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Qian C, Klimchak AC, Szabo SM, Popoff E, Iannaccone ST, Gooch KL. Observing the Clinical Course of Duchenne Muscular Dystrophy in Medicaid Real-World Healthcare Data. Adv Ther 2024; 41:2519-2530. [PMID: 38698169 PMCID: PMC11133018 DOI: 10.1007/s12325-024-02865-2] [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] [Received: 02/08/2024] [Accepted: 04/03/2024] [Indexed: 05/05/2024]
Abstract
INTRODUCTION Duchenne muscular dystrophy (DMD) is a rare, severe progressive neuromuscular disease. Health insurance claims allow characterization of population-level real-world outcomes, based on observed healthcare resource use. An analysis of data specific to those with Medicaid insurance is presently unavailable. The objective was to describe the real-world clinical course of DMD based on claims data from Medicaid-insured individuals in the USA. METHODS Individuals with DMD were identified from the MarketScan Multi-State Medicaid datasets (2013-2018). Diagnosis and procedure codes from healthcare claims were used to characterize the occurrence of DMD-relevant clinical observations; categories were scoliosis, cardiovascular-related, respiratory and severe respiratory-related, and neurologic/neuropsychiatric. Age-restricted analyses were conducted to focus on the ages at which DMD-relevant clinical observations were more likely to be captured, and to better understand the impact of both age and follow-up time. RESULTS Of 2007 patients with DMD identified, median (interquartile range) age at index was 14 (9-20) years, and median follow-up was 3.1 (1.6-4.7) years. Neurologic and neuropsychiatric observations were most frequently identified, among 49.3% of the cohort; followed by cardiovascular (48.5%), respiratory (38.1%), scoliosis (36.3%), and severe respiratory (25.0%). Prevalence estimates for each category were higher when analyzed within age-restricted subgroups; and increased as follow-up time increased. CONCLUSIONS This study is the first to use diagnosis and procedure codes from real-world Medicaid claims to document the clinical course in DMD. Findings were consistent with previously published estimates from commercially insured populations and clinical registries; and contribute to the expanding body of real-world evidence around clinical progression of patients with DMD.
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Affiliation(s)
- Christina Qian
- Broadstreet Health Economics and Outcomes Research, 201-343 Railway Street, Vancouver, BC, V6A 1A4, Canada
| | - Alexa C Klimchak
- Sarepta Therapeutics, Inc, 215 First Street, Cambridge, MA, 02142, USA
| | - Shelagh M Szabo
- Broadstreet Health Economics and Outcomes Research, 201-343 Railway Street, Vancouver, BC, V6A 1A4, Canada.
| | - Evan Popoff
- Broadstreet Health Economics and Outcomes Research, 201-343 Railway Street, Vancouver, BC, V6A 1A4, Canada
| | - Susan T Iannaccone
- University of Texas Southwestern, 5323 Harry Hines Blvd, Dallas, TX, 75390, USA
| | - Katherine L Gooch
- Sarepta Therapeutics, Inc, 215 First Street, Cambridge, MA, 02142, USA
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Trundle J, Lu-Nguyen N, Malerba A, Popplewell L. Targeted Antisense Oligonucleotide-Mediated Skipping of Murine Postn Exon 17 Partially Addresses Fibrosis in D2. mdx Mice. Int J Mol Sci 2024; 25:6113. [PMID: 38892298 PMCID: PMC11172600 DOI: 10.3390/ijms25116113] [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] [Received: 04/26/2024] [Revised: 05/28/2024] [Accepted: 05/30/2024] [Indexed: 06/21/2024] Open
Abstract
Periostin, a multifunctional 90 kDa protein, plays a pivotal role in the pathogenesis of fibrosis across various tissues, including skeletal muscle. It operates within the transforming growth factor beta 1 (Tgf-β1) signalling pathway and is upregulated in fibrotic tissue. Alternative splicing of Periostin's C-terminal region leads to six protein-coding isoforms. This study aimed to elucidate the contribution of the isoforms containing the amino acids encoded by exon 17 (e17+ Periostin) to skeletal muscle fibrosis and investigate the therapeutic potential of manipulating exon 17 splicing. We identified distinct structural differences between e17+ Periostin isoforms, affecting their interaction with key fibrotic proteins, including Tgf-β1 and integrin alpha V. In vitro mouse fibroblast experimentation confirmed the TGF-β1-induced upregulation of e17+ Periostin mRNA, mitigated by an antisense approach that induces the skipping of exon 17 of the Postn gene. Subsequent in vivo studies in the D2.mdx mouse model of Duchenne muscular dystrophy (DMD) demonstrated that our antisense treatment effectively reduced e17+ Periostin mRNA expression, which coincided with reduced full-length Periostin protein expression and collagen accumulation. The grip strength of the treated mice was rescued to the wild-type level. These results suggest a pivotal role of e17+ Periostin isoforms in the fibrotic pathology of skeletal muscle and highlight the potential of targeted exon skipping strategies as a promising therapeutic approach for mitigating fibrosis-associated complications.
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MESH Headings
- Animals
- Cell Adhesion Molecules/genetics
- Cell Adhesion Molecules/metabolism
- Mice
- Fibrosis
- Exons
- Mice, Inbred mdx
- Oligonucleotides, Antisense/pharmacology
- Oligonucleotides, Antisense/genetics
- Alternative Splicing
- Muscular Dystrophy, Duchenne/genetics
- Muscular Dystrophy, Duchenne/therapy
- Muscular Dystrophy, Duchenne/metabolism
- Muscular Dystrophy, Duchenne/pathology
- Muscle, Skeletal/metabolism
- Muscle, Skeletal/pathology
- Transforming Growth Factor beta1/metabolism
- Transforming Growth Factor beta1/genetics
- Fibroblasts/metabolism
- Disease Models, Animal
- Protein Isoforms/genetics
- Protein Isoforms/metabolism
- Male
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Affiliation(s)
- Jessica Trundle
- Department of Biological Sciences, School of Life Sciences and Environment, Royal Holloway University of London, Surrey TW20 0EX, UK; (J.T.); (N.L.-N.)
- Developmental Biology and Cancer Research and Teaching Department, University College London Great Ormond Street Institute of Child Health, London WC1N 1EH, UK
| | - Ngoc Lu-Nguyen
- Department of Biological Sciences, School of Life Sciences and Environment, Royal Holloway University of London, Surrey TW20 0EX, UK; (J.T.); (N.L.-N.)
| | - Alberto Malerba
- Department of Biological Sciences, School of Life Sciences and Environment, Royal Holloway University of London, Surrey TW20 0EX, UK; (J.T.); (N.L.-N.)
| | - Linda Popplewell
- Department of Biological Sciences, School of Life Sciences and Environment, Royal Holloway University of London, Surrey TW20 0EX, UK; (J.T.); (N.L.-N.)
- National Horizons Centre, Teesside University, Darlington DL1 1HG, UK
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3
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Conway KM, Thomas S, Ciafaloni E, Khan RS, Mann JR, Romitti PA, Mathews KD. Prophylactic use of cardiac medications for delay of left ventricular dysfunction in Duchenne muscular dystrophy. Birth Defects Res 2024; 116:e2260. [PMID: 37850663 DOI: 10.1002/bdr2.2260] [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] [Received: 06/27/2023] [Revised: 09/21/2023] [Accepted: 09/25/2023] [Indexed: 10/19/2023]
Abstract
BACKGROUND Epidemiological support for prophylactic treatment of left ventricular dysfunction (LVD) in Duchenne muscular dystrophy is limited. We used retrospective, population-based surveillance data from the Muscular Dystrophy Surveillance, Tracking and Research Network to evaluate whether prophylaxis delays LVD onset. METHODS We analyzed 455 males born during 1982-2009. Age at first abnormal echocardiogram (ejection fraction <55% or shortening fraction <28%) determined LVD onset. Prophylaxis was defined as cardiac medication use at least 1 year prior to LVD. Corticosteroid use was also coded. Kaplan-Meier curve estimation and Cox Proportional Hazard modeling with time-varying covariates describe associations. RESULTS LVD was identified among 40.7%; average onset age was 14.2 years. Prophylaxis was identified for 20.2% and corticosteroids for 57.4%. Prophylaxis showed delayed LVD onset (p < .001) and lower hazard of dysfunction (adjusted hazard ratio [aHR] = 0.39, 95%CL = 0.22, 0.65) compared to untreated. Compared to no treatment, continuous corticosteroids only (aHR = 1.01, 95%CL = 0.66, 1.53) and prophylaxis only (aHR = 0.67, 95%CL = 0.25, 1.50) were not cardioprotective, but prophylaxis plus continuous corticosteroids were associated with lower hazard of dysfunction (aHR = 0.37, 95%CL = 0.15, 0.80). CONCLUSIONS Proactive cardiac treatment and monitoring are critical aspects of managing Duchenne muscular dystrophy. Consistent with clinical care guidelines, this study supports clinical benefit from cardiac medications initiated prior to documented LVD and suggests further benefit when combined with corticosteroids.
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Affiliation(s)
- Kristin M Conway
- Department of Epidemiology, College of Public Health, The University of Iowa, Iowa City, Iowa, USA
| | - Shiny Thomas
- New York State Department of Health, Albany, New York, USA
| | - Emma Ciafaloni
- Department of Neurology, School of Medicine and Dentistry, University of Rochester Medical Center, Rochester, New York, USA
| | - Rabia S Khan
- Department of Pediatrics, UCLA Health Sciences, Los Angeles, California, USA
- Department of Pediatrics, Roy J and Lucille A Carver College of Medicine, The University of Iowa, Iowa City, Iowa, USA
| | - Joshua R Mann
- Department of Preventive Medicine, School of Medicine and John D. Bower School of Population Health, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Paul A Romitti
- Department of Epidemiology, College of Public Health, The University of Iowa, Iowa City, Iowa, USA
| | - Katherine D Mathews
- Department of Pediatrics, Roy J and Lucille A Carver College of Medicine, The University of Iowa, Iowa City, Iowa, USA
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Mackels L, Servais L. The Importance of Early Treatment of Inherited Neuromuscular Conditions. J Neuromuscul Dis 2024; 11:253-274. [PMID: 38306060 DOI: 10.3233/jnd-230189] [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: 02/03/2024]
Abstract
There has been tremendous progress in treatment of neuromuscular diseases over the last 20 years, which has transformed the natural history of these severely debilitating conditions. Although the factors that determine the response to therapy are many and in some instance remain to be fully elucidated, early treatment clearly has a major impact on patient outcomes across a number of inherited neuromuscular conditions. To improve patient care and outcomes, clinicians should be aware of neuromuscular conditions that require prompt treatment initiation. This review describes data that underscore the importance of early treatment of children with inherited neuromuscular conditions with an emphasis on data resulting from newborn screening efforts.
