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Kim C, Higgins M, Liu L, Volkova N, Zolin A, Naehrlich L. Effectiveness of lumacaftor/ivacaftor initiation in children with cystic fibrosis aged 2 through 5 years on disease progression: Interim results from an ongoing registry-based study. J Cyst Fibros 2024; 23:436-442. [PMID: 38402082 DOI: 10.1016/j.jcf.2024.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 01/31/2024] [Accepted: 02/09/2024] [Indexed: 02/26/2024]
Abstract
BACKGROUND Lumacaftor/ivacaftor (LUM/IVA) has been shown to be safe and efficacious in people with cystic fibrosis (CF) ≥1 year of age. To assess the impact of early LUM/IVA initiation on CF disease progression, a 6-year observational study leveraging data from existing CF patient registries is being conducted in children with CF homozygous for F508del (F/F genotype) who were aged 2 through 5 years at treatment initiation. Here we present interim results from this study focusing on data from the European CF Society Patient Registry (ECFSPR). METHODS The LUM/IVA cohort included children in the ECFSPR who started LUM/IVA between 15 January 2019 and 31 December 2020. Longitudinal trends in growth parameters, pulmonary exacerbations, hospitalizations, safety outcomes, and other effectiveness outcomes in the LUM/IVA cohort were compared to those in two modulator-naïve cohorts: (i) matched concurrent cohort heterozygous for F508del and a minimal function mutation (F/MF concurrent comparator cohort) and (ii) matched concurrent cohort with the F/F genotype from countries without commercial access to LUM/IVA as of 2020 (F/F concurrent comparator cohort). RESULTS The LUM/IVA cohort matched to the F/MF concurrent comparator cohort had 681 children and the LUM/IVA cohort matched to the F/F concurrent comparator cohort had 183 children. LUM/IVA cohorts had increases in body mass index percentiles relative to the matched F/MF and F/F concurrent comparator cohorts (mean difference in change from baseline: 8.4 [95% CI: 5.5, 11.3] and 11.8 [95% CI: 5.9, 17.7], respectively). Increases in height and weight percentiles were also observed in the LUM/IVA cohort relative to the F/MF and F/F concurrent comparator cohorts. Reductions in pulmonary exacerbations and hospitalizations relative to baseline and the F/F concurrent comparator cohort were seen in 2021. CONCLUSIONS This interim analysis showed favorable trends in clinical outcomes, including growth parameters, pulmonary exacerbations, and hospitalizations, suggesting an early beneficial effect of LUM/IVA treatment in children aged 2 through 5 years at treatment initiation.
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Affiliation(s)
- Claire Kim
- Vertex Pharmaceuticals Incorporated, Boston, MA, USA.
| | - Mark Higgins
- Vertex Pharmaceuticals Incorporated, Boston, MA, USA
| | - Lingyun Liu
- Vertex Pharmaceuticals Incorporated, Boston, MA, USA
| | | | - Anna Zolin
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Lutz Naehrlich
- Department of Pediatrics, Justus-Liebig-University Giessen, Giessen, Germany
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2
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Patel T, McBennett K, Sankararaman S, Schindler T, Sundaram K, Minich NM, Malay S, Kutney K. Impact of elexacaftor/tezacaftor/ivacaftor on lipid and fat-soluble vitamin levels and association with body mass index. Pediatr Pulmonol 2024; 59:734-742. [PMID: 38179878 DOI: 10.1002/ppul.26823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Revised: 11/04/2023] [Accepted: 12/04/2023] [Indexed: 01/06/2024]
Abstract
INTRODUCTION Cystic fibrosis transmembrane conductance regulator (CFTR) modulators improve gastrointestinal absorption of nutrients and may result in changes in body mass index (BMI), serum lipids, and fat-soluble vitamin levels. We hypothesized that serum lipids and vitamin levels would increase with CFTR modulator therapy and that greater increase in lipids and vitamin levels would be related to greater increase in BMI. METHODS A retrospective study was performed to evaluate the impact of elexacaftor/tezacaftor/ivacaftor (ETI) on nutritional parameters, serum lipids, and fat-soluble vitamin levels. Pre-ETI values (<2 years prior) and post-ETI values (>1 month after) were compared. Linear regression was used to evaluate whether change in BMI is associated with the change in lipid and/or vitamin levels and whether modulator duration is associated with the degree of rise in lipid and/or vitamin levels. RESULTS Adults and adolescents with CF (n = 137) were evaluated before and 31-300 days after starting ETI. Median BMI (adults 21.9 vs. 23.5 kg/m2 ; adolescents 48 vs. 63 percentile) increased after initiation of ETI. Total cholesterol (126 vs. 154 mg/dL), low-density lipoprotein cholesterol (63 vs. 78 mg/dL), non-high-density lipoprotein cholesterol (84 vs. 102 mg/dL), and high density lipoprotein cholesterol (43 vs. 49 mg/dL) increased after ETI, while triglycerides and very low density lipoprotein did not change. Median values for vitamin D (34.5 vs. 38.0 ng/mL) and vitamin A (40.1 vs. 47.9 µg/dL) increased, while vitamin E did not change significantly. There was no significant correlation between BMI change or duration of modulator therapy with vitamin levels or lipid changes. CONCLUSION After initiation of ETI therapy, serum lipids increased in our population, but most values remained within the normal range. Vitamins A and D levels increased post-ETI and no changes were noted in vitamin E. No significant correlation between the degree of BMI change and the magnitude of increase in lipids or vitamin levels was found.
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Affiliation(s)
- Tanvi Patel
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
- Loyola University School of Medicine, Maywood, Illinois, USA
| | - Kimberly McBennett
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
- University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Senthilkumar Sankararaman
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
- University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Teresa Schindler
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
- University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Krithika Sundaram
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Nori Mercuri Minich
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
- University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Sindhoosha Malay
- University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Katherine Kutney
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
- University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
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Yeh HI, Sutcliffe KJ, Sheppard DN, Hwang TC. CFTR Modulators: From Mechanism to Targeted Therapeutics. Handb Exp Pharmacol 2024; 283:219-247. [PMID: 35972584 DOI: 10.1007/164_2022_597] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
People with cystic fibrosis (CF) suffer from a multi-organ disorder caused by loss-of-function variants in the gene encoding the epithelial anion channel cystic fibrosis transmembrane conductance regulator (CFTR). Tremendous progress has been made in both basic and clinical sciences over the past three decades since the identification of the CFTR gene. Over 90% of people with CF now have access to therapies targeting dysfunctional CFTR. This success was made possible by numerous studies in the field that incrementally paved the way for the development of small molecules known as CFTR modulators. The advent of CFTR modulators transformed this life-threatening illness into a treatable disease by directly binding to the CFTR protein and correcting defects induced by pathogenic variants. In this chapter, we trace the trajectory of structural and functional studies that brought CF therapies from bench to bedside, with an emphasis on mechanistic understanding of CFTR modulators.
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Affiliation(s)
- Han-I Yeh
- Department of Pharmacology, National Yang Ming Chiao Tung University, Taipei City, Taiwan
- Department of Medical Pharmacology and Physiology, University of Missouri, Columbia, MO, USA
- Dalton Cardiovascular Research Center, University of Missouri, Columbia, MO, USA
| | - Katy J Sutcliffe
- School of Physiology, Pharmacology and Neuroscience, University of Bristol, Bristol, UK
| | - David N Sheppard
- School of Physiology, Pharmacology and Neuroscience, University of Bristol, Bristol, UK
| | - Tzyh-Chang Hwang
- Department of Pharmacology, National Yang Ming Chiao Tung University, Taipei City, Taiwan.
- Department of Medical Pharmacology and Physiology, University of Missouri, Columbia, MO, USA.
- Dalton Cardiovascular Research Center, University of Missouri, Columbia, MO, USA.
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Lieu N, Prentice BJ, Field P, Fitzgerald DA. Trials and tribulations of highly effective modulator therapies in cystic fibrosis. Paediatr Respir Rev 2023; 48:10-19. [PMID: 37914566 DOI: 10.1016/j.prrv.2023.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 09/13/2023] [Indexed: 11/03/2023]
Abstract
Highly effective modulator therapies (HEMTs) have revolutionised the management approach of most patients living with cystic fibrosis (CF) who have access to these therapies. Clinical trials have reported significant improvements across multiorgan systems, with patients surviving longer. However, there are accumulating case reports and observational data describing various adverse events following initiation of HEMTs including drug-to-drug interactions, drug induced liver injury, Stevens-Johnson syndrome, and neurocognitive symptoms including psychosis and depression, which have required discontinuation of therapy. Current clinical trials are assessing efficacy in younger patients with CF, yet long-term studies are also required to better understand the safety profile in the real-world setting across all ages and the impact of HEMT dose alteration or discontinuation.
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Affiliation(s)
- Nathan Lieu
- Department of Respiratory Medicine, The Children's Hospital at Westmead, Sydney, New South Wales, Australia, 2145; Discipline of Paediatrics and Child Health, University of Sydney, Sydney, New South Wales, Australia.
| | - Bernadette J Prentice
- Department of Respiratory Medicine, Sydney Children's Hospital, Randwick, Sydney, New South Wales, Australia, 2031; Discipline of Paediatrics and Child Health, UNSW, Sydney, New South Wales, Australia
| | - Penelope Field
- Department of Respiratory Medicine, The Children's Hospital at Westmead, Sydney, New South Wales, Australia, 2145; Department of Respiratory Medicine, Sydney Children's Hospital, Randwick, Sydney, New South Wales, Australia, 2031; Discipline of Paediatrics and Child Health, UNSW, Sydney, New South Wales, Australia
| | - Dominic A Fitzgerald
- Department of Respiratory Medicine, The Children's Hospital at Westmead, Sydney, New South Wales, Australia, 2145; Discipline of Paediatrics and Child Health, University of Sydney, Sydney, New South Wales, Australia
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Heneghan M, Southern KW, Murphy J, Sinha IP, Nevitt SJ. Corrector therapies (with or without potentiators) for people with cystic fibrosis with class II CFTR gene variants (most commonly F508del). Cochrane Database Syst Rev 2023; 11:CD010966. [PMID: 37983082 PMCID: PMC10659105 DOI: 10.1002/14651858.cd010966.pub4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2023]
Abstract
BACKGROUND Cystic fibrosis (CF) is a common life-shortening genetic condition caused by a variant in the cystic fibrosis transmembrane conductance regulator (CFTR) protein. A class II CFTR variant F508del is the commonest CF-causing variant (found in up to 90% of people with CF (pwCF)). The F508del variant lacks meaningful CFTR function - faulty protein is degraded before reaching the cell membrane, where it needs to be to effect transepithelial salt transport. Corrective therapy could benefit many pwCF. This review evaluates single correctors (monotherapy) and any combination of correctors (most commonly lumacaftor, tezacaftor, elexacaftor, VX-659, VX-440 or VX-152) and a potentiator (e.g. ivacaftor) (dual and triple therapies). OBJECTIVES To evaluate the effects of CFTR correctors (with or without potentiators) on clinically important benefits and harms in pwCF of any age with class II CFTR mutations (most commonly F508del). SEARCH METHODS We searched the Cochrane CF Trials Register (28 November 2022), reference lists of relevant articles and online trials registries (3 December 2022). SELECTION CRITERIA Randomised controlled trials (RCTs) (parallel design) comparing CFTR correctors to control in pwCF with class II mutations. DATA COLLECTION AND ANALYSIS Two authors independently extracted data, assessed risk of bias and judged evidence certainty (GRADE); we contacted investigators for additional data. MAIN RESULTS We included 34 RCTs (4781 participants), lasting between 1 day and 48 weeks; an extension of two lumacaftor-ivacaftor studies provided additional 96-week safety data (1029 participants). We assessed eight monotherapy RCTs (344 participants) (4PBA, CPX, lumacaftor, cavosonstat and FDL169), 16 dual-therapy RCTs (2627 participants) (lumacaftor-ivacaftor or tezacaftor-ivacaftor) and 11 triple-therapy RCTs (1804 participants) (elexacaftor-tezacaftor-ivacaftor/deutivacaftor; VX-659-tezacaftor-ivacaftor/deutivacaftor; VX-440-tezacaftor-ivacaftor; VX-152-tezacaftor-ivacaftor). Participants in 21 RCTs had the genotype F508del/F508del, in seven RCTs they had F508del/minimal function (MF), in one RCT F508del/gating genotypes, in one RCT either F508del/F508del genotypes or F508del/residual function genotypes, in one RCT either F508del/gating or F508del/residual function genotypes, and in three RCTs either F508del/F508del genotypes or F508del/MF genotypes. Risk of bias judgements varied across different comparisons. Results from 16 RCTs may not be applicable to all pwCF due to age limits (e.g. adults only) or non-standard designs (converting from monotherapy to combination therapy). Monotherapy Investigators reported no deaths or clinically relevant improvements in quality of life (QoL). There was insufficient evidence to determine effects on lung function. No placebo-controlled monotherapy RCT demonstrated differences in mild, moderate or severe adverse effects (AEs); the clinical relevance of these events is difficult to assess due to their variety and few participants (all F508del/F508del). Dual therapy In a tezacaftor-ivacaftor group there was one death (deemed unrelated to the study drug). QoL scores (respiratory domain) favoured both lumacaftor-ivacaftor and tezacaftor-ivacaftor therapy compared to placebo at all time points (moderate-certainty evidence). At six months, relative change in forced expiratory volume in one second (FEV1) % predicted improved with all dual combination therapies compared to placebo (high- to moderate-certainty evidence). More pwCF reported early transient breathlessness with lumacaftor-ivacaftor (odds ratio (OR) 2.05, 99% confidence interval (CI) 1.10 to 3.83; I2 = 0%; 2 studies, 739 participants; high-certainty evidence). Over 120 weeks (initial study period and follow-up), systolic blood pressure rose by 5.1 mmHg and diastolic blood pressure by 4.1 mmHg with twice-daily 400 mg lumacaftor-ivacaftor (80 participants). The tezacaftor-ivacaftor RCTs did not report these adverse effects. Pulmonary exacerbation rates decreased in pwCF receiving additional therapies to ivacaftor compared to placebo (all moderate-certainty evidence): lumacaftor 600 mg (hazard ratio (HR) 0.70, 95% CI 0.57 to 0.87; I2 = 0%; 2 studies, 739 participants); lumacaftor 400 mg (HR 0.61, 95% CI 0.49 to 0.76; I2 = 0%; 2 studies, 740 participants); and tezacaftor (HR 0.64, 95% CI 0.46 to 0.89; 1 study, 506 participants). Triple therapy No study reported any deaths (high-certainty evidence). All other evidence was low- to moderate-certainty. QoL respiratory domain scores probably improved with triple therapy compared to control at six months (six studies). There was probably a greater relative and absolute change in FEV1 % predicted with triple therapy (four studies each across all combinations). The absolute change in FEV1 % predicted was probably greater for F508del/MF participants taking elexacaftor-tezacaftor-ivacaftor compared to placebo (mean difference 14.30, 95% CI 12.76 to 15.84; 1 study, 403 participants; moderate-certainty evidence), with similar results for other drug combinations and genotypes. There was little or no difference in adverse events between triple therapy and control (10 studies). No study reported time to next pulmonary exacerbation, but fewer F508del/F508del participants experienced a pulmonary exacerbation with elexacaftor-tezacaftor-ivacaftor at four weeks (OR 0.17, 99% CI 0.06 to 0.45; 1 study, 175 participants) and 24 weeks (OR 0.29, 95% CI 0.14 to 0.60; 1 study, 405 participants); similar results were seen across other triple therapy and genotype combinations. AUTHORS' CONCLUSIONS There is insufficient evidence of clinically important effects from corrector monotherapy in pwCF with F508del/F508del. Additional data in this review reduced the evidence for efficacy of dual therapy; these agents can no longer be considered as standard therapy. Their use may be appropriate in exceptional circumstances (e.g. if triple therapy is not tolerated or due to age). Both dual therapies (lumacaftor-ivacaftor, tezacaftor-ivacaftor) result in similar small improvements in QoL and respiratory function with lower pulmonary exacerbation rates. While the effect sizes for QoL and FEV1 still favour treatment, they have reduced compared to our previous findings. Lumacaftor-ivacaftor was associated with an increase in early transient shortness of breath and longer-term increases in blood pressure (not observed for tezacaftor-ivacaftor). Tezacaftor-ivacaftor has a better safety profile, although data are lacking in children under 12 years. In this population, lumacaftor-ivacaftor had an important impact on respiratory function with no apparent immediate safety concerns, but this should be balanced against the blood pressure increase and shortness of breath seen in longer-term adult data when considering lumacaftor-ivacaftor. Data from triple therapy trials demonstrate improvements in several key outcomes, including FEV1 and QoL. There is probably little or no difference in adverse events for triple therapy (elexacaftor-tezacaftor-ivacaftor/deutivacaftor; VX-659-tezacaftor-ivacaftor/deutivacaftor; VX-440-tezacaftor-ivacaftor; VX-152-tezacaftor-ivacaftor) in pwCF with one or two F508del variants aged 12 years or older (moderate-certainty evidence). Further RCTs are required in children under 12 years and those with more severe lung disease.
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Affiliation(s)
- Matthew Heneghan
- Department of Women's and Children's Health, University of Liverpool, Liverpool, UK
| | - Kevin W Southern
- Department of Women's and Children's Health, University of Liverpool, Liverpool, UK
| | | | - Ian P Sinha
- Department of Women's and Children's Health, University of Liverpool, Liverpool, UK
| | - Sarah J Nevitt
- Department of Health Data Science, University of Liverpool, Liverpool, UK
- Centre for Reviews and Dissemination, University of York, York, UK
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Diab Cáceres L, Zamarrón de Lucas E. [Cystic fibrosis: Epidemiology, clinical manifestations, diagnosis and treatment]. Med Clin (Barc) 2023; 161:389-396. [PMID: 37558605 DOI: 10.1016/j.medcli.2023.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 06/19/2023] [Accepted: 06/21/2023] [Indexed: 08/11/2023]
Abstract
Cystic fibrosis is a genetic and multisystemic disease. The main comorbidity in adulthood is respiratory involvement, with the presence of bronchiectasis, chronic bronchial infection and airflow obstruction. Until a decade ago, treatments were aimed at favoring secretion drainage, reducing respiratory exacerbations, controlling chronic bronchial infection and slowing functional deterioration, but with the advent of cystic fibrosis transmembrane conductance regulator (CFTR) modulators, the cystic fibrosis paradigm has changed. This novel treatment goes a step further in the management of this disease, it is able to improve the production of defective CFTR protein and increase its expression on the cell surface, thus achieving a better functioning of ion exchange, fluidizing respiratory secretions and reducing airflow obstruction. In addition, there are currently different lines of research aimed at correcting the genetic defect that causes cystic fibrosis.
