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Kaczor M, Malicki S, Folkert J, Dobosz E, Bryzek D, Chruscicka-Smaga B, Greczan M, Wesół- Kucharska D, Piątosa B, Samborowska E, Madzio J, Książyk J, Ehmke vel Emczyńska E, Hajdacka M, Potempa J, Młynarski W, Rokicki D, Veillard F. Neutrophil functions in patients with neutropenia due to glycogen storage disease type 1b treated with empagliflozin. Blood Adv 2024; 8:2790-2802. [PMID: 38531056 PMCID: PMC11176967 DOI: 10.1182/bloodadvances.2023012403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 02/20/2024] [Accepted: 02/27/2024] [Indexed: 03/28/2024] Open
Abstract
ABSTRACT Neutropenia and neutrophil dysfunction in glycogen storage disease type 1b (GSD1b) are caused by the accumulation of 1,5-anhydroglucitol-6-phosphate in granulocytes. The antidiabetic drug empagliflozin reduces the concentration of 1,5-anhydroglucitol (1,5-AG), thus restoring neutrophil counts and functions, leading to promising results in previous case reports. Here, we present a comprehensive analysis of neutrophil function in 7 patients with GSD1b and 11 healthy donors, aiming to evaluate the immediate (after 3 months) and long-term (after 12 months) efficacy of empagliflozin compared with the reference treatment with granulocyte-colony stimulating factor (G-CSF). We found that most patients receiving G-CSF remained neutropenic with dysfunctional granulocytes, whereas treatment with empagliflozin increased neutrophil counts and improved functionality by inhibiting apoptosis, restoring phagocytosis and the chemotactic response, normalizing the oxidative burst, and stabilizing cellular and plasma levels of defensins and lactotransferrin. These improvements correlated with the decrease in serum 1,5-AG levels. However, neither G-CSF nor empagliflozin overcame deficiencies in the production of cathelicidin/LL-37 and neutrophil extracellular traps. Given the general improvement promoted by empagliflozin treatment, patients were less susceptible to severe infections. G-CSF injections were therefore discontinued in 6 patients (and the dose was reduced in the seventh) without adverse effects. Our systematic analysis, the most extensive reported thus far, has demonstrated the superior efficacy of empagliflozin compared with G-CSF, restoring the neutrophil population and normal immune functions. This trial was registered as EudraCT 2021-000580-78.
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Affiliation(s)
- Magdalena Kaczor
- Department of Pediatrics, Nutrition and Metabolic Diseases, Children’s Memorial Health Institute, Warsaw, Poland
| | - Stanislaw Malicki
- Department of Microbiology, Faculty of Biochemistry, Biophysics and Biotechnologies, Jagiellonian University, Krakow, Poland
| | - Justyna Folkert
- Department of Microbiology, Faculty of Biochemistry, Biophysics and Biotechnologies, Jagiellonian University, Krakow, Poland
| | - Ewelina Dobosz
- Department of Microbiology, Faculty of Biochemistry, Biophysics and Biotechnologies, Jagiellonian University, Krakow, Poland
| | - Danuta Bryzek
- Department of Microbiology, Faculty of Biochemistry, Biophysics and Biotechnologies, Jagiellonian University, Krakow, Poland
| | - Barbara Chruscicka-Smaga
- Department of Microbiology, Faculty of Biochemistry, Biophysics and Biotechnologies, Jagiellonian University, Krakow, Poland
| | - Milena Greczan
- Department of Pediatrics, Nutrition and Metabolic Diseases, Children’s Memorial Health Institute, Warsaw, Poland
| | - Dorota Wesół- Kucharska
- Department of Pediatrics, Nutrition and Metabolic Diseases, Children’s Memorial Health Institute, Warsaw, Poland
| | - Barbara Piątosa
- Histocompatibility Laboratory, Children’s Memorial Health Institute, Warsaw, Poland
| | - Emilia Samborowska
- Inborn Errors of Metabolism Laboratory, Children’s Memorial Health Institute, Warsaw, Poland
| | - Joanna Madzio
- Department of Pediatrics, Oncology & Hematology, Medical University of Łódź, Łódź, Poland
| | - Janusz Książyk
- Department of Pediatrics, Nutrition and Metabolic Diseases, Children’s Memorial Health Institute, Warsaw, Poland
| | - Ewa Ehmke vel Emczyńska
- Department of Pediatrics, Nutrition and Metabolic Diseases, Children’s Memorial Health Institute, Warsaw, Poland
| | - Małgorzata Hajdacka
- Department of Pediatrics, Nutrition and Metabolic Diseases, Children’s Memorial Health Institute, Warsaw, Poland
| | - Jan Potempa
- Department of Microbiology, Faculty of Biochemistry, Biophysics and Biotechnologies, Jagiellonian University, Krakow, Poland
- Department of Oral Immunology and Infectious Diseases, University of Louisville School of Dentistry, Louisville, KY
| | - Wojciech Młynarski
- Department of Pediatrics, Oncology & Hematology, Medical University of Łódź, Łódź, Poland
| | - Dariusz Rokicki
- Department of Pediatrics, Nutrition and Metabolic Diseases, Children’s Memorial Health Institute, Warsaw, Poland
| | - Florian Veillard
- Department of Microbiology, Faculty of Biochemistry, Biophysics and Biotechnologies, Jagiellonian University, Krakow, Poland
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Klinc A, Groselj U, Mlinaric M, Homan M, Markelj G, Mezek Novak A, Sirca Campa A, Sikonja J, Battelino T, Zerjav Tansek M, Drole Torkar A. Case report: The success of empagliflozin therapy for glycogen storage disease type 1b. Front Endocrinol (Lausanne) 2024; 15:1365700. [PMID: 38919482 PMCID: PMC11197935 DOI: 10.3389/fendo.2024.1365700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 05/21/2024] [Indexed: 06/27/2024] Open
Abstract
Introduction Glycogen storage disease type 1b (GSD-1b) is characterized by neutropenia and neutrophil dysfunction generated by the accumulation of 1,5-anhydroglucitol-6-phosphate in neutrophils. Sodium-glucose co-transporter 2 inhibitors, such as empagliflozin, facilitate the removal of this toxic metabolite and ameliorate neutropenia-related symptoms, including severe infections and inflammatory bowel disease (IBD). Our case series presents the treatment of three pediatric GSD-1b patients with empagliflozin over a follow-up of three years; the most extended reported follow-up period to date. Cases description A retrospective analysis of empagliflozin treatment of three pediatric GSD-1b patients (two male and one female; ages at treatment initiation: 4.5, 2.5 and 6 years) was performed. Clinical and laboratory data from a symmetrical period of up to three years before and after the therapy introduction was reported. Data on the clinical course of the treatment, IBD activity, the need for antibiotic treatment and hospitalizations, neutrophil count and function, and markers of inflammation were assessed. Prior the introduction of empagliflozin, patients had recurrent oral mucosa lesions and infections, abdominal pain, and anemia. During empagliflozin treatment, the resolution of aphthous stomatitis, termination of abdominal pain, reduced frequency and severity of infections, anemia resolution, increased appetite, and improved wound healing was observed in all patients, as well as an increased body mass index in two of them. In a patient with IBD, long-term deep remission was confirmed. An increased and stabilized neutrophil count and an improved neutrophil function enabled the discontinuation of G-CSF treatment in all patients. A trend of decreasing inflammation markers was detected. Conclusions During the three-year follow-up period, empagliflozin treatment significantly improved clinical symptoms and increased the neutrophil count and function, suggesting that targeted metabolic treatment could improve the immune function in GSD-1b patients.