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Affiliation(s)
- Laurane Mackels
- MDUK Oxford Neuromuscular Centre, Department of Paediatrics, University of Oxford, Oxford, United Kingdom
- Adult Neurology Department, Citadelle Hospital, Liège, Belgium
| | - Laurent Servais
- Neuromuscular Centre, Division of Paediatrics, University and University Hospital of Liège, Liège, Belgium
- MDUK Oxford Neuromuscular Centre, Department of Paediatrics, University of Oxford & NIHR Oxford Biomedical Research Centre, Oxford, United Kingdom
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Landfeldt E, Aleman A, Abner S, Zhang R, Werner C, Tomazos I, Lochmüller H, Quinlivan R. Factors Associated with Respiratory Health and Function in Duchenne Muscular Dystrophy: A Systematic Review and Evidence Grading. J Neuromuscul Dis 2024; 11:25-57. [PMID: 37980679 PMCID: PMC10789346 DOI: 10.3233/jnd-230094] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/03/2023] [Indexed: 11/21/2023]
Abstract
BACKGROUND Despite advances in the medical management of the disease, respiratory involvement remains a significant source of morbidity and mortality in children and adults with Duchenne muscular dystrophy (DMD). OBJECTIVE The objective of this systematic literature review was to synthesize and grade published evidence of factors associated with respiratory health and function in DMD. METHODS We searched MEDLINE, Embase, and the Cochrane Library for records of studies published from January 1, 2000 (to ensure relevance to current care practices), up until and including December 31, 2022, reporting evidence of prognostic indicators and predictors of disease progression in DMD. The quality of evidence (i.e., very low to high) was assessed using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) framework. RESULTS The bibliographic search strategy resulted in the inclusion of 29 articles. In total, evidence of 10 factors associated with respiratory health and function in patients with DMD was identified: glucocorticoid exposure (high- to very low-quality evidence), DMD mutations (low-quality evidence), DMD genetic modifiers (low-quality evidence), other pharmacological interventions (i.e., ataluren, eteplirsen, idebenone, and tamoxifen) (moderate- to very low-quality evidence), body mass index and weight (low-quality evidence), and functional ability (low-quality evidence). CONCLUSIONS In conclusion, we identified a total of 10 factors associated with respiratory health in function in DMD, encompassing both pharmacological therapies, genetic mutations and modifiers, and patient clinical characteristics. Yet, more research is needed to further delineate sources of respiratory heterogeneity, in particular the genotype-phenotype association and the impact of novel DMD therapies in a real-world setting. Our synthesis and grading should be helpful to inform clinical practice and future research of this heavily burdened patient population.
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Affiliation(s)
| | - A. Aleman
- Department of Pediatrics, Division of Neurology, Children’s Hospital of Eastern Ontario, Research Institute, University of Ottawa, Ottawa, ON, Canada
- Department of Medicine, Division of Neurology, The Ottawa Hospital, Brain and Mind Research Institute, University of Ottawa, Ottawa, ON, Canada
| | | | - R. Zhang
- PTC Therapeutics Sweden AB, Askim, Sweden
| | - C. Werner
- PTC Therapeutics Germany GmbH, Frankfurt, Germany
| | - I. Tomazos
- PTC Therapeutics Inc, South Plainfield, NJ, USA
| | - H. Lochmüller
- Department of Pediatrics, Division of Neurology, Children’s Hospital of Eastern Ontario, Research Institute, University of Ottawa, Ottawa, ON, Canada
- Department of Medicine, Division of Neurology, The Ottawa Hospital, Brain and Mind Research Institute, University of Ottawa, Ottawa, ON, Canada
- Department of Neuropediatrics and Muscle Disorders, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - R.M. Quinlivan
- Centre for Neuromuscular Diseases, UCL Institute of Neurology, National Hospital, London, UK
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Fujimoto A, Mizuno K, Iwata Y, Yajima H, Nishida D, Komaki H, Ishiyama A, Mori-yoshimura M, Tachimori H, Kobayashi Y. Long-term Observation in Patients with Duchenne Muscular Dystrophy with Early Introduction of a Standing Program Using Knee-ankle-foot Orthoses. Prog Rehabil Med 2023; 8:20230038. [PMID: 37901357 PMCID: PMC10602754 DOI: 10.2490/prm.20230038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 10/11/2023] [Indexed: 10/31/2023] Open
Abstract
Objectives This study investigated the outcomes of the early introduction of a standing program for patients with Duchenne muscular dystrophy (DMD). Methods This was a retrospective observational study of 41 outpatients with DMD aged 15-20 years. We introduced the standing program using knee-ankle-foot orthoses (KAFO) to slow the progression of scoliosis when ankle dorsiflexion became less than 0° in the ambulatory period. Results Thirty-two patients with DMD were offered the standing program with KAFO; 12 continued the program until the age of 15 years (complete group) and 20 discontinued the program before the age of 15 years (incomplete group). The non-standing program group included 9 patients. The standing program with KAFO was significantly associated with the Cobb angle at the age of 15 years after adjustment for the duration of corticosteroid use and DMD mutation type (P=0.0004). At the age of 15 years, significant correlations were found between the ankle dorsiflexion range of motion (ROM) and non-ambulatory period (P=0.0010), non-ambulatory period and Cobb angle (P<0.0001), Cobb angle and percent predicted forced vital capacity (P=0.0004), and ankle dorsiflexion ROM and Cobb angle (P=0.0066). In the complete group, the age at ambulation loss (log-rank P=0.0015), scoliosis progression (log-rank P=0.0032), and pulmonary dysfunction (log-rank P=0.0006) were significantly higher than in the non-standing program group. Conclusions The early introduction of a standing program for DMD patients may prolong the ambulation period and slow the progression of scoliosis and pulmonary dysfunction.
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Affiliation(s)
- Akiko Fujimoto
- Department of Physical Rehabilitation, National Center Hospital, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Katsuhiro Mizuno
- Department of Physical Rehabilitation, National Center Hospital, National Center of Neurology and Psychiatry, Tokyo, Japan
- Department of Rehabilitation Medicine, Tokai University School of Medicine, Isehara, Japan
| | - Yasuyuki Iwata
- Department of Physical Rehabilitation, National Center Hospital, National Center of Neurology and Psychiatry, Tokyo, Japan
- Department of Rehabilitation, National Hakone Hospital, Odawara, Japan
| | - Hiroyuki Yajima
- Department of Physical Rehabilitation, National Center Hospital, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Daisuke Nishida
- Department of Physical Rehabilitation, National Center Hospital, National Center of Neurology and Psychiatry, Tokyo, Japan
- Department of Rehabilitation Medicine, Tokai University School of Medicine, Isehara, Japan
- Department of Rehabilitation Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Hirofumi Komaki
- Department of Child Neurology, National Center Hospital, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Akihiko Ishiyama
- Department of Child Neurology, National Center Hospital, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Madoka Mori-yoshimura
- Department of Neurology, National Center Hospital, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Hisateru Tachimori
- Endowed Course for Health System Innovation, Keio University School of Medicine, Tokyo, Japan
- Department of Clinical Data Science, Clinical Research and Education Promotion Division, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Yoko Kobayashi
- Department of Physical Rehabilitation, National Center Hospital, National Center of Neurology and Psychiatry, Tokyo, Japan
- Department of Rehabilitation, National Hakone Hospital, Odawara, Japan
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Leon-Astudillo C, Okorie CUA, McCown MY, Dy FJ, Puranik S, Prero M, ElMallah MK, Treat L, Gross JE. ATS Core Curriculum 2022. Pediatric Pulmonary Medicine: Updates in pediatric neuromuscular disease. Pediatr Pulmonol 2023. [PMID: 37144867 DOI: 10.1002/ppul.26448] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 04/23/2023] [Indexed: 05/06/2023]
Abstract
The American Thoracic Society Core Curriculum updates clinicians annually in pediatric pulmonary disease. This is a concise review of the Pediatric Pulmonary Medicine Core Curriculum presented at the 2022 American Thoracic Society International Conference. Neuromuscular diseases (NMD) comprise a variety of conditions that commonly affect the respiratory system and cause significant morbidity including dysphagia, chronic respiratory failure, and sleep disordered breathing. Respiratory failure is the most common cause of mortality in this population. Substantial progress has been made in diagnosis, monitoring and treatment for NMD over the last decade. Pulmonary function testing (PFT) is utilized to objectively measure respiratory pump function and PFT milestones are utilized in NMD-specific pulmonary care guidelines. New disease modifying therapies are approved for the treatment of patients with Duchenne muscular dystrophy and spinal muscular atrophy (SMA), including the first ever approved systemic gene therapy, in the case of SMA. Despite extraordinary progress in the medical management of NMD, little is known regarding the respiratory implications and long-term outcomes for patients in the era of advanced therapeutics and precision medicine. The combination of technological and biomedical advancements has increased the complexity of the medical decision-making process for patients and families, thus emphasizing the importance of balancing respect for autonomy with the other foundational principles of medical ethics. This review features an overview of PFT, noninvasive ventilation strategies, novel and developing therapies, as well as the ethical considerations specific to the management of patients with pediatric NMD.
