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Terlizzi V, Fevola C, Presti S, Castaldo A, Daccò V, Claut L, Sepe A, Majo F, Casciaro R, Esposito I, Vitullo P, Salvi M, Troiani P, Ficili F, Parisi GF, Pantano S, Costa S, Leonetti G, Palladino N, Taccetti G, Bonomi P, Salvatore D. Reported Adverse Events in a Multicenter Cohort of Patients Ages 6-18 Years with Cystic Fibrosis and at Least one F508del Allele Receiving Elexacaftor/Tezacaftor/Ivacaftor. J Pediatr 2024:114176. [PMID: 38945446 DOI: 10.1016/j.jpeds.2024.114176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 05/21/2024] [Accepted: 06/24/2024] [Indexed: 07/02/2024]
Abstract
OBJECTIVE To describe reported adverse events (AEs) associated with elexacaftor/tezacaftor/ivacaftor (ETI) in a pediatric sample with cystic fibrosis (CF) aged 6-18 years, with at least one F508del variant, followed at multiple Italian CF centers. STUDY DESIGN This was a retrospective, multicenter, observational study. All children receiving ETI therapy from October 2019 to December 2023 were included. We assessed the prevalence and type of any reported potential drug-related AEs, regardless of discontinuation necessity. Persistent AEs were defined as those continuing at the end of the observation period. RESULTS Among 608 patients on ETI, 109 (17.9%) reported at least one AE. The majority (N=85, 77.9%) were temporary, with a median duration of 11 days (range 1-441 days). Only 7 (1.1%) patients permanently discontinued treatment, suggesting good overall safety of ETI. The most common AEs leading to discontinuation were transaminase elevations (temporary 14.1%, persistent 25.9%) and urticaria (temporary 41.2%, persistent 7.4%). Creatinine phosphokinase elevation was uncommon. No significant differences in AEs were observed based on sex, age groups (6-11 vs. 12-18 years), or genotype. Pre-existing CF-related liver disease was associated with an increased risk of transaminase elevations. We identified significant variability in the percentage of reported AEs (ANOVA p-value 0·026). CONCLUSIONS This real-world study highlights significant variability in reported AEs. Our findings suggest that ETI is a safe and well-tolerated therapy in children and adolescents with CF. However, further long-term safety and effectiveness investigations are warranted.
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Affiliation(s)
- V Terlizzi
- Department of Pediatric Medicine, Meyer Children's Hospital IRCCS, Cystic Fibrosis Regional Reference Center, Viale Gaetano Pieraccini 24, Florence 50139, Italy.
| | - C Fevola
- Department of Pediatric Medicine, Meyer Children's Hospital IRCCS, Cystic Fibrosis Regional Reference Center, Viale Gaetano Pieraccini 24, Florence 50139, Italy
| | - S Presti
- Pediatric Respiratory Unit, Department of Clinical and Experimental Medicine, San Marco Hospital, University of Catania, Viale Carlo Azeglio Ciampi, sn, 95121, Catania, Italy
| | - A Castaldo
- Department of Pediatric Medicine, Meyer Children's Hospital IRCCS, Cystic Fibrosis Regional Reference Center, Viale Gaetano Pieraccini 24, Florence 50139, Italy; SC di Pneumologia e UTSIR, AORN Santobono-Pausilipon, Naples, Italy; Paediatric Unit, Department of Translational Medical Sciences, Cystic Fibrosis Regional Reference Center, University of Naples Federico II, Naples, Italy
| | - V Daccò
- Department of Pathophysiology and Transplantation, Cystic Fibrosis Regional Reference Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - L Claut
- Department of Pathophysiology and Transplantation, Cystic Fibrosis Regional Reference Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - A Sepe
- Paediatric Unit, Department of Translational Medical Sciences, Cystic Fibrosis Regional Reference Center, University of Naples Federico II, Naples, Italy
| | - F Majo
- Cystic Fibrosis Centre, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - R Casciaro
- Department of Pediatrics, IRCCS Institute "Giannina Gaslini", Cystic Fibrosis Centre, Genoa, Italy
| | - I Esposito
- Paediatric Pulmonology Unit, Regina Margherita Hospital AOU Città della Salute e della Scienza, 10126 Torino, Italy
| | - P Vitullo
- Cystic Fibrosis Support Center, Ospedale G. Tatarella di Cerignola, Cerignola, Italy