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Affiliation(s)
- Ana Klinc
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Urh Groselj
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
- Department of Endocrinology, Diabetes, and Metabolic Diseases, University Children’s Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Matej Mlinaric
- Department of Endocrinology, Diabetes, and Metabolic Diseases, University Children’s Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Matjaz Homan
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
- Department of Gastroenterology, University Children’s Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Gasper Markelj
- Department of Allergology, Rheumatology and Clinical Immunology, University Children’s Hospital Ljubljana, Ljubljana, Slovenia
| | - Ajda Mezek Novak
- Department of Endocrinology, Diabetes, and Metabolic Diseases, University Children’s Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Andreja Sirca Campa
- Department of Endocrinology, Diabetes, and Metabolic Diseases, University Children’s Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Jaka Sikonja
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
- Department of Endocrinology, Diabetes and Metabolic Disease, Division of Internal Medicine, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Tadej Battelino
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
- Department of Endocrinology, Diabetes, and Metabolic Diseases, University Children’s Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Mojca Zerjav Tansek
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
- Department of Endocrinology, Diabetes, and Metabolic Diseases, University Children’s Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Ana Drole Torkar
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
- Department of Endocrinology, Diabetes, and Metabolic Diseases, University Children’s Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia
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3
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Lava SAG, Laurence C, Di Deo A, Sekarski N, Burch M, Della Pasqua O. Dapagliflozin and Empagliflozin in Paediatric Indications: A Systematic Review. Paediatr Drugs 2024; 26:229-243. [PMID: 38635113 DOI: 10.1007/s40272-024-00623-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/27/2024] [Indexed: 04/19/2024]
Abstract
INTRODUCTION In adults, sodium-glucose cotransporter type 2 inhibitors have revolutionised the treatment of type 2 diabetes mellitus, heart failure, and chronic kidney disease. OBJECTIVE We aimed to review information on compassionate use, clinical pharmacology, efficacy, and safety of dapagliflozin and empagliflozin in children. METHODS We conducted a systematic review of published clinical trials, case reports, and observational studies in Medline, Excerpta Medica, and Web of Science databases from inception to September 2023. For the two randomised controlled trials on type 2 diabetes mellitus (T2DM), we implemented a meta-analysis on the primary outcome (mean difference in glycosylated haemoglobin [HbA1c] between intervention and placebo groups). Review Manager (RevMan), version 5.4.1, was used for this purpose. RESULTS Thirty-five articles (nine case reports, ten case series, one prospective non-controlled trial, four controlled randomised trials, two surveys, six pharmacokinetic studies, and three pharmacovigilance studies) were selected, in which 415 children were exposed to either dapagliflozin or empagliflozin: 189 diabetic patients (mean age 14.7 ± 2.9 years), 32 children with glycogen storage disease type Ib (GSD Ib), glucose-6-phosphatase catalytic subunit 3 (G6PC3) deficiency, or severe congenital neutropenia type 4 (8.5 ± 5.1 years), 47 children with kidney disease or heart failure (11.2 ± 6.1 years), 84 patients in pharmacokinetic studies (15.1 ± 2.3 years), and 63 patients in toxicological series. The effect of dapagliflozin and empagliflozin in T2DM was demonstrated by HbA1c reduction in two randomised trials among a total of 177 adolescents, with a mean HbA1c difference of -0.82% (95% confidence interval -1.34 to -0.29) as compared to placebo (no heterogeneity, I2 = 0%). Dosage ranged between 5 and 20 mg (mean 11.4 ± 3.7) once daily for dapagliflozin and between 5 and 25 mg (mean 15.4 ± 7.4) once daily for empagliflozin. Among the paediatric cases of GSD Ib, empagliflozin 0.1-1.3 mg/kg/day improved neutropenia, infections, and gastrointestinal health. Dapagliflozin (mean dosage 6.9 ± 5.2 mg once daily) was well-tolerated in children with chronic kidney disease and heart failure. Side effects were generally mild, the most frequent being hypoglycaemia in children with GSD Ib (33% of patients) or T2DM (14% of patients) on concomitant hypoglycaemic drugs. Diabetic ketoacidosis is rare in children. CONCLUSION Early evidence suggests that dapagliflozin and empagliflozin are well tolerated in children. A clinical pharmacology rationale currently exists only for adolescents with diabetes mellitus. PROSPERO REGISTRATION NUMBER CRD42023438162.
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Affiliation(s)
- Sebastiano A G Lava
- Pediatric Cardiology Unit, Department of Pediatrics, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Switzerland.
- Heart Failure and Transplantation, Department of Paediatric Cardiology, Great Ormond Street Hospital, London, UK.
- Clinical Pharmacology and Therapeutics Group, University College London, London, UK.
- Division of Clinical Pharmacology and Toxicology, Institute of Pharmacological Sciences of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland.
| | - Craig Laurence
- Heart Failure and Transplantation, Department of Paediatric Cardiology, Great Ormond Street Hospital, London, UK
| | - Alessandro Di Deo
- Clinical Pharmacology and Therapeutics Group, University College London, London, UK
| | - Nicole Sekarski
- Pediatric Cardiology Unit, Department of Pediatrics, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Michael Burch
- Heart Failure and Transplantation, Department of Paediatric Cardiology, Great Ormond Street Hospital, London, UK
| | - Oscar Della Pasqua
- Clinical Pharmacology and Therapeutics Group, University College London, London, UK
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Rossi A, Simeoli C, Pivonello R, Salerno M, Rosano C, Brunetti B, Strisciuglio P, Colao A, Parenti G, Melis D, Derks TGJ. Endocrine involvement in hepatic glycogen storage diseases: pathophysiology and implications for care. Rev Endocr Metab Disord 2024:10.1007/s11154-024-09880-2. [PMID: 38556561 DOI: 10.1007/s11154-024-09880-2] [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] [Accepted: 03/23/2024] [Indexed: 04/02/2024]
Abstract
Hepatic glycogen storage diseases constitute a group of disorders due to defects in the enzymes and transporters involved in glycogen breakdown and synthesis in the liver. Although hypoglycemia and hepatomegaly are the primary manifestations of (most of) hepatic GSDs, involvement of the endocrine system has been reported at multiple levels in individuals with hepatic GSDs. While some endocrine abnormalities (e.g., hypothalamic‑pituitary axis dysfunction in GSD I) can be direct consequence of the genetic defect itself, others (e.g., osteopenia in GSD Ib, insulin-resistance in GSD I and GSD III) may be triggered by the (dietary/medical) treatment. Being aware of the endocrine abnormalities occurring in hepatic GSDs is essential (1) to provide optimized medical care to this group of individuals and (2) to drive research aiming at understanding the disease pathophysiology. In this review, a thorough description of the endocrine manifestations in individuals with hepatic GSDs is presented, including pathophysiological and clinical implications.
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Affiliation(s)
- Alessandro Rossi
- Section of Metabolic Diseases, Beatrix Children's Hospital, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
- Department of Translational Medicine, Section of Pediatrics, University of Naples "Federico II", Naples, Italy.