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Affiliation(s)
| | - Caroline U A Okorie
- Department of Pediatrics, Stanford Children's Health, Stanford, California, USA
| | - Michael Y McCown
- Department of Pediatrics, Inova Children's Hospital, Fairfax, Virginia, USA
| | - Fei J Dy
- Department of Pediatrics, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Sandeep Puranik
- Department of Pediatrics, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Moshe Prero
- Department of Pediatrics, Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
| | - Mai K ElMallah
- Department of Pediatrics, Duke University Medical Center, Durham, North Carolina, USA
| | - Lauren Treat
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Jane E Gross
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA
- Departments of Pediatrics and Medicine, National Jewish Health, Denver, Colorado, USA
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Szabo SM, Klimchak AC, Qian C, Iannaccone S, Popoff E, Gooch KL. Characterizing the Occurrence of Key Clinical Milestones in Duchenne Muscular Dystrophy in the United States Using Real-World Data. J Neuromuscul Dis 2022; 9:689-699. [DOI: 10.3233/jnd-220816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Background: Data on the clinical course of Duchenne muscular dystrophy (DMD) exist from well-characterized clinical cohorts but estimates from real-world populations are fewer. Objective: The objective was to estimate the prevalence of key clinical milestones by age, among real-world commercially-insured DMD patients in the United States. Methods: MarketScan claims (2013–2018) were used to identify males with DMD. The percentages with wheelchair use or experiencing scoliosis, neurologic/neuropsychiatric involvement, cardiomyopathy, and respiratory involvement were tabulated; as were the median (interquartile range [IQR]) ages at first observed occurrence within the claims data. Results: Among DMD patients (n = 1,964), the median (IQR) baseline age was 15 (9–21) years, and median follow-up was 1.7 years. Wheelchair use was observed in 55% of those aged 8 to 13 years at cohort entry; scoliosis, among 38% of those 8 to 10 and 52% of those 11 to 13 years; neurologic/neuropsychiatric involvement, among 41–43% of those 8 to 13 years; respiratory involvement, among 45% of those 14 to 19 years; and cardiomyopathy, among 68% of those 14 to 16 and 58% of those 17 to 19 years. Conclusions: The prevalence of key clinical milestones across ages was broadly consistent with published findings. Variability in estimates reflect clinical heterogeneity; these contemporary estimates from real-world data help characterize clinical outcomes in DMD.
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Affiliation(s)
- Shelagh M. Szabo
- Broadstreet Health Economics & Outcomes Research, Vancouver BC, Canada
| | | | - Christina Qian
- Broadstreet Health Economics & Outcomes Research, Vancouver BC, Canada
| | - Susan Iannaccone
- University of Texas Southwestern, Harry Hines Blvd, Dallas TX, USA
| | - Evan Popoff
- Broadstreet Health Economics & Outcomes Research, Vancouver BC, Canada
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Gan S, Liu S, Yang H, Wu L. Clinical and genetic characteristics of Chinese Duchenne/Becker muscular dystrophy patients with small mutations. Front Neurosci 2022; 16:992546. [DOI: 10.3389/fnins.2022.992546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 10/20/2022] [Indexed: 11/09/2022] Open
Abstract
BackgroundDuchenne muscular dystrophy (DMD) and Becker muscular dystrophy (BMD) are amongst the inherited neuromuscular diseases with the highest incidence. Small mutations are less common and therefore have been poorly studied in China.Materials and methodsThe clinical data of 150 patients diagnosed with DMD/BMD by genetic analysis in Hunan Children’s Hospital from 2009 to 2021 were analyzed. The patients were followed up for an average of 3.42 years and their clinical characteristics were collected. Loss of ambulation (LOA) was used to evaluate the severity of disease progression. The correlation among clinical features, different variants, and glucocorticoid (GC) treatment was analyzed by Cox regression analysis.Results150 different variants were detected in this study, including 21 (14%) novel mutations, 88 (58.7%) non-sense mutations, 33 (22.0%) frameshift mutations, 22 (14.7%) splicing mutations, and 7 (4.7%) missense mutations. Single-exon skipping and single- or double-exon (double/single-exon) skipping strategies covered more than 90% of patients with small mutations. A case with frameshift mutation combined with Klinefelter’s syndrome (47, XXY) and another one with missense mutation combined with epilepsy was found in our study. De novo mutations accounted for 30.0% of all patients. The mean onset age was 4.19 ± 1.63 years old, and the mean diagnosed age was 5.60 ± 3.13 years old. The mean age of LOA was 10.4 years old (40 cases). 60.7% of them received GC treatment at 7.0 ± 2.7 years old. The main causes of complaints were muscle weakness, high creatine kinase (CK), motor retardation, and family history. The risk factors of LOA were positive family history (HR 5.52, CI 1.26–24.18), short GC treatment duration (HR 0.54, CI 0.36–0.82) and frameshift mutation (HR 14.58, CI 1.74–121.76). DMD patients who treated with GC after 7 years old had a higher risk of earlier LOA compared to those receiving treatment before the age of 7 (HR 0.083, CI 0.009–0.804). Moreover, an earlier onset age, a higher CK value, and a larger LOA population were found in the DMD patients compared to the BMD ones. Finally, the locations of the most frequent mutation were in exon 70 and exon 22.ConclusionIn conclusion, 150 small mutations were identified in this study, and 21 of them were discovered for the first time. We found the hotspots of small mutations were in exon 70 and exon 20. Also, the analysis showed that positive family history, frameshift mutation, short duration of GC treatment, and delayed GC treatment resulted in earlier LOA for the DMD patients. Taken together, our findings complement the mutation spectrum of DMD/BMD, benefit us understanding to the DMD disease, and lay foundations for the clinical trials.
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10
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Weber FJ, Latshang TD, Blum MR, Kohler M, Wertli MM. Prognostic factors, disease course, and treatment efficacy in Duchenne muscular dystrophy: A systematic review and meta-analysis. Muscle Nerve 2022; 66:462-470. [PMID: 35860996 PMCID: PMC9804574 DOI: 10.1002/mus.27682] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 07/10/2022] [Accepted: 07/17/2022] [Indexed: 01/05/2023]
Abstract
INTRODUCTION/AIMS Prognostic factors in Duchenne muscular dystrophy (DMD) predict the disease course and may help individualize patient care. The aim was to summarize the evidence on prognostic factors that may support treatment decisions. METHODS We searched six databases for prospective studies that each included ≥50 DMD patients with a minimum follow-up of 1 y. Primary outcomes were age at loss of ambulation (LoA), pulmonary function (forced vital capacity percent of predicted, FVC%p), and heart failure. RESULTS Out of 5074 references, 59 studies were analyzed. Corticosteroid use was associated with a delayed LoA (pooled effect hazard ratio [HR] 0.42, 95% confidence interval [CI] 0.23-0.75, I2 94%), better pulmonary function tests (higher peak FVC%, prolonged time with FVC%p > 50%, and reduced need for assisted ventilation) and delayed cardiomyopathy. Longer corticosteroid treatment was associated with later LoA (>1 y compared to <1 y; pooled HR: 0.50, 95% CI 0.27-0.90) and early treatment start (aged <5 y) may be associated with early cardiomyopathy and higher fracture risk. Genotype appeared to be an independent driver of LoA in some studies. Higher baseline physical function tests (e.g., 6-minute walk test) were associated with delayed LoA. Left ventricular dysfunction and FVC <1 L increased and the use of angiotensin-converting enzyme (ACE) inhibitors reduced the risk of heart failure and death. Fusion surgery in scoliosis may potentially preserve pulmonary function. DISCUSSION Prognostic factors that may inform clinical decisions include age at corticosteroid treatment initiation and treatment duration, ACE-inhibitor use, baseline physical function tests, pulmonary function, and cardiac dysfunction.
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Affiliation(s)
- Fabio J Weber
- Sleep Disorders Center and Pulmonary Division, University Hospital Zurich, Zurich, Switzerland
| | - Tsogyal D Latshang
- Sleep Disorders Center and Pulmonary Division, University Hospital Zurich, Zurich, Switzerland.,Sleep Disorders Center and Pulmonary Division, Kantonsspital Graubuenden, Chur, Switzerland
| | - Manuel R Blum
- Department of General Internal Medicine, University Hospital Bern, University of Bern, Bern, Switzerland.,Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Malcolm Kohler
- Sleep Disorders Center and Pulmonary Division, University Hospital Zurich, Zurich, Switzerland.,Zurich Center for Interdisciplinary Sleep Research, University of Zurich, Zurich, Switzerland
| | - Maria M Wertli
- Department of General Internal Medicine, University Hospital Bern, University of Bern, Bern, Switzerland.,Department of Internal Medicine, Cantonal Hospital Baden, Baden, Switzerland
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Myxomavirus Serp-1 Protein Ameliorates Inflammation in a Mouse Model of Duchenne Muscular Dystrophy. Biomedicines 2022; 10:biomedicines10051154. [PMID: 35625891 PMCID: PMC9138346 DOI: 10.3390/biomedicines10051154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 05/11/2022] [Accepted: 05/13/2022] [Indexed: 01/27/2023] Open
Abstract
Duchenne muscular dystrophy is an X-linked disease afflicting 1 in 3500 males that is characterized by muscle weakness and wasting during early childhood, and loss of ambulation and death by early adulthood. Chronic inflammation due to myofiber instability leads to fibrosis, which is a primary cause of loss of ambulation and cardiorespiratory insufficiency. Current standard of care focuses on reducing inflammation with corticosteroids, which have serious adverse effects. It is imperative to identify alternate immunosuppressants as treatments to reduce fibrosis and mortality. Serp-1, a Myxoma virus-derived 55 kDa secreted glycoprotein, has proven efficacy in a range of animal models of acute inflammation, and its safety and efficacy has been shown in a clinical trial. In this initial study, we examined whether pegylated Serp-1 (PEGSerp-1) treatment would ameliorate chronic inflammation in a mouse model for Duchenne muscular dystrophy. Our data revealed a significant reduction in diaphragm fibrosis and increased myofiber diameter, and significantly decreased pro-inflammatory M1 macrophage infiltration. The M2a macrophage and overall T cell populations showed no change. These data demonstrate that treatment with this new class of poxvirus-derived immune-modulating serpin has potential as a therapeutic approach designed to ameliorate DMD pathology and facilitate muscle regeneration.