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Affiliation(s)
- Layla Diab Cáceres
- Unidad de Fibrosis Quística, Servicio de Neumología, Hospital Universitario 12 de Octubre, Madrid, España.
| | - Ester Zamarrón de Lucas
- Unidad de Fibrosis Quística, Servicio de de Neumología, Hospital Universitario La Paz, Madrid
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Wang S, Niroula S, Hoffman A, Khorrami M, Khorrami M, Yuan F, Gasser GN, Choi S, Liu B, Li J, Metersky ML, Vincent M, Crum CP, Boucher RC, Karmouty-Quintana H, Huang HJ, Sheshadri A, Dickey BF, Parekh KR, Engelhardt JF, McKeon FD, Xian W. Inflammatory Activity of Epithelial Stem Cell Variants from Cystic Fibrosis Lungs Is Not Resolved by CFTR Modulators. Am J Respir Crit Care Med 2023; 208:930-943. [PMID: 37695863 PMCID: PMC10870857 DOI: 10.1164/rccm.202305-0818oc] [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: 05/06/2023] [Accepted: 09/11/2023] [Indexed: 09/13/2023] Open
Abstract
Rationale: CFTR (cystic fibrosis transmembrane conductance regulator) modulator drugs restore function to mutant channels in patients with cystic fibrosis (CF) and lead to improvements in body mass index and lung function. Although it is anticipated that early childhood treatment with CFTR modulators will significantly delay or even prevent the onset of advanced lung disease, lung neutrophils and inflammatory cytokines remain high in patients with CF with established lung disease despite modulator therapy, underscoring the need to identify and ultimately target the sources of this inflammation in CF lungs. Objectives: To determine whether CF lungs, like chronic obstructive pulmonary disease (COPD) lungs, harbor potentially pathogenic stem cell "variants" distinct from the normal p63/Krt5 lung stem cells devoted to alveolar fates, to identify specific variants that might contribute to the inflammatory state of CF lungs, and to assess the impact of CFTR genetic complementation or CFTR modulators on the inflammatory variants identified herein. Methods: Stem cell cloning technology developed to resolve pathogenic stem cell heterogeneity in COPD and idiopathic pulmonary fibrosis lungs was applied to end-stage lungs of patients with CF (three homozygous CFTR:F508D, one CFTR F508D/L1254X; FEV1, 14-30%) undergoing therapeutic lung transplantation. Single-cell-derived clones corresponding to the six stem cell clusters resolved by single-cell RNA sequencing of these libraries were assessed by RNA sequencing and xenografting to monitor inflammation, fibrosis, and mucin secretion. The impact of CFTR activity on these variants after CFTR gene complementation or exposure to CFTR modulators was assessed by molecular and functional studies. Measurements and Main Results: End-stage CF lungs display a stem cell heterogeneity marked by five predominant variants in addition to the normal lung stem cell, of which three are proinflammatory both at the level of gene expression and their ability to drive neutrophilic inflammation in xenografts in immunodeficient mice. The proinflammatory functions of these three variants were unallayed by genetic or pharmacological restoration of CFTR activity. Conclusions: The emergence of three proinflammatory stem cell variants in CF lungs may contribute to the persistence of lung inflammation in patients with CF with advanced disease undergoing CFTR modulator therapy.
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Affiliation(s)
- Shan Wang
- Department of Biology and Biochemistry, University of Houston, Houston, Texas
| | - Suchan Niroula
- Department of Biology and Biochemistry, University of Houston, Houston, Texas
| | - Ashley Hoffman
- Department of Biology and Biochemistry, University of Houston, Houston, Texas
| | - Melika Khorrami
- Department of Biology and Biochemistry, University of Houston, Houston, Texas
| | - Melina Khorrami
- Department of Biology and Biochemistry, University of Houston, Houston, Texas
| | - Feng Yuan
- Department of Anatomy and Cell Biology
- Gene Therapy Center for Cystic Fibrosis and Other Genetic Diseases, and
| | - Grace N. Gasser
- Department of Anatomy and Cell Biology
- Gene Therapy Center for Cystic Fibrosis and Other Genetic Diseases, and
| | - Soon Choi
- Department of Anatomy and Cell Biology
- Gene Therapy Center for Cystic Fibrosis and Other Genetic Diseases, and
| | - Bovey Liu
- Department of Biology and Biochemistry, University of Houston, Houston, Texas
| | | | - Mark L. Metersky
- Center for Bronchiectasis Care, Pulmonary, Critical Care, and Sleep Medicine, University of Connecticut Health Center, Farmington, Connecticut
| | | | - Christopher P. Crum
- Women’s and Perinatal Pathology, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Richard C. Boucher
- Cystic Fibrosis and Pulmonary Research and Treatment Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Harry Karmouty-Quintana
- Department of Biochemistry and Molecular Biology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas
| | - Howard J. Huang
- Department of Medicine, Houston Methodist Hospital, Houston, Texas; and
| | - Ajay Sheshadri
- Department of Pulmonary Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Burton F. Dickey
- Department of Pulmonary Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Kalpaj R. Parekh
- Department of Anatomy and Cell Biology
- Gene Therapy Center for Cystic Fibrosis and Other Genetic Diseases, and
- Division of Thoracic Surgery, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - John F. Engelhardt
- Department of Anatomy and Cell Biology
- Gene Therapy Center for Cystic Fibrosis and Other Genetic Diseases, and
| | - Frank D. McKeon
- Department of Biology and Biochemistry, University of Houston, Houston, Texas
| | - Wa Xian
- Department of Biology and Biochemistry, University of Houston, Houston, Texas
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8
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Savi D, Lucca F, Tridello G, Meneghelli I, Comello I, Tomezzoli S, Signorini M, Proietti E, Cucchetto G, Volpi S, Cipolli M. Long-term clinical outcomes of elexacaftor/tezacaftor/ivacaftor therapy in adults with cystic fibrosis and advanced pulmonary disease. Respir Med 2023; 219:107406. [PMID: 37690570 DOI: 10.1016/j.rmed.2023.107406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 08/29/2023] [Accepted: 09/04/2023] [Indexed: 09/12/2023]
Abstract
BACKGROUND The combination of cystic fibrosis transmembrane conductance regulator (CFTR) modulators elexacaftor, tezacaftor and ivacaftor (ELX/TEZ/IVA) has been approved for treatment of cystic fibrosis (CF) patients (pwCF) homozygous and heterozygous for Phe508del. We aim to assess the long-term effects of ELX/TEZ/IVA therapy on clinical outcomes in severe pwCF. METHODS Lung function, pulmonary exacerbation (PEx), sweat chloride concentration, body mass index (BMI) and the respiratory domain of the cystic fibrosis questionnaire-revised (CFQ-R RD) were prospectively evaluated in a cohort of pwCF who were candidates for inclusion in a compassionate program of ELX/TEZ/IVA therapy. All procedures were performed at baseline and then at 12 and 24 months after initiation of modulator therapy. The number of PExs in the year before the study enrollment was collected from our records. RESULTS Thirty-six adult pwCF (median age 36.7 years; BMI 19.8 kg/m2; FEV1 36.5% predicted) were recruited from 2019. At 12 and 24 months after initiation, the absolute change in ppFEV1 (percent predicted forced expiratory volume in 1 s) from baseline was +12.5% (p < 0.0001) and +13% (p < 0.0001), respectively. A median of 4.0 exacerbations per patient was reported in the preceding year, while the median number of PExs was 0.0 and 1.0 after 12 and 24 months, respectively, of modulator therapy (both p < 0.0001). After 12 and 24 months of ELX/TEZ/IVA therapy, the CFQ-R RD score improved by 22.4 points (p < 0.0001) and 16.7 points (p < 0.0001), and sweat chloride levels decreased by 65.5 mmol/L (p < 0.0001) and 60 mmol/L (p < 0.0001), respectively. BMI significantly increased. CONCLUSIONS Long-term ELX/TEZ/IVA combination therapy markedly impacts the clinical status of patients with severe CF, showing a sustained improvement in lung function and PEx rate.
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Affiliation(s)
- Daniela Savi
- Cystic Fibrosis Center, Azienda Ospedaliero Universitaria Integrata di Verona, Pl. Aristide Stefani 1, 37126, Verona, Italy.
| | - Francesca Lucca
- Cystic Fibrosis Center, Azienda Ospedaliero Universitaria Integrata di Verona, Pl. Aristide Stefani 1, 37126, Verona, Italy.
| | - Gloria Tridello
- Cystic Fibrosis Center, Azienda Ospedaliero Universitaria Integrata di Verona, Pl. Aristide Stefani 1, 37126, Verona, Italy.
| | - Ilaria Meneghelli
- Cystic Fibrosis Center, Azienda Ospedaliero Universitaria Integrata di Verona, Pl. Aristide Stefani 1, 37126, Verona, Italy.
| | - Isabella Comello
- UOSD Cystic Fibrosis Unit, Department of Medical Direction of the Hospital, Treviso, Italy; Department of Women and Child Health, University of Padova, Padova, Italy.
| | - Sara Tomezzoli
- Cystic Fibrosis Center, Azienda Ospedaliero Universitaria Integrata di Verona, Pl. Aristide Stefani 1, 37126, Verona, Italy.
| | - Monica Signorini
- Cystic Fibrosis Center, Azienda Ospedaliero Universitaria Integrata di Verona, Pl. Aristide Stefani 1, 37126, Verona, Italy.
| | | | - Giulia Cucchetto
- Cystic Fibrosis Center, Azienda Ospedaliero Universitaria Integrata di Verona, Pl. Aristide Stefani 1, 37126, Verona, Italy.
| | - Sonia Volpi
- Cystic Fibrosis Center, Azienda Ospedaliero Universitaria Integrata di Verona, Pl. Aristide Stefani 1, 37126, Verona, Italy.
| | - Marco Cipolli
- Cystic Fibrosis Center, Azienda Ospedaliero Universitaria Integrata di Verona, Pl. Aristide Stefani 1, 37126, Verona, Italy.
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9
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Kuek S, McCullagh A, Paul E, Armstrong D. Real world outcomes of CFTR modulator therapy in Australian adults and children. Pulm Pharmacol Ther 2023; 82:102247. [PMID: 37574040 DOI: 10.1016/j.pupt.2023.102247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Revised: 07/23/2023] [Accepted: 08/07/2023] [Indexed: 08/15/2023]
Abstract
BACKGROUND Recent advances in CFTR modulator therapy have the potential to change the face of cystic fibrosis (CF). This retrospective observational study describes real world experience of the four available CFTR modulators in adults and children with CF in a single centre in Melbourne, Australia. METHOD Data were collected for all patients treated with CFTR modulators at MonashCF between May 2012 and September 2020. Primary outcomes included lung function, admission days and BMI/BMI centile over time. Adverse events and reasons for changing or ceasing medications were also analysed. RESULTS 55% (74/133) adult and 46% (55/119) paediatric patients were treated with CFTR modulators. FEV1 increased in adults treated with ivacaftor (IVA) and elexacaftor/tezacaftor/ivacaftor (ELX/TEZ/IVA) by 4.73% and 10.07% respectively, and BMI also improved in these groups. Nutrition improved in adults and children treated with lumacaftor/ivacaftor (LUM/IVA). There was no significant improvement in FEV1 or admission days with LUM/IVA or tezacaftor/ivacaftor (TEZ/IVA). 36% (31/85) ceased LUM/IVA, due to adverse effects in 81% (25/31). Of these, 92% (23/25) changed to TEZ/IVA, 78% (18/23) without significant adverse effects. CONCLUSIONS Our findings for LUM/IVA and TEZ/IVA are less encouraging than those seen in clinical trials, with no significant improvement in lung function or admission days and a higher rate of adverse effects with LUM/IVA compared with phase 3 clinical trials. TEZ/IVA was generally well tolerated by those who experienced side effects with LUM/IVA. The small number of patients treated with ELX/TEZ/IVA had improvements in all parameters. These findings support ongoing use of IVA for individuals with gating mutations, and transition to ELX/TEZ/IVA once available for patients with at least one Phe508del mutation.
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Affiliation(s)
- Stephanie Kuek
- Department of Respiratory Medicine, Monash Children's Hospital, 246 Clayton Road, Clayton, VIC, 3168, Australia.
| | - Angela McCullagh
- Department of Respiratory Medicine, Monash Children's Hospital, 246 Clayton Road, Clayton, VIC, 3168, Australia
| | - Eldho Paul
- Monash Centre for Health Research and Implementation, Monash University, 43-51 Kanooka Grove, Clayton, VIC, 3168, Australia
| | - David Armstrong
- Department of Respiratory Medicine, Monash Children's Hospital, 246 Clayton Road, Clayton, VIC, 3168, Australia; Department of Paediatrics, Monash University, 246 Clayton Road, Clayton, VIC, 3168, Australia
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10
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Burgener EB, Cornfield DN. Delivering a New Future for People With Cystic Fibrosis. Pediatrics 2023; 152:e2023062985. [PMID: 37671451 PMCID: PMC10522926 DOI: 10.1542/peds.2023-062985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/14/2023] [Indexed: 09/07/2023] Open
Abstract
Treatment, prognosis, and quality of life for people with cystic fibrosis (CF) have improved steadily since the initial description of the disease, but most dramatically in the past decade. In 2021, the median predicted survival increased to 53 years, compared with 17 years in 1970. The recent improvement in outcomes is attributable to the advent of cystic fibrosis transmembrane regulator (CFTR) modulators, small molecules that enhance the function of defective CFTR protein. The first CFTR modulator, ivacaftor, received Food and Drug Administration approval in 2011 to treat a single CFTR variant, comprising only 4% of those affected by CF. With the demonstration of efficacy, drug approval has been expanded to other variants. Multiple CFTR modulators used in combination with ivacaftor augment efficacy and increase the number of CFTR variants amenable to therapy. Approval of elexecaftor/tezecaftor/ivacaftor in 2019 increased the number of individuals who could benefit from highly effective modulator therapy (HEMT) to ∼90% of the CF population in the United States. HEMT has been dramatically effective, with overall improvements in lung function, quality of life, nutritional status, and, in women, increased fertility. HEMT may delay the onset of other CF-related comorbidities. Although off-target effects, including hepatotoxicity, drug-drug interactions, and putative mental health issues can complicate use, modulator therapy has been generally well tolerated. Ten percent of people with CF have variants that are not amenable to modulator treatment. HEMT, despite its great cost and limited global access, has brought legitimate hope and changed the lives of a significant majority of individuals and families affected by CF in North America.
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Affiliation(s)
- Elizabeth B. Burgener
- Center for Excellence in Pulmonary Biology, Divisions of Pulmonary, Asthma, and Sleep Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - David N. Cornfield
- Center for Excellence in Pulmonary Biology, Divisions of Pulmonary, Asthma, and Sleep Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
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11
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Lussac-Sorton F, Charpentier É, Imbert S, Lefranc M, Bui S, Fayon M, Berger P, Enaud R, Delhaes L. The gut-lung axis in the CFTR modulator era. Front Cell Infect Microbiol 2023; 13:1271117. [PMID: 37780857 PMCID: PMC10540301 DOI: 10.3389/fcimb.2023.1271117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 08/30/2023] [Indexed: 10/03/2023] Open
Abstract
The advent of CFTR modulators represents a turning point in the history of cystic fibrosis (CF) management, changing profoundly the disease's clinical course by improving mucosal hydration. Assessing changes in airway and digestive tract microbiomes is of great interest to better understand the mechanisms and to predict disease evolution. Bacterial and fungal dysbiosis have been well documented in patients with CF; yet the impact of CFTR modulators on microbial communities has only been partially deciphered to date. In this review, we aim to summarize the current state of knowledge regarding the impact of CFTR modulators on both pulmonary and digestive microbiomes. Our analysis also covers the inter-organ connections between lung and gut communities, in order to highlight the gut-lung axis involvement in CF pathophysiology and its evolution in the era of novel modulators therapies.