| | - Chiara Simeoli
- Dipartmento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Diabetologia ed Andrologia, University of Naples "Federico II", Naples, Italy
| | - Rosario Pivonello
- Dipartmento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Diabetologia ed Andrologia, University of Naples "Federico II", Naples, Italy
| | - Mariacarolina Salerno
- Department of Translational Medicine, Section of Pediatrics, University of Naples "Federico II", Naples, Italy
| | - Carmen Rosano
- Department of Translational Medicine, Section of Pediatrics, University of Naples "Federico II", Naples, Italy
| | - Barbara Brunetti
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", Section of Pediatrics, University of Salerno, Baronissi, Italy
| | - Pietro Strisciuglio
- Department of Translational Medicine, Section of Pediatrics, University of Naples "Federico II", Naples, Italy
| | - Annamaria Colao
- Dipartmento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Diabetologia ed Andrologia, University of Naples "Federico II", Naples, Italy
| | - Giancarlo Parenti
- Department of Translational Medicine, Section of Pediatrics, University of Naples "Federico II", Naples, Italy
- Telethon Institute of Genetics and Medicine, Pozzuoli, Italy
| | - Daniela Melis
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", Section of Pediatrics, University of Salerno, Baronissi, Italy
| | - Terry G J Derks
- Section of Metabolic Diseases, Beatrix Children's Hospital, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Grünert SC, Derks TGJ, Mundy H, Dalton RN, Donadieu J, Hofbauer P, Jones N, Uçar SK, LaFreniere J, Contreras EL, Pendyal S, Rossi A, Schneider B, Spiegel R, Stepien KM, Wesol-Kucharska D, Veiga-da-Cunha M, Wortmann SB. Treatment recommendations for glycogen storage disease type IB- associated neutropenia and neutrophil dysfunction with empagliflozin: Consensus from an international workshop. Mol Genet Metab 2024; 141:108144. [PMID: 38277989 DOI: 10.1016/j.ymgme.2024.108144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 12/08/2023] [Accepted: 01/15/2024] [Indexed: 01/28/2024]
Abstract
Glycogen storage disease type Ib (GSD Ib, biallelic variants in SLC37A4) is a rare disorder of glycogen metabolism complicated by neutropenia/neutrophil dysfunction. Since 2019, the SGLT2-inhibitor empagliflozin has provided a mechanism-based treatment option for the symptoms caused by neutropenia/neutrophil dysfunction (e.g. mucosal lesions, inflammatory bowel disease). Because of the rarity of GSD Ib, the published evidence on safety and efficacy of empagliflozin is still limited and does not allow to develop evidence-based guidelines. Here, an international group of experts provides 14 best practice consensus treatment recommendations based on expert practice and review of the published evidence. We recommend to start empagliflozin in all GSD Ib individuals with clinical or laboratory signs related to neutropenia/neutrophil dysfunction with a dose of 0.3-0.4 mg/kg/d given as a single dose in the morning. Treatment can be started in an outpatient setting. The dose should be adapted to the weight and in case of inadequate clinical treatment response or side effects. We strongly recommend to pause empagliflozin immediately in case of threatening dehydration and before planned longer surgeries. Discontinuation of G-CSF therapy should be attempted in all individuals. If available, 1,5-AG should be monitored. Individuals who have previously not tolerated starches should be encouraged to make a new attempt to introduce starch in their diet after initiation of empagliflozin treatment. We advise to monitor certain safety and efficacy parameters and recommend continuous, alternatively frequent glucose measurements during the introduction of empagliflozin. We provide specific recommendations for special circumstances like pregnancy and liver transplantation.
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Affiliation(s)
- Sarah C Grünert
- Department of General Pediatrics, Adolescent Medicine and Neonatology, Medical Centre- University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Terry G J Derks
- Section of Metabolic Diseases, Beatrix Children's Hospital, University Medical Center of Groningen, University of Groningen, Hanzeplein 1, 9700 RB Groningen, the Netherlands
| | - Helen Mundy
- Evelina London Children's Hospital, London, UK
| | | | - Jean Donadieu
- Centre de reference des neutropénies chroniques, Paris Sorbonne Université, Assistance Publique des Hopitaux de Paris, Hopital Trousseau, Paris 75012, France
| | - Peter Hofbauer
- Department of Production, Landesapotheke Salzburg, Hospital Pharmacy, Salzburg, Austria
| | - Neil Jones
- University Children's Hospital Salzburg, Paracelsus Medical University and Salzburger Landeskliniken, Salzburg, Austria
| | - Sema Kalkan Uçar
- Division of Metabolism and Nutrition, Department of Pediatrics, Ege University Children's Hospital, Izmir, Turkey
| | | | | | | | - Alessandro Rossi
- Department of Translational Medicine, Section of Paediatrics, University of Naples "Federico II", Naples, Italy
| | | | - Ronen Spiegel
- Pediatric Department B, Emek Medical Center, Afula, Rappaport School of Medicine, Technion, Haifa, Israel
| | - Karolina M Stepien
- Adult Inherited Metabolic Diseases, Salford Royal Organisation, Northern Care Alliance NHS Foundation Trust, M6 8HD Salford, Greater Manchester, United Kingdom
| | - Dorota Wesol-Kucharska
- Department of Pediatrics, Nutrition, and Metabolic Diseases, Children's Memorial Health Institute, Warsaw, Poland
| | - Maria Veiga-da-Cunha
- Groupe de Recherches Metaboliques, de Duve Institute, UCLouvain (Université Catholique de Louvain), B-1200 Brussels, Belgium
| | - Saskia B Wortmann
- University Children's Hospital Salzburg, Paracelsus Medical University and Salzburger Landeskliniken, Salzburg, Austria; Amalia Children's Hospital, Nijmegen, the Netherlands.
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6
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Wang Z, Zhao R, Jia X, Li X, Ma L, Fu H. Three novel SLC37A4 variants in glycogen storage disease type 1b and a literature review. J Int Med Res 2023; 51:3000605231216633. [PMID: 38087503 PMCID: PMC10718061 DOI: 10.1177/03000605231216633] [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: 08/10/2023] [Accepted: 11/08/2023] [Indexed: 12/18/2023] Open
Abstract
Glycogen storage disease type 1b (GSD1b) is a rare genetic disorder, resulting from mutations in the SLC37A4 gene located on chromosome 11q23.3. Although the SLC37A4 gene has been identified as the pathogenic gene for GSD1b, the complete variant spectrum of this gene remains to be fully elucidated. In this study, we present three patients diagnosed with GSD1b through genetic testing. We detected five variants of the SLC37A4 gene in these three patients, with three of these mutations (p. L382Pfs*15, p. G117fs*28, and p. T312Sfs*13) being novel variants not previously reported in the literature. We also present a literature review and general overview of the currently reported SLC37A4 gene variants. Our study expands the mutation spectrum of SLC37A4, which may help enable genetic testing to facilitate prompt diagnosis, appropriate intervention, and genetic counseling for affected families.
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Affiliation(s)
- Zhuolin Wang
- Department of Gastroenterology, Hebei Children's Hospital, 133 Jianhua South Street, Shijiazhuang 050031, Hebei Province, China
| | - Ruiqin Zhao
- Department of Gastroenterology, Hebei Children's Hospital, 133 Jianhua South Street, Shijiazhuang 050031, Hebei Province, China
| | - Xiaoyun Jia
- Department of Gastroenterology, Hebei Children's Hospital, 133 Jianhua South Street, Shijiazhuang 050031, Hebei Province, China
| | - Xiaolei Li
- Department of Gastroenterology, Hebei Children's Hospital, 133 Jianhua South Street, Shijiazhuang 050031, Hebei Province, China
| | - Li Ma
- Department of Neonatology, Hebei Children's Hospital, 133 Jianhua South Street, Shijiazhuang 050031, Hebei Province, China
| | - Haiyan Fu
- Department of Gastroenterology, Hebei Children's Hospital, 133 Jianhua South Street, Shijiazhuang 050031, Hebei Province, China
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7
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Calia M, Arosio AML, Crescitelli V, Fornari A, Pretese R, Gasperini S, Zuin G. Crohn-like disease long remission in a pediatric patient with glycogen storage disease type Ib treated with empagliflozin: a case report. Therap Adv Gastroenterol 2023; 16:17562848231202138. [PMID: 37779861 PMCID: PMC10540602 DOI: 10.1177/17562848231202138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 09/01/2023] [Indexed: 10/03/2023] Open
Abstract
Glycogen storage disease type Ib (GSD Ib) is a rare hereditary glycogen disorder that results in inadequate maintenance of glucose homeostasis, accumulation of glycogen in different organs, loss and dysfunction of neutrophils. Crohn's-like disease is observed in up to 24-77% of GDS Ib cases. Recently, empagliflozin has been recommended as a treatment for neutrophil dysfunction in GDS Ib patients with or without Crohn's-like disease. There are no guidelines for the treatment of inflammatory bowel disease (IBD) manifestation in GSD Ib patients, although some cases have been treated with granulocyte colony-stimulating factor and others with IBD conventional therapy, resulting in partial IBD remission. Herein, we describe a child with GDS Ib and Crohn's-like disease who was treated with empagliflozin and achieved complete remission after 2 years of treatment. This case is the first one with such a long follow-up evaluation including endoscopic and magnetic resonance enterography assessment. Our clinical evidence of remission of IBD manifestation in our GSD Ib patient and the role of neutrophils in GDS Ib described in the literature suggest a strong association with IBD pathophysiology and neutrophil function. The use of empagliflozin resulted in significant improvements in gastrointestinal symptoms, reduced drug usage, and enhanced quality of life in the patient, with a favorable safety profile, offering a promising new therapeutic option for this population.