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12
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Landfeldt E, Ferizović N, Buesch K. Timing of Clinical Interventions in Patients With Duchenne Muscular Dystrophy: A Systematic Review and Grading of Evidence. J Neuromuscul Dis 2022; 9:353-364. [DOI: 10.3233/jnd-220804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Clinical medical management guidelines of Duchenne muscular dystrophy (DMD) emphasize prevention and early identification and treatment. Objective: The objective of our study was to review, synthesize, and grade published evidence of the impact of the timing of clinical interventions in DMD. Methods: We searched PubMed, Embase, and the Cochrane Library for records published from inception up until November 19, 2021, reporting evidence of the impact of the timing of clinical interventions in DMD. We assessed the quality of evidence using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) framework. Results: We included 12 publications encompassing 1,623 patients with DMD from seven countries (Australia, France, Germany, Italy, Japan, the United Kingdom, and the United States of America). Six (50%) studies reported evidence of an impact of the timing of initiation of glucocorticoids on loss of ambulation, cardiomyopathy, fractures, forced vital capacity, and height and BMI; four (33%) of cardiac medication (i.e., angiotensin-converting enzyme inhibitors, β-blockers, and eplerenone) on left ventricular size and function and survival; one (8%) of lower limb surgery on motor quotient and loss of ambulation; and one (8%) of ataluren on lower extremity and motor function. The overall quality of the body of evidence was low. Conclusion: While there is a clinical rationale for anticipatory diagnostic and therapeutic strategies, evidence of the impact of the timing of initiation of treatments in patients with DMD is still emerging. Further research of this topic is warranted to inform treatment guidelines in this indication.
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Affiliation(s)
| | | | - K. Buesch
- PTC Therapeutics Switzerland GmbH, Zug, Switzerland
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13
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Ferizovic N, Summers J, de Zárate IBO, Werner C, Jiang J, Landfeldt E, Buesch K. Prognostic indicators of disease progression in Duchenne muscular dystrophy: A literature review and evidence synthesis. PLoS One 2022; 17:e0265879. [PMID: 35333888 PMCID: PMC8956179 DOI: 10.1371/journal.pone.0265879] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 03/09/2022] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Duchenne muscular dystrophy (DMD) is a rare, severely debilitating, and fatal neuromuscular disease characterized by progressive muscle degeneration. Like in many orphan diseases, randomized controlled trials are uncommon in DMD, resulting in the need to indirectly compare treatment effects, for example by pooling individual patient-level data from multiple sources. However, to derive reliable estimates, it is necessary to ensure that the samples considered are comparable with respect to factors significantly affecting the clinical progression of the disease. To help inform such analyses, the objective of this study was to review and synthesise published evidence of prognostic indicators of disease progression in DMD. We searched MEDLINE (via Ovid), Embase (via Ovid) and the Cochrane Library (via Wiley) for records published from inception up until April 23 2021, reporting evidence of prognostic indicators of disease progression in DMD. Risk of bias was established with the grading system of the Centre for Evidence-Based Medicine (CEBM). RESULTS Our search included 135 studies involving 25,610 patients from 18 countries across six continents (Africa, Asia, Australia, Europe, North America and South America). We identified a total of 23 prognostic indicators of disease progression in DMD, namely age at diagnosis, age at onset of symptoms, ataluren treatment, ATL1102, BMI, cardiac medication, DMD genetic modifiers, DMD mutation type, drisapersen, edasalonexent, eteplirsen, glucocorticoid exposure, height, idebenone, lower limb surgery, orthoses, oxandrolone, spinal surgery, TAS-205, vamorolone, vitlolarsen, ventilation support, and weight. Of these, cardiac medication, DMD genetic modifiers, DMD mutation type, and glucocorticoid exposure were designated core prognostic indicators, each supported by a high level of evidence and significantly affecting a wide range of clinical outcomes. CONCLUSION This study provides a current summary of prognostic indicators of disease progression in DMD, which will help inform the design of comparative analyses and future data collection initiatives in this patient population.
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Affiliation(s)
- Nermina Ferizovic
- MAP BioPharma Ltd, Cambridge, England, United Kingdom
- BresMed Health Solutions, Sheffield, England, United Kingdom
| | | | | | | | - Joel Jiang
- PTC Therapeutics, South Plainfield, New Jersey, United States of America
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Matsuzaka Y, Hirai Y, Hashido K, Okada T. Therapeutic Application of Extracellular Vesicles-Capsulated Adeno-Associated Virus Vector via nSMase2/Smpd3, Satellite, and Immune Cells in Duchenne Muscular Dystrophy. Int J Mol Sci 2022; 23:1551. [PMID: 35163475 PMCID: PMC8836108 DOI: 10.3390/ijms23031551] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 01/21/2022] [Accepted: 01/25/2022] [Indexed: 02/04/2023] Open
Abstract
Duchenne muscular dystrophy (DMD) is caused by loss-of-function mutations in the dystrophin gene on chromosome Xp21. Disruption of the dystrophin-glycoprotein complex (DGC) on the cell membrane causes cytosolic Ca2+ influx, resulting in protease activation, mitochondrial dysfunction, and progressive myofiber degeneration, leading to muscle wasting and fragility. In addition to the function of dystrophin in the structural integrity of myofibers, a novel function of asymmetric cell division in muscular stem cells (satellite cells) has been reported. Therefore, it has been suggested that myofiber instability may not be the only cause of dystrophic degeneration, but rather that the phenotype might be caused by multiple factors, including stem cell and myofiber functions. Furthermore, it has been focused functional regulation of satellite cells by intracellular communication of extracellular vesicles (EVs) in DMD pathology. Recently, a novel molecular mechanism of DMD pathogenesis-circulating RNA molecules-has been revealed through the study of target pathways modulated by the Neutral sphingomyelinase2/Neutral sphingomyelinase3 (nSMase2/Smpd3) protein. In addition, adeno-associated virus (AAV) has been clinically applied for DMD therapy owing to the safety and long-term expression of transduction genes. Furthermore, the EV-capsulated AAV vector (EV-AAV) has been shown to be a useful tool for the intervention of DMD, because of the high efficacy of the transgene and avoidance of neutralizing antibodies. Thus, we review application of AAV and EV-AAV vectors for DMD as novel therapeutic strategy.
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Affiliation(s)
- Yasunari Matsuzaka
- Division of Molecular and Medical Genetics, Center for Gene and Cell Therapy, The Institute of Medical Science, University of Tokyo, Minato-ku, Tokyo 108-8639, Japan;
- Administrative Section of Radiation Protection, National Institute of Neuroscience, National Center of Neurology and Psychiatry, Kodaira, Tokyo 187-8551, Japan;
| | - Yukihiko Hirai
- Division of Molecular and Medical Genetics, Center for Gene and Cell Therapy, The Institute of Medical Science, University of Tokyo, Minato-ku, Tokyo 108-8639, Japan;
| | - Kazuo Hashido
- Administrative Section of Radiation Protection, National Institute of Neuroscience, National Center of Neurology and Psychiatry, Kodaira, Tokyo 187-8551, Japan;
| | - Takashi Okada
- Division of Molecular and Medical Genetics, Center for Gene and Cell Therapy, The Institute of Medical Science, University of Tokyo, Minato-ku, Tokyo 108-8639, Japan;
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15
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Mah JK, Clemens PR, Guglieri M, Smith EC, Finkel RS, Tulinius M, Nevo Y, Ryan MM, Webster R, Castro D, Kuntz NL, McDonald CM, Damsker JM, Schwartz BD, Mengle-Gaw LJ, Jackowski S, Stimpson G, Ridout DA, Ayyar-Gupta V, Baranello G, Manzur AY, Muntoni F, Gordish-Dressman H, Leinonen M, Ward LM, Hoffman EP, Dang UJ. Efficacy and Safety of Vamorolone in Duchenne Muscular Dystrophy: A 30-Month Nonrandomized Controlled Open-Label Extension Trial. JAMA Netw Open 2022; 5:e2144178. [PMID: 35076703 PMCID: PMC8790668 DOI: 10.1001/jamanetworkopen.2021.44178] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
IMPORTANCE Vamorolone is a synthetic steroidal drug with potent anti-inflammatory properties. Initial open-label, multiple ascending dose-finding studies of vamorolone among boys with Duchenne muscular dystrophy (DMD) found significant motor function improvement after 6 months treatment in higher-dose (ie, ≥2.0 mg/kg/d) groups. OBJECTIVE To investigate outcomes after 30 months of open-label vamorolone treatment. DESIGN, SETTING, AND PARTICIPANTS This nonrandomized controlled trial was conducted by the Cooperative International Neuromuscular Research Group at 11 US and non-US study sites. Participants were 46 boys ages 4.5 to 7.5 years with DMD who completed the 6-month dose-finding study. Data were analyzed from July 2020 through November 2021. INTERVENTIONS Participants were enrolled in a 24-month, long-term extension (LTE) study with vamorolone dose escalated to 2.0 or 6.0 mg/kg/d. MAIN OUTCOMES AND MEASURES Change in time-to-stand (TTSTAND) velocity from dose-finding baseline to end of LTE study was the primary outcome. Efficacy assessments included timed function tests, 6-minute walk test, and NorthStar Ambulatory Assessment (NSAA). Participants with DMD treated with glucocorticoids from the Duchenne Natural History Study (DNHS) and NorthStar United Kingdom (NSUK) Network were matched and compared with participants in the LTE study receiving higher doses of vamorolone. RESULTS Among 46 boys with DMD who completed the dose-finding study, 41 boys (mean [SD] age, 5.33 [0.96] years) completed the LTE study. Among 21 participants treated with higher-dose (ie, ≥2.0 mg/kg/d) vamorolone consistently throughout the 6-month dose-finding and 24-month LTE studies with data available at 30 months, there was a decrease in mean (SD) TTSTAND velocity from baseline to 30 months (0.206 [0.070] rises/s vs 0.189 (0.124) rises/s), which was not a statistically significant change (-0.011 rises/s; CI, -0.068 to 0.046 rises/s). There were no statistically significant differences between participants receiving higher-dose vamorolone and matched participants in the historical control groups receiving glucocorticoid treatment (75 patients in DNHS and 110 patients in NSUK) over a 2-year period in NSAA total score change (0.22 units vs NSUK; 95% CI, -4.48 to 4.04]; P = .92), body mass index z score change (0.002 vs DNHS SD/mo; 95% CI, -0.006 to 0.010; P = .58), or timed function test change. Vamorolone at doses up to 6.0 mg/kg/d was well tolerated, with 5 of 46 participants discontinuing prematurely and for reasons not associated with study drug. Participants in the DNHS treated with glucocorticoids had significant growth delay in comparison with participants treated with vamorolone who had stable height percentiles (0.37 percentile/mo; 95% CI, 0.23 to 0.52 percentile/mo) over time. CONCLUSIONS AND RELEVANCE This study found that vamorolone treatment was not associated with a change in TTSTAND velocity from baseline to 30 months among boys with DMD aged 4 to 7 years at enrollment. Vamorolone was associated with maintenance of muscle strength and function up to 30 months, similar to standard of care glucocorticoid therapy, and improved height velocity compared with growth deceleration associated with glucocorticoid treatment, suggesting that vamorolone may be an attractive candidate for treatment of DMD. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03038399.
