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Colpo A, Marchetti M, Bianco I, Cruciani F, Ipsevich F, Montanari M, Stanghellini MTL. Treatment of acute and chronic graft-versus-host disease with extracorporeal photopheresis: Update of best practice recommendations from Italian Society of Hemapheresis and Cell Manipulation (SIdEM) and the Italian Transplant Group for Bone Marrow Transplantation, Hematopoietic Stem Cells and Cell Therapy (GITMO). Transfus Apher Sci 2024; 63:103990. [PMID: 39208662 DOI: 10.1016/j.transci.2024.103990] [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: 05/01/2024] [Revised: 08/08/2024] [Accepted: 08/08/2024] [Indexed: 09/04/2024]
Abstract
These guidelines represent a GRADE-method revision of the recommendations produced by the Italian Society of Hemapheresis and Cell Manipulation (SIDEM) and the Italian Transplant Group for Bone Marrow Transplantation, Hematopoietic Stem Cells and Cell Therapy (GITMO) in 2013. Since 2013 several studies have been published that have strengthened the role of ECP in the management of GVHD. Thus, it was deemed appropriate to proceed with an update, with the aim to define uniform criteria for the application of ECP in adult and pediatric patients affected by GVHD throughout the national territory, in line with international guidelines, in maintaining of high standards of safety for patients and quality of the procedures provide. Post-HSCT GvHD therapies other than ECP and ECP therapy of other diseases, such as CTCL, are not covered by these guidelines.The development panel for this guideline includes professionals from various specialties who routinely interact in the management of the patient with GVHD, namely the transfusionist, the adult and pediatric hematologist, and the hospital pharmacist. A hematologist experienced in systematic reviews and GRADE guideline development ccordinated the development process, and an experienced transfusionist coordinated the assignment of tasks and reporting. External reviewers of the guideline included a patient representative.
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Affiliation(s)
- Anna Colpo
- Therapeutic Apheresis Unit, Department of Transfusion Medicine, Padova University Hospital, Padova, Italy.
| | - Monia Marchetti
- Division of Hematology, Azienda Ospedaliera SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Irene Bianco
- Therapeutic Apheresis Unit, Transfusion Medicine and Transplant Biology, Pisa University Hospital, Pisa, Italy
| | - Fabio Cruciani
- Transfusion Medicine Department, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Francesco Ipsevich
- Transfusion Medicine Department, Leukapheresis and Cellular Therapy Unit, S. Camillo-Forlanini Hospital, Rome, Italy
| | - Mauro Montanari
- Transfusion Medicine Department, Marche University Hospital, Ancona, Italy
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Sassone A, Testard J, Saulo A, Julia A, Schaiquevich P. Treatment of graft versus host disease with photopheresis interferes in voriconazole therapeutic drug monitoring: A case study. Pract Lab Med 2023; 37:e00340. [PMID: 37842330 PMCID: PMC10570002 DOI: 10.1016/j.plabm.2023.e00340] [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: 07/08/2023] [Revised: 10/03/2023] [Accepted: 10/04/2023] [Indexed: 10/17/2023] Open
Abstract
Extracorporeal photopheresis is an established procedure for refractory graft-versus-host disease, a major complication associated with notable morbidity and mortality in patients with allogeneic hematopoietic stem cell transplant. Despite being implemented over a decade ago, there is scant information about potential interactions or analytical interferences with concomitant drugs in this polymedicated population. Here we report the case of a pediatric patient diagnosed with cutaneous steroid-refractory acute graft-versus-host disease after unrelated allogeneic hematopoietic stem cell transplant that was treated with photopheresis. Analytical quantification of voriconazole by HPLC-PDA the day following photopheresis treatment did not permit therapeutic drug monitoring (TDM) due to the presence of interference at the voriconazole retention time. Following investigations, it was demonstrated that the interference is likely attributable to a psoralen-based compound. The interference was not present when samples were obtained prior to photopheresis, enabling TDM. This case underscores the relevance of communication among the members of the treating team to perform reliable TDM, especially in routine clinical practice of pediatric patients with complex diseases undergoing innovative treatments. This finding is relevant to voriconazole quantification by HPLC-PDA, frequently used in laboratories based in middle-income countries.
