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Ebisawa K, Iwashita T, Uchiyama K, Kitayama Y, Takeuchi T. Epstein-Barr virus-positive mucocutaneous ulcer resulting in severe methotrexate intoxication: a case report. J Med Case Rep 2024; 18:409. [PMID: 39210427 PMCID: PMC11363652 DOI: 10.1186/s13256-024-04730-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2024] [Accepted: 07/30/2024] [Indexed: 09/04/2024] Open
Abstract
BACKGROUND Epstein-Barr virus-positive mucocutaneous ulcer is one of the mature B-cell lymphoproliferative diseases occurring in patients with immune dysfunction including those with immunosuppressive treatment such as methotrexate. CASE PRESENTATION A Japanese elderly man in his 80s with rheumatoid arthritis on methotrexate was admitted to our hospital complaining persistent pharyngeal pain. Laboratory tests revealed severe pancytopenia, elevated C-reactive protein, and increased creatinine levels. An otolaryngological examination showed ulceration of the right tonsil, from which diagnostic biopsy was performed. The diagnosis of Epstein-Barr virus-positive mucocutaneous ulcer was made and bone marrow aspiration revealed hypocellularity and megaloblastic changes. Pancytopenia was improved after discontinuing methotrexate, and repeated bone marrow aspiration test revealed recovery of normal cellularity and disappearance of dysplasia, confirming the diagnosis of methotrexate intoxication. Tonsil ulcer was improved only with discontinuation of methotrexate, which strongly supported the diagnosis of EBV-MCU. CONCLUSION Our case suggested that even this best prognosis form of lymphoproliferative disease could lead to fatal complications if not appropriately managed.
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Affiliation(s)
- Kazutoshi Ebisawa
- Department of Hematology, Shizuoka Saiseikai General Hospital, 1-1 Oshika, Suruga-ku, Shizuoka, 422-8021, Japan.
| | - Toshihide Iwashita
- Department of Regenerative & Infectious Pathology, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Kohdai Uchiyama
- Department of Otorhinolaryngology, Shizuoka Saiseikai General Hospital, 1-1 Oshika, Suruga-ku, Shizuoka, 422-8021, Japan
| | - Yasuhiko Kitayama
- Department of Pathology, Shizuoka Saiseikai General Hospital, 1-1 Oshika, Suruga-ku, Shizuoka, 422-8021, Japan
| | - Takahiro Takeuchi
- Department of Hematology, Shizuoka Saiseikai General Hospital, 1-1 Oshika, Suruga-ku, Shizuoka, 422-8021, Japan
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Au-Yeung NM, Regennitter NS, Stepherson J, Seele J, Rosenblatt E, Carter W. Folate Deficiency and Medication-Induced Severe Pancytopenia in a Bilateral Lung Transplantee. Cureus 2024; 16:e65780. [PMID: 39211639 PMCID: PMC11361740 DOI: 10.7759/cureus.65780] [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] [Accepted: 07/30/2024] [Indexed: 09/04/2024] Open
Abstract
Folate is a water-soluble vitamin that is essential to DNA synthesis and replication. Its deficiency is a leading cause of megaloblastic anemia, which is often asymptomatic but can present with nonspecific symptoms, such as fatigue and lightheadedness. Folate deficiency can rarely present with pancytopenia, which has been described in past case reports but even more scarcely in transplant recipients. We present a 74-year-old bilateral lung transplantee who presented with presyncope and was found to have severe pancytopenia with folate deficiency during the initial workup. Some medications, including mycophenolate mofetil, valganciclovir, and posaconazole were held. Peripheral blood smear showed blastoid cells, but follow-up imaging and flow cytometry negated any concern for a malignant process. Bone marrow biopsy showed an extremely hypocellular marrow with marked trilineage hypoplasia. He required blood product transfusions, but his admission was overall uneventful with no life-threatening sequelae. His blood counts improved with folate replacement and discontinuation of offending medications. He was discharged after nine days in stable condition. Two months later, he experienced a milder and self-limited recurrence of pancytopenia with normal folate and cobalamin levels.
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Affiliation(s)
| | | | | | - Justin Seele
- Anesthesiology, Ochsner Clinic Foundation, New Orleans, USA
| | | | - William Carter
- Hospital Medicine, Ochsner Clinic Foundation, New Orleans, USA
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Koury MJ, Hausrath DJ. Macrocytic anemias. Curr Opin Hematol 2024; 31:82-88. [PMID: 38334746 DOI: 10.1097/moh.0000000000000804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2024]
Abstract
PURPOSE OF REVIEW Over the last century, the diseases associated with macrocytic anemia have been changing with more patients currently having hematological diseases including malignancies and myelodysplastic syndrome. The intracellular mechanisms underlying the development of anemia with macrocytosis can help in understanding normal erythropoiesis. Adaptations to these diseases involving erythroid progenitor and precursor cells lead to production of fewer but larger red blood cells, and understanding these mechanisms can provide information for possible treatments. RECENT FINDINGS Both inherited and acquired bone marrow diseases involving primarily impaired or delayed erythroid cell division or secondary adaptions to basic erythroid cellular deficits that results in prolonged cell division frequently present with macrocytic anemia. SUMMARY OF FINDINGS In marrow failure diseases, large accumulations of iron and heme in early stages of erythroid differentiation make cells in those stages especially susceptible to death, but the erythroid cells that can survive the early stages of terminal differentiation yield fewer but larger erythrocytes that are recognized clinically as macrocytic anemia. Other disorders that limit deoxynucleosides required for DNA synthesis affect a broader range of erythropoietic cells, but they also lead to macrocytic anemia. The source of macrocytosis in other diseases remains uncertain.
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Affiliation(s)
- Mark J Koury
- Division of Hematology and Oncology, Vanderbilt University Medical Center, Nashville, Tennessee, USA and Medical Service, Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee, USA
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Savic-Hartwig M, Kerlikowsky F, van de Flierdt E, Hahn A, Schuchardt JP. A micronutrient supplement modulates homocysteine levels regardless of vitamin B biostatus in elderly subjects. INT J VITAM NUTR RES 2024; 94:120-132. [PMID: 36715360 DOI: 10.1024/0300-9831/a000777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Elevated homocysteine (Hcy) levels (≥15 μmol/L) in the elderly are frequently associated with a higher risk of cardiovascular disease and cognitive decline. Several studies have already shown an Hcy-lowering effect of B vitamin supplementation in cohorts deficient in these nutrients. The aim of this randomized, double-blinded 12-week intervention study was to investigate whether Hcy levels in healthy elderly subjects (75.4±4.5 years, n=133) could be lowered with a micronutrient supplement (i.e., 400 μg folic acid, 100 μg cobalamin). Difference in mean initial Hcy levels between intervention (17.6±7.1 μmol/L, n=65) and placebo group (18.9±6.1 μmol/L, n=68) was not significant. The prevalence of cobalamin and folate deficiency in the total study population was low: 27% had serum-cobalamin levels ≤150 pmol/L, 12% holo-transcobalamin (Holo-TC) levels ≤50 pmol/L, 13% low cobalamin status using the aggregated cobalamin marker 4cB12 and 10% red blood cell (RBC) folate ≤570 nmol/L. Nevertheless, the treated subjects still showed improved cobalamin and folate biostatus (serum cobalamin Δt12-t0: 63±48 pmol/L; Holo-TC Δt12-t0: 17±19 pmol/L; RBC folate Δt12-t0: 326±253 nmol/L) and Hcy levels (Δt12-t0: -3.6±5.7 μmol/L). The effects were statistically significant compared to the placebo group with p=0.005 (serum cobalamin), p=0.021 (Holo-TC), p=0.014 (RBC-folate) and p<0.001 (Hcy). The Hcy-lowering effect was dependent on the initial Hcy levels (p<0.001). Our findings suggest that elevated Hcy levels in elderly subjects can be lowered regardless of the initial cobalamin and folate biostatus.
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Affiliation(s)
- Marija Savic-Hartwig
- Institute of Food Science and Human Nutrition, Leibniz University Hannover, Germany
| | - Felix Kerlikowsky
- Institute of Food Science and Human Nutrition, Leibniz University Hannover, Germany
| | - Edda van de Flierdt
- Institute of Food Science and Human Nutrition, Leibniz University Hannover, Germany
| | - Andreas Hahn
- Institute of Food Science and Human Nutrition, Leibniz University Hannover, Germany
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Yan X, Kong J, Wang J, Wang C, Shen H. Severe megaloblastic anemia in a patient with advanced lung adenocarcinoma during treatment with erlotinib: a case report and literature review. BMC Pulm Med 2024; 24:121. [PMID: 38448889 PMCID: PMC10919028 DOI: 10.1186/s12890-024-02935-9] [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: 09/12/2023] [Accepted: 02/27/2024] [Indexed: 03/08/2024] Open
Abstract
BACKGROUND Erlotinib is a first-generation, tyrosine kinase inhibitor of the epidermal growth factor receptor (EGFR-TKI) used for the treatment patients with NSCLC. Erlotinib is considered as a safe and effective treatment option, with generally good tolerance. Diarrhea and rash are the most common side effects, and more rare side effects appear in long-term real-world applications. Severe erlotinib related megaloblastic anemia is rare and remains unreported. This is the first case report of severe megaloblastic anemia in a patient with advanced lung adenocarcinoma with an EGFR L858R mutation treated with erlotinib. In this report, the clinical manifestations, diagnosis and treatment of erlotinib related severe megaloblastic anemia are described, and the possible pathogenesis and related treatment options are discussed. CASE DESCRIPTION Herein, we present a 57- year-old non-smoking female diagnosed with metastatic lung adenocarcinoma harboring an EGFR L858R mutation, who had received erlotinib as the first-line therapy. After 44 weeks of treatment, the patient developed severe anemia. Anemia was manifested as megaloblastic anemia with elevated mean corpuscular volume and mean corpuscular hemoglobin. The total vitamin B12 level was below the detection limit of 50.00 pg /mL. Bone marrow smear suggested megaloblastic anemia. Her hematologic parameters were markedly recovered following the withdrawal of erlotinib and vitamin B12 supplement. As a result, the patient was diagnosed with erlotinib-associated megaloblastic anemia. CONCLUSIONS This is the first case of severe megaloblastic anemia reported with erlotinib. Few of these hematologic adverse effects have been observed in studies on erlotinib, this case report highlights this possibility for long-term erlotinib administration. Close clinical and blood monitoring is recommended for patients receiving long-term TKI therapy.