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Affiliation(s)
- Jean K. Mah
- Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, Canada
| | - Paula R. Clemens
- University of Pittsburgh and Department of Veterans Affairs Medical Center, Pittsburgh, Pennsylvania
| | - Michela Guglieri
- John Walton Muscular Dystrophy Research Centre, Newcastle University, Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | | | - Richard S. Finkel
- Nemours Children’s Hospital, Orlando, Florida
- St. Jude Children’s Research Hospital, Memphis, Tennessee
| | - Mar Tulinius
- Queen Silvia Children’s Hospital, Gothenburg, Sweden
| | - Yoram Nevo
- Schneider Children’s Medical Center of Israel, Tel Aviv University, Petah Tikvah, Israel
| | - Monique M. Ryan
- Royal Children’s Hospital and Murdoch Children’s Research Institute, Melbourne, Australia
| | | | | | - Nancy L. Kuntz
- Ann and Robert H. Lurie Children’s Hospital, Chicago, Illinois
| | | | | | | | | | - Stefan Jackowski
- Children’s Hospital of Eastern Ontario, Ottawa, Ontario, Canada
- University of Saskatchewan, Saskatoon, Canada
| | - Georgia Stimpson
- Dubowitz Neuromuscular Centre, University College London Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Deborah A. Ridout
- Dubowitz Neuromuscular Centre, University College London Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Vandana Ayyar-Gupta
- Dubowitz Neuromuscular Centre, University College London Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Giovanni Baranello
- Dubowitz Neuromuscular Centre, University College London Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Adnan Y. Manzur
- Dubowitz Neuromuscular Centre, University College London Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Francesco Muntoni
- Dubowitz Neuromuscular Centre, University College London Great Ormond Street Institute of Child Health, London, United Kingdom
| | | | | | - Leanne M. Ward
- Children’s Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Eric P. Hoffman
- ReveraGen BioPharma, Rockville, Maryland
- Binghamton University-State University of New York, Binghamton
| | - Utkarsh J. Dang
- Binghamton University-State University of New York, Binghamton
- Carleton University, Ottawa, Canada
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16
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Klimchak AC, Szabo SM, Qian C, Popoff E, Iannaccone S, Gooch KL. Characterizing demographics, comorbidities, and costs of care among populations with Duchenne muscular dystrophy with Medicaid and commercial coverage. J Manag Care Spec Pharm 2021; 27:1426-1437. [PMID: 34595954 PMCID: PMC10391028 DOI: 10.18553/jmcp.2021.27.10.1426] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND: Duchenne muscular dystrophy (DMD) is a severe X-linked progressive neurodegenerative disease characterized by loss of ambulation, cardiomyopathy, respiratory insufficiency, and early mortality. Few data are available that describe the direct medical costs among patients with DMD in the United States. OBJECTIVE: To characterize the demographics, comorbidity burden, and direct monthly costs of care among patients with DMD with Medicaid and with commercial insurance coverage. METHODS: IBM MarketScan Commercial and Multi-State Medicaid claims (2013-2018) were used to identify males aged 30 years or under with diagnostic codes for muscular dystrophy or DMD; additional exclusion criteria were applied to identify those with probable DMD. Baseline characteristics and comorbidities were tabulated. The frequency of health care resource use and median (interquartile range [IQR]) monthly costs (in 2018 USD) were estimated from those with at least 12 months of continuous follow-up. RESULTS: Median (IQR) baseline ages were similar between the Medicaid (14 [9-20] years; n = 2,007) and commercial (15 [9-21] years; n = 1,964) DMD cohorts. The frequency of comorbidities over the period was slightly higher with those on Medicaid. The median duration of follow-up was 3.1 years among members of the Medicaid DMD cohort and 1.7 years among the commercial DMD cohort. Median monthly resource use was generally higher among the Medicaid DMD cohort; nonetheless, median (IQR) monthly costs were similar at $1,735 ($367-$5,281) for the Medicaid DMD cohort vs $1,883 ($657-$6,796) for the commercial DMD cohort. CONCLUSIONS: The demographic characteristics and median direct medical costs were similar between patients with commercial vs Medicaid coverage, even though patients with Medicaid coverage had higher resource use. Despite challenges in definitively identifying DMD patients using claims data, these findings help characterize contemporary DMD populations in the United States and the related direct economic burden to the payer. DISCLOSURES: This study was funded by Sarepta Therapeutics, Inc. Klimchak and Gooch are employees of Sarepta Therapeutics Inc. Szabo, Qian, and Popoff are employees of Broadstreet HEOR, which received funds from Sarepta Therapeutics, Inc., for work on this study. Iannaccone has received research funding or consulting fees from Avexis, Biogen, Fibrogen, Mallinkrodt, Regeneron, Sarepta Therapeutics, Inc., Scholar Rock, PTC Therapeutics, Pfizer, MDA, CureSMA, NIH, Genentech-Roche, and BCBS. Publication of the study results was not contingent on the sponsor's approval or censorship of the manuscript. Information from this study was presented, in part, at the AMCP Virtual Annual Meeting, April 21-24, 2020.
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Affiliation(s)
| | | | | | | | - Susan Iannaccone
- Children's Medical Center Ambulatory Care Pavilion, University of Texas Southwestern Medical Center, Dallas
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17
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Szabo SM, Salhany RM, Deighton A, Harwood M, Mah J, Gooch KL. The clinical course of Duchenne muscular dystrophy in the corticosteroid treatment era: a systematic literature review. Orphanet J Rare Dis 2021; 16:237. [PMID: 34022943 PMCID: PMC8141220 DOI: 10.1186/s13023-021-01862-w] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 05/10/2021] [Indexed: 12/19/2022] Open
Abstract
Background Duchenne muscular dystrophy (DMD) is a severe rare progressive inherited neuromuscular disorder, leading to loss of ambulation (LOA) and premature mortality. The standard of care for patients with DMD has been treatment with corticosteroids for the past decade; however a synthesis of contemporary data describing the clinical course of DMD is lacking. The objective was to summarize age at key clinical milestones (loss of ambulation, scoliosis, ventilation, cardiomyopathy, and mortality) in the corticosteroid-treatment-era. Methods A systematic review was conducted using MEDLINE and EMBASE. The percentage experiencing key clinical milestones, and the mean or median age at those milestones, was synthesized from studies from North American populations, published between 2007 and 2018. Results From 5637 abstracts, 29 studies were included. Estimates of the percentage experiencing key clinical milestones, and age at those milestones, showed heterogeneity. Up to 30% of patients lost ambulation by age 10 years, and up to 90% by 15 years of age. The mean age at scoliosis onset was approximately 14 years. Ventilatory support began from 15 to 18 years, and up to half of patients required ventilation by 20 years of age. Registry-based estimates suggest that 70% had evidence of cardiomyopathy by 15 years and almost all by 20 years of age. Finally, mortality rates up to 16% by age 20 years were reported; among those surviving to adulthood mortality was up to 60% by age 30 years. Conclusions Contemporary natural history studies from North America report that LOA on average occurs in the early teens, need for ventilation and cardiomyopathy in the late teens, and death in the third or fourth decade of life. Variability in rates may be due to differences in study design, treatment with corticosteroids or other disease-modifying agents, variations in clinical practices, and dystrophin mutations. Despite challenges in synthesizing estimates, these findings help characterize disease progression among contemporary North American DMD patients. Supplementary Information The online version contains supplementary material available at 10.1186/s13023-021-01862-w.
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Affiliation(s)
- Shelagh M Szabo
- Broadstreet HEOR, 201 - 343 Railway St, Vancouver, BC, V6A 1A4, Canada.
| | - Renna M Salhany
- Sarepta Therapeutics, 215 First St, Cambridge, MA, 02142, USA
| | - Alison Deighton
- Broadstreet HEOR, 201 - 343 Railway St, Vancouver, BC, V6A 1A4, Canada
| | - Meagan Harwood
- Broadstreet HEOR, 201 - 343 Railway St, Vancouver, BC, V6A 1A4, Canada
| | - Jean Mah
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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18
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Kourakis S, Timpani CA, Campelj DG, Hafner P, Gueven N, Fischer D, Rybalka E. Standard of care versus new-wave corticosteroids in the treatment of Duchenne muscular dystrophy: Can we do better? Orphanet J Rare Dis 2021; 16:117. [PMID: 33663533 PMCID: PMC7934375 DOI: 10.1186/s13023-021-01758-9] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 02/18/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Pharmacological corticosteroid therapy is the standard of care in Duchenne Muscular Dystrophy (DMD) that aims to control symptoms and slow disease progression through potent anti-inflammatory action. However, a major concern is the significant adverse effects associated with long term-use. MAIN: This review discusses the pros and cons of standard of care treatment for DMD and compares it to novel data generated with the new-wave dissociative corticosteroid, vamorolone. The current status of experimental anti-inflammatory pharmaceuticals is also reviewed, with insights regarding alternative drugs that could provide therapeutic advantage. CONCLUSIONS Although novel dissociative steroids may be superior substitutes to corticosteroids, other potential therapeutics should be explored. Repurposing or developing novel pharmacological therapies capable of addressing the many pathogenic features of DMD in addition to anti-inflammation could elicit greater therapeutic advantages.