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Affiliation(s)
- Adriana Sassone
- Central Laboratory, Hospital de Pediatría JP Garrahan, Buenos Aires, Argentina
| | - Juliana Testard
- PharmacyService, Hospital de Pediatría JP Garrahan, Buenos Aires, Argentina
| | - Andrea Saulo
- Central Laboratory, Hospital de Pediatría JP Garrahan, Buenos Aires, Argentina
| | - Analia Julia
- BoneMarrowTransplantUnit, Hospital de Pediatría JP Garrahan, Buenos Aires, Argentina
| | - Paula Schaiquevich
- Unit of InnovativeTreatments, Hospital de Pediatría JP Garrahan, Buenos Aires, Argentina
- Consejo Nacional de Investigaciones Científicas y Técnicas, Buenos Aires, Argentina
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Wu A, Lu J, Zhong G, Lu L, Qu Y, Zhang C. Xanthotoxin (8-methoxypsoralen): A review of its chemistry, pharmacology, pharmacokinetics, and toxicity. Phytother Res 2022; 36:3805-3832. [PMID: 35913174 DOI: 10.1002/ptr.7577] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 06/30/2022] [Accepted: 07/14/2022] [Indexed: 11/11/2022]
Abstract
Xanthotoxin (XAT) is a natural furanocoumarins, a bioactive psoralen isolated from the fruit of the Rutaceae plant Pepper, which has received increasing attention in recent years due to its wide source and low cost. By collecting and compiling literature on XAT, the results show that XAT exhibits significant activity in the treatment of various diseases, including neuroprotection, skin repair, osteoprotection, organ protection, anticancer, antiinflammatory, antioxidative stress and antibacterial. In this paper, we review the pharmacological activity and potential molecular mechanisms of XAT for the treatment of related diseases. The data suggest that XAT can mechanistically induce ROS production and promote apoptosis through mitochondrial or endoplasmic reticulum pathways, regulate NF-κB, MAPK, JAK/STAT, Nrf2/HO-1, MAPK, AKT/mTOR, and ERK1/2 signaling pathways to exert pharmacological effects. In addition, the pharmacokinetics properties and toxicity of XAT are discussed in this paper, further elucidating the relationship between structure and efficacy. It is worth noting that data from clinical studies of XAT are still scarce, limiting the use of XAT in the clinic, and in the future, more in-depth studies are needed to determine the clinical efficacy of XAT.
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Affiliation(s)
- Anxin Wu
- College Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, PR China.,State Key Laboratory of Southwestern Chinese Medicine Resources, School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, PR China
| | - Jing Lu
- College Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, PR China.,State Key Laboratory of Southwestern Chinese Medicine Resources, School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, PR China
| | - Guofeng Zhong
- College Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, PR China.,State Key Laboratory of Southwestern Chinese Medicine Resources, School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, PR China
| | - Ling Lu
- Chengdu University of Technology, Chengdu, PR China
| | - Yan Qu
- College Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, PR China.,State Key Laboratory of Southwestern Chinese Medicine Resources, School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, PR China
| | - Chen Zhang
- College Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, PR China.,State Key Laboratory of Southwestern Chinese Medicine Resources, School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, PR China
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Hähnel V, Brosig AM, Ehrenschwender M, Burkhardt R, Offner R, Ahrens N. Apoptosis induction by extracorporeal photopheresis is enhanced by increasing the 8-methoxypsoralen concentration and by replacing plasma with saline. Transfusion 2021; 61:2991-2999. [PMID: 34427336 DOI: 10.1111/trf.16634] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 07/26/2021] [Accepted: 07/26/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Extracorporeal photopheresis (ECP), an apheresis-based therapy for various immunological diseases, works mainly by inducing apoptosis in lymphocytes. Several factors influence the efficacy of ECP with the photosensitizer 8-methoxypsoralen (8-MOP) and ultraviolet light A (UVA). This study aimed to optimize treatment by