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Affiliation(s)
- Xin Yan
- Department of Oncology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong Province, China
| | - Jingxian Kong
- Department of Gastroenterological surgery, Shanxian Central Hospital, Heze, Shandong Province, China
| | - Jiacheng Wang
- Department of Oncology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong Province, China
| | - Caixia Wang
- Department of Oncology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong Province, China
| | - Hongchang Shen
- Department of Oncology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong Province, China.
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Gómez CT, Borda N, Moscovicz F, Fernandez F, Lazarowski A, Auzmendi J. In vitro Effect of Cannabidiol on Red Blood Cells: Implication in Long-Lasting Pathology Treatment. Curr Pharm Des 2024; 30:2222-2228. [PMID: 38874045 DOI: 10.2174/0113816128287272240529072040] [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: 11/15/2023] [Revised: 02/28/2024] [Accepted: 03/28/2024] [Indexed: 06/15/2024]
Abstract
BACKGROUND Cannabidiol (CBD) is the principal non-hallucinogenic compound of Cannabis plants with high clinical interest because CBD has been described as having anti-inflammatory, analgesic and anticonvulsant properties. CBD is considered a multitarget compound as it can interact with a wide range of targets, explaining their multiplicity of effects. Some clinical studies have indicated certain side effects of CBD, including somnolence, anemia and diarrhea, while the elevation of transaminases is considered as an exclusion criterion from the trial. Since the red blood cells (RBCs) are a source of transaminase, we assayed in vitro effect on RBCs stability. METHODS We performed in vitro experiments with RBCs obtained from human peripheral blood with normal hematological parameters exposed to CBD in the range of therapeutic uses. We evaluated RBCs morphological changes, membrane fragility and hemoglobin release as a reflection of hemolysis. RESULTS CBD induced an increase in the hemoglobin release (3.27 μg/106 RBC), without altered RBC osmotic fragility. When RBCs suspensions were incubated with CBD the initial number of elements (RBCs + vesicles) was increased up to 65% after 20 min and returned to basal level after 40 min of incubation. In the first 20 min, the accounts of elements were enriched in the smaller vesicles that disappeared after the remaining 20 minutes. CONCLUSION These results suggest that CBD affects the indemnity of erythrocytes in vitro, inducing the formation of hemolytic vesicles that can provide the basis for the development of anemia, transaminase elevation and underlying tissular iron overload in patients chronically treated with CBD.
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Affiliation(s)
- Claudia Taborda Gómez
- Departamento de Bioquímica Clínica, Facultad de Farmacia y Bioquímica, Instituto de Fisiopatología y Bioquímica Clínica (INFIBIOC), Universidad de Buenos Aires, Buenos Aires, Argentina
- Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Buenos Aires, Argentina
| | - Natalia Borda
- Departamento de Bioquímica Clínica, Facultad de Farmacia y Bioquímica, Instituto de Fisiopatología y Bioquímica Clínica (INFIBIOC), Universidad de Buenos Aires, Buenos Aires, Argentina
| | - Franco Moscovicz
- Departamento de Bioquímica Clínica, Facultad de Farmacia y Bioquímica, Instituto de Fisiopatología y Bioquímica Clínica (INFIBIOC), Universidad de Buenos Aires, Buenos Aires, Argentina
- Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Buenos Aires, Argentina
| | - Florencia Fernandez
- Departamento de Bioquímica Clínica, Facultad de Farmacia y Bioquímica, Instituto de Fisiopatología y Bioquímica Clínica (INFIBIOC), Universidad de Buenos Aires, Buenos Aires, Argentina
| | - Alberto Lazarowski
- Departamento de Bioquímica Clínica, Facultad de Farmacia y Bioquímica, Instituto de Fisiopatología y Bioquímica Clínica (INFIBIOC), Universidad de Buenos Aires, Buenos Aires, Argentina
| | - Jerónimo Auzmendi
- Departamento de Bioquímica Clínica, Facultad de Farmacia y Bioquímica, Instituto de Fisiopatología y Bioquímica Clínica (INFIBIOC), Universidad de Buenos Aires, Buenos Aires, Argentina
- Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Buenos Aires, Argentina
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7
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Xu Z, Li Y, Liu Y, Liu S, Zhang L, Wang J, Su S, Liu L, Meng L, Zhu H, Sun J, Shao L, Li L, Zhai Y, Li G, Cao Z. Diverse associations observed between pregnancy complications and RBC or plasma folates determined by an in-house developed LC-MS/MS method. Ann Med 2023; 55:2265381. [PMID: 37824254 PMCID: PMC10572033 DOI: 10.1080/07853890.2023.2265381] [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: 06/27/2023] [Accepted: 09/26/2023] [Indexed: 10/14/2023] Open
Abstract
BACKGROUND As folates are essential for embryonic development and growth, it is necessary to accurately determine the levels of folates in plasma and red blood cells (RBCs) for clinical intervention. The aims of this study were to develop and validate a liquid chromatography-tandem mass spectrometry (LC-MS/MS) method for quantitation of folates in plasma and RBCs and to examine the association between plasma and RBC folate concentrations and gestational diabetes mellitus (GDM), gestational hypertension (GH) and preeclampsia (PE). METHODS With the in-house developed LC-MS/MS, a retrospective cross-sectional study was conducted. The healthy pregnant women of first- (n = 147), second- (n = 84) and third-trimester (n = 141) or the women diagnosed with GDM (n = 84), GH (n = 58) or PE (n = 23), that were aged between 22 and 46 years old and registered at our institute, were subjected for measurement of folic acid (FA) and 5-methyltetrahydrofolate (5-MTHF), followed by appropriate statistical association analysis. RESULTS The assay for simultaneous quantitation of FA and 5-MTHF in plasma and RBCs was linear, stable, with imprecision less than 15% and recoveries within ±10%. The lower limits of quantification for FA and 5-MTHF measurement in whole blood were 0.57 and 1.09 nmol/L, and in plasma were 0.5 and 1 nmol/L, respectively. In the association analysis, the patients with lower RBC folate level (<906 nmol/L) presented higher risks of PE development (OR 4.861 [95% CI 1.411-16.505]) by logistic regression and restricted cubic spline (RCS) regression in a nonlinear fashion. In addition, higher level of plasma folates in pregnancy was significantly associated with GH risk but may be protective for the development of GDM. CONCLUSIONS The in-house developed LC-MS/MS method for folates and metabolites in plasma or RBC showed satisfactory analytical performance for clinical application. Further, the levels of folates and metabolites were diversely associated with GDM, GH and PE development.
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Affiliation(s)
- Zhengwen Xu
- Department of Laboratory Medicine, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing Maternal and Child Health Care Hospital, Beijing, PR China
- Center of Clinical Mass Spectrometry, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing Maternal and Child Health Care Hospital, Beijing, PR China
| | - Youran Li
- Department of Laboratory Medicine, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing Maternal and Child Health Care Hospital, Beijing, PR China
- Center of Clinical Mass Spectrometry, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing Maternal and Child Health Care Hospital, Beijing, PR China
| | - Ying Liu
- Department of Laboratory Medicine, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing Maternal and Child Health Care Hospital, Beijing, PR China
- Center of Clinical Mass Spectrometry, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing Maternal and Child Health Care Hospital, Beijing, PR China
| | | | - Lin Zhang
- Department of Internal Medicine, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing Maternal and Child Health Care Hospital, Beijing, PR China
| | - Jing Wang
- Department of Internal Medicine, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing Maternal and Child Health Care Hospital, Beijing, PR China
| | - Shaofei Su
- Central Laboratory, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing Maternal and Child Health Care Hospital, Beijing, PR China
| | - Lin Liu
- Department of Laboratory Medicine, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing Maternal and Child Health Care Hospital, Beijing, PR China
- Center of Clinical Mass Spectrometry, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing Maternal and Child Health Care Hospital, Beijing, PR China
| | - Lanlan Meng
- Department of Laboratory Medicine, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing Maternal and Child Health Care Hospital, Beijing, PR China
- Center of Clinical Mass Spectrometry, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing Maternal and Child Health Care Hospital, Beijing, PR China
| | - Hongyuan Zhu
- Department of Laboratory Medicine, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing Maternal and Child Health Care Hospital, Beijing, PR China
- Center of Clinical Mass Spectrometry, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing Maternal and Child Health Care Hospital, Beijing, PR China
| | - Jingru Sun
- Health Biotech Co. Ltd, Beijing, PR China
| | - Lijun Shao
- Health Biotech Co. Ltd, Beijing, PR China
| | - Lin Li
- Health Biotech Co. Ltd, Beijing, PR China
| | - Yanhong Zhai
- Department of Laboratory Medicine, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing Maternal and Child Health Care Hospital, Beijing, PR China
- Center of Clinical Mass Spectrometry, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing Maternal and Child Health Care Hospital, Beijing, PR China
| | - Guanghui Li
- Department of Obstetrics, Beijing Obstetrics and Gynecology Hospital, Division of Endocrinology and Metabolism, Capital Medical University, Beijing Maternal and Child Health Care Hospital, Beijing, PR China
| | - Zheng Cao
- Department of Laboratory Medicine, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing Maternal and Child Health Care Hospital, Beijing, PR China
- Center of Clinical Mass Spectrometry, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing Maternal and Child Health Care Hospital, Beijing, PR China
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Kumar N. Nutritional Neuropathies. Continuum (Minneap Minn) 2023; 29:1469-1491. [PMID: 37851039 DOI: 10.1212/con.0000000000001292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2023]
Abstract
OBJECTIVE This article reviews the etiologies, presentations, and management of neuropathies related to nutritional deficiencies. LATEST DEVELOPMENTS Peripheral neuropathy can be the predominant or only manifestation of certain nutrient deficiencies. Cognitive difficulties or involvement of other parts of the central nervous system, such as the optic nerve and spinal cord, may accompany nutritional peripheral neuropathies. In most patients, the nutritional deficiency may have a single predominant cause, but in some cases, multiple causes may coexist. Obesity, for unclear reasons, can be associated with nutrient deficiencies. The rising rates of bariatric surgery and the incidence of nutrient deficiencies following bariatric surgery make this a particularly relevant topic for neurologists. ESSENTIAL POINTS Neuropathies caused by nutrient deficiencies are preventable with appropriate supplementation in high-risk situations. Early recognition and prompt treatment are essential to ensure an optimal outcome and minimize neurologic morbidity.