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Affiliation(s)
- Stephanie Kourakis
- Institute for Health and Sport (IHeS), Victoria University, Melbourne, VIC, Australia
| | - Cara A Timpani
- Institute for Health and Sport (IHeS), Victoria University, Melbourne, VIC, Australia.,Australian Institute for Musculoskeletal Science (AIMSS), St Albans, VIC, Australia
| | - Dean G Campelj
- Institute for Health and Sport (IHeS), Victoria University, Melbourne, VIC, Australia.,Australian Institute for Musculoskeletal Science (AIMSS), St Albans, VIC, Australia
| | - Patricia Hafner
- Division of Neuropediatrics and Developmental Medicine, University Children's Hospital of Basel (UKBB), Basel, Switzerland
| | - Nuri Gueven
- School of Pharmacy and Pharmacology, University of Tasmania, Hobart, TAS, Australia
| | - Dirk Fischer
- Division of Neuropediatrics and Developmental Medicine, University Children's Hospital of Basel (UKBB), Basel, Switzerland
| | - Emma Rybalka
- Institute for Health and Sport (IHeS), Victoria University, Melbourne, VIC, Australia. .,Australian Institute for Musculoskeletal Science (AIMSS), St Albans, VIC, Australia.
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19
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Sussman MD, Sienko SE, Buckon CE, Hilton C, De Mattos CB, d’Amato C. Efficacy of corticosteroid in decreasing scoliosis and extending time to loss of ambulation in a single clinic: an effectiveness trial. J Child Orthop 2020; 14:421-432. [PMID: 33204350 PMCID: PMC7666798 DOI: 10.1302/1863-2548.14.200156] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
PURPOSE Pharmacologic doses of corticosteroid (CS) have been shown to ameliorate the progression of Duchenne muscular dystrophy (DMD) preserving strength, pulmonary function and ambulation as well as reducing the incidence of scoliosis. However, there are serious side effects of CS, which may impact dose tolerance. The purpose of this study was to compare the magnitude of positive CS effects on patients in our clinic to those reported in the literature. METHODS We retrospectively reviewed medical records and radiographs of 142 DMD patients who were seen between 1st January 1991 and 31st December 2017. RESULTS In total, 101 boys met study inclusion criteria. Of these 32 were steroid naïve, 37 took the recommended dose (standard of care, SOC) of Prednisone or Deflazacort, and 32 took a lower dose (LD). Following initiation of CS, both treatment groups showed an increase in weight velocity and decrease in linear growth velocity. Although there was a trend to later loss of ambulation (LOA) in the SOC group relative to the naïve group by one year, this was not significant, however, a small subgroup of boys on Deflazacort showed a 3.4 year later LOA than the naïve group. The incidence of scoliosis was reduced from 69% in the naïve, to 41% in the LD and 47% in the SOC group. CONCLUSIONS Although there was a reduction in the incidence of scoliosis, it was not as robust as seen elsewhere. Many published studies have inadequate data on scoliosis probably due to the lack of inclusion of orthopaedists in the study group. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Michael D. Sussman
- Department of Orthopaedic Surgery, Shriners Hospital for Children, Portland, Oregon, USA,Correspondence should be sent to Michael D. Sussman, Shriners Hospitals for Children, 3101 SW Sam Jackson Park Road, Portland, OR 97239-3009, USA. E-mail:
| | - Susan E. Sienko
- Department of Clinical Research, Shriners Hospital for Children, Portland, Oregon, USA
| | - Cathleen E. Buckon
- Department of Clinical Research, Shriners Hospital for Children, Portland, Oregon, USA
| | - Coleman Hilton
- Department of Clinical Research, Shriners Hospital for Children, Portland, Oregon, USA
| | | | - Charles d’Amato
- Department of Orthopaedic Surgery, Shriners Hospital for Children, Portland, Oregon, USA
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20
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Waldrop MA, Yaou RB, Lucas KK, Martin AS, O’Rourke E, Ferlini A, Muntoni F, Leturcq F, Tuffery-Giraud S, Weiss RB, Flanigan KM. Clinical Phenotypes of DMD Exon 51 Skip Equivalent Deletions: A Systematic Review. J Neuromuscul Dis 2020; 7:217-229. [PMID: 32417793 DOI: 10.3233/jnd-200483] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Eteplirsen, the first FDA-approved RNA-modifying therapy for DMD, is applicable to ∼13% of patients with DMD. Because multiple exonic deletions are amenable to exon 51 skipping, the isoforms resulting from the various exon 51-skipped transcripts may vary in stability, function, and phenotype. OBJECTIVE/METHODS We conducted a detailed review of dystrophinopathy published literature and unpublished databases to compile phenotypic features of patients with exon 51 "skip-equivalent" deletions. RESULTS Theoretically, 48 different in-frame transcripts may result from exon 51 skipping. We found sufficient clinical information on 135 patients carrying mutations that would result in production of 11 (23%) of these transcripts, suggesting the remainder have not been identified in vivo. The majority had mild phenotypes: BMD (n = 81) or isolated dilated cardiomyopathy (n = 3). Particularly interesting are the asymptomatic (n = 10) or isolated hyperCKemia (n = 20) patients with deletions of exons 45- 51, 48- 51, 49- 51 and 50- 51. Finally, 16 (12%) had more severe phenotypes described as intermediate (n = 2) or DMD (n = 14), and 6 reports had no definitive phenotype. CONCLUSIONS This review shows that the majority of exon 51 "skip-equivalent" deletions result in milder (BMD) phenotypes and supports that exon 51 skipping therapy could provide clinical benefit, although we acknowledge that other factors, such as age at treatment initiation or ongoing standard of care, may influence the degree of benefit.
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Affiliation(s)
- Megan A. Waldrop
- The Center for Gene Therapy, Nationwide Children’s Hospital, Columbus, OH, USA
- Departments of Neurology and Pediatrics, The Ohio State University, Columbus, OH, USA
| | - Rabah Ben Yaou
- Center of Research in Myology, Sorbonne Université - Inserm UMRS 974; Databases unit; APHP, Nord/Est/Ile-de-France Neuromuscular reference center, Institut de Myologie, Hôpital Pitié-Salpêtrière, Paris, France
| | | | - Ann S. Martin
- Parent Project Muscular Dystrophy, Hackensack, NJ, USA
| | | | | | - Francesco Muntoni
- Dubowitz Neuromuscular Centre, Molecular Neurosciences Section, Developmental Neuroscience Programme, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
- NIHR Great Ormond Street Hospital Biomedical Research Centre, London, United Kingdom
| | - France Leturcq
- APHP, Laboratoire de Génétique et Biologie Moléculaires, HUPC Hôpital Cochin, Paris, France; Center of Research in Myology, Sorbonne Université - Inserm UMRS 974
| | - Sylvie Tuffery-Giraud
- Université de Montpellier, Laboratoire de Génétique de Maladies Rares, Montpellier, France
| | - Robert B. Weiss
- Department of Human Genetics, The University of Utah, Salt Lake City, UT, USA
| | - Kevin M. Flanigan
- The Center for Gene Therapy, Nationwide Children’s Hospital, Columbus, OH, USA
- Departments of Neurology and Pediatrics, The Ohio State University, Columbus, OH, USA
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21
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Kim MJ, Bible KL, Regnier M, Adams ME, Froehner SC, Whitehead NP. Simvastatin provides long-term improvement of left ventricular function and prevents cardiac fibrosis in muscular dystrophy. Physiol Rep 2020; 7:e14018. [PMID: 30912308 PMCID: PMC6434171 DOI: 10.14814/phy2.14018] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Revised: 01/23/2019] [Accepted: 01/28/2019] [Indexed: 11/24/2022] Open
Abstract
Duchenne muscular dystrophy (DMD), caused by absence of the protein dystrophin, is a common, degenerative muscle disease affecting 1:5000 males worldwide. With recent advances in respiratory care, cardiac dysfunction now accounts for 50% of mortality in DMD. Recently, we demonstrated that simvastatin substantially improved skeletal muscle health and function in mdx (DMD) mice. Given the known cardiovascular benefits ascribed to statins, the aim of this study was to evaluate the efficacy of simvastatin on cardiac function in mdx mice. Remarkably, in 12‐month old mdx mice, simvastatin reversed diastolic dysfunction to normal after short‐term treatment (8 weeks), as measured by echocardiography in animals anesthetized with isoflurane and administered dobutamine to maintain a physiological heart rate. This improvement in diastolic function was accompanied by increased phospholamban phosphorylation in simvastatin‐treated mice. Echocardiography measurements during long‐term treatment, from 6 months up to 18 months of age, showed that simvastatin significantly improved in vivo cardiac function compared to untreated mdx mice, and prevented fibrosis in these very old animals. Cardiac dysfunction in DMD is also characterized by decreased heart rate variability (HRV), which indicates autonomic function dysregulation. Therefore, we measured cardiac ECG and demonstrated that short‐term simvastatin treatment significantly increased heart rate variability (HRV) in 14‐month‐old conscious mdx mice, which was reversed by atropine. This finding suggests that enhanced parasympathetic function is likely responsible for the improved HRV mediated by simvastatin. Together, these findings indicate that simvastatin markedly improves cardiac health and function in dystrophic mice, and therefore may provide a novel approach for treating cardiomyopathy in DMD.