varying the 8-MOP starting concentration and the cell suspension medium. MATERIALS AND METHODS All patients (n = 13) included in this study received photopheresis as medically indicated. Cells collected with a Spectra Optia apheresis system were suspended in plasma or physiological saline (NaCl) and incubated with 200 ng/ml versus 340 ng/ml photosensitizer before UVA irradiation (Macogenic G2 or UVA PIT system). Lymphocyte apoptosis and caspase activity were analyzed by flow cytometry and fluorimetry, and residual 8-methoxypsoralen concentrations by liquid chromatography-mass spectrometry. RESULTS Raising the 8-MOP starting concentration significantly increased lymphocyte apoptosis, with values of 22% versus 35% (plasma) and 28%-46% (NaCl) at 24 h post-ECP and 37% versus 86% (plasma) and 74% versus 97% (NaCl) at 48 h for 200 ng/ml versus 340 ng/ml. Pre-transfusion residual 8-MOP levels were 168 ng/ml (plasma) and 162 ng/ml (NaCl) versus 290 ng/ml (plasma) and 266 ng/ml (NaCl) for the lower versus higher dose, respectively. DISCUSSION Hence, 8-MOP concentration influences the efficacy of photopheresis as lymphocyte apoptosis rates were significantly higher with the higher starting concentration and with NaCl versus plasma. This indicates that increased 8-MOP starting doses and saline as additional suspension medium could help in improving ECP's efficacy.
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Affiliation(s)
- Viola Hähnel
- Institute for Clinical Chemistry and Laboratory Medicine, Transfusion Medicine, University Hospital Regensburg, Regensburg, Germany
| | - Andreas-Michael Brosig
- Institute for Clinical Chemistry and Laboratory Medicine, Transfusion Medicine, University Hospital Regensburg, Regensburg, Germany
| | - Martin Ehrenschwender
- Institute of Clinical Microbiology and Hygiene, University Hospital Regensburg, Regensburg, Germany
| | - Ralph Burkhardt
- Institute for Clinical Chemistry and Laboratory Medicine, Transfusion Medicine, University Hospital Regensburg, Regensburg, Germany
| | - Robert Offner
- Institute for Clinical Chemistry and Laboratory Medicine, Transfusion Medicine, University Hospital Regensburg, Regensburg, Germany
| | - Norbert Ahrens
- Institute for Clinical Chemistry and Laboratory Medicine, Transfusion Medicine, University Hospital Regensburg, Regensburg, Germany.,MVZ for Laboratory Diagnostics, amedes, Raubling, Germany
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Zagaja M, Bryda J, Szewczyk A, Szala-Rycaj J, Łuszczki JJ, Walczak M, Kuś K, Andres-Mach M. Xanthotoxin enhances the anticonvulsant potency of levetiracetam and valproate in the 6-Hz corneal stimulation model in mice. Fundam Clin Pharmacol 2021; 36:133-142. [PMID: 34216038 DOI: 10.1111/fcp.12713] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 06/28/2021] [Indexed: 01/16/2023]
Abstract
Xanthotoxin (8-methoxypsoralen; XANT) is a furanocoumarin that has many biological properties, including antiepileptic activity. This study evaluated the effect of XANT on the ability of classical and novel antiepileptic drugs to prevent seizures evoked by the 6-Hz corneal stimulation-induced seizure model, which is thought to be an experimental model of psychomotor (limbic) seizures in humans. XANT (50 mg/kg, administered i.p.) significantly potentiated the anticonvulsant activity of levetiracetam and valproate, decreasing their median effective dose (ED50 ) values from 19.37 to 2.83 mg/kg (P < 0.01) for levetiracetam and from 92.89 to 44.44 mg/kg (P < 0.05) for valproate. Neither XANT (50 mg/kg) alone nor its combination with the anticonvulsant drugs (at their ED50 values from the 6-Hz test) affected motor coordination; skeletal muscular strength and long-term memory, as determined in the chimney; and grip strength and passive avoidance tests, respectively. Measurement of total brain antiepileptic drug concentrations revealed that XANT (50 mg/kg) had no impact on levetiracetam total brain concentrations, indicating the pharmacodynamic nature of interaction between these antiepileptic drugs in the mouse 6-Hz model. However, XANT (50 mg/kg, i.p.) significantly increased total brain concentrations of valproate (P < 0.01), indicating the pharmacokinetic nature of interactions between drugs. XANT in combination with levetiracetam exerts beneficial anticonvulsant pharmacodynamic interactions in the 6-Hz mouse psychomotor seizure model.