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Mirceta M, Shum N, Schmidt MHM, Pearson CE. Fragile sites, chromosomal lesions, tandem repeats, and disease. Front Genet 2022; 13:985975. [PMID: 36468036 PMCID: PMC9714581 DOI: 10.3389/fgene.2022.985975] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 09/02/2022] [Indexed: 09/16/2023] Open
Abstract
Expanded tandem repeat DNAs are associated with various unusual chromosomal lesions, despiralizations, multi-branched inter-chromosomal associations, and fragile sites. Fragile sites cytogenetically manifest as localized gaps or discontinuities in chromosome structure and are an important genetic, biological, and health-related phenomena. Common fragile sites (∼230), present in most individuals, are induced by aphidicolin and can be associated with cancer; of the 27 molecularly-mapped common sites, none are associated with a particular DNA sequence motif. Rare fragile sites ( ≳ 40 known), ≤ 5% of the population (may be as few as a single individual), can be associated with neurodevelopmental disease. All 10 molecularly-mapped folate-sensitive fragile sites, the largest category of rare fragile sites, are caused by gene-specific CGG/CCG tandem repeat expansions that are aberrantly CpG methylated and include FRAXA, FRAXE, FRAXF, FRA2A, FRA7A, FRA10A, FRA11A, FRA11B, FRA12A, and FRA16A. The minisatellite-associated rare fragile sites, FRA10B, FRA16B, can be induced by AT-rich DNA-ligands or nucleotide analogs. Despiralized lesions and multi-branched inter-chromosomal associations at the heterochromatic satellite repeats of chromosomes 1, 9, 16 are inducible by de-methylating agents like 5-azadeoxycytidine and can spontaneously arise in patients with ICF syndrome (Immunodeficiency Centromeric instability and Facial anomalies) with mutations in genes regulating DNA methylation. ICF individuals have hypomethylated satellites I-III, alpha-satellites, and subtelomeric repeats. Ribosomal repeats and subtelomeric D4Z4 megasatellites/macrosatellites, are associated with chromosome location, fragility, and disease. Telomere repeats can also assume fragile sites. Dietary deficiencies of folate or vitamin B12, or drug insults are associated with megaloblastic and/or pernicious anemia, that display chromosomes with fragile sites. The recent discovery of many new tandem repeat expansion loci, with varied repeat motifs, where motif lengths can range from mono-nucleotides to megabase units, could be the molecular cause of new fragile sites, or other chromosomal lesions. This review focuses on repeat-associated fragility, covering their induction, cytogenetics, epigenetics, cell type specificity, genetic instability (repeat instability, micronuclei, deletions/rearrangements, and sister chromatid exchange), unusual heritability, disease association, and penetrance. Understanding tandem repeat-associated chromosomal fragile sites provides insight to chromosome structure, genome packaging, genetic instability, and disease.
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Affiliation(s)
- Mila Mirceta
- Program of Genetics and Genome Biology, The Hospital for Sick Children, The Peter Gilgan Centre for Research and Learning, Toronto, ON, Canada
- Program of Molecular Genetics, University of Toronto, Toronto, ON, Canada
| | - Natalie Shum
- Program of Genetics and Genome Biology, The Hospital for Sick Children, The Peter Gilgan Centre for Research and Learning, Toronto, ON, Canada
- Program of Molecular Genetics, University of Toronto, Toronto, ON, Canada
| | - Monika H. M. Schmidt
- Program of Genetics and Genome Biology, The Hospital for Sick Children, The Peter Gilgan Centre for Research and Learning, Toronto, ON, Canada
- Program of Molecular Genetics, University of Toronto, Toronto, ON, Canada
| | - Christopher E. Pearson
- Program of Genetics and Genome Biology, The Hospital for Sick Children, The Peter Gilgan Centre for Research and Learning, Toronto, ON, Canada
- Program of Molecular Genetics, University of Toronto, Toronto, ON, Canada
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10
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Cora M. Black Cohosh Herbal Extract and Hematologic Alterations in B6C3F1/N Mice. Toxicol Pathol 2022; 50:886-889. [DOI: 10.1177/01926233221133549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Black cohosh is a readily available dietary supplement currently marketed as a remedy for dysmenorrhea and menopausal symptoms and is one of the top-selling herbal supplements in the United States. Black cohosh extract (BCE) was nominated to the National Toxicology Program (NTP) by the National Cancer Institute and the National Institute of Environmental Health Sciences due to its widespread use and lack of animal toxicity studies. Results of the NTP BCE subchronic mouse toxicity study revealed a dose-dependent, non-regenerative decrease in the erythron with an increase in the mean corpuscular volume (macrocytosis). Howell-Jolly bodies, or micronuclei, were significantly increased. These particular changes indicated an ineffective erythropoiesis consistent with a condition known as megaloblastic anemia. Megaloblastic anemia is due to disruptions in DNA synthesis during hematopoiesis and can be a result of an inherited or drug-induced disorder or a consequence of folate or cobalamin deficiency. Subsequent mouse studies revealed hematological and biochemical changes that were consistent with a functional cobalamin deficiency. This article will review basic mechanisms and laboratory features of megaloblastic anemia. The results of our studies including morphological abnormalities of the erythron and biomarkers of folate and cobalamin deficiencies, as well as hepatic microarray gene changes, are also discussed.
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11
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Zamek-Gliszczynski MJ, Sangha V, Shen H, Feng B, Wittwer MB, Varma MVS, Liang X, Sugiyama Y, Zhang L, Bendayan R. Transporters in drug development: International transporter consortium update on emerging transporters of clinical importance. Clin Pharmacol Ther 2022; 112:485-500. [PMID: 35561119 DOI: 10.1002/cpt.2644] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 05/08/2022] [Indexed: 11/07/2022]
Abstract
During its 4th transporter workshop in 2021, the International Transporter Consortium (ITC) provided updates on emerging clinically relevant transporters for drug development. Previously highlighted and new transporters were considered based on up-to-date clinical evidence of their importance in drug-drug interactions and potential for altered drug efficacy and safety, including drug-nutrient interactions leading to nutrient deficiencies. For the first time, folate transport pathways (PCFT, RFC, and FRα) were examined in-depth as a potential mechanism of drug-induced folate deficiency and related toxicities (e.g., neural tube defects, megaloblastic anemia). However, routine toxicology studies conducted in support of drug development appear sufficient to flag such folate deficiency toxicities, while prospective prediction from in vitro folate metabolism and transport inhibition is not well enough established to inform drug development. Previous suggestion of retrospective study of intestinal OATP2B1 inhibition to explain unexpected decreases in drug exposure were updated. Furthermore, when the absorption of a new molecular entity is more rapid and extensive than can be explained by passive permeability, evaluation of OATP2B1 transport may be considered. Emerging research on hepatic and renal OAT2 is summarized, but current understanding of the importance of OAT2 was deemed insufficient to justify specific consideration for drug development. Hepatic, renal, and intestinal MRPs (MRP2, MRP3, MRP4) were revisited. MRPs may be considered when they are suspected to be the major determinant of drug disposition (e.g., direct glucuronide conjugates); MRP2 inhibition as a mechanistic explanation for drug-induced hyperbilirubinemia remains justified. There were no major changes in recommendations from previous ITC whitepapers.
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Affiliation(s)
| | - Vishal Sangha
- Department of Pharmaceutical Sciences, University of Toronto, Leslie Dan Faculty of Pharmacy, 144 College Street, Toronto, ON, M5S 3M2, Canada
| | - Hong Shen
- Drug Metabolism and PK, Bristol Myers Squibb Company, Route 206 & Province Line Road, Princeton, NJ, 08543, USA
| | - Bo Feng
- Drug Metabolism and PK, Vertex Pharmaceuticals, Inc, 50 Northern Avenue, Boston, MA, 02210, USA
| | - Matthias B Wittwer
- Roche Pharma Research and Early Development, Pharmaceutical Sciences, Roche Innovation Center Basel, F. Hoffmann-La Roche Ltd, Grenzacherstrasse 124, CH-4070, Basel, Switzerland
| | - Manthena V S Varma
- PK, Dynamics and Metabolism, Medicine Design, Pfizer Inc, Worldwide R&D, Groton, CT, 06340, USA
| | - Xiaomin Liang
- Drug Metabolism, Gilead Sciences, Inc, 333 Lakeside Drive, Foster City, CA, 94404, USA
| | - Yuichi Sugiyama
- Laboratory of Quantitative System PK/Pharmacodynamics, School of Pharmacy, Josai International University, Kioicho Campus, Tokyo, 102-0093, Japan
| | - Lei Zhang
- Office of Research and Standards, Office of Generic Drugs, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, 10903 New Hampshire Ave, Silver Spring, MD, 20993, USA
| | - Reina Bendayan
- Department of Pharmaceutical Sciences, University of Toronto, Leslie Dan Faculty of Pharmacy, 144 College Street, Toronto, ON, M5S 3M2, Canada
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12
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Torrez M, Chabot-Richards D, Babu D, Lockhart E, Foucar K. How I investigate acquired megaloblastic anemia. Int J Lab Hematol 2022; 44:236-247. [PMID: 34981651 DOI: 10.1111/ijlh.13789] [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: 03/23/2021] [Accepted: 10/20/2021] [Indexed: 12/01/2022]
Abstract
In this review of megaloblastic anemia (MA), an overview of vitamin B12 and folate body requirements, biochemical pathways, and laboratory testing strategies will be provided. However, the focus of this review is the classic and unique features of MA in blood and bone marrow. Acquired MA is a benign disorder for many, but can be detrimental for some. The clinical presentation can vary considerably, and the spectrum of symptoms and signs is diverse and quite broad. Prompt recognition and therapy are critical to prevent potential irreversible damage and clinical sequelae, especially in patients with vitamin B12 deficiency. A delay in diagnosis of vitamin B12 deficiency can result in significant neurologic sequelae that may not fully resolve with treatment, including in neonates and young infants. The blood and bone marrow features in MA can closely mimic thrombocytopenic purpura, myelodysplasia, and other myeloid neoplasms. Both pancytopenia and normal MCV at presentation are common in MA and raise unique challenges for the diagnostician. Partially treated MA is also a significant diagnostic "trap". MA is highly responsive to treatment, and patients tend to improve rapidly upon treatment initiation. However, the broad range of clinical and hematologic features makes the rapid, successful diagnosis of MA a unique challenge for the hematopathologist. Even in the era of state-of-the-art laboratory testing, a high suspicion is required.
