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Paparella G, Stragà C, Pesenti N, Dal Molin V, Martorel GA, Merotto V, Genova C, Piazza A, Piccoli G, Panzeri E, Rufini A, Testi R, Martinuzzi A. A Pilot Phase 2 Randomized Trial to Evaluate the Safety and Potential Efficacy of Etravirine in Friedreich Ataxia Patients. CHILDREN (BASEL, SWITZERLAND) 2024; 11:958. [PMID: 39201893 PMCID: PMC11352957 DOI: 10.3390/children11080958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/04/2024] [Revised: 08/01/2024] [Accepted: 08/07/2024] [Indexed: 09/03/2024]
Abstract
BACKGROUND A drug repositioning effort supported the possible use of the anti-HIV drug etravirine as a disease-modifying drug for Friedreich ataxia (FRDA). Etravirine increases frataxin protein and corrects the biochemical defects in cells derived from FRDA patients. Because of these findings, and since etravirine displays a favorable safety profile, we conducted a pilot open-label phase 2 clinical trial assessing the safety and potential efficacy of etravirine in FRDA patients. METHODS Thirty-five patients were stratified into three severity groups and randomized to etravirine 200 mg/day or 400 mg/day. They were treated for 4 months. Safety endpoints were the number and type of adverse events and number of dropouts. Efficacy endpoints were represented by changes in peak oxygen uptake and workload as measured by incremental exercise test, SARA score, cardiac measures, measures of QoL and disability. Data were collected 4 months before the start of the treatment (T - 4), at the start (T0), at the end (T4) and 4 months after the termination of the treatment (T + 4). RESULTS Etravirine was reasonably tolerated, and adverse events were generally mild. Four months of etravirine treatment did not significantly increase the peak oxygen uptake but was associated with a change in the progression of the SARA score (p value < 0.001), compared to the 4 months pre- and post-treatment. It also significantly increased peak workload (p value = 0.021). No changes in the cardiac measures were observed. Health and QoL measures showed a worsening at the suspension of the drug. CONCLUSIONS In this open trial etravirine treatment was safe, reasonably well tolerated and appreciably improved neurological function and exercise performance. Even though a placebo effect cannot be ruled out, these results suggest that etravirine may represent a potential therapeutic agent in FRDA deserving testing in a randomized placebo-controlled clinical trial.
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Affiliation(s)
- Gabriella Paparella
- Department of Conegliano, Scientific Institute IRCCS E. Medea, 31015 Conegliano, Treviso, Italy; (G.P.)
| | - Cristina Stragà
- Department of Conegliano, Scientific Institute IRCCS E. Medea, 31015 Conegliano, Treviso, Italy; (G.P.)
| | - Nicola Pesenti
- Department of Statistics and Quantitative Methods, Division of Biostatistics, Epidemiology and Public Health, University of Milano-Bicocca, 20126 Milan, Milan, Italy
| | - Valentina Dal Molin
- Department of Conegliano, Scientific Institute IRCCS E. Medea, 31015 Conegliano, Treviso, Italy; (G.P.)
| | - Gian Antonio Martorel
- Department of Conegliano, Scientific Institute IRCCS E. Medea, 31015 Conegliano, Treviso, Italy; (G.P.)
| | - Vasco Merotto
- Department of Conegliano, Scientific Institute IRCCS E. Medea, 31015 Conegliano, Treviso, Italy; (G.P.)
| | - Cristina Genova
- Department of Conegliano, Scientific Institute IRCCS E. Medea, 31015 Conegliano, Treviso, Italy; (G.P.)
| | - Arianna Piazza
- Department of Conegliano, Scientific Institute IRCCS E. Medea, 31015 Conegliano, Treviso, Italy; (G.P.)
| | - Giuseppe Piccoli
- Department of Conegliano, Scientific Institute IRCCS E. Medea, 31015 Conegliano, Treviso, Italy; (G.P.)
| | - Elena Panzeri
- Department of Bosisio Parini, Scientific Institute IRCCS E. Medea, 23842 Bosisio Parini, Lecco, Italy
| | - Alessandra Rufini
- Department of Biomedicine and Prevention, University of Rome “Tor Vergata”, 00133 Rome, Italy
| | - Roberto Testi
- Department of Biomedicine and Prevention, University of Rome “Tor Vergata”, 00133 Rome, Italy
| | - Andrea Martinuzzi
- Department of Conegliano, Scientific Institute IRCCS E. Medea, 31015 Conegliano, Treviso, Italy; (G.P.)