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Affiliation(s)
- Florian Lussac-Sorton
- Univ. Bordeaux, Centre de Recherche Cardio-Thoracique de Bordeaux, INSERM U1045, Pessac, France
- INSERM, Centre de Recherche Cardio-thoracique de Bordeaux, Pessac, France
| | - Éléna Charpentier
- Univ. Bordeaux, Centre de Recherche Cardio-Thoracique de Bordeaux, INSERM U1045, Pessac, France
- INSERM, Centre de Recherche Cardio-thoracique de Bordeaux, Pessac, France
| | - Sébastien Imbert
- Univ. Bordeaux, Centre de Recherche Cardio-Thoracique de Bordeaux, INSERM U1045, Pessac, France
- INSERM, Centre de Recherche Cardio-thoracique de Bordeaux, Pessac, France
- CHU Bordeaux, Service de Parasitologie et Mycologie, Centre de Ressources et de Compétences de la Mucoviscidose (CRCM), Service de Pédiatrie, Service d’Exploration Fonctionnelle Respiratoire, CIC, Bordeaux, France
| | - Maxime Lefranc
- CHU Bordeaux, Service de Parasitologie et Mycologie, Centre de Ressources et de Compétences de la Mucoviscidose (CRCM), Service de Pédiatrie, Service d’Exploration Fonctionnelle Respiratoire, CIC, Bordeaux, France
| | - Stéphanie Bui
- Univ. Bordeaux, Centre de Recherche Cardio-Thoracique de Bordeaux, INSERM U1045, Pessac, France
- INSERM, Centre de Recherche Cardio-thoracique de Bordeaux, Pessac, France
- CHU Bordeaux, Service de Parasitologie et Mycologie, Centre de Ressources et de Compétences de la Mucoviscidose (CRCM), Service de Pédiatrie, Service d’Exploration Fonctionnelle Respiratoire, CIC, Bordeaux, France
| | - Michael Fayon
- Univ. Bordeaux, Centre de Recherche Cardio-Thoracique de Bordeaux, INSERM U1045, Pessac, France
- INSERM, Centre de Recherche Cardio-thoracique de Bordeaux, Pessac, France
- CHU Bordeaux, Service de Parasitologie et Mycologie, Centre de Ressources et de Compétences de la Mucoviscidose (CRCM), Service de Pédiatrie, Service d’Exploration Fonctionnelle Respiratoire, CIC, Bordeaux, France
| | - Patrick Berger
- Univ. Bordeaux, Centre de Recherche Cardio-Thoracique de Bordeaux, INSERM U1045, Pessac, France
- INSERM, Centre de Recherche Cardio-thoracique de Bordeaux, Pessac, France
- CHU Bordeaux, Service de Parasitologie et Mycologie, Centre de Ressources et de Compétences de la Mucoviscidose (CRCM), Service de Pédiatrie, Service d’Exploration Fonctionnelle Respiratoire, CIC, Bordeaux, France
| | - Raphaël Enaud
- Univ. Bordeaux, Centre de Recherche Cardio-Thoracique de Bordeaux, INSERM U1045, Pessac, France
- INSERM, Centre de Recherche Cardio-thoracique de Bordeaux, Pessac, France
- CHU Bordeaux, Service de Parasitologie et Mycologie, Centre de Ressources et de Compétences de la Mucoviscidose (CRCM), Service de Pédiatrie, Service d’Exploration Fonctionnelle Respiratoire, CIC, Bordeaux, France
| | - Laurence Delhaes
- Univ. Bordeaux, Centre de Recherche Cardio-Thoracique de Bordeaux, INSERM U1045, Pessac, France
- INSERM, Centre de Recherche Cardio-thoracique de Bordeaux, Pessac, France
- CHU Bordeaux, Service de Parasitologie et Mycologie, Centre de Ressources et de Compétences de la Mucoviscidose (CRCM), Service de Pédiatrie, Service d’Exploration Fonctionnelle Respiratoire, CIC, Bordeaux, France
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12
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Sahakyan Y, Abrahamyan L, Ratjen F, Bear C, Strug L, Eckford PDW, Peel JK, Krahn M, Sander B. Cost-effectiveness analysis of genetic tools to predict treatment response in patients with cystic fibrosis. J Cyst Fibros 2023; 22:933-940. [PMID: 37100704 DOI: 10.1016/j.jcf.2023.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 04/17/2023] [Accepted: 04/19/2023] [Indexed: 04/28/2023]
Abstract
BACKGROUND Cystic fibrosis (CF) transmembrane conductance regulator (CFTR) modulator therapies show variable efficacy for patients with CF. Patient-derived predictive tools may identify individuals likely to respond to CFTRs, but are not in routine use. We aimed to determine the cost-utility of predictive tool-guided treatment with CFTRs as add-on to standard of care (SoC) for individuals with CF. METHODS This economic evaluation compared two strategies using an individual level simulation: (i) Treat All, where all patients received CFTRs plus SoC and (ii) Test→Treat, where patients who tested positive on predictive tools received CFTRs plus SoC and those who tested negative received SoC only. We simulated 50,000 individuals over their lifetime, and estimated costs (2020 CAD) per quality-adjusted life year (QALY) from the healthcare payer's perspective, discounted at 1.5% annually. The model was populated using Canadian CF registry data and published literature. Probabilistic and deterministic sensitivity were conducted. RESULTS The Treat All and Test→Treat and strategies yielded 22.41 and 21.36 QALYs, and cost $4.21 M and $3.15 M respectively. Results of probabilistic sensitivity analysis showed that Test→Treat was highly cost-effective compared to Treat All in 100% of simulations at cost-effectiveness thresholds as high as $500,000 per QALY. Test→Treat may save between $931 K to $1.1 M per QALY lost, depending on sensitivity and specificity of predictive tools. CONCLUSION The use of predictive tools could optimize the health benefits of CFTR modulators while reducing costs. Our findings support the use of pre-treatment predictive testing and may help inform coverage and reimbursement policies for individuals with CF.
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Affiliation(s)
- Yeva Sahakyan
- Toronto Health Economics and Technology Assessment Collaborative (THETA), University Health Network, Toronto, ON, Canada.
| | - Lusine Abrahamyan
- Toronto Health Economics and Technology Assessment Collaborative (THETA), University Health Network, Toronto, ON, Canada; Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Felix Ratjen
- Division of Respiratory Medicine, Department of Pediatrics, Translational Medicine, Research Institute, Hospital for Sick Children, Toronto, ON, Canada; Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Christine Bear
- Molecular Medicine Programme, Hospital for Sick Children, Toronto, ON, Canada; Department of Physiology, University of Toronto, Toronto, ON, Canada
| | - Lisa Strug
- Program in Genetics and Genome Biology, Hospital for Sick Children, Toronto, ON, Canada; Departments of Statistical Sciences and Computer Science, University of Toronto, Toronto, ON, Canada
| | - Paul D W Eckford
- Molecular Medicine Programme, Hospital for Sick Children, Toronto, ON, Canada
| | - John K Peel
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Murray Krahn
- Toronto Health Economics and Technology Assessment Collaborative (THETA), University Health Network, Toronto, ON, Canada; Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Beate Sander
- Toronto Health Economics and Technology Assessment Collaborative (THETA), University Health Network, Toronto, ON, Canada; Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada; Public Health Ontario, Toronto, ON, Canada; ICES, Toronto, ON, Canada
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13
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McNally P, Linnane B, Williamson M, Elnazir B, Short C, Saunders C, Kirwan L, David R, Kemner-Van de Corput MPC, Tiddens HAWM, Davies JC, Cox DW. The clinical impact of Lumacaftor-Ivacaftor on structural lung disease and lung function in children aged 6-11 with cystic fibrosis in a real-world setting. Respir Res 2023; 24:199. [PMID: 37568199 PMCID: PMC10416528 DOI: 10.1186/s12931-023-02497-0] [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: 02/13/2023] [Accepted: 07/21/2023] [Indexed: 08/13/2023] Open
Abstract
BACKGROUND Data from clinical trials of lumacaftor-ivacaftor (LUM-IVA) demonstrate improvements in lung clearance index (LCI) but not in FEV1 in children with Cystic Fibrosis (CF) aged 6-11 years and homozygous for the Phe508del mutation. It is not known whether LUM/IVA use in children can impact the progression of structural lung disease. We sought to determine the real-world impact of LUM/IVA on lung structure and function in children aged 6-11 years. METHODS This real-world observational cohort study was conducted across four paediatric sites in Ireland over 24-months using spirometry-controlled CT scores and LCI as primary outcome measures. Children commencing LUM-/IVA as part of routine care were included. CT scans were manually scored with the PRAGMA CF scoring system and analysed using the automated bronchus-artery (BA) method. Secondary outcome measures included rate of change of ppFEV1, nutritional indices and exacerbations requiring hospitalisation. RESULTS Seventy-one participants were recruited to the study, 31 of whom had spirometry-controlled CT performed at baseline, and after one year and two years of LUM/IVA treatment. At two years there was a reduction from baseline in trapped air scores (0.13 to 0.07, p = 0.016), but an increase from baseline in the % bronchiectasis score (0.84 to 1.23, p = 0.007). There was no change in overall % disease score (2.78 to 2.25, p = 0.138). Airway lumen to pulmonary artery ratios (AlumenA ratio) were abnormal at baseline and worsened over the course of the study. In 28 participants, the mean annual change from baseline LCI2.5 (-0.055 (-0.61 to 0.50), p = 0.85) measurements over two years were not significant. Improvements from baseline in weight (0.10 (0.06 to 0.15, p < 0.0001), height (0.05 (0.02 to 0.09), p = 0.002) and BMI (0.09 (0.03 to 0.15) p = 0.005) z-scores were seen with LUM/IVA treatment. The mean annual change from baseline ppFEV1 (-2.45 (-4.44 to 2.54), p = 0.66) measurements over two years were not significant. CONCLUSION In a real-world setting, the use of LUM/IVA over two years in children with CF aged 6-11 resulted in improvements in air trapping on CT but worsening in bronchiectasis scores. Our results suggest that LUM/IVA use in this age group improves air trapping but does not prevent progression of bronchiectasis over two years of treatment.
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Affiliation(s)
- Paul McNally
- Respiratory Department, Children's Health Ireland, Crumlin, Dublin, Ireland
- RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Barry Linnane
- University of Limerick School of Medicine, Limerick, Ireland
| | - Michael Williamson
- Respiratory Department, Children's Health Ireland, Crumlin, Dublin, Ireland
| | - Basil Elnazir
- Respiratory Department, Children's Health Ireland, Crumlin, Dublin, Ireland
- Trinity College, Dublin, Ireland
| | - Christopher Short
- NHLI, Imperial College, London, UK
- Royal Brompton and Harefield Hospitals, Guy's and St Thomas' Trust, London, UK
| | - Clare Saunders
- NHLI, Imperial College, London, UK
- Royal Brompton and Harefield Hospitals, Guy's and St Thomas' Trust, London, UK
| | - Laura Kirwan
- Cystic Fibrosis Registry of Ireland, Dublin, Ireland
| | - Rea David
- Respiratory Department, Children's Health Ireland, Crumlin, Dublin, Ireland
| | - Mariette P C Kemner-Van de Corput
- Department of Paediatric Pulmonology and Allergology, Department of Radiology and Nuclear Medicine, Erasmus Medical Centre - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Harm A W M Tiddens
- Respiratory Department, Children's Health Ireland, Crumlin, Dublin, Ireland
| | - Jane C Davies
- NHLI, Imperial College, London, UK
- Royal Brompton and Harefield Hospitals, Guy's and St Thomas' Trust, London, UK
| | - Des W Cox
- Respiratory Department, Children's Health Ireland, Crumlin, Dublin, Ireland.
- University College Dublin, Dublin, Ireland.
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14
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Stahl M, Roehmel J, Eichinger M, Doellinger F, Naehrlich L, Kopp MV, Dittrich AM, Lee C, Sommerburg O, Tian S, Xu T, Wu P, Joshi A, Ray P, Duncan ME, Wielpütz MO, Mall MA. Effects of Lumacaftor/Ivacaftor on Cystic Fibrosis Disease Progression in Children 2 through 5 Years of Age Homozygous for F508del-CFTR: A Phase 2 Placebo-controlled Clinical Trial. Ann Am Thorac Soc 2023; 20:1144-1155. [PMID: 36943405 PMCID: PMC10405608 DOI: 10.1513/annalsats.202208-684oc] [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: 08/08/2022] [Accepted: 03/21/2023] [Indexed: 03/23/2023] Open
Abstract
Rationale: Lumacaftor/ivacaftor (LUM/IVA) was shown to be safe and well tolerated in children 2 through 5 years of age with cystic fibrosis (CF) homozygous for F508del-CFTR in a Phase 3 open-label study. Improvements in sweat chloride concentration, markers of pancreatic function, and lung clearance index2.5 (LCI2.5), along with increases in growth parameters, suggested the potential for early disease modification with LUM/IVA treatment. Objective: To further assess the effects of LUM/IVA on CF disease progression in children 2 through 5 years of age using chest magnetic resonance imaging (MRI). Methods: This Phase 2 study had two parts: a 48-week, randomized, double-blind, placebo-controlled treatment period in which children 2 through 5 years of age with CF homozygous for F508del-CFTR received either LUM/IVA or placebo (Part 1) followed by an open-label period in which all children received LUM/IVA for an additional 48 weeks (Part 2). The results from Part 1 are reported. The primary endpoint was absolute change from baseline in chest MRI global score at Week 48. Secondary endpoints included absolute change in LCI2.5 through Week 48 and absolute changes in weight-for-age, stature-for-age, and body mass index-for-age z-scores at Week 48. Additional endpoints included absolute changes in sweat chloride concentration, fecal elastase-1 levels, serum immunoreactive trypsinogen, and fecal calprotectin through Week 48. The primary endpoint was analyzed using Bayesian methods, where the actual Bayesian posterior probability of LUM/IVA being superior to placebo in the chest MRI global score at Week 48 was calculated using a vague normal prior distribution; secondary and additional endpoints were analyzed using descriptive summary statistics. Results: Fifty-one children were enrolled and received LUM/IVA (n = 35) or placebo (n = 16). For the change in chest MRI global score at Week 48, the Bayesian posterior probability of LUM/IVA being better than placebo (treatment difference, <0; higher score indicates greater abnormality) was 76%; the mean treatment difference was -1.5 (95% credible interval, -5.5 to 2.6). Treatment with LUM/IVA also led to within-group numerical improvements in LCI2.5, growth parameters, and biomarkers of pancreatic function as well as greater decreases in sweat chloride concentration compared with placebo from baseline through Week 48. Safety data were consistent with the established safety profile of LUM/IVA. Conclusions: This placebo-controlled study suggests the potential for early disease modification with LUM/IVA treatment, including that assessed by chest MRI, in children as young as 2 years of age. Clinical trial registered with www.clinicaltrials.gov (NCT03625466).
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Affiliation(s)
- Mirjam Stahl
- Department of Pediatric Respiratory Medicine, Immunology, and Critical Care Medicine and
- German Center for Lung Research, Associated Partner Site, Berlin, Germany
- Berlin Institute of Health at Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Jobst Roehmel
- Department of Pediatric Respiratory Medicine, Immunology, and Critical Care Medicine and
| | - Monika Eichinger
- Translational Lung Research Center Heidelberg, German Center for Lung Research, Heidelberg, Germany
- Department of Diagnostic and Interventional Radiology
- Department of Diagnostic and Interventional Radiology with Nuclear Medicine, Thoraxklinik, and
| | - Felix Doellinger
- Department of Radiology, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Lutz Naehrlich
- Department of Pediatrics, Justus Liebig University Giessen, Giessen, Germany
- Universities of Giessen and Marburg Lung Center, German Center for Lung Research, Giessen, Germany
| | - Matthias V. Kopp
- Pediatric Respiratory Medicine, Department of Pediatrics, Inselspital, University of Bern, Bern, Switzerland
- Airway Research Center North, German Center for Lung Research, Grosshansdorf, Germany
| | - Anna-Maria Dittrich
- Department for Pediatric Pulmonology, Allergology, and Neonatology and
- BREATH, German Center for Lung Research, Hannover Medical School, Hannover, Germany; and
| | | | - Olaf Sommerburg
- Translational Lung Research Center Heidelberg, German Center for Lung Research, Heidelberg, Germany
- Division of Pediatric Pulmonology and Allergy and Cystic Fibrosis Center, Department of Pediatrics, Heidelberg University Hospital, Heidelberg, Germany
| | - Simon Tian
- Vertex Pharmaceuticals Incorporated, Boston, Massachusetts
| | - Tu Xu
- Vertex Pharmaceuticals Incorporated, Boston, Massachusetts
| | - Pan Wu
- Vertex Pharmaceuticals Incorporated, Boston, Massachusetts
| | - Aniket Joshi
- Vertex Pharmaceuticals Incorporated, Boston, Massachusetts
| | - Partha Ray
- Vertex Pharmaceuticals Incorporated, Boston, Massachusetts
| | | | - Mark O. Wielpütz
- Translational Lung Research Center Heidelberg, German Center for Lung Research, Heidelberg, Germany
- Department of Diagnostic and Interventional Radiology
- Department of Diagnostic and Interventional Radiology with Nuclear Medicine, Thoraxklinik, and
| | - Marcus A. Mall
- Department of Pediatric Respiratory Medicine, Immunology, and Critical Care Medicine and
- German Center for Lung Research, Associated Partner Site, Berlin, Germany
- Berlin Institute of Health at Charité – Universitätsmedizin Berlin, Berlin, Germany
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15
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Lopez A, Daly C, Vega-Hernandez G, MacGregor G, Rubin JL. Elexacaftor/tezacaftor/ivacaftor projected survival and long-term health outcomes in people with cystic fibrosis homozygous for F508del. J Cyst Fibros 2023; 22:607-614. [PMID: 36849331 DOI: 10.1016/j.jcf.2023.02.004] [Citation(s) in RCA: 33] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 01/31/2023] [Accepted: 02/06/2023] [Indexed: 02/27/2023]
Abstract
BACKGROUND A series of phase 3 clinical trials have demonstrated that elexacaftor plus tezacaftor plus ivacaftor (ELX/TEZ/IVA) is safe and efficacious in people with cystic fibrosis (pwCF) aged ≥12 years with ≥1 F508del mutation in the cystic fibrosis transmembrane conductance regulator (CFTR) gene. The impact of this treatment on lifetime clinical outcomes and survival, however, has yet to be assessed. METHODS We used a person-level microsimulation model to estimate the survival and lifetime clinical benefits of ELX/TEZ/IVA treatment versus other CFTR modulator combinations (tezacaftor plus ivacaftor [TEZ/IVA] or lumacaftor plus ivacaftor [LUM/IVA]) or best supportive care (BSC) alone in pwCF aged ≥12 years who are homozygous for F508del-CFTR. Disease progression inputs were derived from published literature; clinical efficacy inputs were derived from an indirect treatment comparison conducted using relevant phase 3 clinical trial data and extrapolations of clinical data. RESULTS The median projected survival for pwCF homozygous for F508del-CFTR treated with ELX/TEZ/IVA was 71.6 years. This was an increase of 23.2 years versus TEZ/IVA, 26.2 years versus LUM/IVA, and 33.5 years versus BSC alone. Treatment with ELX/TEZ/IVA also reduced disease severity as well as the number of pulmonary exacerbations and lung transplants. In a scenario analysis, the median projected survival for pwCF initiating ELX/TEZ/IVA between the ages of 12 and 17 years was 82.5 years, an increase of 45.4 years compared with BSC alone. CONCLUSIONS The results from our model suggest ELX/TEZ/IVA treatment may substantially increase survival for pwCF, with early initiation potentially allowing pwCF to achieve near-normal life expectancy.