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Affiliation(s)
- Mary Torrez
- Department of Pathology, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA
| | - Devon Chabot-Richards
- Department of Pathology, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA
| | - Daniel Babu
- Department of Pathology, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA
| | - Evelyn Lockhart
- Department of Pathology, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA
| | - Kathryn Foucar
- Department of Pathology, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA
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13
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Kinoshita H, Watanabe A, Taji Y, Yoshimura M, Ohta A, Fukushima T, Tanaka R, Ebihara Y. Cobalamin deficiency during treatment of pediatric precursor B-cell acute lymphoblastic leukemia. Pediatr Blood Cancer 2021; 68:e29258. [PMID: 34302713 DOI: 10.1002/pbc.29258] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 07/08/2021] [Accepted: 07/09/2021] [Indexed: 11/09/2022]
Affiliation(s)
- Hiromi Kinoshita
- Clinical Laboratory, Saitama Medical University International Medical Center, Saitama, Japan
| | - Atsuko Watanabe
- Department of Pediatric Hematology/Oncology, Saitama Medical University International Medical Center, Saitama, Japan
| | - Yoshitada Taji
- Clinical Laboratory, Saitama Medical University International Medical Center, Saitama, Japan
| | - Moe Yoshimura
- Department of Pediatric Hematology/Oncology, Saitama Medical University International Medical Center, Saitama, Japan
| | - Atsuhiko Ohta
- Department of Pediatric Hematology/Oncology, Saitama Medical University International Medical Center, Saitama, Japan
| | - Takashi Fukushima
- Department of Pediatric Hematology/Oncology, Saitama Medical University International Medical Center, Saitama, Japan
| | - Ryuhei Tanaka
- Department of Pediatric Hematology/Oncology, Saitama Medical University International Medical Center, Saitama, Japan
| | - Yasuhiro Ebihara
- Clinical Laboratory, Saitama Medical University International Medical Center, Saitama, Japan.,Department of Laboratory Medicine, Saitama Medical University International Medical Center, Saitama, Japan
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14
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Hofmann P, Buetikofer C, Bächli E. Hyperregenerative macrocytic anaemia: the role of copper and zinc. BMJ Case Rep 2021; 14:e241028. [PMID: 33853819 PMCID: PMC8054059 DOI: 10.1136/bcr-2020-241028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/31/2021] [Indexed: 11/04/2022] Open
Abstract
In a patient with a history of bariatric surgery, severe copper deficiency presenting with macrocytic hyperregenerative anaemia was diagnosed. Besides the impaired intestinal absorption due to a short bowel syndrome, the enteral zinc supplementation competitively decreased the intestinal copper uptake. Once the zinc supplementation was stopped, enteral copper replacement ensued and normalised haemoglobin levels with decreasing median corpuscular volume were observed during follow-up visits.
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Affiliation(s)
| | | | - Esther Bächli
- Internal Medicine, Hospital Uster, Uster, Switzerland
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15
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Madrazo L, Jones E, Hsia CC. Anémie grave induite par l’azathioprine et potentialisée par l’emploi concomitant d’allopurinol. CMAJ 2021; 193:E460-E463. [PMID: 33782177 PMCID: PMC8099162 DOI: 10.1503/cmaj.201022-f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Lorenzo Madrazo
- Département de médecine (Madrazo, Jones) et division d'hématologie (Hsia), Département de médecine, Centre des sciences de la santé de London, Université Western Ontario, London, Ont.
| | - Emily Jones
- Département de médecine (Madrazo, Jones) et division d'hématologie (Hsia), Département de médecine, Centre des sciences de la santé de London, Université Western Ontario, London, Ont
| | - Cyrus C Hsia
- Département de médecine (Madrazo, Jones) et division d'hématologie (Hsia), Département de médecine, Centre des sciences de la santé de London, Université Western Ontario, London, Ont
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16
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Enogieru OJ, Koleske ML, Vora B, Ngo H, Yee SW, Chatad D, Sirota M, Giacomini KM. The Effects of Genetic Mutations and Drugs on the Activity of the Thiamine Transporter, SLC19A2. AAPS JOURNAL 2021; 23:35. [PMID: 33649974 PMCID: PMC7921063 DOI: 10.1208/s12248-021-00562-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 01/26/2021] [Indexed: 01/12/2023]
Abstract
A rare cause of megaloblastic anemia (MA) is thiamine-responsive megaloblastic anemia (TRMA), a genetic disorder caused by mutations in SLC19A2 (encoding THTR1), a thiamine transporter. The study objectives were to (1) functionally characterize selected TRMA-associated SLC19A2 variants and (2) determine whether current prescription drugs associated with drug-induced MA (DIMA) may act via inhibition of SLC19A2. Functional characterization of selected SLC19A2 variants was performed by confocal microscopy and isotopic uptake studies of [3H]-thiamine in HEK293 cells. Sixty-three drugs associated with DIMA were screened for SLC19A2 inhibition in isotopic uptake studies. Three previously uncharacterized SLC19A2 variants identified in TRMA patients exhibited disrupted localization to the plasma membrane along with near-complete loss-of-function. Ten of 63 drugs inhibited SLC19A2-mediated thiamine transport ≥ 50% at screening concentrations; however, with the exception of erythromycin, none was predicted to inhibit SLC19A2 at clinically relevant unbound plasma concentrations. Data from electronic health records revealed reduced levels of thiamine pyrophosphate (TPP) in patients prescribed erythromycin, consistent with inhibition of SLC19A2-mediated thiamine transport. Here, we confirmed the role of three SLC19A2 variants in TRMA pathology. Additionally, we report that inhibition of SLC19A2 is a potential, but uncommon mechanism for DIMA.
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Affiliation(s)
- Osatohanmwen J Enogieru
- Department of Bioengineering and Therapeutic Sciences, University of California at San Francisco, San Francisco, California, 94158, USA
| | - Megan L Koleske
- Department of Bioengineering and Therapeutic Sciences, University of California at San Francisco, San Francisco, California, 94158, USA
| | - Bianca Vora
- Department of Bioengineering and Therapeutic Sciences, University of California at San Francisco, San Francisco, California, 94158, USA
| | - Huy Ngo
- Department of Bioengineering and Therapeutic Sciences, University of California at San Francisco, San Francisco, California, 94158, USA
| | - Sook Wah Yee
- Department of Bioengineering and Therapeutic Sciences, University of California at San Francisco, San Francisco, California, 94158, USA
| | - Derrick Chatad
- College of Medicine, SUNY Downstate Health Sciences University, Brooklyn, New York, 11203, USA
| | - Marina Sirota
- Department of Pediatrics, University of California at San Francisco, San Francisco, California, 94158, USA.,Institute of Human Genetics, University of California at San Francisco, San Francisco, California, 94158, USA.,Bakar Computational Health Sciences Institute, University of California at San Francisco, San Francisco, California, 94158, USA
| | - Kathleen M Giacomini
- Department of Bioengineering and Therapeutic Sciences, University of California at San Francisco, San Francisco, California, 94158, USA. .,Institute of Human Genetics, University of California at San Francisco, San Francisco, California, 94158, USA.
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17
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Upadhyay B, Green SD, Khanal N, Antony AC. Clinical conundrum: managing iron overload after renal transplantation. BMJ Case Rep 2021; 14:14/2/e239568. [PMID: 33547097 PMCID: PMC7871264 DOI: 10.1136/bcr-2020-239568] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Iatrogenic iron overload, which is not uncommon in patients undergoing long-term haemodialysis, arises from a combination of multiple red cell transfusions and parenteral iron infusions that are administered to maintain a haemoglobin concentration of approximately 10 g/dL. Although iron overload due to genetic haemochromatosis is conventionally managed by phlebotomy, patients with haemoglobinopathies and chronic transfusion-induced iron overload are treated with iron-chelation therapy. However, the management of iron overload in our patient who presented with hepatic dysfunction and immunosuppressive drug-induced mild anaemia in the post-renal transplant setting posed unique challenges. We report on the decision-making process used in such a case that led to a successful clinical resolution of hepatic iron overload through the combined use of phlebotomy and erythropoiesis stimulating agents, while avoiding use of iron-chelating agents that could potentially compromise both hepatic and renal function.
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Affiliation(s)
- Binayak Upadhyay
- Internal Medicine, AMITA Health Saint Francis Hospital Evanston, Evanston, Illinois, USA
| | - Steven D Green
- Division of Hematology-Oncology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Nabin Khanal
- Division of Hematology-Oncology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Aśok C Antony
- Division of Hematology-Oncology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA,Medicine Service (Hematology-Oncology Section), Richard L Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana, USA
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18
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Heidemann J, Schmitz B, Kostev K. Association between antiseizure medication use and risk of urinary tract infection: A case-control study. Epilepsy Behav 2021; 115:107502. [PMID: 33323337 DOI: 10.1016/j.yebeh.2020.107502] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 08/31/2020] [Accepted: 09/11/2020] [Indexed: 12/23/2022]
Abstract
AIM The aim of this study was to analyze the association between antiseizure medication (ASM) and the risk of urinary tract infections (UTI) in patients with epilepsy treated in general practices in Germany. METHODS This study includes a total of 2201 patients (mean age: 61.4) whose first documented UTI diagnosis occurred between January 2015 and December 2019 (index date) and who were prescribed at least one ASM in 1198 general practices in Germany within one year prior to the index date. Based on a case-control design, the association between predefined criteria and UTI was investigated by matching (1:1) controls without UTI to cases with UTI by sex, age, and codiagnoses. Logistic regression models were used to analyze the association between ASM use and UTI risk. RESULTS In the first regression model, phenytoin (PHT), primidone, carbamazepine (CBZ), and valproate (VPA) were associated with an increased risk of UTI. In the second model, these associations were confirmed with effects per prescription for PHT, primidone, CBZ, and VPA use. Additionally, the effect per prescription was significant for oxcarbazepine (OXC), topiramate, and gabapentin. CONCLUSION The study found that PHT, primidone, CBZ, and VPA in particular are associated with an increased risk of infections of the urinary tract. Oxcarbazepine, topiramate, and gabapentin are also associated with increased risk of UTI, albeit to a less significant extent. In general, the immunological and hematological side effects of these molecules may play an important role in the development of UTI under anticonvulsant therapy.