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Affiliation(s)
- Margherita Calia
- Pediatrics, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italia
| | | | | | - Anna Fornari
- Pediatrics, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italia
| | - Roberta Pretese
- Pediatrics, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italia
| | - Serena Gasperini
- Pediatrics, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italia
| | - Giovanna Zuin
- Pediatrics, Fondazione IRCCS San Gerardo dei Tintori, Via G. B. Pergolesi, 33, 20900 Monza (MB), Italy
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8
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Gümüş E, Özen H. Glycogen storage diseases: An update. World J Gastroenterol 2023; 29:3932-3963. [PMID: 37476587 PMCID: PMC10354582 DOI: 10.3748/wjg.v29.i25.3932] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 02/15/2023] [Accepted: 04/30/2023] [Indexed: 06/28/2023] Open
Abstract
Glycogen storage diseases (GSDs), also referred to as glycogenoses, are inherited metabolic disorders of glycogen metabolism caused by deficiency of enzymes or transporters involved in the synthesis or degradation of glycogen leading to aberrant storage and/or utilization. The overall estimated GSD incidence is 1 case per 20000-43000 live births. There are over 20 types of GSD including the subtypes. This heterogeneous group of rare diseases represents inborn errors of carbohydrate metabolism and are classified based on the deficient enzyme and affected tissues. GSDs primarily affect liver or muscle or both as glycogen is particularly abundant in these tissues. However, besides liver and skeletal muscle, depending on the affected enzyme and its expression in various tissues, multiorgan involvement including heart, kidney and/or brain may be seen. Although GSDs share similar clinical features to some extent, there is a wide spectrum of clinical phenotypes. Currently, the goal of treatment is to maintain glucose homeostasis by dietary management and the use of uncooked cornstarch. In addition to nutritional interventions, pharmacological treatment, physical and supportive therapies, enzyme replacement therapy (ERT) and organ transplantation are other treatment approaches for both disease manifestations and long-term complications. The lack of a specific therapy for GSDs has prompted efforts to develop new treatment strategies like gene therapy. Since early diagnosis and aggressive treatment are related to better prognosis, physicians should be aware of these conditions and include GSDs in the differential diagnosis of patients with relevant manifestations including fasting hypoglycemia, hepatomegaly, hypertransaminasemia, hyperlipidemia, exercise intolerance, muscle cramps/pain, rhabdomyolysis, and muscle weakness. Here, we aim to provide a comprehensive review of GSDs. This review provides general characteristics of all types of GSDs with a focus on those with liver involvement.
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Affiliation(s)
- Ersin Gümüş
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Hacettepe University Faculty of Medicine, Ihsan Dogramaci Children’s Hospital, Ankara 06230, Turkey
| | - Hasan Özen
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Hacettepe University Faculty of Medicine, Ihsan Dogramaci Children’s Hospital, Ankara 06230, Turkey
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9
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Veiga-da-Cunha M, Wortmann SB, Grünert SC, Van Schaftingen E. Treatment of the Neutropenia Associated with GSD1b and G6PC3 Deficiency with SGLT2 Inhibitors. Diagnostics (Basel) 2023; 13:diagnostics13101803. [PMID: 37238286 DOI: 10.3390/diagnostics13101803] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 05/12/2023] [Accepted: 05/17/2023] [Indexed: 05/28/2023] Open
Abstract
Glycogen storage disease type Ib (GSD1b) is due to a defect in the glucose-6-phosphate transporter (G6PT) of the endoplasmic reticulum, which is encoded by the SLC37A4 gene. This transporter allows the glucose-6-phosphate that is made in the cytosol to cross the endoplasmic reticulum (ER) membrane and be hydrolyzed by glucose-6-phosphatase (G6PC1), a membrane enzyme whose catalytic site faces the lumen of the ER. Logically, G6PT deficiency causes the same metabolic symptoms (hepatorenal glycogenosis, lactic acidosis, hypoglycemia) as deficiency in G6PC1 (GSD1a). Unlike GSD1a, GSD1b is accompanied by low neutrophil counts and impaired neutrophil function, which is also observed, independently of any metabolic problem, in G6PC3 deficiency. Neutrophil dysfunction is, in both diseases, due to the accumulation of 1,5-anhydroglucitol-6-phosphate (1,5-AG6P), a potent inhibitor of hexokinases, which is slowly formed in the cells from 1,5-anhydroglucitol (1,5-AG), a glucose analog that is normally present in blood. Healthy neutrophils prevent the accumulation of 1,5-AG6P due to its hydrolysis by G6PC3 following transport into the ER by G6PT. An understanding of this mechanism has led to a treatment aimed at lowering the concentration of 1,5-AG in blood by treating patients with inhibitors of SGLT2, which inhibits renal glucose reabsorption. The enhanced urinary excretion of glucose inhibits the 1,5-AG transporter, SGLT5, causing a substantial decrease in the concentration of this polyol in blood, an increase in neutrophil counts and function and a remarkable improvement in neutropenia-associated clinical signs and symptoms.
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Affiliation(s)
- Maria Veiga-da-Cunha
- Metabolic Research Group, de Duve Institute and UCLouvain, B-1200 Brussels, Belgium
| | - Saskia B Wortmann
- University Children's Hospital, Paracelsus Medical University, 5020 Salzburg, Austria
- Amalia Children's Hospital, Radboudumc, 6525 Nijmegen, The Netherlands
| | - Sarah C Grünert
- Department of General Pediatrics, Adolescent Medicine and Neonatology, Medical Center, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
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10
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Grünert SC, Venema A, LaFreniere J, Schneider B, Contreras E, Wortmann SB, Derks TGJ. Patient-reported outcomes on empagliflozin treatment in glycogen storage disease type Ib: An international questionnaire study. JIMD Rep 2023; 64:252-258. [PMID: 37151361 PMCID: PMC10159866 DOI: 10.1002/jmd2.12364] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 03/29/2023] [Accepted: 04/06/2023] [Indexed: 05/09/2023] Open
Abstract
In patients with glycogen storage disease type Ib (GSD Ib), quality of life is severely hampered by neutropenia and neutropenia-associated symptoms. SGLT2 inhibitors are a new treatment option and have shown improved medical outcomes in more than 120 patients so far. The aim of this international questionnaire study was to assess patient-reported outcomes of this new treatment in GSD Ib patients. Patients and caregivers of pediatric patients were invited to complete a web-based questionnaire. This was designed to evaluate treatment effects of the SGLT2 inhibitor empagliflozin on clinical symptoms and important aspects of daily life including physical performance, sleep, social and work life, traveling, socioeconomic aspects, and quality of life. The questionnaire was completed by 73 respondents from 17 different countries. The mean duration of treatment was 15 months, the cumulative treatment time was 94.8 years. More than 80% of patients reported an improved quality of life. The number of hospitalizations was reduced (66% of patients), as well as the number of days absent from school or work. Granulocyte colony-stimulating factor (G-CSF) treatment could be stopped in 49% of patients and reduced in another 42%. Clear improvement of neutropenia and all neutropenia-associated symptoms was reported by the majority of patients. Additionally, patients or caregivers reported positive effects on appetite (63%), level of activity (75%), overall well-being (96%), and sleep (63%). Empagliflozin positively impacts many aspects of daily life including work and social life and thereby significantly improves quality of life of patients and caregivers.