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Affiliation(s)
- Mirosław Zagaja
- Isobolographic Analysis Laboratory, Institute of Rural Health, Lublin, Poland
| | - Jarosław Bryda
- Isobolographic Analysis Laboratory, Institute of Rural Health, Lublin, Poland.,Department of Veterinary Hygiene, Voivodeship Veterinary Inspectorate, Lublin, Poland
| | - Aleksandra Szewczyk
- Isobolographic Analysis Laboratory, Institute of Rural Health, Lublin, Poland
| | - Joanna Szala-Rycaj
- Isobolographic Analysis Laboratory, Institute of Rural Health, Lublin, Poland
| | - Jarogniew J Łuszczki
- Isobolographic Analysis Laboratory, Institute of Rural Health, Lublin, Poland.,Department of Pathophysiology, Medical University, Lublin, Poland
| | - Maria Walczak
- Chair and Department of Toxicology, Faculty of Pharmacy, Jagiellonian University Medical College, Cracow, Poland
| | - Kamil Kuś
- Jagiellonian Centre for Experimental Therapeutics, Jagiellonian University, Cracow, Poland
| | - Marta Andres-Mach
- Isobolographic Analysis Laboratory, Institute of Rural Health, Lublin, Poland
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Hähnel V, Weber I, Tuemmler S, Graf B, Gruber M, Burkhardt R, Ahrens N. Matrix-dependent absorption of 8-methoxypsoralen in extracorporeal photopheresis. Photochem Photobiol Sci 2020; 19:1099-1103. [PMID: 32638713 DOI: 10.1039/c9pp00378a] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
BACKGROUND Extracorporeal photopheresis (ECP) is an effective immunomodulatory therapy for various diseases. Autologous leukocytes are collected, photoactivated with a photosensitizer (8-methoxypsoralen, 8-MOP) and UVA light, and subsequently reinfused back to the patient. Leukapheresis and UVA irradiation systems can be integrated into one device (inline) or handled by two separate devices (offline). ECP works via intercalation of 8-MOP into DNA helices and UVA-based interactions to inhibit DNA replication. 8-MOP is known to adhere to plastic materials, which might reduce its availability for intercalation. In the present study we examined the bioavailability of 8-MOP when different plastic materials and solvents are used as matrices. METHODS Varying amounts of shredded ethylene vinyl acetate (EVA) and polyvinylchloride (PVC) from the MacoGenic irradiation bag (EVA1), UVA PIT irradiation bag (EVA2), UVA PIT recirculation bag (PVC A) and UVA PIT tubing (PVC B) by MacoPharma and PIT Medical Systems, respectively, were incubated with 200 ng mL-1 8-MOP dissolved in diisopropyl ether (DIPE) plus toluene 90/10 vol%, deionized water or plasma. After 2 h 8-MOP concentrations were determined by GC-MS. RESULTS After incubation, 8-MOP concentrations varied depending on the amount and type of plastic (PVC > EVA) and solvent (water > plasma > DIPE/toluene). Absorption to 200 mg EVA1 or EVA2 resulted in 8-MOP concentrations of 57% or 32% in water, 91% or 80% in plasma, and 93% or 92% in DIPE/toluene, while 200 mg PVC A and PVC B yielded recovery rates of 26% and 10% in water, 76% and 75% in plasma, and 55% and 30% in DIPE/toluene, respectively. Remaining 8-MOP differed significantly between container materials (EVA vs. PVC; p < 0.022) but not manufacturers (MacoPharma vs. PIT Medical Systems). CONCLUSION Absorption loss of 8-MOP depends on the type of plastic and solvent and is more pronounced with water than with plasma. As the DNA binding effect of 8-MOP is dose-dependent, ECP starting doses should be adjusted to ensure that a sufficient concentration of free bioavailable 8-MOP is present during UV irradiation.