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Affiliation(s)
| | - Bettina Schmitz
- Department of Neurology, Vivantes Humboldt-Klinikum, Berlin, Germany
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19
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Madrazo L, Jones E, Hsia CC. Azathioprine-induced severe anemia potentiated by the concurrent use of allopurinol. CMAJ 2021; 193:E94-E97. [PMID: 33462145 PMCID: PMC7835086 DOI: 10.1503/cmaj.201022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Affiliation(s)
- Lorenzo Madrazo
- Department of Medicine (Madrazo, Jones) and Division of Hematology (Hsia), Department of Medicine, London Health Sciences Centre, University of Western Ontario, London, Ont.
| | - Emily Jones
- Department of Medicine (Madrazo, Jones) and Division of Hematology (Hsia), Department of Medicine, London Health Sciences Centre, University of Western Ontario, London, Ont
| | - Cyrus C Hsia
- Department of Medicine (Madrazo, Jones) and Division of Hematology (Hsia), Department of Medicine, London Health Sciences Centre, University of Western Ontario, London, Ont
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20
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Bessière B, Iris F, Milet A, Beopoulos A, Billoet C, Farjot G. A new mechanistic approach for the treatment of chronic neuropathic pain with nitrous oxide integrated from a systems biology narrative review. Med Gas Res 2021; 11:34-41. [PMID: 33642336 PMCID: PMC8103977 DOI: 10.4103/2045-9912.310058] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 07/24/2020] [Accepted: 07/24/2020] [Indexed: 12/25/2022] Open
Abstract
The limitations of the currently available treatments for chronic neuropathic pain highlight the need for safer and more effective alternatives. The authors carried out a focused review using a systems biology approach to integrate the complex mechanisms of nociception and neuropathic pain, and to decipher the effects of nitrous oxide (N2O) on those pathways, beyond the known effect of N2O on N-methyl-D-aspartate receptors. This review identified a number of potential mechanisms by which N2O could impact the processes involved in peripheral and central sensitization. In the ascending pathway, the effects of N2O include activating TWIK-related K+ channel 1 potassium channels on first-order neurons, blocking voltage-dependent calcium channels to attenuate neuronal excitability, attenuating postsynaptic glutamatergic receptor activation, and possibly blocking voltage-dependent sodium channels. In the descending pathway, N2O induces the release of endogenous opioid ligands and stimulates norepinephrine release. In addition, N2O may mediate epigenetic changes by inhibiting methionine synthase, a key enzyme involved in DNA and RNA methylation. This could explain why this short-acting analgesic has shown long-lasting anti-pain sensitization effects in animal models of chronic pain. These new hypotheses support the rationale for investigating N2O, either alone or in combination with other analgesics, for the management of chronic neuropathic pain.
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Affiliation(s)
- Baptiste Bessière
- Air Liquide Santé International, Paris Innovation Campus, Jouy-en-Josas, France
| | | | - Aude Milet
- Air Liquide Santé International, Paris Innovation Campus, Jouy-en-Josas, France
| | | | - Catherine Billoet
- Air Liquide Santé International, Paris Innovation Campus, Jouy-en-Josas, France
| | - Géraldine Farjot
- Air Liquide Santé International, Paris Innovation Campus, Jouy-en-Josas, France
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21
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Malka R, Brugnara C, Cialic R, Higgins JM. Non-Parametric Combined Reference Regions and Prediction of Clinical Risk. Clin Chem 2020; 66:363-372. [PMID: 32040586 DOI: 10.1093/clinchem/hvz020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 09/25/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Many clinical decisions depend on estimating patient risk of clinical outcomes by interpreting test results relative to reference intervals, but standard application of reference intervals suffers from two major limitations that reduce the accuracy of clinical decisions: (1) each test result is assessed separately relative to a univariate reference interval, ignoring the rich pathophysiologic information in multivariate relationships, and (2) reference intervals are intended to reflect a population's biological characteristics and are not calibrated for outcome prediction. METHODS We developed a combined reference region (CRR), derived CRRs for some pairs of complete blood count (CBC) indices (RBC, MCH, RDW, WBC, PLT), and assessed whether the CRR could enhance the univariate reference interval's prediction of a general clinical outcome, 5-year mortality risk (MR). RESULTS The CRR significantly improved MR estimation for 21/21 patient subsets defined by current univariate reference intervals. The CRR identified individuals with >2-fold increase in MR in many cases and uniformly improved the accuracy for all five pairs of tests considered. Overall, the 95% CRR identified individuals with a >7× increase in 5-year MR. CONCLUSIONS The CRR enhances the accuracy of the prediction of 5-year MR relative to current univariate reference intervals. The CRR generalizes to higher numbers of tests or biomarkers, as well as to clinical outcomes more specific than MR, and may provide a general way to use existing data to enhance the accuracy and precision of clinical decisions.
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Affiliation(s)
- Roy Malka
- Center for Systems Biology and Department of Pathology, Massachusetts General Hospital, Boston, MA.,Department of Systems Biology, Harvard Medical School, Boston, MA
| | - Carlo Brugnara
- Department of Laboratory Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Ron Cialic
- Tel Aviv Sourasky Medical Center, Tel Aviv University, Sackler Medical School, Tel Aviv, Israel
| | - John M Higgins
- Center for Systems Biology and Department of Pathology, Massachusetts General Hospital, Boston, MA.,Department of Systems Biology, Harvard Medical School, Boston, MA
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22
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Management of antiepileptic drug-induced nutrition-related adverse effects. Neurol Sci 2020; 41:3491-3502. [PMID: 32661886 DOI: 10.1007/s10072-020-04573-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 07/02/2020] [Indexed: 12/28/2022]
Abstract
Although antiepileptic drugs (AEDs) are mainstay of the treatment of epilepsy, they are associated with significant adverse effects. The present study reviews the adverse effects of AEDs on some of the nutrition-related issues, including bone health, body weight, glucose and lipid metabolism, vitamin homeostasis, antioxidant defense system, and pregnancy. This paper also provides some nutritional recommendations for people with epilepsy. Patients with epilepsy should be regularly evaluated with regard to their nutrition status and any possible nutritional problems. Daily intake of adequate amounts of all nutrients from various sources should be encouraged, especially for vulnerable groups such as children, adolescents, elderly, and pregnant women. When necessary, preventative or therapeutic supplementation with appropriate micronutrients could be helpful. Graphical abstract.
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23
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Cobalamin Deficiency in the Elderly. Mediterr J Hematol Infect Dis 2020; 12:e2020043. [PMID: 32670521 PMCID: PMC7340236 DOI: 10.4084/mjhid.2020.043] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 05/30/2020] [Indexed: 12/16/2022] Open
Abstract
Older people are at risk for cobalamin (vitamin B12) deficiency because of a number of common disorders (e.g., autoimmune gastritis) and drugs (e.g., antacids) that may alter its absorption and utilization. The prevalence of cobalamin deficiency increases with age, resulting, particularly elevated, in frail and institutionalized subjects. At variance with common sense, the diagnosis is far from simple. It requires a high degree of suspicion, due to heterogeneity and non-specificity of the signs and symptoms, ranging from macrocytosis (with or without anemia) to neuropsychiatric manifestations, that characterize several other aging-related disorders, like hematological malignancies, diabetes, hypothyroidism or vasculopathy. Furthermore, the detection of low levels of serum vitamin B12 appears poorly sensitive and specific. Other biomarkers, like serum homocysteine or methylmalonic acid, have improved the diagnostic possibilities but are expensive, not widely available, and may be influenced by some confounders (e.g., folate deficiency, or chronic renal failure). Early recognition and treatment are crucial since a proportion of patients develop severe complications, such as bone marrow failure and irreversible neurological impairment. High-dose oral treatment has proven to be as effective as the parenteral route, even in subjects with malabsorption, ensuring the complete resolution in the majority of cases. In this review, we trace the essential role of cobalamin in humans, the possible causes and impact of deficiency, the diagnostic challenges and the therapeutic options, between old and emerging concepts, with a particular focus on the elderly.
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24
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Ao M, Nagae A, Makino S, Kitagawa M, Kumode M, Kuwabara A, Fukuwatari T, Miyawaki T, Tanaka K. Gastric and Jejunal Enteral Feeding Differently Affect Vitamin B 12 Status in Subjects with Severe Motor and Intellectual Disabilities. J Nutr Sci Vitaminol (Tokyo) 2020; 65:541-544. [PMID: 31902868 DOI: 10.3177/jnsv.65.541] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The absorption of vitamin B12 is a complex process involving gastric acid and intrinsic factor as the indispensable components. In this study, we have investigated the effects of the administration site in enteral feeding on vitamin B12 status in subjects with severe motor and intellectual disabilities (SMID). This is a cross-sectional study conducted from January to June 2016. Blood concentrations of vitamin B12, folate, vitamin B6, and homocysteine (Hcy) were measured in a total of 82 subjects (38 men, 44 women). Also, nutrients intake was assessed. Subjects with enteral feeding (EF) had significantly higher intakes of vitamin B12, folate, and vitamin B6 than those with oral ingestion (OI). Serum folate and vitamin B6 concentrations in subjects with EF were significantly higher than those with OI. Among the EF subjects, serum vitamin B12 concentration was significantly higher in those fed with gastric tube than those fed with jejunal tube in spite of similar vitamin B12 intakes. No significant difference was observed between the two groups regarding the circulating concentrations of folate, vitamin B6, or Hcy. Although each administration route has its own benefit, gastric tube is advantageous in the absorption of vitamin B12.