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Affiliation(s)
- Sarah C. Grünert
- Department of General Pediatrics, Adolescent Medicine and Neonatology, Faculty of MedicineMedical Center‐University of FreiburgFreiburgGermany
| | - Annieke Venema
- Division of Metabolic Diseases, Beatrix Children's Hospital, University of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | | | - Blair Schneider
- Sophie's Hope Foundation (CureGSD1b)HopkintonMassachusettsUSA
| | - Enrique Contreras
- Asociacion Española de Enfermos de Glucogenosis (Spanish Patient Organisation for Glycogen Storage Diseases)Santiago de CompostelaSpain
| | - Saskia B. Wortmann
- University Children's Hospital Salzburg, Paracelsus Medical UniversitySalzburgAustria
- Amalia Children's Hospital, RadboudumcNijmegenThe Netherlands
| | - Terry G. J. Derks
- Division of Metabolic Diseases, Beatrix Children's Hospital, University of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
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11
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Maiorana A, Tagliaferri F, Dionisi-Vici C. Current understanding on pathogenesis and effective treatment of glycogen storage disease type Ib with empagliflozin: new insights coming from diabetes for its potential implications in other metabolic disorders. Front Endocrinol (Lausanne) 2023; 14:1145111. [PMID: 37152929 PMCID: PMC10160627 DOI: 10.3389/fendo.2023.1145111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Accepted: 04/10/2023] [Indexed: 05/09/2023] Open
Abstract
Glycogen storage type Ib (GSDIb) is a rare inborn error of metabolism caused by glucose-6-phosphate transporter (G6PT, SLC37A4) deficiency. G6PT defect results in excessive accumulation of glycogen and fat in the liver, kidney, and intestinal mucosa and into both glycogenolysis and gluconeogenesis impairment. Clinical features include hepatomegaly, hypoglycemia, lactic acidemia, hyperuricemia, hyperlipidemia, and growth retardation. Long-term complications are liver adenoma, hepatocarcinoma, nephropathy and osteoporosis. The hallmark of GSDIb is neutropenia, with impaired neutrophil function, recurrent infections and inflammatory bowel disease. Alongside classical nutritional therapy with carbohydrates supplementation and immunological therapy with granulocyte colony-stimulating factor, the emerging role of 1,5-anhydroglucitol in the pathogenesis of neutrophil dysfunction led to repurpose empagliflozin, an inhibitor of the renal glucose transporter SGLT2: the current literature of its off-label use in GSDIb patients reports beneficial effects on neutrophil dysfunction and its clinical consequences. Surprisingly, this glucose-lowering drug ameliorated the glycemic and metabolic control in GSDIb patients. Furthermore, numerous studies from big cohorts of type 2 diabetes patients showed the efficacy of empagliflozin in reducing the cardiovascular risk, the progression of kidney disease, the NAFLD and the metabolic syndrome. Beneficial effects have also been described on peripheral neuropathy in a prediabetic rat model. Increasing evidences highlight the role of empagliflozin in regulating the cellular energy sensors SIRT1/AMPK and Akt/mTOR, which leads to improvement of mitochondrial structure and function, stimulation of autophagy, decrease of oxidative stress and suppression of inflammation. Modulation of these pathways shift the oxidative metabolism from carbohydrates to lipids oxidation and results crucial in reducing insulin levels, insulin resistance, glucotoxicity and lipotoxicity. For its pleiotropic effects, empagliflozin appears to be a good candidate for drug repurposing also in other metabolic diseases presenting with hypoglycemia, organ damage, mitochondrial dysfunction and defective autophagy.
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Affiliation(s)
- Arianna Maiorana
- Division of Metabolism, Ospedale Pediatrico Bambino Gesù, IRCCS, Rome, Italy
- *Correspondence: Arianna Maiorana,
| | - Francesco Tagliaferri
- SCDU of Pediatrics, Azienda Ospedaliero-Universitaria Maggiore della Carità, University of Piemonte Orientale, Novara, Italy
| | - Carlo Dionisi-Vici
- Division of Metabolism, Ospedale Pediatrico Bambino Gesù, IRCCS, Rome, Italy
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12
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Makrilakis K, Barmpagianni A, Veiga-da-Cunha M. Repurposing of Empagliflozin as a Possible Treatment for Neutropenia and Inflammatory Bowel Disease in Glycogen Storage Disease Type Ib: A Case Report. Cureus 2022; 14:e27264. [PMID: 36039216 PMCID: PMC9403211 DOI: 10.7759/cureus.27264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/24/2022] [Indexed: 11/18/2022] Open
Abstract
Glycogen storage disease type Ib (GSD-Ib) is an autosomal-recessive inborn error of carbohydrate metabolism, where severe fasting hypoglycemia is associated (among other manifestations) with neutropenia and neutrophil dysfunction (predisposing to recurrent, potentially life-threatening infections) and inflammatory bowel disease (IBD). Granulocyte colony-stimulating factors (G-CSFs) are commonly used for its treatment. Although they have improved the prognosis of the disease, these medicines have also led to concerns about complications associated with their use (namely splenomegaly and hematopoietic malignancies), not to mention their increased cost. Recently, a novel new treatment for neutropenia associated with this disease was discovered. It was found that sodium-glucose cotransporter type 2 (SGLT-2) inhibitors, usually used for the treatment of diabetes mellitus, can ameliorate both neutropenia and IBD-related symptoms and improve the quality of life in patients suffering from these diseases. They do it by inhibiting the renal reabsorption of 1,5-anhydroglucitol, a dietary analog of glucose, whose accumulation due to the specific enzyme deficiency leads to toxic effects on granulocytes. Herein we report the treatment of an adult patient suffering from GSD-Ib with empagliflozin, an SGLT-2 inhibitor.
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13
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Boulanger C, Stephenne X, Diederich J, Mounkoro P, Chevalier N, Ferster A, Van Schaftingen E, Veiga‐da‐Cunha M. Successful use of empagliflozin to treat neutropenia in two G6PC3-deficient children: Impact of a mutation in SGLT5. J Inherit Metab Dis 2022; 45:759-768. [PMID: 35506446 PMCID: PMC9540799 DOI: 10.1002/jimd.12509] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 04/28/2022] [Accepted: 05/02/2022] [Indexed: 11/10/2022]
Abstract
Neutropenia and neutrophil dysfunction found in deficiencies in G6PC3 and in the glucose-6-phosphate transporter (G6PT/SLC37A4) are due to accumulation of 1,5-anhydroglucitol-6-phosphate (1,5-AG6P), an inhibitor of hexokinase made from 1,5-anhydroglucitol (1,5-AG), an abundant polyol present in blood. Lowering blood 1,5-AG with an SGLT2 inhibitor greatly improved neutrophil counts and function in G6PC3-deficient mice and in patients with G6PT-deficiency. We evaluate this treatment in two G6PC3-deficient children. While neutropenia was severe in one child (PT1), which was dependent on granulocyte cololony-stimulating factor (GCSF), it was significantly milder in the other one (PT2), which had low blood 1,5-AG levels and only required GCSF during severe infections. Treatment with the SGLT2-inhibitor empagliflozin decreased 1,5-AG in blood and 1,5-AG6P in neutrophils and improved (PT1) or normalized (PT2) neutrophil counts, allowing to stop GCSF. On empagliflozin, both children remained infection-free (>1 year - PT2; >2 years - PT1) and no side effects were reported. Remarkably, sequencing of SGLT5, the gene encoding the putative renal transporter for 1,5-AG, disclosed a rare heterozygous missense mutation in PT2, replacing the extremely conserved Arg401 by a histidine. The higher urinary clearance of 1,5-AG explains the more benign neutropenia and the outstanding response to empagliflozin treatment found in this child. Our data shows that SGLT2 inhibitors are an excellent alternative to treat the neutropenia present in G6PC3-deficiency.