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Affiliation(s)
- Viola Hähnel
- Institute of Clinical Chemistry and Laboratory Medicine, Transfusion Medicine, University Hospital Regensburg, Regensburg, Germany
| | - Isabell Weber
- Department of Anesthesiology, University Hospital Regensburg, Regensburg, Germany
| | - Simon Tuemmler
- Department of Anesthesiology, University Hospital Regensburg, Regensburg, Germany
| | - Bernhard Graf
- Department of Anesthesiology, University Hospital Regensburg, Regensburg, Germany
| | - Michael Gruber
- Department of Anesthesiology, University Hospital Regensburg, Regensburg, Germany.
| | - Ralph Burkhardt
- Department of Anesthesiology, University Hospital Regensburg, Regensburg, Germany
| | - Norbert Ahrens
- Institute of Clinical Chemistry and Laboratory Medicine, Transfusion Medicine, University Hospital Regensburg, Regensburg, Germany
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Laulhé M, Lefebvre S, Le Broc-Ryckewaert D, Pierre M, Ferry A, Delorme B. A standardized methodical approach to characterize the influence of key parameters on the in vitro efficacy of extracorporeal photopheresis. PLoS One 2019; 14:e0212835. [PMID: 30822323 PMCID: PMC6396964 DOI: 10.1371/journal.pone.0212835] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 02/11/2019] [Indexed: 12/11/2022] Open
Abstract
Extracorporeal photopheresis (ECP) is an autologous immunomodulatory cell therapy that consists of the ex vivo collection of mononuclear cells (MNCs), which are irradiated with UVA in the presence of the photosensitizing agent 8-methoxypsoralen (8-MOP) to induce cell apoptosis. This photoactivated cell preparation is then reinfused into the patient. While the clinical benefits of ECP are well-demonstrated, no study has yet characterized the influence of variations in the composition of the cell preparation on the efficacy of ECP in vitro. Here, we describe a standardized methodology for the in vitro assessment of ECP that uses the human lymphoma T-cell line and mimics the clinical procedure. By quantifying cell apoptosis, inhibition of cell proliferation, and 8-MOP consumption, we used this approach to characterize the specific influence of key variables on the cellular response to ECP. We found that (i) increases in hematocrit and plasma concentrations attenuated the cellular response to ECP; (ii) plasma concentration was the only variable tested that influenced 8-MOP consumption; and (iii) the loss of efficacy due to variations in the concentration of certain blood components could be counteracted by modulating the UVA dose. This methodology may enable evaluation of other leukapheresis preparation protocols and better determination of the optimal working parameters for ECP.
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Affiliation(s)
- Marie Laulhé
- MacoPharma, Biotherapy Division, Rue Lorthiois, Mouvaux, France
| | - Sylvie Lefebvre
- MacoPharma, Biotherapy Division, Rue Lorthiois, Mouvaux, France
| | | | - Maxime Pierre
- MacoPharma, Biotherapy Division, Rue Lorthiois, Mouvaux, France
| | - Aurélie Ferry
- MacoPharma, Biotherapy Division, Rue Lorthiois, Mouvaux, France
| | - Bruno Delorme
- MacoPharma, Biotherapy Division, Rue Lorthiois, Mouvaux, France
- * E-mail:
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European Reflections on New Indications for Extracorporeal Photopheresis in Solid Organ Transplantation. Transplantation 2018; 102:1279-1283. [DOI: 10.1097/tp.0000000000002244] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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