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Affiliation(s)
- Min J Kim
- Department of Physiology & Biophysics, University of Washington, Seattle, Washington
| | - Kenneth L Bible
- Department of Physiology & Biophysics, University of Washington, Seattle, Washington
| | - Michael Regnier
- Department of Bioengineering, University of Washington, Seattle, Washington
| | - Marvin E Adams
- Department of Physiology & Biophysics, University of Washington, Seattle, Washington
| | - Stanley C Froehner
- Department of Physiology & Biophysics, University of Washington, Seattle, Washington
| | - Nicholas P Whitehead
- Department of Physiology & Biophysics, University of Washington, Seattle, Washington
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22
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Wittlieb‑Weber CA, Knecht KR, Villa CR, Cunningham C, Conway J, Bock MJ, Gambetta KE, Lal AK, Schumacher KR, Law SP, Deshpande SR, West SC, Friedland‑Little JM, Lytrivi ID, McCulloch MA, Butts RJ, Weber DR, Johnson JN. Risk Factors for Cardiac and Non-cardiac Causes of Death in Males with Duchenne Muscular Dystrophy. Pediatr Cardiol 2020; 41:764-771. [PMID: 32016582 PMCID: PMC7328368 DOI: 10.1007/s00246-020-02309-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 01/22/2020] [Indexed: 01/14/2023]
Abstract
As survival and neuromuscular function in Duchenne muscular dystrophy (DMD) have improved with glucocorticoid (GC) therapy and ventilatory support, cardiac deaths are increasing. Little is known about risk factors for cardiac and non-cardiac causes of death in DMD. A multi-center retrospective cohort study of 408 males with DMD, followed from January 1, 2005 to December 31, 2015, was conducted to identify risk factors for death. Those dying of cardiac causes were compared to those dying of non-cardiac causes and to those alive at study end. There were 29 (7.1%) deaths at a median age of 19.5 (IQR: 16.9-24.6) years; 8 (27.6%) cardiac, and 21 non-cardiac. Those living were younger [14.9 (IQR: 11.0-19.1) years] than those dying of cardiac [18 (IQR 15.5-24) years, p = 0.03] and non-cardiac [19 (IQR: 16.5-23) years, p = 0.002] causes. GC use was lower for those dying of cardiac causes compared to those living [2/8 (25%) vs. 304/378 (80.4%), p = 0.001]. Last ejection fraction prior to death/study end was lower for those dying of cardiac causes compared to those living (37.5% ± 12.8 vs. 54.5% ± 10.8, p = 0.01) but not compared to those dying of non-cardiac causes (37.5% ± 12.8 vs. 41.2% ± 19.3, p = 0.58). In a large DMD cohort, approximately 30% of deaths were cardiac. Lack of GC use was associated with cardiac causes of death, while systolic dysfunction was associated with death from any cause. Further work is needed to ensure guideline adherence and to define optimal management of systolic dysfunction in males with DMD with hopes of extending survival.
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Affiliation(s)
- Carol A. Wittlieb‑Weber
- Golisano Children’s Hospital, University of Rochester Medical Center, Rochester, NY, USA,Present Address: Division of Cardiology, The Children’s Hospital of Philadelphia, 34th and Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - Kenneth R. Knecht
- Arkansas Children’s Hospital, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Chet R. Villa
- The Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Chentel Cunningham
- Stollery Children’s Hospital, University of Alberta, Edmonton, AB, Canada
| | - Jennifer Conway
- Stollery Children’s Hospital, University of Alberta, Edmonton, AB, Canada
| | - Matthew J. Bock
- Loma Linda University Children’s Hospital, Loma Linda, CA, USA
| | - Katheryn E. Gambetta
- Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Ashwin K. Lal
- Primary Children’s Hospital, University of Utah, Salt Lake City, UT, USA
| | - Kurt R. Schumacher
- C.S. Mott Children’s Hospital, University of Michigan, Ann Arbor, MI, USA
| | - Sabrina P. Law
- Morgan Stanley Children’s Hospital of New York Presbyterian, New York, NY, USA
| | | | - Shawn C. West
- Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA
| | | | - Irene D. Lytrivi
- Morgan Stanley Children’s Hospital of New York Presbyterian, New York, NY, USA
| | | | - Ryan J. Butts
- Children’s Medical Center of Dallas, UT Southwestern Medical Center, Dallas, TX, USA
| | - David R. Weber
- Golisano Children’s Hospital, University of Rochester Medical Center, Rochester, NY, USA
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23
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Fang XB, Song ZB, Xie MS, Liu YM, Zhang WX. Synergistic effect of glucocorticoids and IGF-1 on myogenic differentiation through the Akt/GSK-3β pathway in C2C12 myoblasts. Int J Neurosci 2020; 130:1125-1135. [PMID: 32070170 DOI: 10.1080/00207454.2020.1730367] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Purpose: Glucocorticoids are the only therapeutics that can delay the progression of Duchenne musculardystrophy (DMD), the most prevalent type of inherited neuromuscular disorder in males. However, beyond theiranti-inflammatory effects, glucocorticoids have other underlying mechanisms that remain unclear. Moreover, muscleand circulating levels of insulin growth factor-1 (IGF-1) often decrease in response to glucocorticoids. Therefore, wehypothesized that glucocorticoids, either alone or in combination with IGF-1, can improve myogenic differentiation.Materials and methods: Established C2C12 myoblasts were employed as an in vitro model of myogenic differentiation,and myogenic differentiation markers, as assessed by Western blot (myogenin, MyoD, and MyHC protein expression),cellular morphology analysis (fusion index) and RT-PCR (MCK mRNA expression), were measured.Results: Myogenic differentiation markers were increased by glucocorticoid treatment. Furthermore, this effect was furtherenhanced by IGF-1, and these results suggest that glucocorticoids, either alone or together with IGF-1, can promotemyogenic differentiation. Akt and GSK-3β play important roles in myogenic differentiation. Interestingly, the levels ofboth phosphorylated Ser473-Akt and phosphorylated Ser9-GSK-3β were increased by glucocorticoid and IGF-1 cotreatment.Pharmacological manipulation with LY294002 and LiCl was employed to inhibit Akt and GSK-3β, respectively.We found that cellular differentiability was inhibited by LY294002 and enhanced by LiCl, indicating that theAkt/GSK-3β signaling pathway is activated by glucocorticoid and IGF-1 treatment to promote myogenic differentiation.Conclusions: Glucocorticoids together with IGF-1 promote myogenic differentiation through the Akt/GSK-3βpathway. Thus, these results further our knowledge of myogenic differentiation and may offer a potential alternativestrategy for DMD treatment based on glucocorticoid and IGF-1.
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Affiliation(s)
- Xiao-Bo Fang
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Zu-Biao Song
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Meng-Shu Xie
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Yan-Mei Liu
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Wei-Xi Zhang
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
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24
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Finanger E, Vandenborne K, Finkel RS, Lee Sweeney H, Tennekoon G, Yum S, Mancini M, Bista P, Nichols A, Liu H, Fretzen A, Donovan JM. Phase 1 Study of Edasalonexent (CAT-1004), an Oral NF-κB Inhibitor, in Pediatric Patients with Duchenne Muscular Dystrophy. J Neuromuscul Dis 2020; 6:43-54. [PMID: 30452422 PMCID: PMC6398836 DOI: 10.3233/jnd-180341] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Background: Edasalonexent is an orally administered small molecule designed to inhibit NF-κB, which is activated from infancy in Duchenne muscular dystrophy and is central to causing muscle damage and preventing muscle regeneration. Objective: Evaluate the safety, tolerability, pharmacokinetics and exploratory pharmacodynamics of three doses of edasalonexent in ambulatory males ≥4 to <8 years of age with genetically confirmed Duchenne muscular dystrophy. Methods: This was a 1-week, open-label, multiple-dose study with 3 sequential ascending doses (33, 67 and 100 mg/kg/day) of edasalonexent administered under different dietary conditions to 17 males with a mean age of 5.5 years. Results: All doses of edasalonexent were well tolerated, with no serious adverse events, no drug discontinuations and no dose reductions. The majority of adverse events were mild, and the most common adverse events were gastrointestinal (primarily diarrhea). Edasalonexent was rapidly absorbed with peak levels observed 2–6 hours after dosing and exposures appeared to increase nearly proportionally to dose for the 2 lower and all 3 doses under low-fat and high-fat meal conditions, respectively. Only minor plasma accumulation of edasalonexent was observed with 7 days of dosing. After treatment with edasalonexent for 7 days, levels of NF-κB-regulated genes and serum proteins were decreased. Conclusions: This first report of edasalonexent oral administration for one week in male pediatric patients with Duchenne muscular dystrophy showed that treatment was well tolerated and inhibited NF-kB pathways.
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Affiliation(s)
- Erika Finanger
- Oregon Health Sciences University Pediatrics, Portland, OR, USA
| | | | - Richard S Finkel
- Nemours Children's Hospital, Division of Pediatric Neurology, Orlando, FL, USA
| | - H Lee Sweeney
- University of Florida Health Myology Institute, Gainesville, FL, USA
| | - Gihan Tennekoon
- Children's Hospital of Philadelphia Pediatric Neurology, Philadelphia, PA, USA
| | - Sabrina Yum
- Children's Hospital of Philadelphia Pediatric Neurology, Philadelphia, PA, USA
| | | | | | | | - Hanlan Liu
- Catabasis Pharmaceuticals, Inc., Cambridge, MA, USA
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25
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Rogers RG, Fournier M, Sanchez L, Ibrahim AG, Aminzadeh MA, Lewis MI, Marbán E. Disease-modifying bioactivity of intravenous cardiosphere-derived cells and exosomes in mdx mice. JCI Insight 2019; 4:125754. [PMID: 30944252 DOI: 10.1172/jci.insight.125754] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 02/14/2019] [Indexed: 02/05/2023] Open
Abstract
Dystrophin deficiency leads to progressive muscle degeneration in Duchenne muscular dystrophy (DMD) patients. No known cure exists, and standard care relies on the use of antiinflammatory steroids, which are associated with side effects that complicate long-term use. Here, we report that a single intravenous dose of clinical-stage cardiac stromal cells, called cardiosphere-derived cells (CDCs), improves the dystrophic phenotype in mdx mice. CDCs augment cardiac and skeletal muscle function, partially reverse established heart damage, and boost the regenerative capacity of skeletal muscle. We further demonstrate that CDCs work by secreting exosomes, which normalize gene expression at the transcriptome level, and alter cell signaling and biological processes in mdx hearts and skeletal muscle. The work reported here motivated the ongoing HOPE-2 clinical trial of systemic CDC delivery to DMD patients, and identifies exosomes as next-generation cell-free therapeutic candidates for DMD.