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Affiliation(s)
- Andrea Lopez
- Vertex Pharmaceuticals Incorporated, 50 Northern Avenue, Boston, MA 02210, USA.
| | - Conor Daly
- Vertex Pharmaceuticals (Europe) Limited, 2 Kingdom Street, London, W2 6BD, UK
| | | | - Gordon MacGregor
- Department of Respiratory Medicine, NHS Greater Glasgow and Clyde, Glasgow Royal Infirmary, 84 Glasgow Street, Glasgow, G4 0SF, UK
| | - Jaime L Rubin
- Vertex Pharmaceuticals Incorporated, 50 Northern Avenue, Boston, MA 02210, USA
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16
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Abstract
Importance Cystic fibrosis, a genetic disorder defined by variants in the cystic fibrosis transmembrane conductance regulator (CFTR) gene, affects more than 30 000 individuals in the US and approximately 89 000 worldwide. Absent or decreased function of the CFTR protein is associated with multiorgan dysfunction and shortened life expectancy. Observations CFTR is an anion channel in the apical membrane of epithelial cells. Loss of function leads to obstructed exocrine glands. Of people with cystic fibrosis in the US, approximately 85.5% have the gene variant F508del. Manifestations of cystic fibrosis in patients with the F508del gene variant begin in infancy with steatorrhea, poor weight gain, and respiratory symptoms (coughing, wheezing). As people with cystic fibrosis age, chronic respiratory bacterial infections cause loss of lung function and bronchiectasis. With the availability of universal newborn screening in multiple countries including the US, many people with cystic fibrosis are asymptomatic at diagnosis. With multidisciplinary care teams that included dietitians, respiratory therapists, and social workers, treatment of cystic fibrosis can slow disease progression. Median survival has improved from 36.3 years (95% CI, 35.1-37.9) in 2006 to 53.1 years (95% CI, 51.6-54.7) in 2021. Pulmonary therapies for patients with cystic fibrosis consist of mucolytics (eg, dornase alfa), anti-inflammatories (eg, azithromycin), and antibiotics (such as tobramycin delivered by a nebulizer). Four small molecular therapies, termed CFTR modulators, that facilitate CFTR production and/or function have received regulatory approval. Examples are ivacaftor and elexacaftor-tezacaftor-ivacaftor. For example, in patients with 1 F508del variant, the combination of ivacaftor, tezacaftor, and elexacaftor improved lung function from -0.2% in the placebo group to 13.6% (difference, 13.8%; 95% CI, 12.1%-15.4%) and decreased the annualized estimated rate of pulmonary exacerbations from 0.98 to 0.37 (rate ratio, 0.37; 95% CI, 0.25-0.55). Improved respiratory function and symptoms have lasted up to 144 weeks in postapproval observational studies. An additional 177 variants are eligible for treatment with the elexacaftor-tezacaftor-ivacaftor combination. Conclusion Cystic fibrosis affects approximately 89 000 people worldwide and is associated with a spectrum of disease related to exocrine dysfunction, including chronic respiratory bacterial infections and reduced life expectancy. First-line pulmonary therapies consist of mucolytics, anti-inflammatories, and antibiotics, and approximately 90% of people with cystic fibrosis who are 2 years or older may benefit from a combination of ivacaftor, tezacaftor, and elexacaftor.
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Affiliation(s)
- Thida Ong
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Washington, Seattle Children's Hospital, Seattle
| | - Bonnie W Ramsey
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Washington, Seattle Children's Hospital, Seattle
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17
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Berges J, Graeber SY, Hämmerling S, Yu Y, Krümpelmann A, Stahl M, Hirtz S, Scheuermann H, Mall MA, Sommerburg O. Effects of lumacaftor-ivacaftor therapy on cystic fibrosis transmembrane conductance regulator function in F508del homozygous patients with cystic fibrosis aged 2-11 years. Front Pharmacol 2023; 14:1188051. [PMID: 37324488 PMCID: PMC10266342 DOI: 10.3389/fphar.2023.1188051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 05/18/2023] [Indexed: 06/17/2023] Open
Abstract
Rationale: Lumacaftor/ivacaftor was approved for the treatment of patients with cystic fibrosis who are homozygous for F508del aged 2 years and older following positive results from phase three trials. However, the improvement in CFTR function associated with lumacaftor/ivacaftor has only been studied in patients over 12 years of age, while the rescue potential in younger children is unknown. Methods: In a prospective study, we aimed to evaluate the effect of lumacaftor/ivacaftor on the CFTR biomarkers sweat chloride concentration and intestinal current measurement as well as clinical outcome parameters in F508del homozygous CF patients 2-11 years before and 8-16 weeks after treatment initiation. Results: A total of 13 children with CF homozygous for F508del aged 2-11 years were enrolled and 12 patients were analyzed. Lumacaftor/ivacaftor treatment reduced sweat chloride concentration by 26.8 mmol/L (p = 0.0006) and showed a mean improvement in CFTR activity, as assessed by intestinal current measurement in the rectal epithelium, of 30.5% compared to normal (p = 0.0015), exceeding previous findings of 17.7% of normal in CF patients homozygous for F508del aged 12 years and older. Conclusion: Lumacaftor/ivacaftor partially restores F508del CFTR function in children with CF who are homozygous for F508del, aged 2-11 years, to a level of CFTR activity seen in patients with CFTR variants with residual function. These results are consistent with the partial short-term improvement in clinical parameters.
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Affiliation(s)
- Julian Berges
- Division of Pediatric Pulmonology and Allergology and Cystic Fibrosis Center, Department of Pediatrics, University of Heidelberg, Heidelberg, Germany
- Department of Translational Pulmonology, Translational Lung Research Center Heidelberg (TLRC), German Center for Lung Research (DZL), University of Heidelberg, Heidelberg, Germany
| | - Simon Y. Graeber
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine and Cystic Fibrosis Center, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Berlin Institute of Health at Charité—Universitätsmedizin Berlin, Berlin, Germany
- German Center for Lung Research (DZL), Associated Partner Site, Berlin, Germany
| | - Susanne Hämmerling
- Division of Pediatric Pulmonology and Allergology and Cystic Fibrosis Center, Department of Pediatrics, University of Heidelberg, Heidelberg, Germany
- Department of Translational Pulmonology, Translational Lung Research Center Heidelberg (TLRC), German Center for Lung Research (DZL), University of Heidelberg, Heidelberg, Germany
| | - Yin Yu
- Division of Pediatric Pulmonology and Allergology and Cystic Fibrosis Center, Department of Pediatrics, University of Heidelberg, Heidelberg, Germany
- Department of Translational Pulmonology, Translational Lung Research Center Heidelberg (TLRC), German Center for Lung Research (DZL), University of Heidelberg, Heidelberg, Germany
| | - Arne Krümpelmann
- Division of Pediatric Pulmonology and Allergology and Cystic Fibrosis Center, Department of Pediatrics, University of Heidelberg, Heidelberg, Germany
- Department of Translational Pulmonology, Translational Lung Research Center Heidelberg (TLRC), German Center for Lung Research (DZL), University of Heidelberg, Heidelberg, Germany
| | - Mirjam Stahl
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine and Cystic Fibrosis Center, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Berlin Institute of Health at Charité—Universitätsmedizin Berlin, Berlin, Germany
- German Center for Lung Research (DZL), Associated Partner Site, Berlin, Germany
| | - Stephanie Hirtz
- Division of Pediatric Pulmonology and Allergology and Cystic Fibrosis Center, Department of Pediatrics, University of Heidelberg, Heidelberg, Germany
- Department of Translational Pulmonology, Translational Lung Research Center Heidelberg (TLRC), German Center for Lung Research (DZL), University of Heidelberg, Heidelberg, Germany
| | - Heike Scheuermann
- Division of Pediatric Pulmonology and Allergology and Cystic Fibrosis Center, Department of Pediatrics, University of Heidelberg, Heidelberg, Germany
- Department of Translational Pulmonology, Translational Lung Research Center Heidelberg (TLRC), German Center for Lung Research (DZL), University of Heidelberg, Heidelberg, Germany
| | - Marcus A. Mall
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine and Cystic Fibrosis Center, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Berlin Institute of Health at Charité—Universitätsmedizin Berlin, Berlin, Germany
- German Center for Lung Research (DZL), Associated Partner Site, Berlin, Germany
| | - Olaf Sommerburg
- Division of Pediatric Pulmonology and Allergology and Cystic Fibrosis Center, Department of Pediatrics, University of Heidelberg, Heidelberg, Germany
- Department of Translational Pulmonology, Translational Lung Research Center Heidelberg (TLRC), German Center for Lung Research (DZL), University of Heidelberg, Heidelberg, Germany
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18
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Gaschignard M, Beaufils F, Gallet P, Clouzeau H, Menard J, Costanzo A, Nouard L, Delhaes L, Tetard C, Lamireau T, Fayon M, Bui S, Enaud R. Dietary intake assessment in children with cystic fibrosis using 3-day food diaries: a single-centre study. Front Pediatr 2023; 11:1130792. [PMID: 37228437 PMCID: PMC10203471 DOI: 10.3389/fped.2023.1130792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 04/21/2023] [Indexed: 05/27/2023] Open
Abstract
Background Malnutrition is both a feature and major cause of morbidity in cystic fibrosis (CF). Therefore, nutritional management is an essential element of patient care. In 2016, an international guideline for nutritional management in patients with CF was published. In light of these recommendations, the aim of this study was to investigate the dietary intake of children with CF at the University Hospital of Bordeaux. Methods We conducted a retrospective study at the Paediatric CF Centre of the University Hospital of Bordeaux. Patients aged 2-18 years with CF who completed a 3-day food diary at home between January 2015 and December 2020 were included. Results A total of 130 patients, with a median age of 11.8 [interquartile range (IQR): 8.3; 13.4] years, were included. The median Z-score for BMI was -0.35 (IQR: -0.9; 0.2) and 20% of the patients had a Z-score for BMI < -1. Recommended total energy intakes were achieved in 53% of the patients, particularly those with nutritional support. Recommended protein intake was met in 28% of the cases, while fat and carbohydrate intakes were met in 54%. Vitamin and micronutrient levels were normal in 80% of the patients, with the exception of vitamin K, which was within the therapeutic range in only 42% of the cases. Conclusion Recommended nutritional targets are difficult to achieve in patients with CF, and providing nutritional support during follow-up remains a challenge.
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Affiliation(s)
- Margaux Gaschignard
- Pediatric Cystic Fibrosis Reference Center (CRCM), Bordeaux University Hospital, Hôpital Pellegrin-Enfants, Centre d’Investigation Clinique (CIC 1401), Bordeaux, France
| | - Fabien Beaufils
- Pediatric Cystic Fibrosis Reference Center (CRCM), Bordeaux University Hospital, Hôpital Pellegrin-Enfants, Centre d’Investigation Clinique (CIC 1401), Bordeaux, France
- Centre de Recherche Cardio-Thoracique de Bordeaux, Bordeaux University, INSERM U1045, U1045, Bordeaux, France
| | - Pauline Gallet
- Pediatric Cystic Fibrosis Reference Center (CRCM), Bordeaux University Hospital, Hôpital Pellegrin-Enfants, Centre d’Investigation Clinique (CIC 1401), Bordeaux, France
| | - Haude Clouzeau
- Pediatric Cystic Fibrosis Reference Center (CRCM), Bordeaux University Hospital, Hôpital Pellegrin-Enfants, Centre d’Investigation Clinique (CIC 1401), Bordeaux, France
| | - Joris Menard
- Pediatric Cystic Fibrosis Reference Center (CRCM), Bordeaux University Hospital, Hôpital Pellegrin-Enfants, Centre d’Investigation Clinique (CIC 1401), Bordeaux, France
| | - Aurélie Costanzo
- Pediatric Cystic Fibrosis Reference Center (CRCM), Bordeaux University Hospital, Hôpital Pellegrin-Enfants, Centre d’Investigation Clinique (CIC 1401), Bordeaux, France
| | - Lucie Nouard
- Pediatric Cystic Fibrosis Reference Center (CRCM), Bordeaux University Hospital, Hôpital Pellegrin-Enfants, Centre d’Investigation Clinique (CIC 1401), Bordeaux, France
| | - Laurence Delhaes
- Centre de Recherche Cardio-Thoracique de Bordeaux, Bordeaux University, INSERM U1045, U1045, Bordeaux, France
| | - Candice Tetard
- Pediatric Cystic Fibrosis Reference Center (CRCM), Bordeaux University Hospital, Hôpital Pellegrin-Enfants, Centre d’Investigation Clinique (CIC 1401), Bordeaux, France
| | - Thierry Lamireau
- Pediatric Cystic Fibrosis Reference Center (CRCM), Bordeaux University Hospital, Hôpital Pellegrin-Enfants, Centre d’Investigation Clinique (CIC 1401), Bordeaux, France
| | - Michael Fayon
- Pediatric Cystic Fibrosis Reference Center (CRCM), Bordeaux University Hospital, Hôpital Pellegrin-Enfants, Centre d’Investigation Clinique (CIC 1401), Bordeaux, France
- Centre de Recherche Cardio-Thoracique de Bordeaux, Bordeaux University, INSERM U1045, U1045, Bordeaux, France
| | - Stéphanie Bui
- Pediatric Cystic Fibrosis Reference Center (CRCM), Bordeaux University Hospital, Hôpital Pellegrin-Enfants, Centre d’Investigation Clinique (CIC 1401), Bordeaux, France
- Centre de Recherche Cardio-Thoracique de Bordeaux, Bordeaux University, INSERM U1045, U1045, Bordeaux, France
| | - Raphaël Enaud
- Pediatric Cystic Fibrosis Reference Center (CRCM), Bordeaux University Hospital, Hôpital Pellegrin-Enfants, Centre d’Investigation Clinique (CIC 1401), Bordeaux, France
- Centre de Recherche Cardio-Thoracique de Bordeaux, Bordeaux University, INSERM U1045, U1045, Bordeaux, France
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19
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Paterson I, Johnson C, MacGregor G. Tezacaftor-ivacaftor use in routine care of adults with cystic fibrosis: a medicine use evaluation. Eur J Hosp Pharm 2023; 30:142-146. [PMID: 34103394 PMCID: PMC10176985 DOI: 10.1136/ejhpharm-2020-002676] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 06/01/2021] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Cystic fibrosis is a devastating life-limiting genetic condition characterised by a progressive decline in lung function, respiratory infections and premature death. Tezacaftor-ivacaftor is a combined cystic fibrosis transmembrane conductance regulator (CFTR) modulator that targets the underlying cause of the disease. This study aimed to assess the impact of tezacaftor-ivacaftor use in routine clinical practice for adults with cystic fibrosis. METHODS A retrospective observational longitudinal cohort study design was applied to examine the clinical effect of tezacaftor-ivacaftor in routine practice in the West of Scotland Adult Cystic Fibrosis Unit. Adults receiving tezacaftor-ivacaftor for at least 4 weeks were included in this medicine use evaluation.A standardised data form was used to collect patient-level data: demographics, genotype, complications of cystic fibrosis, medicine access process. Fifty-two weeks pre and post tezacaftor-ivacaftor initiation data: lung function, body mass index (BMI), days spent in hospital, days receiving antibiotic treatment for respiratory exacerbations. Anonymised data were collated and analysed using SPSS V.26. RESULTS Of 121 potential patients, 45 received treatment with tezacaftor-ivacaftor; median age 30 years (range 17-64) at initiation, 56% were male, 76% were deemed to be homozygote and 41 patients continued treatment for at least 52 weeks. There was no significant change in % predicted FEV1; median difference 0 (IQR -3 to 6). There was a significant improvement in BMI, mean 0.6 kg/m2 (95% CI 0.2 to 1.0), as well as a median 4 (IQR -17 to 0) day reduction in days in hospital and 21 (IQR -42 to 0) day reduction in days receiving antibiotics. CONCLUSIONS The use of tezacaftor-ivacaftor in routine practice for people with cystic fibrosis was associated with improvements in weight, as well as reducing the number of days people needed to spend in hospital and receive antibiotics.
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Affiliation(s)
- Iona Paterson
- Pharmacy, Queen Elizabeth University Hospital Campus, Glasgow, UK
| | - Chris Johnson
- Pharmacy Services, NHS Greater Glasgow and Clyde Primary Care Division, Glasgow, Glasgow, UK
| | - Gordon MacGregor
- Department of Respiratory Medicine, Queen Elizabeth University Hospital Campus, Glasgow, Glasgow, UK
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20
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Lee T, Sawicki GS, Altenburg J, Millar SJ, Geiger JM, Jennings MT, Lou Y, McGarry LJ, Van Brunt K, Linnemann RW. EFFECT OF ELEXACAFTOR/TEZACAFTOR/IVACAFTOR ON ANNUAL RATE OF LUNG FUNCTION DECLINE IN PEOPLE WITH CYSTIC FIBROSIS. J Cyst Fibros 2023; 22:402-406. [PMID: 36581485 DOI: 10.1016/j.jcf.2022.12.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 12/06/2022] [Accepted: 12/18/2022] [Indexed: 12/28/2022]
Abstract
Elexacaftor/tezacaftor/ivacaftor (ELX/TEZ/IVA) was shown to be safe and efficacious in people with cystic fibrosis (CF) with ≥ 1 F508del-CFTR allele in Phase 3 clinical trials. ELX/TEZ/IVA treatment led to improved lung function, with increases in percent predicted forced expiratory volume in 1 second (ppFEV1) and Cystic Fibrosis Questionnaire-Revised respiratory domain score. Here, we evaluated the impact of ELX/TEZ/IVA on the rate of lung function decline over time by comparing changes in ppFEV1 in participants from the Phase 3 trials with a matched group of people with CF from the US Cystic Fibrosis Foundation Patient Registry not eligible for cystic fibrosis transmembrane conductance regulator (CFTR) modulator therapy. Participants treated with ELX/TEZ/IVA had on average no loss of pulmonary function over a 2-year period (mean annualized rate of change in ppFEV1, +0.39 percentage points [95% CI, -0.06 to 0.85]) compared with a 1.92 percentage point annual decline (95% CI, -2.16 to -1.69) in ppFEV1 in untreated controls. ELX/TEZ/IVA is the first CFTR modulator therapy shown to halt lung function decline over an extended time period.
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Affiliation(s)
- Tim Lee
- Leeds Children's Hospital, Leeds, United Kingdom of Great Britain and Northern Ireland United Kingdom.
| | | | - Josje Altenburg
- Amsterdam University Medical Centres, Amsterdam, the Netherlands.
| | | | | | - Mark T Jennings
- Vertex Pharmaceuticals Incorporated, Boston, MA, United States of America.
| | - Yiyue Lou
- Vertex Pharmaceuticals Incorporated, Boston, MA, United States of America.
| | - Lisa J McGarry
- Vertex Pharmaceuticals Incorporated, Boston, MA, United States of America.
| | - Kate Van Brunt
- Vertex Pharmaceuticals Incorporated, Boston, MA, United States of America.