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Cilenti NA, Tamaroff JG, Capiola CJ, Faig W, McBride MG, Paridon SM, O'Malley S, Edelson JB, Lynch DR, McCormack SE, Lin KY. Cardiopulmonary exercise testing on adaptive equipment in children and adults with Friedreich ataxia. Muscle Nerve 2024; 69:613-619. [PMID: 38515223 PMCID: PMC11013735 DOI: 10.1002/mus.28085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 02/29/2024] [Accepted: 03/10/2024] [Indexed: 03/23/2024]
Abstract
INTRODUCTION/AIMS Traditional exercise is often difficult for individuals with Friedreich ataxia (FRDA), and evidence is limited regarding how to measure exercise performance in this population. We evaluated the feasibility, reliability, and natural history of adaptive cardiopulmonary exercise test (CPET) performance in children and adults with FRDA. METHODS Participants underwent CPET on either an arm cycle ergometer (ACE) or recumbent leg cycle ergometer (RLCE) at up to four visits (baseline, 2 weeks, 4 weeks, and 1 year). Maximum work, oxygen consumption (peak VO2), oxygen (O2) pulse, and anaerobic threshold (AT) were measured in those who reached maximal volition. Test-retest reliability was assessed with intraclass coefficients, and longitudinal change was assessed using regression analysis. RESULTS In our cohort (N = 23), median age was 18 years (interquartile range [IQR], 14-23), median age of FRDA onset was 8 years (IQR 6-13), median Friedreich Ataxia Rating Scale score was 58 (IQR 54-62), and GAA repeat length on the shorter FXN allele (GAA1) was 766 (IQR, 650-900). Twenty-one (91%) completed a maximal CPET (n = 8, ACE and n = 13, RLCE). Age, sex, and GAA1 repeat length were each associated with peak VO2. Preliminary estimates demonstrated reasonable agreement between visits 2 and 3 for peak work by both ACE and RLCE, and for peak VO2, O2 pulse, and AT by RLCE. We did not detect significant performance changes over 1 year. DISCUSSION Adaptive CPET is feasible in FRDA, a relevant clinical trial outcome for interventions that impact exercise performance and will increase access to participation as well as generalizability of findings.
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Affiliation(s)
- Nicolette A. Cilenti
- Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jaclyn G. Tamaroff
- Division of Pediatric Endocrinology and Diabetes, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Christopher J. Capiola
- Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Walter Faig
- Biostatistics and Data Management Core, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Michael G. McBride
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Stephen M. Paridon
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Shannon O'Malley
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jonathan B. Edelson
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David R. Lynch
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Shana E. McCormack
- Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kimberly Y. Lin
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Barbuto S, Lee S, Stein J, Kuo SH, Quinn L, Spinner M, Derovanessian T, Stern Y. Physical Activity and Fitness Levels of Individuals With Ataxia: A Cross-Sectional Study. Arch Phys Med Rehabil 2023; 104:1669-1675. [PMID: 37380120 PMCID: PMC10543624 DOI: 10.1016/j.apmr.2023.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 06/06/2023] [Accepted: 06/20/2023] [Indexed: 06/30/2023]
Abstract
OBJECTIVE To investigate physical activity levels of individuals with ataxia and correlate fitness to ataxia severity. DESIGN An observational study SETTING: An outpatient ataxia clinic in a large, tertiary, urban hospital in the US. PARTICIPANTS Individuals with cerebellar ataxia (N=42). INTERVENTION Not applicable. MAIN OUTCOME MEASURE Participants were classified as sedentary or physically active using the International Physical Activity Questionnaire-Short Form (IPAQ-SF). Maximal oxygen consumption (V̇o2max) as an indicator of fitness level was measured, and ataxia severity was determined by the Scale for the Assessment and Rating of Ataxia (SARA). Mixed effect models were used to correlate ataxia severity to fitness levels. RESULTS Most participants (28 out of 42) lived sedentary lifestyles, and these individuals had poor fitness levels (only 67.3% of their predicted measure). The main barriers to physical activity included lack of energy, lack of time, and fear of falling. There were no differences in age, sex, disease type, disease duration, ataxia severity, fatigue level, and medication use between sedentary and active groups. Measures of V̇o2max, maximal work, maximal heart rate, and anerobic threshold demonstrated statistically significant differences between groups whereas maximal respiratory rate and expired ventilation/carbon dioxide production were similar between groups. When adjusting for age, sex, functional mobility status, and disease duration, ataxia severity was inversely correlated with fitness level in the sedentary group. There was no relationship between ataxia severity and fitness level in the 14 individuals who were physically active. CONCLUSIONS Lower fitness levels were associated with more ataxia symptoms in the sedentary group. This relationship was not seen in individuals who were more active. Given the poor health outcomes associated with low fitness, physical activity should be encouraged in this population.