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Affiliation(s)
- Cécile Boulanger
- Biologie HématologiqueCliniques Universitaires Saint‐Luc, UCLouvainBrusselsBelgium
| | - Xavier Stephenne
- Service de Gastro‐Entérologie et Hépatologie PédiatriqueCliniques Universitaires Saint‐Luc, UCLouvainBrusselsBelgium
| | - Jennifer Diederich
- Groupe de Recherches Metaboliquesde Duve Institute, UCLouvainBrusselsBelgium
| | - Pierre Mounkoro
- Groupe de Recherches Metaboliquesde Duve Institute, UCLouvainBrusselsBelgium
| | - Nathalie Chevalier
- Groupe de Recherches Metaboliquesde Duve Institute, UCLouvainBrusselsBelgium
| | - Alina Ferster
- Department of Hematology/OncologyHôpital Universitaire des Enfants Reine Fabiola, Université Libre de BruxellesBrusselsBelgium
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14
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Tallis E, Karsenty CL, Grimes AB, Karam LB, Elsea SH, Sutton VR, Rawls‐Castillo BL, Liu N, Soler‐Alfonso C. Untargeted metabolomic profiling in a patient with glycogen storage disease
Ib
receiving empagliflozin treatment. JIMD Rep 2022; 63:309-315. [PMID: 35822097 PMCID: PMC9259396 DOI: 10.1002/jmd2.12304] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 05/09/2022] [Accepted: 05/11/2022] [Indexed: 11/29/2022] Open
Abstract
Glycogen storage disease type Ib (GSD‐Ib) is a rare inborn error of glycogen metabolism uniquely associated with neutropenia and neutrophil dysfunction, causing severe infections, inflammatory bowel disease (IBD), and impaired wound healing. Recently, kidney sodium‐glucose co‐transporter‐2 (SGLT2) inhibitors such as empagliflozin known to reduce plasma levels of 1,5‐anhydroglucitol (1,5‐AG) and its toxic derivatives in neutrophils, have been described as a new treatment option in case reports of patients with GSD‐Ib from Europe and Asia. We report our experience with an 11‐year‐old girl with GSD‐Ib presenting with short fasting hypoglycemia, neutropenia with neutrophil dysfunction, recurrent infections, suboptimal growth, iron‐deficiency anemia, and IBD. Treatment with daily empagliflozin improved neutrophil counts and function with a significant reduction in G‐CSF needs. Significant improvement in IBD has led to weight gain with improved nutritional markers and improved fasting tolerance. Reduction of maximum empagliflozin dose was needed due to arthralgia. No other significant side effects of empagliflozin were observed. This report uniquely highlights the novel use of untargeted metabolomics profiling for monitoring plasma levels of 1,5‐AG to assess empagliflozin dose responsiveness and guide dietary management and G‐CSF therapy. Clinical improvement correlated to rapid normalization of 1,5‐AG levels in plasma sustained after dose reduction. In conclusion, empagliflozin appeared to be a safe treatment option for GSD‐Ib‐associated neutropenia and neutrophil dysfunction. Global untargeted metabolomics is an efficient method to assess biochemical responsiveness to treatment.
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Affiliation(s)
- Eran Tallis
- Department of Molecular and Human Genetics Baylor College of Medicine Houston Texas USA
| | - Cecile L. Karsenty
- Department of Pediatrics Baylor College of Medicine Houston Texas USA
- Texas Children's Cancer and Hematology Centers Houston Texas USA
| | - Amanda B. Grimes
- Department of Pediatrics Baylor College of Medicine Houston Texas USA
- Texas Children's Cancer and Hematology Centers Houston Texas USA
| | - Lina B. Karam
- Department of Pediatrics‐Gastroenterology Baylor College of Medicine Houston Texas USA
| | - Sarah H. Elsea
- Department of Molecular and Human Genetics Baylor College of Medicine Houston Texas USA
- Baylor Genetics Houston Texas USA
| | - Vernon Reed Sutton
- Department of Molecular and Human Genetics Baylor College of Medicine Houston Texas USA
- Baylor Genetics Houston Texas USA
| | | | - Ning Liu
- Department of Molecular and Human Genetics Baylor College of Medicine Houston Texas USA
- Baylor Genetics Houston Texas USA
| | - Claudia Soler‐Alfonso
- Department of Molecular and Human Genetics Baylor College of Medicine Houston Texas USA
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15
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Halligan RK, Dalton RN, Turner C, Lewis KA, Mundy HR. Understanding the role of SGLT2 inhibitors in glycogen storage disease type Ib: the experience of one UK centre. Orphanet J Rare Dis 2022; 17:195. [PMID: 35549996 PMCID: PMC9096769 DOI: 10.1186/s13023-022-02345-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 04/26/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Glycogen storage disease type Ib (GSD Ib) is a severe disorder of carbohydrate metabolism due to bi-allelic variants in SLC37A4. It is associated with neutropaenia and neutrophil dysfunction, which has recently been attributed to the accumulation of 1,5-anhydroglucitol-6-phosphate (1,5AG6P) within neutrophils. Treatment with sodium-glucose co-transporter-2 (SGLT2) inhibitors, such as empagliflozin, is a novel therapy that reduces 1,5-anhydroglucitol (1,5AG) in plasma. RESULTS We report our experience in treating 8 paediatric GSD Ib patients with empagliflozin with a cumulative treatment time greater than 12 years. Treatment with a median dose of 5 mg (0.22 mg/kg height weight) of empagliflozin resulted in improvement in bowel health, growth, and laboratory parameters. Plasma 1,5AG levels reduced by a median of 78%. Baseline 1,5AG levels in our cohort were higher than in adult patients with GSD Ib. Hypoglycaemia on empagliflozin treatment occurred in 50% of our cohort. CONCLUSION We report the largest single centre cohort of GSD Ib patients treated with empagliflozin to date. Treatment with SGLT2 inhibitors is a novel and favourable treatment option for neutropaenia and neutrophil dysfunction in GSD Ib. We suggest a low starting dose of empagliflozin with careful titration due to the risk of hypoglycaemia. The interpretation of 1,5AG levels and their role in treatment monitoring is yet to be established, and requires ongoing research.
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Affiliation(s)
- Rebecca K Halligan
- Inherited Metabolic Diseases, Evelina London Children's Hospital, London, SE1 7EH, UK.
| | - R Neil Dalton
- WellChild Laboratory, Evelina London Children's Hospital, London, UK
| | - Charles Turner
- WellChild Laboratory, Evelina London Children's Hospital, London, UK
| | - Katherine A Lewis
- Inherited Metabolic Diseases, Evelina London Children's Hospital, London, SE1 7EH, UK
| | - Helen R Mundy
- Inherited Metabolic Diseases, Evelina London Children's Hospital, London, SE1 7EH, UK
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16
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Grünert SC, Derks TGJ, Adrian K, Al-Thihli K, Ballhausen D, Bidiuk J, Bordugo A, Boyer M, Bratkovic D, Brunner-Krainz M, Burlina A, Chakrapani A, Corpeleijn W, Cozens A, Dawson C, Dhamko H, Milosevic MD, Eiroa H, Finezilber Y, Moura de Souza CF, Garcia-Jiménez MC, Gasperini S, Haas D, Häberle J, Halligan R, Fung LH, Hörbe-Blindt A, Horka LM, Huemer M, Uçar SK, Kecman B, Kilavuz S, Kriván G, Lindner M, Lüsebrink N, Makrilkakis K, Mei-Kwun Kwok A, Maier EM, Maiorana A, McCandless SE, Mitchell JJ, Mizumoto H, Mundy H, Ochoa C, Pierce K, Fraile PQ, Regier D, Rossi A, Santer R, Schuman HC, Sobieraj P, Spenger J, Spiegel R, Stepien KM, Tal G, Tanšek MZ, Torkar AD, Tchan M, Thyagu S, Schrier Vergano SA, Vucko E, Weinhold N, Zsidegh P, Wortmann SB. Efficacy and safety of empagliflozin in glycogen storage disease type Ib: Data from an international questionnaire. Genet Med 2022; 24:1781-1788. [PMID: 35503103 DOI: 10.1016/j.gim.2022.04.001] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 03/31/2022] [Accepted: 04/01/2022] [Indexed: 01/10/2023] Open
Abstract
PURPOSE This paper aims to report collective information on safety and efficacy of empagliflozin drug repurposing in individuals with glycogen storage disease type Ib (GSD Ib). METHODS This is an international retrospective questionnaire study on the safety and efficacy of empagliflozin use for management of neutropenia/neutrophil dysfunction in patients with GSD Ib, conducted among the respective health care providers from 24 countries across the globe. RESULTS Clinical data from 112 individuals with GSD Ib were evaluated, representing a total of 94 treatment years. The median age at start of empagliflozin treatment was 10.5 years (range = 0-38 years). Empagliflozin showed positive effects on all neutrophil dysfunction-related symptoms, including oral and urogenital mucosal lesions, recurrent infections, skin abscesses, inflammatory bowel disease, and anemia. Before initiating empagliflozin, most patients with GSD Ib were on G-CSF (94/112; 84%). At the time of the survey, 49 of 89 (55%) patients previously treated with G-CSF had completely stopped G-CSF, and another 15 (17%) were able to reduce the dose. The most common adverse event during empagliflozin treatment was hypoglycemia, occurring in 18% of individuals. CONCLUSION Empagliflozin has a favorable effect on neutropenia/neutrophil dysfunction-related symptoms and safety profile in individuals with GSD Ib.