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21
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Arooj P, Morrissy DV, McCarthy Y, Vagg T, McCarthy M, Fleming C, Daly M, Eustace JA, Murphy DM, Plant BJ. ROCK STUDY in CF: sustained anti-inflammatory effects of lumacaftor-ivacaftor in sputum and peripheral blood samples of adult patients with cystic fibrosis-an observational study. BMJ Open Respir Res 2023; 10:10/1/e001590. [PMID: 37130650 PMCID: PMC10163494 DOI: 10.1136/bmjresp-2022-001590] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2022] [Accepted: 04/14/2023] [Indexed: 05/04/2023] Open
Abstract
BACKGROUND Previous studies showed that the combination of Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) corrector and potentiator, lumacaftor-ivacaftor (LUMA-IVA) provides meaningful clinical benefits in patients with cystic fibrosis who are homozygous for the Phe508del CFTR mutation. However, little is known about the effect of LUMA-IVA on Proinflammatory Cytokines (PICs). OBJECTIVES To investigate the impact of LUMA-IVA CFTR modulation on circulatory and airway cytokines before and after 12 months of LUMA-IVA treatment in a real-world setting. METHODS We assessed both plasma and sputum PICs, as well as standard clinical outcomes including Forced Expiratory Volume in one second (FEV1) %predicted, Body Mass Index (BMI), sweat chloride and pulmonary exacerbations at baseline and prospectively for one year post commencement of LUMA-IVA in 44 patients with cystic fibrosis aged 16 years and older homozygous for the Phe508del CFTR mutation. RESULTS Significant reduction in plasma cytokines including interleukin (IL)-8 (p<0.05), tumour necrosis factor (TNF)-α (p<0.001), IL-1ß (p<0.001) levels were observed while plasma IL-6 showed no significant change (p=0.599) post-LUMA-IVA therapy. Significant reduction in sputum IL-6 (p<0.05), IL-8 (p<0.01), IL-1ß (p<0.001) and TNF-α (p<0.001) levels were observed after LUMA-IVA therapy. No significant change was noted in anti-inflammatory cytokine IL-10 levels in both plasma and sputum (p=0.305) and (p=0.585) respectively. Clinically significant improvements in FEV1 %predicted (mean+3.38%, p=0.002), BMI (mean+0.8 kg/m2, p<0.001), sweat chloride (mean -19 mmol/L, p<0.001), as well as reduction in intravenous antibiotics usage (mean -0.73, p<0.001) and hospitalisation (mean -0.38, p=0.002) were observed after initiation of LUMA-IVA therapy. CONCLUSION This real-world study demonstrates that LUMA-IVA has significant and sustained beneficial effects on both circulatory and airway inflammation. Our findings suggest that LUMA-IVA may improve inflammatory responses, which could potentially contribute to improved standard clinical outcomes.
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Affiliation(s)
- Parniya Arooj
- Cork Adult Cystic Fibrosis Centre (3CF), Cork University Hospital, Cork, Ireland
- HRB Clinical Research Facility, University College Cork, Cork, Ireland
- Department of Respiratory Medicine, Cork University Hospital, Cork, Ireland
| | - David V Morrissy
- Cork Adult Cystic Fibrosis Centre (3CF), Cork University Hospital, Cork, Ireland
- HRB Clinical Research Facility, University College Cork, Cork, Ireland
- Department of Respiratory Medicine, Cork University Hospital, Cork, Ireland
| | - Yvonne McCarthy
- Cork Adult Cystic Fibrosis Centre (3CF), Cork University Hospital, Cork, Ireland
- HRB Clinical Research Facility, University College Cork, Cork, Ireland
| | - Tamara Vagg
- Cork Adult Cystic Fibrosis Centre (3CF), Cork University Hospital, Cork, Ireland
- HRB Clinical Research Facility, University College Cork, Cork, Ireland
| | - Mairead McCarthy
- Cork Adult Cystic Fibrosis Centre (3CF), Cork University Hospital, Cork, Ireland
| | - Claire Fleming
- Cork Adult Cystic Fibrosis Centre (3CF), Cork University Hospital, Cork, Ireland
| | - Mary Daly
- HRB Clinical Research Facility, University College Cork, Cork, Ireland
| | - Joseph A Eustace
- HRB Clinical Research Facility, University College Cork, Cork, Ireland
| | - Desmond M Murphy
- HRB Clinical Research Facility, University College Cork, Cork, Ireland
- Department of Respiratory Medicine, Cork University Hospital, Cork, Ireland
| | - B J Plant
- Cork Adult Cystic Fibrosis Centre (3CF), Cork University Hospital, Cork, Ireland
- HRB Clinical Research Facility, University College Cork, Cork, Ireland
- Department of Respiratory Medicine, Cork University Hospital, Cork, Ireland
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22
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Katz JB, Shah P, Trillo CA, Alshaer MH, Peloquin C, Lascano J. Therapeutic drug monitoring in cystic fibrosis and associations with pulmonary exacerbations and lung function. Respir Med 2023; 212:107237. [PMID: 37030586 DOI: 10.1016/j.rmed.2023.107237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 02/20/2023] [Accepted: 04/01/2023] [Indexed: 04/10/2023]
Abstract
BACKGROUND Cystic fibrosis transmembrane conductance regulator (CFTR) modulator therapy have resulted in longer life expectancies, yet pulmonary exacerbations remain a leading cause of morbidity. Intravenous antibiotics is the mainstay treatment, however achieving adequate concentrations remains challenging. The effect of therapeutic drug monitoring (TDM) of beta-lactams on exacerbations and lung function has not been studied. METHODS Patient demographics, antibiotic regimens, forced expiratory volume 1 second (FEV1), and exacerbation history was obtained from 32 patients with cystic fibrosis admitted for exacerbations. All patients were colonized with Pseudomonas aeruginosa, received CFTR therapy for at least one year, and had 3-month interval follow ups. Plasma concentrations, FEV1, and exacerbation history was obtained before and after therapeutic drug monitoring. This included peak and trough plasma concentrations of piperacillin-tazobactam and cefepime using liquid chromatography with mass spectrometry. T-test and Mann-Whitney U test were used to compare medians/means of FEV1 and pulmonary exacerbations pre and post-TDM as well as free trough-to-minimum inhibitory concentration ratio (fCmin/MIC) ≥1 and ≥ 4. RESULTS TDM was associated with decreased exacerbations/year from 1.91 to 1.31 (p = 0.04) and among the cohort with >/ = 2 exacerbations per year, there was a longer exacerbation free interval after TDM (196.2 vs 103.7 days, p = 0.02). The decline in FEV1% predicted after therapeutic drug monitoring to the first exacerbation was -4.9 compared to -9.7 prior (p = 0.03). CONCLUSIONS TDM for cystic fibrosis pulmonary exacerbations results in decreased pulmonary exacerbations, longer intervals to pulmonary exacerbation, and lower decline in FEV1% predicted.
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Affiliation(s)
- Jason Brandon Katz
- Department of Internal Medicine, Pulmonary and Critical Care Division, UF Health-Shands Hospital, University of Florida, Gainesville, FL, 32611, USA.
| | - Purav Shah
- Department of Internal Medicine, Pulmonary and Critical Care Division, Emory, Atlanta, GA, 30322, USA.
| | - Cesar A Trillo
- Department of Internal Medicine, Pulmonary and Critical Care Division, UF Health-Shands Hospital, University of Florida, Gainesville, FL, 32611, USA.
| | - Mohammad H Alshaer
- Department of Pharmacotherapy and Translational Research, University of Florida Infectious Disease Pharmacokinetics Laboratory, UF College of Pharmacy, Gainesville, FL, 32610, USA.
| | - Charles Peloquin
- Department of Pharmacotherapy and Translational Research, University of Florida Infectious Disease Pharmacokinetics Laboratory, UF College of Pharmacy, Gainesville, FL, 32610, USA.
| | - Jorge Lascano
- Department of Internal Medicine, Pulmonary and Critical Care Division, UF Health-Shands Hospital, University of Florida, Gainesville, FL, 32611, USA.
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23
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Acaster S, Mukuria C, Rowen D, Brazier JE, Wainwright CE, Quon BS, Duckers J, Quittner AL, Lou Y, Sosnay PR, McGarry LJ. Development of the Cystic Fibrosis Questionnaire-Revised-8 Dimensions: Estimating Utilities From the Cystic Fibrosis Questionnaire-Revised. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2023; 26:567-578. [PMID: 36509366 DOI: 10.1016/j.jval.2022.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 11/09/2022] [Accepted: 12/01/2022] [Indexed: 05/06/2023]
Abstract
OBJECTIVES Cystic fibrosis (CF) limits survival and negatively affects health-related quality of life (HRQOL). Cost-effectiveness analysis (CEA) may be used to make reimbursement decisions for new CF treatments; nevertheless, generic utility measures used in CEA, such as EQ-5D, are insensitive to meaningful changes in lung function and HRQOL in CF. Here we develop a new, CF disease-specific, preference-based utility measure based on the adolescent/adult version of the Cystic Fibrosis Questionnaire-Revised (CFQ-R), a widely used, CF-specific, patient-reported measure of HRQOL. METHODS Blinded CFQ-R data from 4 clinical trials (NCT02347657, NCT02392234, NCT01807923, and NCT01807949) were used to identify discriminating items for a classification system using psychometric (eg, factor and Rasch) analyses. Thirty-two health states were selected for a time trade-off (TTO) exercise with a representative sample of the UK general population. TTO utilities were used to estimate a preference-based scoring algorithm by regression analysis (tobit models with robust standard errors clustered on participants with censoring at -1). RESULTS A classification system with 8 dimensions (CFQ-R-8 dimensions; physical functioning, vitality, emotion, role functioning, breathing difficulty, cough, abdominal pain, and body image) was generated. TTO was completed by 400 participants (mean age, 47.3 years; 49.8% female). Among the regression models evaluated, the tobit heteroscedastic-ordered model was preferred, with a predicted utility range from 0.236 to 1, no logical inconsistencies, and a mean absolute error of 0.032. CONCLUSION The CFQ-R-8 dimensions is the first disease-specific, preference-based scoring algorithm for CF, enabling estimation of disease-specific utilities for CEA based on the well-validated and widely used CFQ-R.
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Affiliation(s)
| | - Clara Mukuria
- School of Health and Related Research, The University of Sheffield, Regent Court, Sheffield, England, UK
| | - Donna Rowen
- School of Health and Related Research, The University of Sheffield, Regent Court, Sheffield, England, UK
| | - John E Brazier
- School of Health and Related Research, The University of Sheffield, Regent Court, Sheffield, England, UK
| | - Claire E Wainwright
- Child Health Research Centre, University of Queensland, Brisbane, QLD, Australia
| | - Bradley S Quon
- Centre for Heart Lung Innovation, St. Paul's Hospital, and Division of Respiratory Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Jamie Duckers
- Department of Respiratory Medicine, Cardiff and Vale University Health Board, NHS Wales, Cardiff, Wales, UK
| | | | - Yiyue Lou
- Biostatistics, Vertex Pharmaceuticals Incorporated, Boston, MA, USA
| | - Patrick R Sosnay
- Clincal Development, Vertex Pharmaceuticals Incorporated, Boston, MA, USA
| | - Lisa J McGarry
- Health Economics and Outcomes Research, Vertex Pharmaceuticals Incorporated, Boston, MA, USA
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Regard L, Martin C, Da Silva J, Burgel PR. CFTR Modulators: Current Status and Evolving Knowledge. Semin Respir Crit Care Med 2023; 44:186-195. [PMID: 36535667 DOI: 10.1055/s-0042-1758851] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
In the past decade, the medical management of people with cystic fibrosis (pwCF) has changed with the development of small molecules that partially restore the function of the defective CF transmembrane conductance regulator (CFTR) protein and are called CFTR modulators. Ivacaftor (IVA), a CFTR potentiator with a large effect on epithelial ion transport, was the first modulator approved in pwCF carrying gating mutations. Because IVA was unable to restore sufficient CFTR function in pwCF with other mutations, two CFTR correctors (lumacaftor and tezacaftor) were developed and used in combination with IVA in pwCF homozygous for F508del, the most common CFTR variant. However, LUM/IVA and TEZ/IVA were only moderately effective in F508del homozygous pwCF and had no efficacy in those with F508del and minimal function mutations. Elexacaftor, a second-generation corrector, was thus developed and combined to tezacaftor and ivacaftor (ELX/TEZ/IVA) to target pwCF with at least one F508del variant, corresponding to approximately 85% of pwCF. Both IVA and ELX/TEZ/IVA are considered highly effective modulator therapies (HEMTs) in eligible pwCF and are now approved for nearly 90% of the CF population over 6 years of age. HEMTs are responsible for rapid improvement in respiratory manifestations, including improvement in symptoms and lung function, and reduction in the rate of pulmonary exacerbations. The impact of HEMT on extrapulmonary manifestations of CF is less well established, although significant weight gain and improvement in quality of life have been demonstrated. Recent clinical trials and real-world studies suggest that benefits of HEMT could even prove greater when used earlier in life (i.e., in younger children and infants). This article shortly reviews the past 10 years of development and use of CFTR modulators. Effects of HEMT on extrapulmonary manifestations and on CF demographics are also discussed.
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Affiliation(s)
- Lucile Regard
- Department of Respiratory Medicine and French Cystic Fibrosis National Reference Center, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Paris, France.,Institut Cochin and Université de Paris, INSERM U1016, Paris, France.,ERN Lung Cystic Fibrosis Network, Frankfurt, Germany
| | - Clémence Martin
- Department of Respiratory Medicine and French Cystic Fibrosis National Reference Center, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Paris, France.,Institut Cochin and Université de Paris, INSERM U1016, Paris, France.,ERN Lung Cystic Fibrosis Network, Frankfurt, Germany
| | - Jennifer Da Silva
- Department of Respiratory Medicine and French Cystic Fibrosis National Reference Center, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Paris, France.,ERN Lung Cystic Fibrosis Network, Frankfurt, Germany
| | - Pierre-Régis Burgel
- Department of Respiratory Medicine and French Cystic Fibrosis National Reference Center, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Paris, France.,Institut Cochin and Université de Paris, INSERM U1016, Paris, France.,ERN Lung Cystic Fibrosis Network, Frankfurt, Germany
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Mutual Effects of Single and Combined CFTR Modulators and Bacterial Infection in Cystic Fibrosis. Microbiol Spectr 2023; 11:e0408322. [PMID: 36625583 PMCID: PMC9927584 DOI: 10.1128/spectrum.04083-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Cystic fibrosis transmembrane conductance regulator (CFTR) modulators improve clinical outcomes with varied efficacies in patients with CF. However, the mutual effects of CFTR modulators and bacterial adaptation, together with antibiotic regimens, can influence clinical outcomes. We evaluated the effects of ivacaftor (IVA), lumacaftor (LUM), tezacaftor, elexacaftor, and a three-modulator combination of elexacaftor, tezacaftor, and ivacaftor (ETI), alone or combined with antibiotics, on sequential CF isolates. IVA and ETI showed direct antimicrobial activities against Staphylococcus aureus but not against Pseudomonas aeruginosa. Additive effects or synergies were observed between the CFTR modulators and antibiotics against both species, independently of adaptation to the CF lung. IVA and LUM were the most effective in potentiating antibiotic activity against S. aureus, while IVA and ETI enhanced mainly polymyxin activity against P. aeruginosa. Next, we evaluated the effect of P. aeruginosa pneumonia on the pharmacokinetics of IVA in mice. IVA and its metabolites in plasma, lung, and epithelial lining fluid were increased by P. aeruginosa infection. Thus, CFTR modulators can have direct antimicrobial properties and/or enhance antibiotic activity against initial and adapted S. aureus and P. aeruginosa isolates. Furthermore, bacterial infection impacts airway exposure to IVA, potentially affecting its efficacy. Our findings suggest optimizing host- and pathogen-directed therapies to improve efficacy for personalized treatment. IMPORTANCE CFTR modulators have been developed to correct and/or enhance CFTR activity in patients with specific cystic fibrosis (CF) genotypes. However, it is of great importance to identify potential off-targets of these novel therapies to understand how they affect lung physiology in CF. Since bacterial infections are one of the hallmarks of CF lung disease, the effects (if any) of CFTR modulators on bacteria could impact their efficacy. This work highlights a mutual interaction between CFTR modulators and opportunistic bacterial infections; in particular, it shows that (i) CFTR modulators have an antibacterial activity per se and influence antibiotic efficacy, and (ii) bacterial airway infections affect levels of CFTR modulators in the airways. These findings may help optimize host- and pathogen-directed drug regimens to improve the efficacy of personalized treatment.
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Nutritional Status and Circulating Levels of Fat-Soluble Vitamins in Cystic Fibrosis Patients: A Cohort Study and Evaluation of the Effect of CFTR Modulators. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10020252. [PMID: 36832382 PMCID: PMC9955178 DOI: 10.3390/children10020252] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 01/15/2023] [Accepted: 01/27/2023] [Indexed: 02/01/2023]
Abstract
BACKGROUND Improved therapy in CF has led to an overall improvement in nutritional status. The objectives of our study are: to cross-sectionally assess nutritional status and serum levels of fat-soluble vitamins; to retrospectively evaluate the efficacy of modulators on nutritional status and fat-soluble vitamin levels. METHODS In patients younger than 2 years of age, we evaluated growth, in patients aged 2-18 years, we assessed BMI z-scores, and in adults, we assessed absolute BMI values. Levels of 25(OH)D, vitamins A, and E were measured. RESULTS A cross-sectional analysis was conducted on 318 patients, 109 (34.3%) with pancreatic sufficiency. Only three patients were under 2 years old. In 135 patients aged 2-18 years, the median BMI z-score was 0.11, and 5 (3.7%) patients had malnutrition (z-score ≤ 2SD). In 180 adults, the median BMI was 21.8 kg/m2. Overall, 15 (13.7%) males (M) and 18 (25.3%) females (F) were underweight (18 < BMI > 20); 3 (2.7%) M and 5 (7.0%) F had a BMI < 18. Suboptimal 25(OH)D levels were found in patients with pancreatic insufficiency. The prevalence of deficiency of vitamins A and E is low. After one year of treatment with modulators, the increase in BMI was more consistent (M: 1.58 ± 1.25 kg/m2 F: 1.77 ± 1.21 kg/m2) in elexacaftor/tezacaftor/ivacaftor (ETI)-treated patients compared with other modulators, with a significant increase in levels of all fat-soluble vitamins. CONCLUSIONS Malnutrition is present in a limited number of subjects. The prevalence of subjects with suboptimal 25(OH)D levels is high. ETI showed a beneficial effect on nutritional status and circulating levels of fat-soluble vitamins.