| | - M Salvi
- Cystic Fibrosis Regional Support Center, Department of Pediatrics, ASST Spedali Civili Brescia, University of Brescia, Brescia, Italy
| | - P Troiani
- Lazio Reference Center for Cystic Fibrosis, Policlinico Umberto I University Hospital, Sapienza University, Viale del Policlinico, 155, 00161 Rome, Italy
| | - F Ficili
- Cystic Fibrosis Center, Ospedale Giovanni Di Cristina, Palermo, Italy
| | - G F Parisi
- Pediatric Respiratory Unit, Department of Clinical and Experimental Medicine, San Marco Hospital, University of Catania, Viale Carlo Azeglio Ciampi, sn, 95121, Catania, Italy
| | - S Pantano
- U.O.S.D. C.R.R. Fibrosi Cistica Ospedale "San Liberatore" di Atri-Dipartimento Materno Infantile-ASL Teramo, Teramo, Italy
| | - S Costa
- Pediatric Gastroenterology and Cystic Fibrosis Unit, Policlinico G. Martino Hospital, University of Messina, Via Consolare Valeria 1, 98125, Messina, Italy
| | - G Leonetti
- Pediatric Cystic Fibrosis Centre, Azienda Universitaria Ospedaliera Consorziale Policlinico, Bari, Italy
| | - N Palladino
- Cystic Fibrosis Center of Umbria Region, Branca Hospital, 06020 Branca, Italy
| | - G Taccetti
- Department of Pediatric Medicine, Meyer Children's Hospital IRCCS, Cystic Fibrosis Regional Reference Center, Viale Gaetano Pieraccini 24, Florence 50139, Italy
| | - P Bonomi
- Freelance Statistician, Milan, Italy
| | - D Salvatore
- Cystic Fibrosis Center, Hospital San Carlo, Potenza, Italy
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Albaiz FA, Semenchuk J, Ma X, Lightfoot D, Gonska T, Tullis E, Stephenson AL. Clinical outcomes after liver transplant in people with cystic fibrosis: A systematic review and meta-analysis. J Cyst Fibros 2024:S1569-1993(24)00781-1. [PMID: 38942722 DOI: 10.1016/j.jcf.2024.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 06/21/2024] [Accepted: 06/22/2024] [Indexed: 06/30/2024]
Abstract
BACKGROUND Data on the impact of liver transplantation (LT) in cystic fibrosis (CF) on lung function and exacerbations are limited. The objective of this study was to summarize the literature on lung function, nutritional status, survival, and complications following LT in people with CF. METHODS Three databases were searched until September 2023, to identify the impact of LT in CF. Lung transplant prior to LT and simultaneous liver-lung transplant were excluded. Pooled hazard ratios were calculated using random-effects models. RESULTS Thirty studies were included in this review, with 3 and 9 studies included in meta-analyses for nutritional status and lung function, respectively. Eighty-three percent of the studies used data that was more than a decade old. There was a significant increase in percent-predicted forced expiratory volume with mean change of 7.16 % (2.13, 12.19; p = 0.005) one year post-LT. Pulmonary exacerbations decreased in the short-term, however there was no significant change in body mass index (BMI). One-year survival post-LT ranged between 75 and 100 %, while five-year survival was lower at 64-89 %. CONCLUSION Existing data suggest that LT improves lung function in the short term and does not increase the likelihood of pulmonary exacerbations, despite ongoing immunosuppression in the setting of chronic lung infection.
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Affiliation(s)
- Faisal A Albaiz
- Division of Respirology, St. Michael's Hospital, University of Toronto, Ontario, Canada; Organ Transplant Centre of Excellence, Lung Health Centre, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Julie Semenchuk
- Division of Respirology, St. Michael's Hospital, University of Toronto, Ontario, Canada
| | - Xiayi Ma
- Division of Respirology, St. Michael's Hospital, University of Toronto, Ontario, Canada
| | - David Lightfoot
- St Michael's Health Sciences Library, St Michael's Hospital, Toronto, Ontario, Canada
| | - Tanja Gonska
- The Hospital for Sick Children, Division of Gastroenterology, Toronto, Ontario, Canada
| | - Elizabeth Tullis
- Division of Respirology, St. Michael's Hospital, University of Toronto, Ontario, Canada
| | - Anne L Stephenson
- Division of Respirology, St. Michael's Hospital, University of Toronto, Ontario, Canada.