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Affiliation(s)
- Scott Barbuto
- Department of Physical Medicine and Rehabilitation, College of Physicians and Surgeons, Columbia University Medical Center, New York, NY.
| | - Seonjoo Lee
- Department of Biostatistics, College of Physicians and Surgeons, Columbia University Medical Center, New York, NY
| | - Joel Stein
- Department of Physical Medicine and Rehabilitation, College of Physicians and Surgeons, Columbia University Medical Center, New York, NY; Department of Physical Medicine and Rehabilitation, Weill Cornell Medical College, New York, NY
| | - Sheng-Han Kuo
- Department of Neurology, College of Physicians and Surgeons, Columbia University Medical Center, New York, NY
| | - Lori Quinn
- Department of Biobehavioral Sciences, Teachers College, Columbia University, New York, NY
| | - Michael Spinner
- Department of Neurology, Psychiatry, Sergievsky Center and Taub Institute, College of Physicians and Surgeons, Columbia University Medical Center, New York, NY
| | - Therese Derovanessian
- Department of Physical Medicine and Rehabilitation, College of Physicians and Surgeons, Columbia University Medical Center, New York, NY
| | - Yaakov Stern
- Department of Neurology, Psychiatry, Sergievsky Center and Taub Institute, College of Physicians and Surgeons, Columbia University Medical Center, New York, NY
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Lynch DR, Mathews KD, Perlman S, Zesiewicz T, Subramony S, Omidvar O, Vogel AP, Krtolica A, Litterman N, van der Ploeg L, Heerinckx F, Milner P, Midei M. Double blind trial of a deuterated form of linoleic acid (RT001) in Friedreich ataxia. J Neurol 2023; 270:1615-1623. [PMID: 36462055 DOI: 10.1007/s00415-022-11501-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 11/20/2022] [Accepted: 11/22/2022] [Indexed: 12/05/2022]
Abstract
OBJECTIVES Friedreich ataxia is (FRDA) an autosomal recessive neurodegenerative disorder associated with intrinsic oxidative damage, suggesting that decreasing lipid peroxidation (LPO) might ameliorate disease progression. The present study tested the ability of RT001, a deuterated form of linoleic acid (D2-LA), to alter disease severity in patients with FRDA in a double-blind placebo-controlled trial. METHODS Sixty-five subjects were recruited across six sites and received either placebo or active drug for an 11-month study. Subjects were evaluated at 0, 4, 9, and 11 months, with the primary outcome measure being maximum oxygen consumption (MVO2) during cardiopulmonary exercise testing (CPET). A key secondary outcome measure was a composite statistical test using results from the timed 1-min walk (T1MW), peak workload, and MVO2. RESULTS Forty-five subjects completed the protocol. RT001 was well tolerated, with no serious adverse events related to drug. Plasma and red blood cell (RBC) membrane levels of D2-LA and its primary metabolite deuterated arachidonic acid (D2-AA) achieved steady-state concentrations by 4 months. No significant changes in MVO2 were observed for RT001 compared to placebo. Similarly, no differences between the groups were found in secondary or exploratory outcome measures. Post hoc evaluations also suggested minimal effects of RT001 at the dosages used in this study. INTERPRETATIONS The results of this study provide no evidence for a significant benefit of RT001 at the dosages tested in this Friedreich ataxia patient population.
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Affiliation(s)
- David R Lynch
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA. .,Departments of Pediatrics and Neurology, The Children's Hospital of Philadelphia, 502F Abramson Research Center, 3615 Civic Center Blvd, Philadelphia, PA, 19104, USA.