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Abstract
Cystic fibrosis (CF) is an inherited multisystemic disease that can cause progressive bronchiectasis, pancreatic endocrine and exocrine insufficiency, distal intestinal obstruction syndrome, liver dysfunction, and other disorders. Traditional therapies focused on the treatment or prevention of damage to each organ system with incremental modalities such as nebulized medications for the lungs, insulin for diabetes, and supplementation with pancreatic enzymes. However, the advent of highly effective modulator therapies that target specific cystic fibrosis transmembrane conductance regulator protein malformations resulting from individual genetic mutations has transformed the lives and prognosis for persons with CF.
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Affiliation(s)
- Shijing Jia
- Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, Michigan, USA;
| | - Jennifer L Taylor-Cousar
- Divisions of Pulmonary Sciences and Critical Care Medicine and Pediatric Pulmonology, National Jewish Health, Denver, Colorado, USA;
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28
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Mariotti Zani E, Grandinetti R, Cunico D, Torelli L, Fainardi V, Pisi G, Esposito S. Nutritional Care in Children with Cystic Fibrosis. Nutrients 2023; 15:nu15030479. [PMID: 36771186 PMCID: PMC9921127 DOI: 10.3390/nu15030479] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 01/05/2023] [Accepted: 01/16/2023] [Indexed: 01/18/2023] Open
Abstract
Patients with cystic fibrosis (CF) are prone to malnutrition and growth failure, mostly due to malabsorption caused by the derangement in the chloride transport across epithelial surfaces. Thus, optimal nutritional care and support should be an integral part of the management of the disease, with the aim of ameliorating clinical outcomes and life expectancy. In this report, we analyzed the nutrition support across the different ages, in patients with CF, with a focus on the relationships with growth, nutritional status, disease outcomes and the use of the CF transmembrane conductance regulator (CFTR) modulators. The nutrition support goal in CF care should begin as early as possible after diagnosis and include the achievement of an optimal nutritional status to support the growth stages and puberty development in children, that will further support the maintenance of an optimal nutritional status in adult life. The cornerstone of nutrition in patients with CF is a high calorie, high-fat diet, in conjunction with a better control of malabsorption due to pancreatic enzyme replacement therapy, and attention to the adequate supplementation of fat-soluble vitamins. When the oral caloric intake is not enough for reaching the anthropometric nutritional goals, supplemental enteral feeding should be initiated to improve growth and the nutritional status. In the last decade, the therapeutic possibilities towards CF have grown in a consistent way. The positive effects of CFTR modulators on nutritional status mainly consist in the improvement in weight gain and BMI, both in children and adults, and in an amelioration in terms of the pulmonary function and reduction of exacerbations. Several challenges need to be overcome with the development of new drugs, to transform CF from a fatal disease to a treatable chronic disease with specialized multidisciplinary care.
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Affiliation(s)
- Elena Mariotti Zani
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | - Roberto Grandinetti
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | - Daniela Cunico
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | - Lisa Torelli
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | - Valentina Fainardi
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | - Giovanna Pisi
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | - Susanna Esposito
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
- Correspondence: ; Tel.: +39-0521-903524
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Gaschignard M, Beaufils F, Lussac-Sorton F, Gallet P, Clouzeau H, Menard J, Costanzo A, Nouard L, Delhaes L, Tetard C, Lamireau T, Fayon M, Bui S, Enaud R. Nutritional impact of CFTR modulators in children with cystic fibrosis. Front Pediatr 2023; 11:1130790. [PMID: 37063653 PMCID: PMC10091219 DOI: 10.3389/fped.2023.1130790] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 03/06/2023] [Indexed: 04/18/2023] Open
Abstract
Background Nutritional status is a major prognostic factor for breathing and the survival of patients with cystic fibrosis (CF). Since 2012, the development of CFTR modulators has considerably transformed the outcome of this disease. Indeed, both lung function and body mass index are improved by CFTR modulators, such as Lumacaftor/Ivacaftor. However, few data exist regarding the outcome of nutritional intakes under Lumacaftor/Ivacaftor. Methods We conducted a prospective single-center study in children with CF treated with Lumacaftor/Ivacaftor to evaluate their nutritional intake before and after treatment. Results Thirty-four children were included in this study, with a median age of 12.4 years [11.9; 14.7]. There was no significant improvement in weight, height or BMI. Patients' total energy intake was not significantly changed with Lumacaftor/Ivacaftor, while carbohydrate intakes decreased significantly. We found that blood levels of vitamin E and Selenium were significantly increased under Lumacaftor/Ivacaftor, without a significant increase in supplementation. In patients with a BMI Z-score < 0 at treatment initiation, there was a significant improvement in weight and BMI Z-score, while TEI and carbohydrate intakes were significantly lower. Conclusion We showed that treatment with Lumacaftor/Ivacaftor improved the nutritional status of patients without necessarily being associated with an increase in nutritional intake. Although these data need to be confirmed in larger cohorts, they support the hypothesis that weight gain under modulators is multifactorial, and may be related to a decrease in energy expenditure or an improvement in absorption.
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Affiliation(s)
- Margaux Gaschignard
- Bordeaux University Hospital, Hôpital Pellegrin-Enfants, Paediatric Cystic Fibrosis Reference Center (CRCM), Centre d'Investigation Clinique (CIC 1401), Bordeaux, France
| | - Fabien Beaufils
- Bordeaux University Hospital, Hôpital Pellegrin-Enfants, Paediatric Cystic Fibrosis Reference Center (CRCM), Centre d'Investigation Clinique (CIC 1401), Bordeaux, France
- Centre de Recherche Cardio-Thoracique de Bordeaux, INSERM U1045, Bordeaux University, Bordeaux, France
| | - Florian Lussac-Sorton
- Centre de Recherche Cardio-Thoracique de Bordeaux, INSERM U1045, Bordeaux University, Bordeaux, France
| | - Pauline Gallet
- Bordeaux University Hospital, Hôpital Pellegrin-Enfants, Paediatric Cystic Fibrosis Reference Center (CRCM), Centre d'Investigation Clinique (CIC 1401), Bordeaux, France
| | - Haude Clouzeau
- Bordeaux University Hospital, Hôpital Pellegrin-Enfants, Paediatric Cystic Fibrosis Reference Center (CRCM), Centre d'Investigation Clinique (CIC 1401), Bordeaux, France
| | - Joris Menard
- Bordeaux University Hospital, Hôpital Pellegrin-Enfants, Paediatric Cystic Fibrosis Reference Center (CRCM), Centre d'Investigation Clinique (CIC 1401), Bordeaux, France
| | - Aurélie Costanzo
- Bordeaux University Hospital, Hôpital Pellegrin-Enfants, Paediatric Cystic Fibrosis Reference Center (CRCM), Centre d'Investigation Clinique (CIC 1401), Bordeaux, France
| | - Lucie Nouard
- Bordeaux University Hospital, Hôpital Pellegrin-Enfants, Paediatric Cystic Fibrosis Reference Center (CRCM), Centre d'Investigation Clinique (CIC 1401), Bordeaux, France
| | - Laurence Delhaes
- Bordeaux University Hospital, Hôpital Pellegrin-Enfants, Paediatric Cystic Fibrosis Reference Center (CRCM), Centre d'Investigation Clinique (CIC 1401), Bordeaux, France
- Centre de Recherche Cardio-Thoracique de Bordeaux, INSERM U1045, Bordeaux University, Bordeaux, France
| | - Candice Tetard
- Bordeaux University Hospital, Hôpital Pellegrin-Enfants, Paediatric Cystic Fibrosis Reference Center (CRCM), Centre d'Investigation Clinique (CIC 1401), Bordeaux, France
| | - Thierry Lamireau
- Bordeaux University Hospital, Hôpital Pellegrin-Enfants, Paediatric Cystic Fibrosis Reference Center (CRCM), Centre d'Investigation Clinique (CIC 1401), Bordeaux, France
| | - Michael Fayon
- Bordeaux University Hospital, Hôpital Pellegrin-Enfants, Paediatric Cystic Fibrosis Reference Center (CRCM), Centre d'Investigation Clinique (CIC 1401), Bordeaux, France
- Centre de Recherche Cardio-Thoracique de Bordeaux, INSERM U1045, Bordeaux University, Bordeaux, France
| | - Stéphanie Bui
- Bordeaux University Hospital, Hôpital Pellegrin-Enfants, Paediatric Cystic Fibrosis Reference Center (CRCM), Centre d'Investigation Clinique (CIC 1401), Bordeaux, France
- Centre de Recherche Cardio-Thoracique de Bordeaux, INSERM U1045, Bordeaux University, Bordeaux, France
| | - Raphaël Enaud
- Bordeaux University Hospital, Hôpital Pellegrin-Enfants, Paediatric Cystic Fibrosis Reference Center (CRCM), Centre d'Investigation Clinique (CIC 1401), Bordeaux, France
- Centre de Recherche Cardio-Thoracique de Bordeaux, INSERM U1045, Bordeaux University, Bordeaux, France
- Correspondence: Raphaël Enaud
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Athanazio RA, Tanni SE, Ferreira J, Dalcin PDTR, Fuccio MBD, Esposito C, Canan MGM, Coelho LS, Firmida MDC, Almeida MBD, Marostica PJC, Monte LDFV, Souza EL, Pinto LA, Rached SZ, Oliveira VSBD, Riedi CA, Silva Filho LVRFD. Brazilian guidelines for the pharmacological treatment of the pulmonary symptoms of cystic fibrosis. Official document of the Sociedade Brasileira de Pneumologia e Tisiologia (SBPT, Brazilian Thoracic Association). J Bras Pneumol 2023; 49:e20230040. [PMID: 37194817 DOI: 10.36416/1806-3756/e20230040] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Accepted: 03/31/2023] [Indexed: 05/18/2023] Open
Abstract
Cystic fibrosis (CF) is a genetic disease that results in dysfunction of the CF transmembrane conductance regulator (CFTR) protein, which is a chloride and bicarbonate channel expressed in the apical portion of epithelial cells of various organs. Dysfunction of that protein results in diverse clinical manifestations, primarily involving the respiratory and gastrointestinal systems, impairing quality of life and reducing life expectancy. Although CF is still an incurable pathology, the therapeutic and prognostic perspectives are now totally different and much more favorable. The purpose of these guidelines is to define evidence-based recommendations regarding the use of pharmacological agents in the treatment of the pulmonary symptoms of CF in Brazil. Questions in the Patients of interest, Intervention to be studied, Comparison of interventions, and Outcome of interest (PICO) format were employed to address aspects related to the use of modulators of this protein (ivacaftor, lumacaftor+ivacaftor, and tezacaftor+ivacaftor), use of dornase alfa, eradication therapy and chronic suppression of Pseudomonas aeruginosa, and eradication of methicillin-resistant Staphylococcus aureus and Burkholderia cepacia complex. To formulate the PICO questions, a group of Brazilian specialists was assembled and a systematic review was carried out on the themes, with meta-analysis when applicable. The results obtained were analyzed in terms of the strength of the evidence compiled, the recommendations being devised by employing the GRADE approach. We believe that these guidelines represent a major advance to be incorporated into the approach to patients with CF, mainly aiming to favor the management of the disease, and could become an auxiliary tool in the definition of public policies related to CF.
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Affiliation(s)
- Rodrigo Abensur Athanazio
- . Divisão de Pneumologia, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | - Suzana Erico Tanni
- . Faculdade de Medicina de Botucatu, Universidade Estadual Paulista Julio de Mesquita Filho - UNESP - Botucatu (SP) Brasil
| | - Juliana Ferreira
- . Divisão de Pneumologia, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | - Paulo de Tarso Roth Dalcin
- . Programa de Pós-Graduação em Ciências Pneumológicas, Universidade Federal do Rio Grande do Sul - UFRGS - Porto Alegre (RS) Brasil
- . Serviço de Pneumologia, Hospital de Clínicas de Porto Alegre - HCPA - Universidade Federal do Rio Grande do Sul - UFRGS - Porto Alegre (RS) Brasil
| | - Marcelo B de Fuccio
- . Hospital Júlia Kubitschek, Fundação Hospitalar do Estado de Minas Gerais - FHEMIG - Belo Horizonte (MG) Brasil
| | | | | | - Liana Sousa Coelho
- . Faculdade de Medicina de Botucatu, Universidade Estadual Paulista Julio de Mesquita Filho - UNESP - Botucatu (SP) Brasil
| | | | - Marina Buarque de Almeida
- . Unidade de Pneumologia, Instituto da Criança, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | - Paulo José Cauduro Marostica
- . Unidade de Pneumologia Infantil, Hospital de Clínicas de Porto Alegre - HCPA - Universidade Federal do Rio Grande do Sul - UFRGS - Porto Alegre (RS) Brasil
| | | | - Edna Lúcia Souza
- . Faculdade de Medicina da Bahia, Universidade Federal da Bahia, Salvador (BA) Brasil
| | | | - Samia Zahi Rached
- . Divisão de Pneumologia, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | - Verônica Stasiak Bednarczuk de Oliveira
- . Hospital de Clínicas, Universidade Federal do Paraná, Curitiba (PR) Brasil
- . Unidos Pela Vida - Instituto Brasileiro de Atenção à Fibrose Cística, Curitiba (PR) Brasil
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Flume PA, Harris RS, Paz-Diaz H, Ahluwalia N, Higgins M, Campbell D, Berhane I, Shih JL, Sawicki G. Long-term tezacaftor/ivacaftor safety and efficacy in people with cystic fibrosis and an F508del-CFTR mutation: 96-week, open-label extension of the EXTEND trial. J Cyst Fibros 2022:S1569-1993(22)01426-6. [PMID: 36581484 DOI: 10.1016/j.jcf.2022.12.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 11/29/2022] [Accepted: 12/13/2022] [Indexed: 12/28/2022]
Abstract
BACKGROUND Study 661-110 (EXTEND) is a phase 3, open-label, three-part rollover study designed to assess the long-term safety and efficacy of tezacaftor/ivacaftor (TEZ/IVA) in participants aged ≥12 years homozygous for F508del (F/F) or heterozygous for F508del and a residual function mutation (F/RF). TEZ/IVA was shown to be safe and efficacious for up to 120 weeks in Part A. Here we report results from Part B, which evaluated safety and efficacy for an additional 96 weeks. METHODS Part B enrolled participants aged ≥12 years with CF and F/F or F/RF genotypes who completed TEZ/IVA treatment in either Study 661-110 Part A, Study 661-112 (F/F), or Study 661-114 (F/F). Participants received TEZ 100 mg/IVA 150 mg fixed-dose combination once daily (morning) and IVA 150 mg once daily (evening) for 96 weeks. Safety endpoints included adverse events (AEs) and serum liver function tests. Efficacy endpoints included absolute change from baseline in percent predicted forced expiratory volume in 1 second (ppFEV1) and pulmonary exacerbation (PEx) rate. RESULTS 464 participants were enrolled from Part A (n=377) and other eligible studies (n=87); 463 received ≥1 dose of TEZ/IVA. Overall, 92.2% had ≥1 AE, 0.9% had AEs leading to treatment discontinuation, and 29.4% reported serious AEs. The most common AEs, which were generally consistent with common manifestations of CF, included infective PEx of CF, cough, nasopharyngitis, hemoptysis, and headache. Lung function was maintained over 96 weeks in both genotype groups. PEx rates per year were comparable with Part A. CONCLUSIONS TEZ/IVA was generally safe and well tolerated over a further 96 weeks; safety data were consistent with Part A. Improvements in ppFEV1 and PEx rates were maintained for an additional 96 weeks in Part B.
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Affiliation(s)
- Patrick A Flume
- MUSC Health Cystic Fibrosis Center, Medical University of South Carolina, 96 Jonathan Lucas St., Charleston, SC, USA.
| | - R Scott Harris
- Vertex Pharmaceuticals Incorporated, 50 Northern Avenue, Boston, MA, USA
| | | | - Neil Ahluwalia
- Vertex Pharmaceuticals Incorporated, 50 Northern Avenue, Boston, MA, USA
| | - Mark Higgins
- Vertex Pharmaceuticals (Europe) Limited, 2 Kingdom Street, London W2 6BD, UK
| | - Daniel Campbell
- Vertex Pharmaceuticals Incorporated, 50 Northern Avenue, Boston, MA, USA
| | - Indrias Berhane
- Vertex Pharmaceuticals Incorporated, 50 Northern Avenue, Boston, MA, USA
| | - Judy L Shih
- Vertex Pharmaceuticals Incorporated, 50 Northern Avenue, Boston, MA, USA
| | - Gregory Sawicki
- Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA, USA
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Toward a Broader Understanding of Cystic Fibrosis Epidemiology and Its Impact on Clinical Manifestations. Clin Chest Med 2022; 43:579-590. [PMID: 36344067 DOI: 10.1016/j.ccm.2022.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The incidence of cystic fibrosis remains constant in North America and Western Europe is 1 in 3500 live births, but survival and quality of life have improved. The cystic fibrosis population has shifted toward the adult age range with a concomitant shift in the spectrum of complications. Survival increased because of aggressive symptomatic therapy, earlier diagnosis by newborn screening, and the introduction of modulators of the cystic fibrosis transmembrane conductance regulator, so that predicted median survival age is now about 50 years. In the United States, members of low socioeconomic status populations or members of racial or ethnic minorities have benefitted less from these advances.
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Mésinèle J, Ruffin M, Guillot L, Corvol H. Modifier Factors of Cystic Fibrosis Phenotypes: A Focus on Modifier Genes. Int J Mol Sci 2022; 23:ijms232214205. [PMID: 36430680 PMCID: PMC9698440 DOI: 10.3390/ijms232214205] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 11/07/2022] [Accepted: 11/11/2022] [Indexed: 11/18/2022] Open
Abstract
Although cystic fibrosis (CF) is recognized as a monogenic disease, due to variants within the CFTR (Cystic Fibrosis Transmembrane Regulator) gene, an extreme clinical heterogeneity is described among people with CF (pwCF). Apart from the exocrine pancreatic status, most studies agree that there is little association between CFTR variants and disease phenotypes. Environmental factors have been shown to contribute to this heterogeneity, accounting for almost 50% of the variability of the lung function of pwCF. Nevertheless, pwCF with similar CFTR variants and sharing the same environment (such as in siblings) may have highly variable clinical manifestations not explained by CFTR variants, and only partly explained by environmental factors. It is recognized that genetic variants located outside the CFTR locus, named "modifier genes", influence the clinical expression of the disease. This short review discusses the latest studies that have described modifier factors associated with the various CF phenotypes as well as the response to the recent CFTR modulator therapies.