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Eldredge JA, Oliver MR, Ooi CY. Cystic fibrosis liver disease in the new era of cystic fibrosis transmembrane conductance regulator (CFTR) modulators. Paediatr Respir Rev 2024; 50:54-61. [PMID: 38281822 DOI: 10.1016/j.prrv.2023.12.005] [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: 12/21/2023] [Accepted: 12/21/2023] [Indexed: 01/30/2024]
Abstract
Cystic fibrosis liver disease (CFLD) is characterised by a wide heterogenity of manifestations and severity. It represents a major cause of morbidity in people with cystic fibrosis (PwCF), which will be of increasing relevance as survival increases in the new era of cystic fibrosis care. No medical therapy currently available has evidence to treat or prevent progression of liver disease. Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) modulators may be transformative on pulmonary, nutritional and quality of life, but direct effect on long term liver disease outcomes is not yet established. Drug-associated hepatic adverse effects may be common, and clinician familiarity with drug-monitoring recommendations is essential. Longitudinal studies are required to understand the effect of CFTR modulators on the incidence and natural history of CFLD, including with early treatment initiation, in established advanced liver disease, and post liver transplantation.
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Affiliation(s)
- Jessica A Eldredge
- Department of Gastroenterology and Clinical Nutrition, Royal Children's Hospital, Melbourne, Australia.
| | - Mark R Oliver
- Department of Gastroenterology and Clinical Nutrition, Royal Children's Hospital, Melbourne, Australia; Department of Paediatrics, Faculty of Medicine, The University of Melbourne, Melbourne, Australia.
| | - Chee Y Ooi
- Department of Gastroenterology, Sydney Children's Hospital Randwick, NSW, Australia; School of Clinical Medicine, Discipline of Paediatrics and Child Health, UNSW Medicine & Health, University of New South Wales, Sydney, Australia.
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Chun SW, Somers ME, Burgener EB. Highly effective cystic fibrosis transmembrane conductance (regulator) modulator therapy: shifting the curve for most while leaving some further behind. Curr Opin Pediatr 2024; 36:290-295. [PMID: 38411576 PMCID: PMC11042992 DOI: 10.1097/mop.0000000000001338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
PURPOSE OF REVIEW Traditional cystic fibrosis (CF) care had been focused on early intervention and symptom mitigation. With the advent of highly effective cystic fibrosis transmembrane conductance regulator (CFTR) modulator therapy (HEMT), in particular, the approval of elexacaftor/tezacaftor/ivacaftor in 2019, there has been a dramatic improvement in outcomes in CF. The purpose of this article is to review the benefits, limitations, and impact of HEMT as well as discuss the new implications, challenges, and hope that modulators bring to people with CF (pwCF). RECENT FINDINGS HEMT has demonstrated sustained improvement in lung function, nutrition, quality of life, and survival for over 90% of pwCF. As HEMT has delivered such promise, there is a small but significant portion of pwCF who do not benefit from HEMT due to ineligible mutations, intolerance, or lack of accessibility to modulators. SUMMARY HEMT has significantly improved outcomes, but continued research is needed to understand the new challenges and implications the era of HEMT will bring, as well as how to provide equitable care to those who are unable to benefit from HEMT.
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Affiliation(s)
- Stanford W Chun
- Division of Pediatric Pulmonology & Sleep Medicine, Department of Pediatrics, Children’s Hospital of Los Angeles, Keck School of Medicine at University of Southern California, Los Angeles, CA
| | - Maya E Somers
- Division of Infectious Disease & Geographic Medicine, Department of Medicine, Stanford University, Stanford, CA
| | - Elizabeth B Burgener
- Division of Pediatric Pulmonology & Sleep Medicine, Department of Pediatrics, Children’s Hospital of Los Angeles, Keck School of Medicine at University of Southern California, Los Angeles, CA
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Protich HE, Molleston JP, Bozic M, Pettit RS. Elexacaftor/Tezacaftor/Ivacaftor use in Pediatric Cystic Fibrosis Patients with Advanced Liver Disease. J Cyst Fibros 2024:S1569-1993(24)00040-7. [PMID: 38580564 DOI: 10.1016/j.jcf.2024.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Revised: 02/29/2024] [Accepted: 03/19/2024] [Indexed: 04/07/2024]
Abstract
BACKGROUND Cystic fibrosis transmembrane conductance regulator (CFTR) modulator therapy extends the life expectancy of people with cystic fibrosis (PwCF). However, CFTR modulators have not been well studied in patients with cystic fibrosis liver disease (CFLD), specifically those with advanced liver disease with portal hypertension. The purpose of this report is to describe the use of elexacaftor/tezacaftor/ivacaftor (ETI) in pediatric CF patients with advanced CFLD. METHODS This retrospective case series included PwCF < 18 years old with baseline advanced CFLD initiated on ETI. RESULTS Eleven PwCF and advanced CFLD were treated with ETI; six started a reduced dose regimen. No patient required treatment interruption and four patients received dose changes related to increase in transaminase and/or bilirubin elevations. Mean (SD) change in ppFEV1 from prior to ETI to highest value during therapy was 14.27 % (4.25) (p = 0.007). When evaluating the group as whole, AST decreased from baseline to last reported -15.18 (23.23) units/L (p = 0.054) and ALT slightly increased 0.73 (39.13) units/L (p = 0.96). Bilirubin increased minimally overall for patients with mean change from baseline of 0.83 (1.33) mg/dL [range -0.5-3] (p = 0.17). A model for time on ETI showed a significant decrease in AST over time of 0.955 per month of ETI but no other liver biochemistries were significant. No patient experienced decompensation of CFLD. CONCLUSION ETI therapy in pediatric CF patients with advanced CFLD can be beneficial in improving pulmonary and nutritional outcomes without negative impact on liver biochemistries or hepatic outcomes. Close monitoring is recommended to ensure safety and tolerability.