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Affiliation(s)
- Misora Ao
- Department of Food and Nutrition, Kyoto Women's University
| | - Akiko Nagae
- Biwakogakuen Kusatsu Medical and Welfare Center for Disabilities
| | - Sumire Makino
- Department of Nutrition, School of Human Cultures, The University of Shiga Prefecture
| | - Mari Kitagawa
- Biwakogakuen Kusatsu Medical and Welfare Center for Disabilities
| | - Masao Kumode
- Biwakogakuen Kusatsu Medical and Welfare Center for Disabilities
| | - Akiko Kuwabara
- Department of Clinical Nutrition, Faculty of Comprehensive Rehabilitation, Osaka Prefecture University
| | - Tsutomu Fukuwatari
- Department of Nutrition, School of Human Cultures, The University of Shiga Prefecture
| | | | - Kiyoshi Tanaka
- Department of Food and Nutrition, Kyoto Women's University.,Faculty of Nutrition, Kobe Gakuin University
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25
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Gwathmey KG, Grogan J. Nutritional neuropathies. Muscle Nerve 2019; 62:13-29. [PMID: 31837157 DOI: 10.1002/mus.26783] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 12/07/2019] [Accepted: 12/07/2019] [Indexed: 12/17/2022]
Abstract
Neuropathies associated with nutritional deficiencies are routinely encountered by the practicing neurologist. Although these neuropathies assume different patterns, most are length-dependent, sensory axonopathies. Cobalamin deficiency neuropathy is the exception, often presenting with a non-length-dependent sensory neuropathy. Patients with cobalamin and copper deficiency neuropathy characteristically have concomitant myelopathy, whereas vitamin E deficiency is uniquely associated with a spinocerebellar syndrome. In contrast to those nutrients for which deficiencies produce neuropathies, pyridoxine toxicity results in a non-length-dependent sensory neuronopathy. Deficiencies occur in the context of malnutrition, malabsorption, increased nutrient loss (such as with dialysis), autoimmune conditions such as pernicious anemia, and with certain drugs that inhibit nutrient absorption. When promptly identified, therapeutic nutrient supplementation may result in stabilization or improvement of these neuropathies.
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Affiliation(s)
| | - James Grogan
- University of Virginia, Charlottesville, Virginia
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Shi Y, Manis M, Long J, Wang K, Sullivan PM, Remolina Serrano J, Hoyle R, Holtzman DM. Microglia drive APOE-dependent neurodegeneration in a tauopathy mouse model. J Exp Med 2019; 216:2546-2561. [PMID: 31601677 PMCID: PMC6829593 DOI: 10.1084/jem.20190980] [Citation(s) in RCA: 243] [Impact Index Per Article: 48.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Revised: 07/21/2019] [Accepted: 08/08/2019] [Indexed: 11/16/2022] Open
Abstract
Shi et al. find that microglia, instead of tau-induced direct neurotoxicity, are the driving force of neurodegeneration in a tauopathy mouse model. Microglia are also required for tau pathogenesis. In addition, apoE strongly regulates neurodegeneration in the setting of tauopathy predominantly by modulating microglial function. Chronic activation of brain innate immunity is a prominent feature of Alzheimer’s disease (AD) and primary tauopathies. However, to what degree innate immunity contributes to neurodegeneration as compared with pathological protein-induced neurotoxicity, and the requirement of a particular glial cell type in neurodegeneration, are still unclear. Here we demonstrate that microglia-mediated damage, rather than pathological tau-induced direct neurotoxicity, is the leading force driving neurodegeneration in a tauopathy mouse model. Importantly, the progression of ptau pathology is also driven by microglia. In addition, we found that APOE, the strongest genetic risk factor for AD, regulates neurodegeneration predominantly by modulating microglial activation, although a minor role of apoE in regulating ptau and insoluble tau formation independent of its immunomodulatory function was also identified. Our results suggest that therapeutic strategies targeting microglia may represent an effective approach to prevent disease progression in the setting of tauopathy.
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Affiliation(s)
- Yang Shi
- Department of Neurology, Hope Center for Neurological Disorders, Charles F. and Joanne Knight Alzheimer's Disease Research Center, Washington University School of Medicine, St. Louis, MO
| | - Melissa Manis
- Department of Neurology, Hope Center for Neurological Disorders, Charles F. and Joanne Knight Alzheimer's Disease Research Center, Washington University School of Medicine, St. Louis, MO
| | - Justin Long
- Department of Neurology, Hope Center for Neurological Disorders, Charles F. and Joanne Knight Alzheimer's Disease Research Center, Washington University School of Medicine, St. Louis, MO
| | - Kairuo Wang
- Department of Neurology, Hope Center for Neurological Disorders, Charles F. and Joanne Knight Alzheimer's Disease Research Center, Washington University School of Medicine, St. Louis, MO
| | | | - Javier Remolina Serrano
- Department of Neurology, Hope Center for Neurological Disorders, Charles F. and Joanne Knight Alzheimer's Disease Research Center, Washington University School of Medicine, St. Louis, MO
| | - Rosa Hoyle
- Department of Neurology, Hope Center for Neurological Disorders, Charles F. and Joanne Knight Alzheimer's Disease Research Center, Washington University School of Medicine, St. Louis, MO
| | - David M Holtzman
- Department of Neurology, Hope Center for Neurological Disorders, Charles F. and Joanne Knight Alzheimer's Disease Research Center, Washington University School of Medicine, St. Louis, MO
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Fan DF, Yu YC, Ding XS, Nie XL, Wei R, Feng XY, Peng XX, Gao MM, Jia LL, Wang XL. Exploring the drug-induced anemia signals in children using electronic medical records. Expert Opin Drug Saf 2019; 18:993-999. [PMID: 31315002 DOI: 10.1080/14740338.2019.1645832] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Objectives: The objectives were to identify drugs related with anemia in children and evaluate the novelty of these correlations. Methods: The authors established a two-step method for detecting the relationship between drugs and anemia using electronic medical records (EMRs), which were obtained from 247,136 patients in Beijing Children's Hospital between 2007 and 2017. The authors extracted potential drugs by mining cases for hemoglobin abnormalities from the EMR and then performed a retrospective cohort study to correlate them with anemia by calculating the matched odds ratios and 95% confidence interval using unconditional logistic regression analysis. Results: In total, nine positive drug-anemia associations were identified. Among them, the correlations of drugs fluconazole (OR 3.95; 95%CI: 2.65-5.87) and cefathiamidine (OR 3.49; 95%CI: 2.94-4.15) with anemia were considered new signals in both children and adults. Three associations of drugs, vancomycin, cefoperazone-sulbactam and ibuprofen, with anemia were considered new signals in children. Conclusion: The authors detected nine signals of drug-induced anemia, including two new signals in children and adults and three new signals in children. This study could serve as a model for using EMR and automatic mining to monitor adverse drug reaction signals in the pediatric population.
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Affiliation(s)
- Duan-Fang Fan
- Clinical Research Center, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University , Beijing , China.,School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University , Nanjing , Jiangsu , China
| | - Yun-Cui Yu
- Clinical Research Center, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University , Beijing , China
| | - Xuan-Sheng Ding
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University , Nanjing , Jiangsu , China
| | - Xiao-Lu Nie
- Center for Clinical Epidemiology and Evidence-based Medicine, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University , Beijing , China
| | - Ran Wei
- Clinical Research Center, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University , Beijing , China
| | - Xin-Ying Feng
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University , Nanjing , Jiangsu , China
| | - Xiao-Xia Peng
- Center for Clinical Epidemiology and Evidence-based Medicine, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University , Beijing , China
| | - Miao-Miao Gao
- Department of Pharmacy, First Hospital of Shanxi Medical University , Taiyuan , Shanxi , China
| | - Lu-Lu Jia
- Clinical Research Center, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University , Beijing , China
| | - Xiao-Ling Wang
- Clinical Research Center, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University , Beijing , China
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Brown JD, Winterstein AG. Potential Adverse Drug Events and Drug-Drug Interactions with Medical and Consumer Cannabidiol (CBD) Use. J Clin Med 2019; 8:jcm8070989. [PMID: 31288397 PMCID: PMC6678684 DOI: 10.3390/jcm8070989] [Citation(s) in RCA: 145] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 07/02/2019] [Accepted: 07/04/2019] [Indexed: 01/18/2023] Open
Abstract
Cannabidiol (CBD) is ubiquitous in state-based medical cannabis programs and consumer products for complementary health or recreational use. CBD has intrinsic pharmacologic effects and associated adverse drug events (ADEs) along with the potential for pharmacokinetic and pharmacodynamic drug–drug interactions (DDIs). Given CBD use among patients with complex conditions and treatment regimens, as well as its expanded consumer use, awareness of potential safety issues with CBD is needed. Prescribing information for federally approved products containing CBD were reviewed. Data on ADEs and DDIs were extracted and summarized. Nearly one-half of CBD users experienced ADEs, which displayed a general dose-response relationship. Common ADEs include transaminase elevations, sedation, sleep disturbances, infection, and anemia. Given CBD effects on common biological targets implicated in drug metabolism (e.g., CYP3A4/2C19) and excretion (e.g., P-glycoprotein), the potential for DDIs with commonly used medication is high. General clinical recommendations of reducing substrate doses, monitoring for ADEs, and finding alternative therapy should be considered, especially in medically complex patients. CBD is implicated as both a victim and perpetrator of DDIs and has its own ADE profile. These effects should be considered in the risk-benefit assessment of CBD therapy and patients and consumers made aware of potential safety issues with CBD use.
