of Washington, Seattle, Washington, USA
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Drug exposure to infants born to mothers taking Elexacaftor, Tezacaftor, and Ivacaftor. J Cyst Fibros 2021; 21:725-727. [PMID: 34952795 DOI: 10.1016/j.jcf.2021.12.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 11/23/2021] [Accepted: 12/05/2021] [Indexed: 11/21/2022]
Abstract
Elexacaftor, tezacaftor, ivacaftor (ETI) have been associated with marked clinical improvements in adults with CF, which appears to be associated with increased fertility. However, maternal and fetal effects of therapy continued during pregnancy are not well understood. We collected maternal blood, infant blood, cord blood, and breast milk from 3 mother-infant pairs from women who elected to remain on ETI therapy while pregnant. Our results demonstrated relatively high levels of ETI in cord blood, suggesting placental transfer of these compounds, as well as low levels of ETI in breast milk and infant blood, suggesting further transfer of these compounds to breast-fed infants in the postnatal period. These data underscore the need for larger studies on the effects of modulator surrounding reproduction.
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48
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Triple combination cystic fibrosis transmembrane conductance regulator modulator therapy in the real world - opportunities and challenges. Curr Opin Pulm Med 2021; 27:554-566. [PMID: 34420018 DOI: 10.1097/mcp.0000000000000819] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
PURPOSE OF REVIEW The purpose of this review is to describe on-going and upcoming real-world studies that will aid the cystic fibrosis (CF) community in understanding the long-term efficacy, safety and challenges in utilizing this therapy and managing care. RECENT FINDINGS The triple combination of elexacaftor, tezacaftor and ivacaftor (ETI) has been demonstrated to improve lung function, weight and quality of life in children and adults with CF with at least one copy of Phe508del. Treatment with ETI will potentially be available for approximately 90% of the CF population and change the face of CF. SUMMARY In spite of early demonstrations of short-term efficacy and safety, for medications that may be given for much of someone's life, continued assessment of these outcomes is necessary. Furthermore, the CF community must evaluate and address the issues that arise with increased longevity including parenthood, preventive care management and the potential comorbidities of aging.
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Jain R, Kazmerski TM, Zuckerwise LC, West NE, Montemayor K, Aitken ML, Cheng E, Roe AH, Wilson A, Mann C, Ladores S, Sjoberg J, Poranski M, Taylor-Cousar JL. Pregnancy in cystic fibrosis: Review of the literature and expert recommendations. J Cyst Fibros 2021; 21:387-395. [PMID: 34456158 DOI: 10.1016/j.jcf.2021.07.019] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 07/23/2021] [Accepted: 07/26/2021] [Indexed: 12/22/2022]
Abstract
Cystic fibrosis (CF) was historically a disease largely afflicting children. Due to therapeutic advancements, there are now more adults with CF than children. In the past decade, medications including Cystic Fibrosis Transmembrane conductance Regulator (CFTR) modulators became available that treat the underlying cause of CF and are dramatically improving lung function as well as quality and quantity of life for people with CF. As a result, more women with CF are becoming pregnant. We gathered a panel of experts in CF care, family planning, high risk obstetrics, nutrition, genetics and women with CF to review current literature on pregnancies and to provide care recommendations for this unique population.
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Affiliation(s)
- Raksha Jain
- Department of Medicine, University of Texas Southwestern, 5323 Harry Hines Blvd., Dallas, TX 75390-8558, United States.
| | - Traci M Kazmerski
- Department of Pediatrics, University of Pittsburgh School of Medicine, 120 Lytton Ave. Suite M060 University Center, Pittsburgh, PA 15213, United States
| | - Lisa C Zuckerwise
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Vanderbilt University Medical Center, 1161 21st Avenue South, B-1100 MCN, Nashville, TN 37232, United States
| | - Natalie E West
- Department of Medicine, Johns Hopkins University, 1830 E. Monument St. 5th Floor, Baltimore, MD 21205, United States
| | - Kristina Montemayor
- Department of Medicine, Johns Hopkins University, 1830 E. Monument St. 5th Floor, Baltimore, MD 21205, United States
| | - Moira L Aitken
- Department of Medicine, University of Washington, 1959 NE Pacific Street - Rm BB 1361, Seattle WA 98195-6522, United States
| | - Edith Cheng
- Maternal Fetal Medicine, Maternal Fetal Medicine, Medical Genetics, University of Washington, United States
| | - Andrea H Roe
- Department of Obstetrics and Gynecology, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, 1000 Courtyard, Philadelphia, PA 19106, United States
| | - Alexandra Wilson
- Department of Medicine, Cystic Fibrosis Clinical Research, National Jewish Health, 1400 Jackson Street, K333b, Denver, CO 80206, United States
| | - Caitlin Mann
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Vanderbilt University Medical Center, 1161 21st Avenue South, B-1100 MCN, Nashville, TN 37232, United States
| | - Sigrid Ladores
- School of Nursing, The University of Alabama at Birmingham, NB 470L, 1720 2nd Avenue South, Birmingham, AL 35294-1210, United States
| | - Jacqui Sjoberg
- Adult with Cystic Fibrosis, 130 Johnston Dr, Highland Park, IL 60035, United States
| | - Madeline Poranski
- Adult with Cystic Fibrosis, 2700 University Ave. W. Apt. 416, St. Paul, MN 55114, United States
| | - Jennifer L Taylor-Cousar
- Departments of Medicine and Pediatrics, National Jewish Health, 1400 Jackson Street; J318, Denver, CO 80206, United States
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Management of Individual Patient Expectations When Starting with Highly Effective CFTR Modulators. J Pers Med 2021; 11:jpm11080811. [PMID: 34442455 PMCID: PMC8398159 DOI: 10.3390/jpm11080811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 08/13/2021] [Accepted: 08/18/2021] [Indexed: 11/17/2022] Open
Abstract
Highly effective CFTR modulators such as elexacaftor/tezacaftor/ivacaftor (ELE/TEZ/IVA will become available for an increasing number of people with cystic fibrosis (pwCF) in the near future. Before the start of this therapy, many questions may arise concerning the expected effects. We assembled the currently available data from the literature about ELE/TEZ/IVA that focused on commonly asked questions from patients. Overall, the literature so far presents a very hopeful prospect of effects, not only on lung function, but also on nutritional status, sinonasal symptoms and quality of life. The effects in patients with pwCF with severe lung damage are also favorable. Treatment is generally well tolerated. In some cases, patient-derived cell models can help in predicting the effects for individual patients.
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