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26
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Sahay KM, Smith T, Conway KM, Romitti PA, Lamb MM, Andrews J, Pandya S, Oleszek J, Cunniff C, Valdez R. A Review of MD STAR net's Research Contributions to Pediatric-Onset Dystrophinopathy in the United States; 2002-2017. J Child Neurol 2019; 34:44-53. [PMID: 30345857 PMCID: PMC6444919 DOI: 10.1177/0883073818801704] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Population studies of rare disorders, such as Duchenne and Becker muscular dystrophies (dystrophinopathies), are challenging due to diagnostic delay and heterogeneity in disorder milestones. To address these challenges, the Centers for Disease Control and Prevention established the Muscular Dystrophy Surveillance, Tracking, and Research Network (MD STAR net) in 2002 in the United States. From 2002 to 2012, MD STAR net longitudinally tracked the prevalence, clinical, and health care outcomes of 1054 individuals born from 1982 to 2011 with pediatric-onset dystrophinopathy through medical record abstraction and survey data collection. This article summarizes 31 MD STAR net peer-reviewed publications. MD STAR net provided the first population-based prevalence estimates of childhood-onset dystrophinopathy in the United States. Additional publications provided insights into diagnostic delay, dystrophinopathy-specific growth charts, and health services use. Ongoing population-based surveillance continually improves our understanding of clinical and diagnostic outcomes of rare disorders.
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Affiliation(s)
| | - Tiffany Smith
- Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | - Paul A. Romitti
- Department of Epidemiology, University of Iowa, Iowa City, IA, USA
| | - Molly M. Lamb
- Department of Epidemiology, University of Colorado, Aurora, CO, USA
| | - Jennifer Andrews
- Department of Pediatrics, University of Arizona, Tucson, AZ, USA
| | - Shree Pandya
- Department of Neurology, University of Rochester, Rochester, NY, USA
| | - Joyce Oleszek
- Department of Physical Medicine and Rehabilitation, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, CO, USA
| | | | - Rodolfo Valdez
- Centers for Disease Control and Prevention, National Center for Birth Defects and Developmental Disabilities, DHDD, Rare Disorders and Health Outcomes team, Atlanta, GA, USA
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27
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Hong Y, Wang Y, Zhang Y, Royer JA, Cai B, Mann JR, McDermott S. Risk factors for falls among boys under 18 years with muscular dystrophy. J Pediatr Rehabil Med 2019; 12:3-10. [PMID: 30883368 DOI: 10.3233/prm-170511] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
PURPOSE Studies have shown that children with muscular dystrophy are at increased risk for falls, however there is insufficient information about what predicts the first and subsequent events. The purpose of this study was to describe the experience of injury with emphasis on identifying risk factors for fall-related injuries. METHODS We studied 269 boys with muscular dystrophy describing their injury experience and identifying risk and protective factors associated with 281 non-simultaneous injuries and 127 falls that resulted in Emergency Department visits and/or inpatient hospitalization during the period 1998-2014. We used a Cox model to estimate the predictors of an initial fall and a zero-inflated Poisson model to identify the predictors for the number of falls. RESULTS Falls accounted for the greatest number of injury occurrences; The most frequent injury type was contusion. The factors that were protective for falls were steroid use, wheelchair use, or having a heart condition. Baseline age was negatively associated with the risk of having any fall, but not significantly related to subsequent falls. CONCLUSION Wheelchair use and heart conditions associated with reduced risk of falls likely reflects decreased mobility. Clinicians should help families identify factors associated with falls among those who remain ambulatory.
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Affiliation(s)
- Yuan Hong
- Department of Epidemiology and Biostatistics, University of South Carolina Arnold School of Public Health, Columbia, SC, USA
| | - Yinding Wang
- Department of Epidemiology and Biostatistics, University of South Carolina Arnold School of Public Health, Columbia, SC, USA
| | - Yanan Zhang
- Department of Epidemiology and Biostatistics, University of South Carolina Arnold School of Public Health, Columbia, SC, USA
| | - Julie A Royer
- Division of Research and Statistics, South Carolina Revenue and Fiscal Affairs, Columbia, SC, USA
| | - Bo Cai
- Department of Epidemiology and Biostatistics, University of South Carolina Arnold School of Public Health, Columbia, SC, USA
| | - Joshua R Mann
- Department of Preventive Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - Suzanne McDermott
- Department of Epidemiology and Biostatistics, University of South Carolina Arnold School of Public Health, Columbia, SC, USA
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28
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Lowe J, Kadakia FK, Zins JG, Haupt M, Peczkowski KK, Rastogi N, Floyd KT, Gomez-Sanchez EP, Gomez-Sanchez CE, Elnakish MT, Rafael-Fortney JA, Janssen PML. Mineralocorticoid Receptor Antagonists in Muscular Dystrophy Mice During Aging and Exercise. J Neuromuscul Dis 2018; 5:295-306. [PMID: 30010143 DOI: 10.3233/jnd-180323] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Mineralocorticoid receptor antagonists added to angiotensin converting enzyme inhibitors have shown preclinical efficacy for both skeletal and cardiac muscle outcomes in young sedentary dystrophin-deficient mdx mice also haploinsufficient for utrophin, a Duchenne muscular dystrophy (DMD) model. The mdx genotypic DMD model has mild pathology, making non-curative therapeutic effects difficult to distinguish at baseline. Since the cardiac benefit of mineralocorticoid receptor antagonists has been translated to DMD patients, it is important to optimize potential advantages for skeletal muscle by further defining efficacy parameters. OBJECTIVE We aimed to test whether therapeutic effects of mineralocorticoid receptor antagonists added to angiotensin converting enzyme inhibitors are detectable using three different reported methods of exacerbating the mdx phenotype. METHODS We tested treatment with lisinopril and the mineralocorticoid receptor antagonist spironolactone in: 10 week-old exercised, 1 year-old sedentary, and 5 month-old isoproterenol treated mdx mice and performed comprehensive functional and histological measurements. RESULTS None of the protocols to exacerbate mdx phenotypes resulted in dramatically enhanced pathology and no significant benefit was observed with treatment. CONCLUSIONS Since endogenous mineralocorticoid aldosterone production from immune cells in dystrophic muscle may explain antagonist efficacy, it is likely that these drugs work optimally during the narrow window of peak inflammation in mdx mice. Exercised and aged mdx mice do not display prolific damage and inflammation, likely explaining the absence of continued efficacy of these drugs. Since inflammation is more prevalent in DMD patients, the therapeutic window for mineralocorticoid receptor antagonists in patients may be longer.
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Affiliation(s)
- Jeovanna Lowe
- Department of Physiology & Cell Biology, College of Medicine, The Ohio State University, Columbus, OH, USA
| | - Feni K Kadakia
- Department of Physiology & Cell Biology, College of Medicine, The Ohio State University, Columbus, OH, USA
| | - Jonathan G Zins
- Department of Physiology & Cell Biology, College of Medicine, The Ohio State University, Columbus, OH, USA
| | - Michael Haupt
- Department of Physiology & Cell Biology, College of Medicine, The Ohio State University, Columbus, OH, USA
| | - Kyra K Peczkowski
- Department of Physiology & Cell Biology, College of Medicine, The Ohio State University, Columbus, OH, USA
| | - Neha Rastogi
- Department of Physiology & Cell Biology, College of Medicine, The Ohio State University, Columbus, OH, USA
| | - Kyle T Floyd
- Department of Physiology & Cell Biology, College of Medicine, The Ohio State University, Columbus, OH, USA
| | - Elise P Gomez-Sanchez
- Department of Pharmacology & Toxicology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Celso E Gomez-Sanchez
- Department of Internal Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - Mohammad T Elnakish
- Department of Physiology & Cell Biology, College of Medicine, The Ohio State University, Columbus, OH, USA.,Department of Pharmacology & Toxicology, Faculty of Pharmacy, Helwan University, Cairo, Egypt
| | - Jill A Rafael-Fortney
- Department of Physiology & Cell Biology, College of Medicine, The Ohio State University, Columbus, OH, USA
| | - Paul M L Janssen
- Department of Physiology & Cell Biology, College of Medicine, The Ohio State University, Columbus, OH, USA
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29
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Pandya S, James KA, Westfield C, Thomas S, Fox DJ, Ciafaloni E, Moxley RT. Health profile of a cohort of adults with Duchenne muscular dystrophy. Muscle Nerve 2018; 58:219-223. [PMID: 29543994 DOI: 10.1002/mus.26129] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 03/06/2018] [Accepted: 03/07/2018] [Indexed: 01/08/2023]
Abstract
INTRODUCTION As the Duchenne muscular dystrophy (DMD) population ages, it is essential that we understand the late-stage health profile and provide the appropriate care for this emerging population. METHODS We undertook a descriptive study to document the health profile of a cohort of adults with DMD using data from the Muscular Dystrophy Surveillance Tracking and Research network (MD STARnet). Data included information collected from Arizona, Colorado, Iowa, Georgia, and 12 counties in western New York on individuals born since January 1982 and followed through December 2012. RESULTS In 208 adults with DMD, the number of individuals (N) and median ages (years) at which certain critical milestones were crossed and interventions initiated were as follows: development of cardiomyopathy, N = 145 (16.7); initiation of non-invasive ventilation, N = 99 (18.0); gastrostomy, N = 47 (19.0); and death, N = 59 (21.8). DISCUSSION These population-based data provide critical information about late-stage health profiles among adults with DMD for developing appropriate models of care. Muscle Nerve 58: 219-223, 2018.
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Affiliation(s)
- Shree Pandya
- Department of Neurology, School of Medicine and Dentistry, University of Rochester, Rochester, Box 673, 601 Elmwood Avenue, New York, 14642, USA
| | - Katherine A James
- Colorado School of Public Health, University of Colorado, Aurora Colorado, USA
| | | | - Shiny Thomas
- Bureau of Environmental and Occupational Epidemiology, New York State Department of Health, Albany, New York, USA
| | - Deborah J Fox
- Congenital Malformations Registry, New York State Department of Health, Albany, New York, USA
| | - Emma Ciafaloni
- Department of Neurology, School of Medicine and Dentistry, University of Rochester, Rochester, Box 673, 601 Elmwood Avenue, New York, 14642, USA
| | - Richard T Moxley
- Department of Neurology, School of Medicine and Dentistry, University of Rochester, Rochester, Box 673, 601 Elmwood Avenue, New York, 14642, USA
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