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Affiliation(s)
- Joshua D Brown
- Center for Drug Evaluation & Safety, Department of Pharmaceutical Outcomes & Policy, University of Florida College of Pharmacy, Gainesville, FL 32610, USA.
| | - Almut G Winterstein
- Center for Drug Evaluation & Safety, Department of Pharmaceutical Outcomes & Policy, University of Florida College of Pharmacy, Gainesville, FL 32610, USA
- Department of Epidemiology, College of Public Health and Health Professions, University of Florida, Gainesville, FL 32610, USA
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Mohamed WA, Abd-Elhakim YM, Ismail SAA. Involvement of the anti-inflammatory, anti-apoptotic, and anti-secretory activity of bee venom in its therapeutic effects on acetylsalicylic acid-induced gastric ulceration in rats. Toxicology 2019; 419:11-23. [PMID: 30885738 DOI: 10.1016/j.tox.2019.03.003] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2018] [Revised: 02/21/2019] [Accepted: 03/12/2019] [Indexed: 12/11/2022]
Abstract
Acetylsalicylic acid (ASA) is the most highly consumed pharmaceutical product worldwide. Importantly, gastrointestinal ulceration due to ASA is a major complication. Hence, the present work aimed to examine, for the first time, the healing properties of bee venom (BV) in acute gastric ulceration induced by ASA. Forty adult male Sprague-Dawley rats were divided into four groups that received distilled water only, ASA (500 mg/kg BW) twice daily for 3 days, ASA for 3 days followed by BV (2 mg/kg BW) for 7 days, or ASA for 3 days followed by ranitidine hydrochloride (50 mg/kg BW) for 7 days. Haematological analysis, haemostatic evaluation, and inflammatory marker estimation were performed. Rat stomachs were collected for ulcer scoring, gene expression analysis, oxidative stress assays, histopathological and immunohistochemical examinations, and tissue eosinophil scoring. The results revealed that BV markedly decreased the ulcer index, pro-inflammatory cytokine levels, malondialdehyde levels, BAX distribution, caspase-3 expression, and tissue eosinophil levels. Additionally, significant increases in antioxidant enzymes and heat shock protein 70 localization in gastric tissue were evident following BV treatment after ASA exposure. Also, BV has been found to attenuate the haematological, haemostatic, and histopathological alterations induced by ASA. Our findings collectively indicate that the gastroprotective effect of BV against ASA-induced ulceration in rats is mediated by its antioxidant, anti-inflammatory, anti-apoptotic, and anti-secretory properties.
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Affiliation(s)
- Wafaa A Mohamed
- Department of Clinical Pathology, Faculty of Veterinary Medicine, Zagazig University, Zagazig, Egypt
| | - Yasmina M Abd-Elhakim
- Department of Forensic Medicine and Toxicology, Faculty of Veterinary Medicine, Zagazig University, Zagazig, Egypt.
| | - Shimaa A A Ismail
- Department of Clinical Pathology, Faculty of Veterinary Medicine, Zagazig University, Zagazig, Egypt
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Gradient Relationship between Increased Mean Corpuscular Volume and Mortality Associated with Cerebral Ischemic Stroke and Ischemic Heart Disease: A Longitudinal Study on 66,294 Taiwanese. Sci Rep 2018; 8:16517. [PMID: 30409990 PMCID: PMC6224537 DOI: 10.1038/s41598-018-34403-w] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Accepted: 10/11/2018] [Indexed: 12/14/2022] Open
Abstract
The gradient relationship between mean corpuscular volume (MCV) and mortality due to ischemic vascular disease has not been researched using a large-scale population-based study. This study evaluated the association between MCV and death attributable to cerebrovascular disease (CVD) and cardiovascular disease (CAD) in a large population- and community-based Taiwanese cohort. A longitudinal study with a 9-year follow-up was conducted to evaluate individuals aged 20 years or older who had participated in the Keelung (the northernmost city in Taiwan) community-based integrated screening (abbreviated as KCIS) program since September 1999. The mortality rates associated with CVD and CAD were classified across a range of different MCV levels. Increased MCV levels were associated with an increased risk of CVD/CAD-related death (adjusted hazard ratio [aHR] = 1.42, trend test P = 0.0119). Marginally statistically significant associations were noted for specific deaths from ischemic heart disease (aHR = 1.44, trend test P = 0.0992) and cerebral ischemic stroke (aHR = 1.66, trend test P = 0.0667), respectively, but no significant gradient relationship was noted for death from cerebral hemorrhage stroke (aHR = 1.23, trend test, P = 0.6278). A gradient relationship between baseline MCV level and CVD/CAD-related death was noted, but whether such gradient relationships existed for two specific deaths and how these relationships may be confounded by extraneous factors that were not considered here should be investigated in the future.
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A comparison of mean corpuscular volume (MCV) between thalassemia-carrier and non-thalassemia-carrier pregnant women receiving highly active antiretroviral therapy (HAART). Taiwan J Obstet Gynecol 2018; 56:736-739. [PMID: 29241911 DOI: 10.1016/j.tjog.2017.10.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/14/2017] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE HIV-infected treatment with antiretroviral drugs is one of the common causes of macrocytosis. In patients receiving highly active antiretroviral therapy (HAART), the mean corpuscular volume (MCV) can be shifted from microcytic to normocytic or macrocytic after treatment and significantly affected the thalassemia screening. This study aimed to compare MCV between thalassemia-carrier and non-thalassemia-carrier antiretroviral drug-naïve, HIV-infected, pregnant women receiving HAART. The results will support the couples at risk identification in prenatal control of severe thalassemia disease. MATERIALS AND METHODS A retrospective cohort study was conducted in antiretroviral drug-naïve, HIV-infected, pregnant women who received HAART between January 2008 and December 2015 in Maharaj Nakorn Chiang Mai Hospital, Chiang Mai, Thailand. Changes in MCV were compared between the thalassemia and non-thalassemia carriers. RESULTS Of 74 pregnant women who were exposed to HAART for at least 4 weeks, increased MCV levels were significantly greater in the non-thalassemia carriers group (n = 58) than in the thalassemia-carrier group (n = 16) (16.60 ± 12.55 fL and 15.61 ± 9.67 fL, respectively; p < 0.001). Pre-HAART exposure, sensitivity of MCV was 83.3% for thalassemia carriers screening using MCV <80 fL. Post-HAART exposure, sensitivity of MCV was 33.3%, and the false negative rate was 66.7%. CONCLUSION Post-HAART exposure, MCV increased substantially in both the thalassemia and non-thalassemia carriers. Using MCV <80 fL as the cutoff for diagnosing thalassemia, false negative results were observed in two thirds of the thalassemia carriers who were exposed to HAART for at least 4 weeks; therefore, the screening test should be interpreted with caution.
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[Rare diseases recognizable from blood smears]. Internist (Berl) 2018; 59:1106-1113. [PMID: 30046890 DOI: 10.1007/s00108-018-0467-5] [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: 10/28/2022]
Abstract
The examination of peripheral blood smears is not only essential for the differential diagnostics of hematological diseases but can also provide important indications for general internal diseases, infections, hereditary diseases and poisoning. By the systematic analysis of a blood smear for alterations to thrombocytes, erythrocytes and leukocytes, a blood smear investigation can make a decisive contribution to the formulation of a diagnosis. In this way evidence of rare diseases can also be gained when taking the corresponding clinical findings into consideration.
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Abstract
PURPOSE OF REVIEW This article provides an update on the clinical presentation and management of neurologic disease related to key nutrient deficiencies. RECENT FINDINGS Major advances have been made in understanding the pathway related to vitamin B12 absorption and distribution. It is now known that deficiencies of vitamin B12 and copper have similar neurologic manifestations. Bariatric surgery is a risk factor for both. Alcoholism is just one of the many causes of thiamine deficiency. Early neurologic complications following bariatric surgery are often due to thiamine deficiency. Encephalopathy in the setting of alcoholism that persists despite thiamine replacement should prompt consideration of niacin deficiency. Pyridoxine deficiency and toxicity both have neurologic sequelae. Vitamin D deficiency and the risk for multiple sclerosis has been an area of ongoing research. SUMMARY Optimal functioning of the nervous system is dependent on a constant supply of certain vitamins and nutrients. This article discusses neurologic manifestations related to deficiency of these key nutrients.
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Development and Validation of a Rapid High-Performance Liquid Chromatography⁻Tandem Mass Spectrometric Method for Determination of Folic Acid in Human Plasma. Pharmaceuticals (Basel) 2018; 11:ph11020052. [PMID: 29861484 PMCID: PMC6027057 DOI: 10.3390/ph11020052] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 05/22/2018] [Accepted: 05/23/2018] [Indexed: 12/31/2022] Open
Abstract
There are health concerns associated with increased folic acid intake from fortified food and supplements. Existing analytical methods, however, which can be employed to carry out epidemiological and bioavailability studies for folic acid involve laborious sample preparation and/or lengthy chromatographic analysis. In this paper we describe a simple, rapid, and sensitive high-performance liquid chromatography–electrospray ionisation-tandem mass spectrometry (HPLC–ESI-MS/MS) method for determination of unmetabolised folic acid in human plasma using folic acid-d4 as an internal standard. The method required only a simple sample preparation step of protein precipitation and had a total run time of 3.5 min, which is the shortest run time reported to date for HPLC–MS/MS method employed for quantifying folic acid in plasma. The analytes were separated on a C18 column (3 µm; 50 × 3.00 mm) using an isocratic mobile phase consisting of ammonium acetate (1 mM)-acetic acid-acetonitrile (9.9:0.1:90, v/v/v). The method was fully validated in terms of accuracy, precision, linearity, selectivity, recovery, matrix effect, and stability. The short run time and the minimal sample preparation makes the method a valuable tool for performing high-throughput analyses. To demonstrate the applicability of the method in real conditions, it was applied successfully in a bioavailability study for the determination of unmetabolised folic acid levels in vivo in human plasma after oral administration of folic acid.
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Vu KT, Zhang F, Hulleman JD. Conditional, Genetically Encoded, Small Molecule-Regulated Inhibition of NFκB Signaling in RPE Cells. Invest Ophthalmol Vis Sci 2017; 58:4126-4137. [PMID: 28829844 PMCID: PMC5566385 DOI: 10.1167/iovs.17-22133] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Purpose Nuclear factor κB (NFκB) is a ubiquitously expressed, proinflammatory transcription factor that controls the expression of genes involved in cell survival, angiogenesis, complement activation, and inflammation. Studies have implicated NFκB-dependent cytokines or complement-related factors as being detrimentally involved in retinal diseases, thus making inhibition of NFκB signaling a potential therapeutic target. We sought to develop a conditional and reversible method that could regulate pathogenic NFκB signaling by the addition of a small molecule. Methods We developed a genetically based, trimethoprim (TMP)-regulated approach that conditionally inhibits NFκB signaling by fusing a destabilized dihydrofolate reductase (DHFR) domain to an inhibitor of NFκB, IκBα, in ARPE-19 cells. We then challenged ARPE-19 cells with a number of stimuli that have been demonstrated to trigger NFκB signaling, including LPS, TNFα, IL-1α, and A2E. Western blotting, electrophoretic mobility shift assay, quantitative PCR, ELISA, and NFκB reporter assays were used to evaluate the effectiveness of this DHFR-IκBα approach. Results This destabilized domain approach, coupled with doxycycline-inducibility, allowed for accurate control over the abundance of DHFR-IκBα. Stabilization of DHFR-IκBα with TMP prevented IL-1α-, A2E-, LPS-, and TNFα-induced NFκB-mediated upregulation and release of the proinflammatory cytokines IL-1β and IL-6 from ARPE-19 cells (by as much as 93%). This strategy is dosable, completely reversible, and can be cycled “on” or “off” within the same cell population repeatedly to confer protection at desired time points. Conclusions These studies lay the groundwork for the use of destabilized domains in retinal pigment epithelium (RPE) cells in vivo and in this context, demonstrate their utility for preventing inflammatory signaling.