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Affiliation(s)
- Julie Mésinèle
- Sorbonne Université, Inserm U938, Centre de Recherche Saint-Antoine (CRSA), 75012 Paris, France
- Inovarion, 75005 Paris, France
| | - Manon Ruffin
- Sorbonne Université, Inserm U938, Centre de Recherche Saint-Antoine (CRSA), 75012 Paris, France
| | - Loïc Guillot
- Sorbonne Université, Inserm U938, Centre de Recherche Saint-Antoine (CRSA), 75012 Paris, France
- Correspondence: (L.G.); (H.C.)
| | - Harriet Corvol
- Sorbonne Université, Inserm U938, Centre de Recherche Saint-Antoine (CRSA), 75012 Paris, France
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Trousseau, Service de Pneumologie Pédiatrique, 75012 Paris, France
- Correspondence: (L.G.); (H.C.)
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Yaacoby-Bianu K, Schnapp Z, Koren I, Ilivitzki A, Khatib M, Shorbaji N, Shteinberg M, Livnat G. Real life evaluation of the multi-organ effects of Lumacaftor/Ivacaftor on F508del homozygous cystic fibrosis patients. BMC Pharmacol Toxicol 2022; 23:80. [PMID: 36266606 PMCID: PMC9585743 DOI: 10.1186/s40360-022-00624-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 09/22/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Lumacaftor/Ivacaftor (LUM-IVA), a cystic fibrosis transmembrane conductance regulator (CFTR) protein corrector-potentiator combination, improves lung function and reduces pulmonary exacerbations (PEx) in F508del homozygous CF patients. However, the systemic effects of LUM-IVA outside the respiratory system have not yet been thoroughly investigated. METHODS A prospective, real-world, yearlong study was performed on F508del homozygous adult CF patients who commenced treatment with LUM-IVA. Pancreatic function, bone metabolism, fertility status, nutritional and pulmonary factors were evaluated. RESULTS Twelve patients, mean age 28.3 years (18.6-43.9) were recruited. Following 12 months of treatment, no changes were detected in glucose, insulin, c-peptide or BMI values. A significant relative decrease in mean alkaline-phosphatase levels (122.8 U/L vs 89.4, p = 0.002) and a trend toward an increase in calcium levels (9.5 vs 9.9 mg/dL, p = 0.074) were observed. A non-significant improvement in mean DEXA spine t-score after a year of treatment (-2.1 vs -1.6, n = 4, p = 0.11) was detected. Sweat chloride concentrations decreased significantly (-21.4 mEq/L; p = 0.003). Pulmonary outcome revealed improvement in spirometry values during the first three months (FEV1 by 5.7% p = 0.009, FEF25-75 by 4.3% p = 0.001) with no change in chest CT Bhalla score and CFQR after one year. There was also a significant decrease in parenteral antibiotic events (17 vs 8, p = 0.039) with shift from IV to oral antibiotics for PEx treatment. CONCLUSIONS After one year of treatment, stabilization was observed in the pancreatic indices, nutritional status, structure and function of the lungs, with a beneficial effect on bone mineral metabolism and CFTR function. Additional studies should investigate the effect of CFTR modulators on extra-pulmonary manifestations.
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Affiliation(s)
- Karin Yaacoby-Bianu
- Pediatric Pulmonology Unit and CF Center, Carmel Medical Center, 7 Michal St, 3436212, Haifa, Israel.,B. Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - Zeev Schnapp
- B. Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel.,Department of Pediatrics, Carmel Medical Center, Haifa, Israel
| | - Ilana Koren
- B. Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel.,Pediatric Endocrinology Unit, Carmel Medical Center, Haifa, Israel
| | - Anat Ilivitzki
- B. Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel.,Pediatric Radiology Unit, Ruth Rappaport Children's Hospital, Rambam Health Care Campus, Haifa, Israel
| | - Mohamed Khatib
- B. Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - Nadeem Shorbaji
- B. Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - Michal Shteinberg
- B. Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel.,Pulmonology Institute and CF Center, Carmel Medical Center, Haifa, Israel
| | - Galit Livnat
- Pediatric Pulmonology Unit and CF Center, Carmel Medical Center, 7 Michal St, 3436212, Haifa, Israel. .,B. Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel.
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Coronary artery disease in patients with cystic fibrosis - A case series and review of the literature. J Clin Transl Endocrinol 2022; 30:100308. [PMID: 36267108 PMCID: PMC9576554 DOI: 10.1016/j.jcte.2022.100308] [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: 05/19/2022] [Revised: 08/30/2022] [Accepted: 10/04/2022] [Indexed: 11/08/2022] Open
Abstract
Progressive obstructive pulmonary disease is the primary life-shortening complication in people with Cystic Fibrosis (CF); improvement in life expectancy has led to increased prevalence of non-pulmonary complications. Patients with CF are considered to be at low risk for coronary artery disease (CAD). We report here a case series of six patients with CF with and without known cystic fibrosis related diabetes (CFRD) who had acute myocardial infarction (AMI) requiring coronary stent placement. This was a heterogeneous group of patients, without a clear pattern of consistent risk factors. Interestingly, most patients in this cohort had low LDL. In this review, we discuss risk factors of cardiovascular disease (CVD) that may apply to the CF population. While CAD is rare in people with CF, it does occur. We postulate that the risk will grow with increased longevity and the increased prevalence of co-morbidities such as obesity and dyslipidemia.
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Carnovale V, Iacotucci P, Qiao D, Ferrillo L, Somma J, Buonaurio S, Marcella d’Ippolito, Celardo A, Savi D. Clinical outcomes of digital health in adults with cystic fibrosis. Respir Med 2022; 202:106970. [DOI: 10.1016/j.rmed.2022.106970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 07/26/2022] [Accepted: 08/24/2022] [Indexed: 11/29/2022]
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Dittrich AM, Chuang SY. Dual CFTR modulator therapy efficacy in the real world: lessons for the future. ERJ Open Res 2022; 8:00464-2022. [PMID: 36382239 PMCID: PMC9661234 DOI: 10.1183/23120541.00464-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 09/21/2022] [Indexed: 11/16/2022] Open
Abstract
Few diseases have undergone such transformative changes in the past four decades as cystic fibrosis. Cystic fibrosis has become the first example of the successful development of mutation-specific drugs. These drugs, known as cystic fibrosis transmembrane conductance regulator (CFTR) modulators, which improve the function of the CFTR channel, have been able to advance incrementally the overall positive development of therapeutic options in cystic fibrosis in only the last 10 years [1]. Stringent analyses caution against drawing conclusions about the real-world efficacy of CFTR modulator therapy too earlyhttps://bit.ly/3dJt6no
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38
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Experience of using lumacaftor/ivacaftor in children with cystic fibrosis in the Astrakhan region. ACTA BIOMEDICA SCIENTIFICA 2022. [DOI: 10.29413/abs.2022-7.4.12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background. Targeted therapy in patients with cystic fibrosis, which aims to restore the function of the cystic fibrosis transmembrane conductance regulator protein, is currently revolutionary in the treatment of the disease. The first drug available in Russia for the treatment of patients with this genetic disease is lumacaftor/ivacaftor (Orkambi®), which was registered on December 2, 2020.The aim. To study the efficacy of lumacaftor/ivacaftor during 12 weeks of administration in children in Astrakhan region.Materials and methods. This article presents the clinical experience of Orkambi medicine use in 3 children with F508del/F508del genotype and a severe course of cystic fibrosis for 12 weeks. According to the study design, such indices as body mass index, indexes of external respiratory function, character of respiratory tract microbiota, level of chloride in sweat fluid and pancreatic elastase in feces, dynamics of biochemical blood indexes were evaluated. The study was performed within the time periods specified in the study protocol, namely, before the start of therapy, 2, 4, and 12 weeks of treatment.Results. Two patients had a decrease in sweat test values by 11 and 19 mmol/l from the baseline, a significant increase in forced vital capacity of lungs. One patient had an adverse event in the form of hepatobiliary disorders manifested by increased liver transaminase activity, which was the reason for discontinuing the drug.Conclusions. The short-term experience of using pathogenetic therapy with lumacaftor/ ivacaftor in children in the Astrakhan region demonstrated both the expected effect on chlorine channel function and the possibility of side effects, including severe ones, that can lead to withdrawal of the drug.
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Advances in Preclinical In Vitro Models for the Translation of Precision Medicine for Cystic Fibrosis. J Pers Med 2022; 12:jpm12081321. [PMID: 36013270 PMCID: PMC9409685 DOI: 10.3390/jpm12081321] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 08/12/2022] [Accepted: 08/16/2022] [Indexed: 11/19/2022] Open
Abstract
The development of preclinical in vitro models has provided significant progress to the studies of cystic fibrosis (CF), a frequently fatal monogenic disease caused by mutations in the gene encoding the CF transmembrane conductance regulator (CFTR) protein. Numerous cell lines were generated over the last 30 years and they have been instrumental not only in enhancing the understanding of CF pathological mechanisms but also in developing therapies targeting the underlying defects in CFTR mutations with further validation in patient-derived samples. Furthermore, recent advances toward precision medicine in CF have been made possible by optimizing protocols and establishing novel assays using human bronchial, nasal and rectal tissues, and by progressing from two-dimensional monocultures to more complex three-dimensional culture platforms. These models also enable to potentially predict clinical efficacy and responsiveness to CFTR modulator therapies at an individual level. In parallel, advanced systems, such as induced pluripotent stem cells and organ-on-a-chip, continue to be developed in order to more closely recapitulate human physiology for disease modeling and drug testing. In this review, we have highlighted novel and optimized cell models that are being used in CF research to develop novel CFTR-directed therapies (or alternative therapeutic interventions) and to expand the usage of existing modulator drugs to common and rare CF-causing mutations.
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Abstract
Over the past decade there have been significant developments in the field of Cystic Fibrosis Transmembrane Regulator modulator drugs. Following treatment in patients with cystic fibrosis with common gating mutations using the potentiator drug ivacaftor, successive development of corrector drugs used in combination has led to highly effective modulator therapy being available to more than 85% of the cystic fibrosis population over 12 years of age in the form of elexacaftor/tezacaftor/ivacaftor. In this article, we review the evidence from clinical trials and mounting real-world observational and registry data that demonstrates the impact highly effective modulators have on both pulmonary and extra-pulmonary manifestations of cystic fibrosis. As clinical trials progress to younger patient groups, we discuss the challenges to demonstrating drug efficacy in early life, and also consider practicalities of drug development in an ever-shrinking modulator-naïve population. Drug-drug interactions are an important consideration in people with cystic fibrosis, where polypharmacy is commonplace, but also as the modulated population look to remain healthier for longer, we identify trials that aim to address treatment burden too. Inequity of care, through drug cost or ineligibility for modulators by genotype, is widening without apparent strategies to address this; however, we present evidence of hopeful early-stage drug development for non-modulatable genes and summarise the current state of gene-therapy development.
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41
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Changes in Glucose Breath Test in Cystic Fibrosis Patients Treated With 1 Month of Lumacaftor/Ivacaftor. J Pediatr Gastroenterol Nutr 2022; 75:42-47. [PMID: 35442228 DOI: 10.1097/mpg.0000000000003459] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND Alteration of the airway microbiota is a hallmark of cystic fibrosis (CF) pulmonary disease. Dysfunction of cystic fibrosis transmembrane regulator (CFTR) in the intestine also promotes changes in local microbiota such as small intestinal bacterial overgrowth (SIBO), which is common in CF. We evaluated whether therapy with the CFTR modulator combination lumacaftor/ivacaftor (luma/iva) has a beneficial impact on SIBO as measured by breath testing (BT). METHODS A multicenter longitudinal study of CFTR-dependent disease profiling (NCT02477319) included a prospective evaluation for SIBO by BT. Tidal breath samples were collected after fasting and 15, 30, 45, 60, 90, and 120 minutes after ingestion of glucose, before and 1 month after subjects initiated luma + iva. RESULTS Forty-two subjects enrolled in the sub-study (mean age = 23.3 years; 51% female; 9.5% Latinx); 38 completed a hydrogen BT at both time points, of which 73.7% had a positive BT before luma/iva (baseline) and 65.8% had a positive test after luma/iva ( P = 0.44); shifts from negative to positive were also seen. Use of azithromycin (63.1%) and inhaled antibiotics (60.5%) were not associated with positive BT. Acid-blocking medications were taken by 73% of those with a negative BT at baseline and by 35% with a positive baseline BT ( P = 0.04). CONCLUSION We found a high rate of positive hydrogen breath tests in individuals with CF, confirming that SIBO is common. One month of luma/iva did not significantly change the proportion of those with positive breath hydrogen measurements.
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42
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Balfour-Lynn IM, King JA. CFTR modulator therapies - Effect on life expectancy in people with cystic fibrosis. Paediatr Respir Rev 2022; 42:3-8. [PMID: 32565113 PMCID: PMC7255286 DOI: 10.1016/j.prrv.2020.05.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 05/14/2020] [Indexed: 12/13/2022]
Abstract
CFTR modulators have dramatically changed the clinical course of CF in those fortunate enough to receive them. Inevitably, randomised controlled trials during the development of these drugs are too short to use mortality as an outcome. Evidence for their effect on life expectancy are best gained from real world registry studies specifically looking at mortality, but these are only available for ivacaftor to date. Therefore, indirect evidence must be obtained by looking at outcomes known to affect mortality and seeing the effect of these drugs on those outcomes.
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Affiliation(s)
- I M Balfour-Lynn
- Department of Paediatric Respiratory Medicine, Royal Brompton Hospital, London, UK.
| | - J A King
- Department of Paediatric Respiratory Medicine, Royal Brompton Hospital, London, UK
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43
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Regard L, Martin C, Burnet E, Da Silva J, Burgel PR. CFTR Modulators in People with Cystic Fibrosis: Real-World Evidence in France. Cells 2022; 11:cells11111769. [PMID: 35681464 PMCID: PMC9179538 DOI: 10.3390/cells11111769] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 05/15/2022] [Accepted: 05/23/2022] [Indexed: 01/18/2023] Open
Abstract
Cystic fibrosis (CF) is a rare genetic multisystemic disease, the manifestations of which are due to mutations in the gene encoding the CF transmembrane conductance regulator (CFTR) protein and can lead to respiratory insufficiency and premature death. CFTR modulators, which were developed in the past decade, partially restore CFTR protein function. Their clinical efficacy has been demonstrated in phase 3 clinical trials, particularly in terms of lung function and pulmonary exacerbations, nutritional status, and quality of life in people with gating mutations (ivacaftor), homozygous for the F508del mutation (lumacaftor/ivacaftor and tezacaftor/ivacaftor), and in those with at least one F508del mutation (elexacaftor/tezacaftor/ivacaftor). However, many questions remain regarding their long-term safety and effectiveness, particularly in patients with advanced lung disease, liver disease, renal insufficiency, or problematic bacterial colonization. The impact of CFTR modulators on other important outcomes such as concurrent treatments, lung transplantation, chest imaging, or pregnancies also warrants further investigation. The French CF Reference Network includes 47 CF centers that contribute patient data to the comprehensive French CF Registry and have conducted nationwide real-world studies on CFTR modulators. This review seeks to summarize the results of these real-world studies and examine their findings against those of randomized control trials.
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Affiliation(s)
- Lucile Regard
- French Cystic Fibrosis National Reference Center, Department of Respiratory Medicine, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, 75014 Paris, France; (L.R.); (C.M.); (E.B.); (J.D.S.)
- Institut Cochin, Université de Paris Cité, INSERM U1016, 75014 Paris, France
- ERN Lung Cystic Fibrosis Network, Frankfurt, Germany
| | - Clémence Martin
- French Cystic Fibrosis National Reference Center, Department of Respiratory Medicine, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, 75014 Paris, France; (L.R.); (C.M.); (E.B.); (J.D.S.)
- Institut Cochin, Université de Paris Cité, INSERM U1016, 75014 Paris, France
- ERN Lung Cystic Fibrosis Network, Frankfurt, Germany
| | - Espérie Burnet
- French Cystic Fibrosis National Reference Center, Department of Respiratory Medicine, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, 75014 Paris, France; (L.R.); (C.M.); (E.B.); (J.D.S.)
- Institut Cochin, Université de Paris Cité, INSERM U1016, 75014 Paris, France
- ERN Lung Cystic Fibrosis Network, Frankfurt, Germany
| | - Jennifer Da Silva
- French Cystic Fibrosis National Reference Center, Department of Respiratory Medicine, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, 75014 Paris, France; (L.R.); (C.M.); (E.B.); (J.D.S.)
- ERN Lung Cystic Fibrosis Network, Frankfurt, Germany
| | - Pierre-Régis Burgel
- French Cystic Fibrosis National Reference Center, Department of Respiratory Medicine, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, 75014 Paris, France; (L.R.); (C.M.); (E.B.); (J.D.S.)
- Institut Cochin, Université de Paris Cité, INSERM U1016, 75014 Paris, France
- ERN Lung Cystic Fibrosis Network, Frankfurt, Germany
- Correspondence: ; Tel.: +33-1-58-41-23-67; Fax: +33-1-46-33-82-53
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Roda J, Pinto-Silva C, Silva IA, Maia C, Almeida S, Ferreira R, Oliveira G. New drugs in cystic fibrosis: what has changed in the last decade? Ther Adv Chronic Dis 2022; 13:20406223221098136. [PMID: 35620188 PMCID: PMC9128052 DOI: 10.1177/20406223221098136] [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: 10/28/2021] [Accepted: 04/13/2022] [Indexed: 11/16/2022] Open
Abstract
Cystic fibrosis (CF), a life-limiting chronic disease caused by mutations in the cystic fibrosis transmembrane regulator (CFTR) gene, affects more than 90,000 people worldwide. Until recently, the only available treatments were directed to symptom control, but they failed to change the course of the disease. New drugs developed in the last decade have the potential to change the expression, function, and stability of CFTR protein, targeting the basic molecular defect. The authors seek to provide an update on the new drugs, with a special focus on the most promising clinical trials that have been carried out to date. These newly approved drugs that target specific CFTR mutations are mainly divided into two main groups of CFTR modulators: potentiators and correctors. New therapies have opened the door for potentially disease-modifying, personalized treatments for patients with CF.