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Affiliation(s)
- Sarah C Grünert
- Department of General Pediatrics, Adolescent Medicine and Neonatology, Medical Centre-University of Freiburg, Faculty of Medicine, Freiburg, Germany.
| | - Terry G J Derks
- Section of Metabolic Diseases, Beatrix Children's Hospital, University Medical Center of Groningen, University of Groningen, Groningen, The Netherlands
| | - Katarina Adrian
- Department of Pediatrics, Queen Silvias Childrens Hospital, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Khalid Al-Thihli
- Genetic and Developmental Medicine Clinic, Sultan Qaboos University Hospital, Muscat, Oman
| | - Diana Ballhausen
- Pediatric Metabolic Unit, Pediatrics, Woman-Mother-Child Department, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Joanna Bidiuk
- Department of Internal Medicine, Hypertension and Vascular Diseases, Medical University of Warsaw, Warsaw, Poland
| | - Andrea Bordugo
- Inherited Metabolic Disease Unit, Pediatric Clinic C, Woman and Child Department, Azienda Ospedaliera Università Integrata, Verona, Italy
| | - Monica Boyer
- Division of Metabolic Disorders, CHOC Children's Hospital, Orange, CA
| | - Drago Bratkovic
- Metabolic Clinic, Women's and Children's Hospital, North Adelaide, South Australia, Australia
| | | | - Alberto Burlina
- Division of Inherited Metabolic Diseases, Department of Diagnostic Services, University Hospital, Padua, Italy
| | - Anupam Chakrapani
- Department of Metabolic Medicine, Great Ormond Street Hospital, London, United Kingdom
| | - Willemijn Corpeleijn
- Department of Pediatrics, Division of Metabolic Disorders, Emma Children's Hospital, Gastroenterology, Endocrinology & Metabolism, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Alison Cozens
- Royal Hospital for Children and Young People, Edinburgh, United Kingdom
| | - Charlotte Dawson
- Department of Endocrinology, Diabetes and Metabolism, University Hospitals Birmingham, Birmingham, United Kingdom
| | - Helena Dhamko
- Division of Medical Oncology and Hematology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Maja Djordjevic Milosevic
- Metabolic and Genetic Department, Mother and Child Health Care Institute of Serbia "Dr Vukan Čupić", Belgrade, Serbia
| | - Hernan Eiroa
- Servicio de Errores Congenitos del Metabolismo, Hospital de Pediatria "J.P. Garrahan", Buenos Aires, Argentina
| | - Yael Finezilber
- Metabolic Diseases Unit and Internal Medicine Department A, Sheba Medical Center, Ramat Gan, Israel
| | | | | | - Serena Gasperini
- Metabolic Rare Diseases Unit, Paediatric Department, San Gerardo Hospital, Monza, Italy
| | - Dorothea Haas
- Center for Child and Adolescent Medicine, Division of Child Neurology and Metabolic Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Johannes Häberle
- Division of Metabolism and Children`s Research Center, University Children's Hospital Zurich, Zürich, Switzerland
| | - Rebecca Halligan
- Department of Metabolic Medicine, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Law Hiu Fung
- Department of Pediatrics and Adolescent Medicine, Queen Mary Hospital, Hong Kong Island, Hong Kong
| | | | - Laura Maria Horka
- Department of Endocrinology, Diabetology and Clinical Nutrition, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Martina Huemer
- Division of Metabolism and Children`s Research Center, University Children's Hospital Zurich, Zürich, Switzerland; Department of Paediatrics, University Children's Hospital Basel and University of Basel, Basel, Switzerland
| | - Sema Kalkan Uçar
- Division of Metabolism and Nutrition, Department of Pediatrics, Ege University Children's Hospital, Izmir, Turkey
| | - Bozica Kecman
- Metabolic and Genetic Department, Mother and Child Health Care Institute of Serbia "Dr Vukan Čupić", Belgrade, Serbia
| | - Sebile Kilavuz
- Division of Pediatric Metabolism, Department of Pediatrics, University of Health Sciences, Van Training and Research Hospital, Van, Turkey
| | - Gergely Kriván
- Department for Pediatric Hematology and Hemopoietic Stem Cell Transplantation, Central Hospital of Southern Pest National Institute of Hematology and Infectious Diseases, Budapest, Hungary
| | - Martin Lindner
- Department of Pediatric Neurology, University Children's Hospital Frankfurt, Frankfurt, Germany
| | - Natalia Lüsebrink
- Department of Pediatric Neurology, University Children's Hospital Frankfurt, Frankfurt, Germany
| | - Konstantinos Makrilkakis
- First Department of Propaedeutic Internal Medicine, National and Kapodistrian University of Athens Medical School, Laiko General Hospital, Athens, Greece
| | - Anne Mei-Kwun Kwok
- Department of Pediatrics and Adolescent Medicine, Hong Kong Children's Hospital, Hong Kong
| | - Esther M Maier
- Section of Inborn Errors of Metabolism, Dr. von Hauner Children's Hospital, University of Munich, Munich, Germany
| | - Arianna Maiorana
- Division of Metabolism, Department of Pediatric Subspecialties, Ospedale Pediatrico Bambino Gesù, Istituti di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Shawn E McCandless
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO; Department of Genetics and Metabolism, Children's Hospital Colorado, Aurora, CO
| | - John James Mitchell
- Division of Pediatric Endocrinology, McGill University Health Center, Montreal, Quebec, Canada
| | - Hiroshi Mizumoto
- Department of Pediatrics, Tazuke Kofukai Medical Research Institute, Kitano Hospital, Osaka, Japan
| | - Helen Mundy
- Evelina Children's Hospital, London, United Kingdom
| | - Carlos Ochoa
- Department of Pediatrics, Complejo Asistencial de Zamora, Zamora, Spain
| | | | - Pilar Quijada Fraile
- Reference Center for Inherited Metabolic Disorders, Department of Pediatrics, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Debra Regier
- Genetics and Metabolism, Children's National Hospital, Washington DC
| | - Alessandro Rossi
- Section of Paediatrics, Department of Translational Medicine, University of Naples "Federico II", Naples, Italy
| | - René Santer
- Department of Pediatrics, University Medical Center Eppendorf, Hamburg, Germany
| | | | - Piotr Sobieraj
- Department of Internal Medicine, Hypertension and Vascular Diseases, Medical University of Warsaw, Warsaw, Poland
| | | | - Ronen Spiegel
- Pediatric Department B, Emek Medical Center, Afula, Rappaport School of Medicine, Technion, Haifa, Israel
| | - Karolina M Stepien
- Adult Inherited Metabolic Diseases, Salford Royal NHS Foundation Trust, Salford, United Kingdom
| | - Galit Tal
- Metabolic Clinic, Ruth Rappaport Children's Hospital, Rambam Health Care Campus, Haifa, Israel
| | - Mojca Zerjav Tanšek
- University Children's Hospital, Department of Endocrinology, Diabetes and Metabolism, Ljubljana University Medical Centre, Ljubljana, Slovenia
| | - Ana Drole Torkar
- University Children's Hospital, Department of Endocrinology, Diabetes and Metabolism, Ljubljana University Medical Centre, Ljubljana, Slovenia
| | - Michel Tchan
- Department of Genetic Medicine, Westmead Hospital, Sydney, New South Wales, Australia; Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Santhosh Thyagu
- Division of Medical Oncology and Hematology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | | | - Erika Vucko
- Division of Genetics, Birth Defects, and Metabolism, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Natalie Weinhold
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Pediatric Gastroenterology, Nephrology and Metabolic Diseases, Center of Chronically Sick Children, Berlin, Germany
| | - Petra Zsidegh
- Newborn Screening and Metabolic Centre, 1(st) Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Saskia B Wortmann
- University Children's Hospital Salzburg, Salzburg, Austria; Amalia Children's Hospital, Nijmegen, The Netherlands
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17
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Hexner-Erlichman Z, Veiga-da-Cunha M, Zehavi Y, Vadasz Z, Sabag AD, Tatour S, Spiegel R. Favorable outcome of empagliflozin treatment in two pediatric glycogen storage disease type 1b patients. Front Pediatr 2022; 10:1071464. [PMID: 36507137 PMCID: PMC9727171 DOI: 10.3389/fped.2022.1071464] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Accepted: 11/07/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Glycogen storage disease type 1b (GSD1b) is an ultra-rare autosomal recessive disorder, caused by mutations in SLC37A4 gene. Affected patients present with episodes of fasting hypoglycemia and lactic acidosis, hepatomegaly, growth retardation, hyperlipidemia and renal impairment. In addition, patients present neutropenia, neutrophil dysfunction and oral, and skin infections as well as a significant predisposition to develop inflammatory bowel disease (IBD). Low neutrophil counts and function is related to the toxic accumulation of 1,5-anhydroglucitol-6-phosphate (1,5-AG6P). Recently, several reports have shown that off-label treatment with empagliflozin (EMPA), an inhibitor of the renal glucose transporter SGLT2, decreased blood 1,5-anhydroglucitol (1,5-AG), and neutrophil 1,5-AG6P, thus resulting in a new therapeutic option for neutropenia and neutrophil dysfunction in patients. METHODS Off-label treatment with EMPA was established in two GSD1b patients after signed informed consent. The patients were followed clinically. We monitored neutrophil counts and function, 1,5-AG levels in plasma and its renal clearance before and during EMPA treatment. RESULTS A 17 year-old girl who had long standing oral ulcers and developed IBD, requiring systemic steroid and regular granulocyte colony-stimulating factor (GCSF) therapy and an 8 year-old boy who had steady non healing oral lesions were treated with empagliflozin during 18-24 months. Treatment led to increase of neutrophil counts and function with substantial clinical improvement. This included remission of IBD in the first patient which allowed to discontinue both GCSF and steroid therapy and resolution of oral lesions in both patients. The concentration of 1,5-AG in blood was greatly decreased within two weeks of treatment and remained stable thereafter. CONCLUSIONS Repurposing of empagliflozin to treat neutropenia in two GSD1b patients was safe and resulted in the urinary excretion of 1,5-AG, the normalization of neutrophil function, and a remarkable improvement of neutropenia-related clinical traits. We showed for the first time that empagliflozin increases concomitantly the renal clearance of both 1,5-anhydroglucitol and glucose in GSD1b patients.