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Affiliation(s)
- Khiem T Vu
- Department of Ophthalmology, University of Texas Southwestern Medical Center, Dallas, Texas, United States
| | - Fang Zhang
- Department of Ophthalmology, University of Texas Southwestern Medical Center, Dallas, Texas, United States
| | - John D Hulleman
- Department of Ophthalmology, University of Texas Southwestern Medical Center, Dallas, Texas, United States.,Department of Pharmacology, University of Texas Southwestern Medical Center, Dallas, Texas, United States
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Cora MC, Gwinn W, Wilson R, King D, Waidyanatha S, Kissling GE, Brar SS, Olivera D, Blystone C, Travlos G. A Black Cohosh Extract Causes Hematologic and Biochemical Changes Consistent with a Functional Cobalamin Deficiency in Female B6C3F1/N Mice. Toxicol Pathol 2017; 45:614-623. [PMID: 28618975 PMCID: PMC5544593 DOI: 10.1177/0192623317714343] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Black cohosh rhizome, available as a dietary supplement, is most commonly marketed as a remedy for dysmenorrhea and menopausal symptoms. A previous subchronic toxicity study of black cohosh dried ethanolic extract (BCE) in female mice revealed a dose-dependent ineffective erythropoiesis with a macrocytosis consistent with the condition known as megaloblastic anemia. The purpose of this study was to investigate potential mechanisms by which BCE induces these particular hematological changes. B6C3F1/N female mice (32/group) were exposed by gavage to vehicle or 1,000 mg/kg BCE for 92 days. Blood samples were analyzed for hematology, renal and hepatic clinical chemistry, serum folate and cobalamin, red blood cell (RBC) folate, and plasma homocysteine and methylmalonic acid (MMA). Folate levels were measured in liver and kidney. Hematological changes included decreased RBC count; increased mean corpuscular volume; and decreased reticulocyte, white blood cell, neutrophil, and lymphocyte counts. Blood smear evaluation revealed increased Howell-Jolly bodies and occasional basophilic stippling in treated animals. Plasma homocysteine and MMA concentrations were increased in treated animals. Under the conditions of our study, BCE administration caused hematological and clinical chemistry changes consistent with a functional cobalamin, and possibly folate, deficiency. Further studies are needed to elucidate the mechanism by which BCE causes increases in homocysteine and MMA.
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Affiliation(s)
- Michelle C Cora
- 1 Division of the National Toxicology Program, National Institute of Environmental Health Sciences, National Institute of Health, Research Triangle Park, North Carolina, USA
| | - William Gwinn
- 1 Division of the National Toxicology Program, National Institute of Environmental Health Sciences, National Institute of Health, Research Triangle Park, North Carolina, USA
| | - Ralph Wilson
- 1 Division of the National Toxicology Program, National Institute of Environmental Health Sciences, National Institute of Health, Research Triangle Park, North Carolina, USA
| | - Debra King
- 1 Division of the National Toxicology Program, National Institute of Environmental Health Sciences, National Institute of Health, Research Triangle Park, North Carolina, USA
| | - Suramya Waidyanatha
- 1 Division of the National Toxicology Program, National Institute of Environmental Health Sciences, National Institute of Health, Research Triangle Park, North Carolina, USA
| | - Grace E Kissling
- 2 Division of Intramural Research, National Institute of Environmental Health Sciences, National Institutes of Health, Research Triangle Park, North Carolina, USA
| | - Sukhdev S Brar
- 1 Division of the National Toxicology Program, National Institute of Environmental Health Sciences, National Institute of Health, Research Triangle Park, North Carolina, USA
| | - Dorian Olivera
- 3 Alion Science and Technology, Research Triangle Park, North Carolina, USA
| | - Chad Blystone
- 1 Division of the National Toxicology Program, National Institute of Environmental Health Sciences, National Institute of Health, Research Triangle Park, North Carolina, USA
| | - Greg Travlos
- 1 Division of the National Toxicology Program, National Institute of Environmental Health Sciences, National Institute of Health, Research Triangle Park, North Carolina, USA
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Abstract
With increasing knowledge of the risks associated with receiving blood transfusions, a new paradigm of bloodless medicine is needed. Principles of bloodless medicine include careful monitoring for obvious and hidden anemias, rapid intervention, minimizing blood losses from laboratory testing and procedures, and careful management of bleeding diatheses. As evidence is revealed and refined, standard treatment of anemia in the intensive care unit will include erythropoietin-stimulating agents, iron, folate, and vitamin B12, which will reduce risks associated with blood transfusions.
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Jansson-Knodell C, Collins CS. 73-Year-Old Asymptomatic Woman With Anemia. Mayo Clin Proc 2017; 92:e89-e93. [PMID: 28499511 DOI: 10.1016/j.mayocp.2016.09.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Revised: 09/28/2016] [Accepted: 09/30/2016] [Indexed: 11/25/2022]
Affiliation(s)
- Claire Jansson-Knodell
- Resident in Internal Medicine, Mayo School of Graduate Medical Education, Mayo Clinic, Rochester, MN
| | - C Scott Collins
- Advisor to Resident and Consultant in General Internal Medicine, Mayo Clinic, Rochester, MN.
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Nagao T, Hirokawa M. Diagnosis and treatment of macrocytic anemias in adults. J Gen Fam Med 2017; 18:200-204. [PMID: 29264027 PMCID: PMC5689413 DOI: 10.1002/jgf2.31] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Accepted: 05/25/2016] [Indexed: 12/19/2022] Open
Abstract
Anemia is one of the most common health problems in the primary care setting. Macrocytosis in adults is defined as a red blood cell (RBC) mean corpuscular volume (MCV) >100 femtoliter (fL). Macrocytic anemias are generally classified into megaloblastic or nonmegaloblastic anemia. Megaloblastic anemia is caused by deficiency or impaired utilization of vitamin B12 and/or folate, whereas nonmegaloblastic macrocytic anemia is caused by various diseases such as myelodysplastic syndrome (MDS), liver dysfunction, alcoholism, hypothyroidism, certain drugs, and by less commonly inherited disorders of DNA synthesis. Macrocytic anemias are treated with cause‐specific therapies, and it is crucial to differentiate nonmegaloblastic from megaloblastic anemia. Because MDS and myeloid neoplasms commonly affect the elderly, primary care physicians may encounter more cases of macrocytic anemias in the near future, as the older population increases. When MDS is suspected along with leukocytopenia and/or thrombocytopenia with anemia, a hematology consultation may be appropriate.
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Affiliation(s)
- Takayo Nagao
- Department of General Internal Medicine and Clinical Laboratory Medicine Akita University Graduate School of Medicine Akita Japan
| | - Makoto Hirokawa
- Department of General Internal Medicine and Clinical Laboratory Medicine Akita University Graduate School of Medicine Akita Japan
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Ku LC, Wu H, Greenberg RG, Hill KD, Gonzalez D, Hornik CP, Berezny A, Guptill JT, Jiang W, Zheng N, Cohen-Wolkowiez M, Melloni C. Use of Therapeutic Drug Monitoring, Electronic Health Record Data, and Pharmacokinetic Modeling to Determine the Therapeutic Index of Phenytoin and Lamotrigine. Ther Drug Monit 2016; 38:728-737. [PMID: 27764025 PMCID: PMC5113813 DOI: 10.1097/ftd.0000000000000354] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Defining a drug's therapeutic index (TI) is important for patient safety and regulating the development of generic drugs. For many drugs, the TI is unknown. A systematic approach was developed to characterize the TI of a drug using therapeutic drug monitoring and electronic health record (EHR) data with pharmacokinetic (PK) modeling. This approach was first tested on phenytoin, which has a known TI, and then applied to lamotrigine, which lacks a defined TI. METHODS Retrospective EHR data from patients in a tertiary hospital were used to develop phenytoin and lamotrigine population PK models and to identify adverse events (anemia, thrombocytopenia, and leukopenia) and efficacy outcomes (seizure-free). Phenytoin and lamotrigine concentrations were simulated for each day with an adverse event or seizure. Relationships between simulated concentrations and adverse events and efficacy outcomes were used to calculate the TI for phenytoin and lamotrigine. RESULTS For phenytoin, 93 patients with 270 total and 174 free concentrations were identified. A de novo 1-compartment PK model with Michaelis-Menten kinetics described the data well. Simulated average total and free concentrations of 10-15 and 1.0-1.5 mcg/mL were associated with both adverse events and efficacy in 50% of patients, resulting in a TI of 0.7-1.5. For lamotrigine, 45 patients with 53 concentrations were identified. A published 1-compartment model was adapted to characterize the PK data. No relationships between simulated lamotrigine concentrations and safety or efficacy endpoints were seen; therefore, the TI could not be calculated. CONCLUSIONS This approach correctly determined the TI of phenytoin but was unable to determine the TI of lamotrigine due to a limited sample size. The use of therapeutic drug monitoring and EHR data to aid in narrow TI drug classification is promising, but it requires an adequate sample size and accurate characterization of concentration-response relationships.
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Affiliation(s)
- Lawrence C. Ku
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Huali Wu
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Rachel G. Greenberg
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Kevin D. Hill
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Daniel Gonzalez
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Christoph P. Hornik
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Alysha Berezny
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Jeffrey T. Guptill
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Neurology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Wenlei Jiang
- Office of Generic Drugs, US Food and Drug Administration, Silver Spring, MD, USA
| | - Nan Zheng
- Office of Generic Drugs, US Food and Drug Administration, Silver Spring, MD, USA
| | - Michael Cohen-Wolkowiez
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Chiara Melloni
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
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