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Affiliation(s)
- Hannah E Protich
- Department of Pharmacy, Riley Hospital for Children at IU Health, 705 Riley Hospital Drive, Simon Family Tower W6111, Indianapolis, IN, USA.
| | - Jean P Molleston
- Department of Pediatric Gastroenterology, Indiana University School of Medicine, 705 Riley Hospital Drive, Room 4210, Indianapolis, Indiana, USA
| | - Molly Bozic
- Department of Pediatric Gastroenterology, Indiana University School of Medicine, 705 Riley Hospital Drive, Room 4210, Indianapolis, Indiana, USA
| | - Rebecca S Pettit
- Department of Pharmacy, Riley Hospital for Children at IU Health, 705 Riley Hospital Drive, Simon Family Tower W6111, Indianapolis, IN, USA
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McDonald CM, Reid EK, Pohl JF, Yuzyuk TK, Padula LM, Vavrina K, Altman K. Cystic fibrosis and fat malabsorption: Pathophysiology of the cystic fibrosis gastrointestinal tract and the impact of highly effective CFTR modulator therapy. Nutr Clin Pract 2024; 39 Suppl 1:S57-S77. [PMID: 38429959 DOI: 10.1002/ncp.11122] [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: 09/28/2023] [Revised: 11/28/2023] [Accepted: 12/28/2023] [Indexed: 03/03/2024] Open
Abstract
Cystic fibrosis (CF) is a progressive, genetic, multi-organ disease affecting the respiratory, digestive, endocrine, and reproductive systems. CF can affect any aspect of the gastrointestinal (GI) tract, including the esophagus, stomach, small intestine, colon, pancreas, liver, and gall bladder. GI pathophysiology associated with CF results from CF membrane conductance regulator (CFTR) dysfunction. The majority of people with CF (pwCF) experience exocrine pancreatic insufficiency resulting in malabsorption of nutrients and malnutrition. Additionally, other factors can cause or worsen fat malabsorption, including the potential for short gut syndrome with a history of meconium ileus, hepatobiliary diseases, and disrupted intraluminal factors, such as inadequate bile salts, abnormal pH, intestinal microbiome changes, and small intestinal bacterial overgrowth. Signs and symptoms associated with fat malabsorption, such as abdominal pain, bloating, malodorous flatus, gastroesophageal reflux, nausea, anorexia, steatorrhea, constipation, and distal intestinal obstruction syndrome, are seen in pwCF despite the use of pancreatic enzyme replacement therapy. Given the association of poor nutrition status with lung function decline and increased mortality, aggressive nutrition support is essential in CF care to optimize growth in children and to achieve and maintain a healthy body mass index in adults. The introduction of highly effective CFTR modulator therapy and other advances in CF care have profoundly changed the course of CF management. However, GI symptoms in some pwCF may persist. The use of current knowledge of the pathophysiology of the CF GI tract as well as appropriate, individualized management of GI symptoms continue to be integral components of care for pwCF.
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Affiliation(s)
| | - Elizabeth K Reid
- Cystic Fibrosis Center, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - John F Pohl
- Pediatric Gastroenterology, Primary Children's Hospital, Salt Lake City, Utah, USA
| | - Tatiana K Yuzyuk
- Pathology, University of Utah School of Medicine, Salt Lake City, Utah, USA
- ARUP Institute for Clinical & Experimental Pathology, Salt Lake City, Utah, USA
| | - Laura M Padula
- Pediatric Specialty, University Health, San Antonio, Texas, USA
| | - Kay Vavrina
- Pediatric Specialty, University Health, San Antonio, Texas, USA
| | - Kimberly Altman
- Gunnar Esiason Adult Cystic Fibrosis and Lung Center, Columbia University Medical Center, New York, New York, USA
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