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Affiliation(s)
- Juliana Roda
- Pediatric Gastroenterology and Nutrition Unit, Centro Hospitalar e Universitario de Coimbra EPE Hospital Pediátrico de Coimbra, Avenida Afonso Romão 3000-602 Coimbra, Portugal
| | - Catarina Pinto-Silva
- Pediatric Gastroenterology and Nutrition Unit, Centro Hospitalar e Universitário de Coimbra EPE, Hospital Pediátrico de Coimbra, Coimbra, Portugal
| | - Iris A.I. Silva
- BioISI – Biosystems and Integrative Sciences Institute, Faculdade de Ciências, Universidade de Lisboa, Lisboa, Portugal
| | - Carla Maia
- Pediatric Gastroenterology and Nutrition Unit, Centro Hospitalar e Universitário de Coimbra EPE, Hospital Pediátrico de Coimbra, Coimbra, Portugal
| | - Susana Almeida
- Pediatric Gastroenterology and Nutrition Unit, Centro Hospitalar e Universitário de Coimbra EPE, Hospital Pediátrico de Coimbra, Coimbra, Portugal
| | - Ricardo Ferreira
- Pediatric Gastroenterology and Nutrition Unit, Centro Hospitalar e Universitário de Coimbra EPE, Hospital Pediátrico de Coimbra, Coimbra, Portugal
| | - Guiomar Oliveira
- Centro de Desenvolvimento da Criança e Centro de Investigação e Formação Clínica, Centro Hospitalar e Universitario de Coimbra EPE, Hospital Pediátrico de Coimbra, Coimbra, Portugal
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Graeber SY, Renz DM, Stahl M, Pallenberg ST, Sommerburg O, Naehrlich L, Berges J, Dohna M, Ringshausen FC, Doellinger F, Vitzthum C, Röhmel J, Allomba C, Hämmerling S, Barth S, Rückes-Nilges C, Wielpütz MO, Hansen G, Vogel-Claussen J, Tümmler B, Mall MA, Dittrich AM. Effects of Elexacaftor/Tezacaftor/Ivacaftor Therapy on Lung Clearance Index and Magnetic Resonance Imaging in Patients with Cystic Fibrosis and One or Two F508del Alleles. Am J Respir Crit Care Med 2022; 206:311-320. [PMID: 35536314 DOI: 10.1164/rccm.202201-0219oc] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE We recently demonstrated that triple combination CFTR modulator therapy with elexacaftor/tezacaftor/ivacaftor (ELX/TEZ/IVA) improves CFTR function in airway and intestinal epithelia to 40 to 50% of normal in patients with cystic fibrosis (CF) with one or two F508del alleles. In previous studies, this improvement of CFTR function was shown to improve clinical outcomes, however, effects on the lung clearance index (LCI) determined by multiple breath washout and abnormalities in lung morphology and perfusion detected by magnetic resonance imaging (MRI) have not been studied. OBJECTIVES To examine the effect of ELX/TEZ/IVA on LCI and lung MRI scores in patients with CF and one or two F508del alleles aged 12 years and older. METHODS This prospective, observational, multicenter, post-approval study assessed LCI and lung MRI scores before and 8-16 weeks after initiation of ELX/TEZ/IVA. MEASUREMENTS AND MAIN RESULTS A total of 91 patients with CF including 45 heterozygous for F508del and a minimal function mutation (MF) and 46 homozygous for F508del were enrolled in this study. Treatment with ELX/TEZ/IVA improved LCI in F508del/MF (-2.4;IQR, -3.7 - -1.1;P<0.001) and F508del homozygous (-1.4;IQR, -2.4 - -0.4;P<0.001) patients. Further, ELX/TEZ/IVA improved the MRI global score in F508del/MF (-6.0;IQR, -11.0 - -1.3;P<0.001) and F508del homozygous (-6.5;IQR, -11.0 - -1.3;P<0.001) patients. CONCLUSIONS Our data demonstrate that improvement of CFTR function by ELX/TEZ/IVA improves lung ventilation and abnormalities in lung morphology including airway mucus plugging and wall thickening in adolescent and adult patients with CF and one or two F508del alleles in a real-world, post-approval setting.
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Affiliation(s)
- Simon Y Graeber
- Charité Universitätsmedizin Berlin, 14903, Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine and Cystic Fibrosis Center, Berlin, Germany.,Berlin Institute of Health at Charité, 522475, Berlin, Germany.,German Center for Lung Research, 542891, associated partner site, Berlin, Germany
| | - Diane M Renz
- Hannover Medical School, 9177, Department for Radiology, Hannover, Germany
| | - Mirjam Stahl
- Charité Universitätsmedizin Berlin, 14903, Department of Pediatric Pulmonology, Immunology and Critical Care Medicine and Cystic Fibrosis Center, Berlin, Germany.,Berlin Institute of Health at Charité, 522475, Berlin, Germany.,German Center for Lung Research, 542891, associated partner site, Berlin, Germany
| | - Sophia T Pallenberg
- Hannover Medical School, 9177, Department of Pediatric Pneumology, Allergology and Neonatology, Hannover, Germany.,German Center for Lung Research, 542891, Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Hannover, Germany
| | - Olaf Sommerburg
- Heidelberg University, 9144, Division of Pediatric Pulmonology & Allergy and Cystic Fibrosis Center, Department of Pediatrics, Heidelberg, Germany.,German Center for Lung Research, 542891, Department of Translational Pulmonology, Translational Lung Research Center Heidelberg (TLRC), Heidelberg, Germany
| | - Lutz Naehrlich
- Justus Liebig Universitat Giessen, 9175, Department of Pediatrics, Giessen, Germany.,German Center for Lung Research, 542891, Universities Giessen and Marburg Lung Center (UGMLC), Giessen, Germany
| | - Julian Berges
- Heidelberg University, 9144, Division of Pediatric Pulmonology & Allergy and Cystic Fibrosis Center, Department of Pediatrics, Heidelberg, Germany.,German Center for Lung Research, 542891, Department of Translational Pulmonology, Translational Lung Research Center Heidelberg (TLRC), Heidelberg, Germany
| | - Martha Dohna
- Hannover Medical School, 9177, Department for Radiology, Hannover, Germany
| | - Felix C Ringshausen
- Hannover Medical School, 9177, Department for Pneumology, Hannover, Germany.,German Center for Lung Research, 542891, Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Hannover, Germany
| | - Felix Doellinger
- Charité Universitätsmedizin Berlin, 14903, Department of Radiology, Berlin, Germany
| | - Constanze Vitzthum
- Charité Universitätsmedizin Berlin, 14903, Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine and Cystic Fibrosis Center, Berlin, Germany.,German Center for Lung Research, 542891, associated partner site, Berlin, Germany
| | - Jobst Röhmel
- Charité Universitätsmedizin Berlin, 14903, Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine and Cystic Fibrosis Center, Berlin, Germany.,German Center for Lung Research, 542891, associated partner site, Berlin, Germany
| | - Christine Allomba
- Charité Universitätsmedizin Berlin, 14903, Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine and Cystic Fibrosis Center, Berlin, Germany.,German Center for Lung Research, 542891, associated partner site, Giessen, Germany
| | - Susanne Hämmerling
- University of Heidelberg, 9144, Department of Pediatrics, Division of Pediatric Pulmonology and Allergy and Cystic Fibrosis Center, Heidelberg, Germany
| | - Sandra Barth
- Justus Liebig Universitat Giessen, 9175, Department of Pediatrics, Giessen, Germany.,German Center for Lung Research, 542891, Universities Giessen and Marburg Lung Center (UGMLC), Giessen, Germany
| | | | - Mark O Wielpütz
- Heidelberg University, 9144, Department of Diagnostic and Interventional Radiology, Heidelberg, Germany.,German Center for Lung Research, 542891, Department of Translational Pulmonology, Translational Lung Research Center Heidelberg (TLRC), Heidelberg, Germany
| | - Gesine Hansen
- Hannover Medical School, 9177, Department for Pediatric Pneumology, Allergology and Neonatology, Hannover, Germany.,German Center for Lung Research, 542891, German Center for Lung Research, Biomedical Research in Endstage and Obstructive Lung Disease (BREATH), Hannover, Germany
| | - Jens Vogel-Claussen
- Hannover Medical School, 9177, Department for Radiology, Hannover, Germany.,Hannover Medical School, 9177, Department for Pediatric Pneumology, Hannover, Germany
| | - Burkhard Tümmler
- Hannover Medical School, 9177, Department for Pediatric Pneumology, Hannover, Germany.,German Center for Lung Research, 542891, Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Hannover, Germany
| | - Marcus A Mall
- Charité Universitätsmedizin Berlin, 14903, Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine and Cystic Fibrosis Center, Berlin, Germany.,Berlin Institute of Health at Charité, 522475, Berlin, Germany.,German Center for Lung Research, 542891, associated partner site, Berlin, Germany;
| | - Anna-Maria Dittrich
- Hannover Medical School, 9177, Department for Pediatric Pneumology, Allergology and Neonatology, Hannover, Germany.,German Center for Lung Research, 542891, Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Hannover, Germany
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Saluzzo F, Riberi L, Messore B, Loré NI, Esposito I, Bignamini E, De Rose V. CFTR Modulator Therapies: Potential Impact on Airway Infections in Cystic Fibrosis. Cells 2022; 11:cells11071243. [PMID: 35406809 PMCID: PMC8998122 DOI: 10.3390/cells11071243] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 03/27/2022] [Accepted: 03/31/2022] [Indexed: 11/16/2022] Open
Abstract
Cystic Fibrosis (CF) is an autosomal recessive disease caused by mutations in the gene encoding for the Cystic Fibrosis Transmembrane conductance Regulator (CFTR) protein, expressed on the apical surface of epithelial cells. CFTR absence/dysfunction results in ion imbalance and airway surface dehydration that severely compromise the CF airway microenvironment, increasing infection susceptibility. Recently, novel therapies aimed at correcting the basic CFTR defect have become available, leading to substantial clinical improvement of CF patients. The restoration or increase of CFTR function affects the airway microenvironment, improving local defence mechanisms. CFTR modulator drugs might therefore affect the development of chronic airway infections and/or improve the status of existing infections in CF. Thus far, however, the full extent of these effects of CFTR-modulators, especially in the long-term remains still unknown. This review aims to provide an overview of current evidence on the potential impact of CFTR modulators on airway infections in CF. Their role in affecting CF microbiology, the susceptibility to infections as well as the potential efficacy of their use in preventing/decreasing the development of chronic lung infections and the recurrent acute exacerbations in CF will be critically analysed.
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Affiliation(s)
- Francesca Saluzzo
- Emerging Bacterial Pathogens Unit, Division of Immunology, Transplantation and Infectious Diseases, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy;
| | - Luca Riberi
- Postgraduate School in Respiratory Medicine, University of Torino, 10124 Torino, Italy;
| | - Barbara Messore
- Adult Cystic Fibrosis Centre, Azienda Ospedaliero-Universitaria San Luigi Gonzaga, 10043 Orbassano, Italy;
| | - Nicola Ivan Loré
- WHO Collaborating Centre and TB Supranational Reference Laboratory, Emerging Bacterial Pathogens Unit, IRCCS Ospedale San Raffaele, 20132 Milan, Italy;
| | - Irene Esposito
- Paediatric Pulmonology Unit, Regina Margherita Hospital AOU Città della Salute e della Scienza, 10126 Torino, Italy; (I.E.); (E.B.)
| | - Elisabetta Bignamini
- Paediatric Pulmonology Unit, Regina Margherita Hospital AOU Città della Salute e della Scienza, 10126 Torino, Italy; (I.E.); (E.B.)
| | - Virginia De Rose
- Department of Molecular Biotechnology and Health Sciences, University of Torino, 10126 Torino, Italy
- Correspondence:
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Effect of elexacaftor-tezacaftor-ivacaftor on body weight and metabolic parameters in adults with cystic fibrosis. J Cyst Fibros 2022; 21:265-271. [PMID: 34862121 PMCID: PMC9999463 DOI: 10.1016/j.jcf.2021.11.012] [Citation(s) in RCA: 57] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 11/20/2021] [Accepted: 11/21/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Though weight gain has been reported in some clinical trials of CFTR modulators, the effect of elexacaftor-tezacaftor-ivacaftor on body weight, body mass index (BMI), blood pressure, lipids and glycemic control in the real-world setting remains incompletely described. METHODS We performed a single-center, retrospective, observational analysis of the effect of elexacaftor-tezacaftor-ivacaftor on body weight and cardiometabolic parameters in 134 adult CF patients of the Washington University Adult Cystic Fibrosis Center. Body weight, BMI, and blood pressure were extracted from outpatient clinic visits for the year preceding and the period following the initiation of elexacaftor-tezacaftor-ivacaftor. Other metabolic parameters were extracted at baseline and at latest available follow-up. RESULTS A mean of 12.2 months of follow-up data was available for analysis. The mean rate of change in BMI was 1.47 kg/m2/yr (95% CI, 1.08 to 1.87) greater after initiation of elexacaftor-tezacaftor-ivacaftor. Significant increases in blood pressure were observed. In those without CFRD, random blood glucose and hemoglobin A1c were decreased after elexacaftor-tezacaftor-ivacaftor initiation. In those with CFRD, elexacaftor-tezacaftor-ivacaftor increased serum total cholesterol, HDL-cholesterol, and LDL-cholesterol. CONCLUSIONS In this single-center, retrospective, observational study of 134 adults with CF, initiation of elexacaftor-tezacaftor-ivacaftor was associated with increases in BMI at a mean follow up of 12.2 months. Changes in other cardiometabolic risk factors were also observed. Widespread use of elexacaftor-tezacaftor-ivacaftor may be expected to increase the incidence of overnutrition in the CF population.
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Elexacaftor/Tezacaftor/Ivacaftor in Patients with Cystic Fibrosis Homozygous for the F508del Mutation and Advanced Lung Disease: A 48-Week Observational Study. J Clin Med 2022; 11:jcm11041021. [PMID: 35207295 PMCID: PMC8876133 DOI: 10.3390/jcm11041021] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 02/04/2022] [Accepted: 02/15/2022] [Indexed: 02/04/2023] Open
Abstract
Background: Elexacaftor/tezacaftor/ivacaftor (ETI) is the newest cystic fibrosis transmembrane conductance regulator (CFTR) modulator drug approved for the treatment of patients with cystic fibrosis (pwCF) aged ≥6 years with at least one copy of the F508del mutation (F) in the CFTR gene or another mutation that is responsive to treatment with ETI. This study determined the effectiveness and safety of ETI in a cohort of severely affected pwCF with an F/F genotype. Methods: Retrospective observational study in F/F pwCF treated for 48 weeks, enrolled in an ETI managed access program available to subjects with advanced lung disease (ppFEV1 < 40). Twenty-six patients from three centres were included. The main outcomes included lung function, sweat chloride concentration (SCC), nutrition, frequency of pulmonary exacerbations (PEx), CFQ-R, and safety. Results: ppFEV1 improved by 12.06 (95%CI 8.54, 15.57) from baseline after 4 weeks of treatment with ETI, 15.32 (11.3, 19.34) after 24 weeks, and 14.48 (10.64, 18.32) after 48 weeks. The increase in FEV1 was accompanied by a decrease in SCC, improvement of BMI, and noticeable reduction in PEx. An overall good safety profile was observed. Conclusions: In F/F pwCF with advanced lung disease with an F/F genotype, ETI was safe and associated with clinical improvement.
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Factors Predisposing the Response to Lumacaftor/Ivacaftor in People with Cystic Fibrosis. J Pers Med 2022; 12:jpm12020252. [PMID: 35207740 PMCID: PMC8876860 DOI: 10.3390/jpm12020252] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 02/03/2022] [Accepted: 02/07/2022] [Indexed: 12/04/2022] Open
Abstract
Lumacaftor/ivacaftor (LUMA-IVA) therapy is prescribed to people with cystic fibrosis (pwCF) homozygous for the Phe508del-CFTR variant to restore CFTR protein function. There is, however, large inter-individual variability in treatment response. Here, we seek to identify clinical and/or genetic factors that may modulate the response to this CFTR modulator therapy. A total of 765 pwCF older than 12 years under LUMA-IVA therapy and with lung function and nutritional measurements available before and after treatment initiation were included. Response to treatment was determined by the change in lung function and nutritional status, from baseline and over the first two years after initiation, and it was assessed by weighted generalized estimating equation models. Gains in lung function and nutritional status were observed after 6 months of treatment (on average 2.11 ± 7.81% for percent predicted FEV1 and 0.44 ± 0.77 kg/m2 for BMI) and sustained over the 2 years. We observed that the more severe patients gained the most in lung function and nutritional status. While females started with a nutritional status more impaired than males, they had a larger response and regained BMI Z-score values similar to men after 2 years of treatment. We observed no association between variants in solute carrier (SLC) genes and the respiratory function response to LUMA-IVA, but the SLC6A14 rs12839137 variant was associated with the nutritional response. Further investigations, including other genomic regions, will be needed to fully explore the inter-individual variability of the response to LUMA-IVA.
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Thee S, Busack LM, Mall MA, Stahl M. Impact of lockdown during the COVID-19 pandemic on health status in patients with cystic fibrosis- a mono-center observational study. ERJ Open Res 2022; 8:00588-2021. [PMID: 35291421 PMCID: PMC8867750 DOI: 10.1183/23120541.00588-2021] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 01/16/2022] [Indexed: 11/05/2022] Open
Abstract
Patients with cystic fibrosis (CF) suffer from impaired mucociliary clearance making them more susceptible to a spectrum of inhaled pathogens including bacteria, fungi and viruses [1, 2]. Therefore, patients with CF were considered at high risk for serious illness following severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection leading to “shielding or cocooning policies” [3]. Usually, patients with CF are cared for in specialised CF clinics with regular check-up visits. FEV1 % predicted decreased substantially in paediatric patients with #cysticfibrosis during the first lockdown of the ongoing #SARSCoV2 pandemic in Germany. More information on consequences of repetitive shutdowns in people with cystic fibrosis is needed.https://bit.ly/3fZwuIb
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