| | - Katherine D Mathews
- Departments of Pediatrics and Neurology, University of Iowa Carver College of Medicine, Iowa City, USA
| | - Susan Perlman
- University of California Los Angeles, Los Angeles, USA
| | - Theresa Zesiewicz
- USF Ataxia Research Center, University of South Florida, James A. Haley Veteran's Hospital, Tampa, FL, USA
| | - Sub Subramony
- Norman Fixel Center for Neurological Disorders, University of Florida College of Medicine, Gainesville, USA
| | - Omid Omidvar
- University of California Los Angeles, Los Angeles, USA
| | - Adam P Vogel
- University of Melbourne, Parkville, Australia.,Redenlab Inc, Melbourne, Australia
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Effects of Exercise on Heart Failure with Preserved Ejection Fraction: An Updated Review of Literature. J Cardiovasc Dev Dis 2022; 9:jcdd9080241. [PMID: 36005405 PMCID: PMC9409671 DOI: 10.3390/jcdd9080241] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 07/17/2022] [Accepted: 07/20/2022] [Indexed: 12/12/2022] Open
Abstract
Heart failure with preserved ejection fraction (HFpEF) represents the most common HF phenotype of patients aged > 65 years, with an incidence and a prevalence that are constantly growing. The HFpEF cardinal symptom is exercise intolerance (EI), defined as the impaired ability to perform physical activity and to reach the predicted age-related level of exercise duration in the absence of symptoms—such as fatigue or dyspnea—and is associated with a poor quality of life, a higher number of hospitalizations, and poor outcomes. The evidence of the protective effect between exercise and adverse cardiovascular outcomes is numerous and long-established. Regular exercise is known to reduce cardiovascular events and overall mortality both in apparently healthy individuals and in patients with established cardiovascular disease, representing a cornerstone in the prevention and treatment of many cardio-metabolic conditions. Several studies have investigated the role of exercise in HFpEF patients. The present review aims to dwell upon the effects of exercise on HFpEF. For this purpose, the relevant data from a literature search (PubMed, EMBASE, and Medline) were reviewed. The analysis of these studies underlines the fact that exercise training programs improve the cardiorespiratory performance of HFpEF patients in terms of the increase in peak oxygen uptake, the 6 min walk test distance, and the ventilatory threshold; on the other hand, diastolic or systolic functions are generally unchanged or only partially modified by exercise, suggesting that multiple mechanisms contribute to the improvement of exercise tolerance in HFpEF patients. In conclusion, considering that exercise training programs are able to improve the cardiorespiratory performance of HFpEF patients, the prescription of exercise training programs should be encouraged in stable HFpEF patients, and further research is needed to better elucidate the pathophysiological mechanisms underpinning the beneficial effects described.
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Halasz G, Piepoli MF. Editor comment. Focus on Sport Cardiology and Exercise Prescription. Eur J Prev Cardiol 2022; 29:433-435. [PMID: 35244148 DOI: 10.1093/eurjpc/zwac047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Geza Halasz
- Cardiac Unit, G. da Saliceto Hospital, AUSL Piacenza and University of Parma, Italy, Deputy Editor, EJPC
| | - Massimo F Piepoli
- Institute of Life Sciences, Sant'Anna School of Advanced Studies, Pisa, Italy. Editor in Chief, EJPC.,Department of Preventive Cardiology, Wroclaw Medical University, Wroclaw, Poland
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Barroso de Queiroz Davoli G, Bartels B, Mattiello-Sverzut AC, Takken T. Cardiopulmonary exercise testing in neuromuscular disease: a systematic review. Expert Rev Cardiovasc Ther 2021; 19:975-991. [PMID: 34826261 DOI: 10.1080/14779072.2021.2009802] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Cardiopulmonary exercise testing (CPET) is increasingly used to determine aerobic fitness in health and disability conditions. Patients with neuromuscular diseases (NMDs) often present with symptoms of cardiac and/or skeletal muscle dysfunction and fatigue that might impede the ability to deliver maximal cardiopulmonary effort. Although an increasing number of studies report on NMDs' physical fitness, the applicability of CPET remains largely unknown. AREAS COVERED This systematic review synthesized evidence about the quality and feasibility of CPET in NMDs and patient's aerobic fitness. The review followed the PRISMA guidelines (PROSPERO number CRD42020211068). Between September and October 2020 one independent reviewer searched the PubMed/MEDLINE, EMBASE, SCOPUS, and Web of Science databases. Excluding reviews and protocol description articles without baseline data, all study designs using CPET to assess adult or pediatric patients with NMDs were included. The methodological quality was assessed according to the American Thoracic Society/American College of Chest Physicians (ATS/ACCP) recommendations. EXPERT OPINION CPET is feasible for ambulatory patients with NMDs when their functional level and the exercise modality are taken into account. However, there is still a vast potential for standardizing and designing disease-specific CPET protocols for patients with NMDs. Moreover, future studies are urged to follow the ATS/ACCP recommendations.
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Affiliation(s)
| | - Bart Bartels
- Child Development & Exercise Center, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Tim Takken
- Child Development & Exercise Center, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
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Abstract
Exercise intolerance represents a typical feature of heart failure with preserved ejection fraction (HFpEF), and is associated with a poor quality of life, frequent hospitalizations, and increased all-cause mortality. The cardiopulmonary exercise test is the best method to quantify exercise intolerance, and allows detection of the main mechanism responsible for the exercise limitation, influencing treatment and prognosis. Exercise training programs improve exercise tolerance in HFpEF. However, studies are needed to identify appropriate type and duration. This article discusses the pathophysiology of exercise limitation in HFpEF, describes methods of determining exercise tolerance class, and evaluates prognostic implications and potential therapeutic strategies.
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