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Affiliation(s)
- Zufit Hexner-Erlichman
- Department of Pediatrics B, Emek Medical Center, Afula, Israel.,Genetic Institute and Center for Rare Diseases, Emek Medical Center, Afula, Israel
| | | | - Yoav Zehavi
- Department of Pediatrics B, Emek Medical Center, Afula, Israel.,Genetic Institute and Center for Rare Diseases, Emek Medical Center, Afula, Israel.,Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Zahava Vadasz
- Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel.,The Proteomic and Clinical Flow Cytometry Unit, Bnai-Zion Medical Center, Haifa, Israel
| | - Adi D Sabag
- The Proteomic and Clinical Flow Cytometry Unit, Bnai-Zion Medical Center, Haifa, Israel
| | - Sameh Tatour
- Pediatric Gastroenterology Unit, Emek Medical Center, Afula, Israel
| | - Ronen Spiegel
- Department of Pediatrics B, Emek Medical Center, Afula, Israel.,Genetic Institute and Center for Rare Diseases, Emek Medical Center, Afula, Israel.,Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
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18
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Resaz R, Raggi F, Segalerba D, Lavarello C, Gamberucci A, Bosco MC, Astigiano S, Assunto A, Melis D, D'Acierno M, Veiga-da-Cunha M, Petretto A, Marcolongo P, Trepiccione F, Eva A. The SGLT2-inhibitor dapagliflozin improves neutropenia and neutrophil dysfunction in a mouse model of the inherited metabolic disorder GSDIb. Mol Genet Metab Rep 2021; 29:100813. [PMID: 34712576 PMCID: PMC8531659 DOI: 10.1016/j.ymgmr.2021.100813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 10/14/2021] [Indexed: 11/09/2022] Open
Abstract
Glycogen Storage Disease type 1b (GSDIb) is a genetic disorder with long term severe complications. Accumulation of the glucose analog 1,5-anhydroglucitol-6-phosphate (1,5AG6P) in neutrophils inhibits the phosphorylation of glucose in these cells, causing neutropenia and neutrophil dysfunctions. This condition leads to serious infections and inflammatory bowel disease (IBD) in GSDIb patients. We show here that dapagliflozin, an inhibitor of the renal sodium-glucose co-transporter-2 (SGLT2), improves neutrophil function in an inducible mouse model of GSDIb by reducing 1,5AG6P accumulation in myeloid cells.
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Key Words
- 1,5-anhydroglucitol-6-phosphate
- 1,5AG, 1,5-anhydroglucitol
- 1,5AG6P, 1,5-anhydroglucitol-6-phosphate
- BM, bone marrow
- CFU, colony forming units
- Dapagliflozin
- G-CSF, granulocyte colony stimulating factor
- G6PC3, glucose-6-phosphatase C3
- G6PT, glucose-6-phospate translocase
- GSDIb, Glycogen Storage Disease type 1b
- Glycogen storage disease type 1b
- M-CSF, macrophage colony stimulating factor
- Mouse model
- NET, neutrophil extracellular trap
- Neutrophils
- PMA, phorbol myristate acetate
- PRM, parallel reaction monitoring
- Renal sodium-glucose co-transporter-2
- SGLT2, sodium-glucose co-transporter-2
- TM, tamoxifen
- fMLP, N-formyl-L-methionyl-L-leucyl-phenylalanine
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Affiliation(s)
- Roberta Resaz
- Laboratory of Molecular Biology, IRCCS Istituto Giannina Gaslini, Via Gerolamo Gaslini 5, 16147 Genova, Italy
| | - Federica Raggi
- Laboratory of Molecular Biology, IRCCS Istituto Giannina Gaslini, Via Gerolamo Gaslini 5, 16147 Genova, Italy
| | - Daniela Segalerba
- Laboratory of Molecular Biology, IRCCS Istituto Giannina Gaslini, Via Gerolamo Gaslini 5, 16147 Genova, Italy
| | - Chiara Lavarello
- Core Facilities-Clinical Proteomics and Metabolomics, IRCCS, Istituto Giannina Gaslini, Via Gerolamo Gaslini 5, 16147 Genova, Italy
| | - Alessandra Gamberucci
- Department of Molecular and Developmental Medicine, Università degli Studi di Siena, Siena, Italy
| | - Maria Carla Bosco
- Laboratory of Molecular Biology, IRCCS Istituto Giannina Gaslini, Via Gerolamo Gaslini 5, 16147 Genova, Italy
| | | | - Antonia Assunto
- Medical, Surgical, and Dental Department, Università degli Studi di Salerno, Salerno, Italy
| | - Daniela Melis
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana," Section of Pediatrics, Università degli Studi di Salerno, Via Salvador Allende, 43 84081, Baronissi, Salerno, Italy
| | - Mariavittoria D'Acierno
- Biogem Research Institute "Gaetano Salvatore", Ariano Irpino, Italy.,Department of Translational Medical Sciences, Università degli Studi della Campania "L. Vanvitelli", Naples, Italy
| | - Maria Veiga-da-Cunha
- Walloon Excellence in Lifesciences and Biotechnology, B-1200 Brussels, Belgium.,Groupe de Recherches Metaboliques, de Duve Institute, UCLouvain, (Université Catholique de Louvain), B-1200 Brussels, Belgium
| | - Andrea Petretto
- Core Facilities-Clinical Proteomics and Metabolomics, IRCCS, Istituto Giannina Gaslini, Via Gerolamo Gaslini 5, 16147 Genova, Italy
| | - Paola Marcolongo
- Department of Molecular and Developmental Medicine, Università degli Studi di Siena, Siena, Italy
| | - Francesco Trepiccione
- Biogem Research Institute "Gaetano Salvatore", Ariano Irpino, Italy.,Department of Translational Medical Sciences, Università degli Studi della Campania "L. Vanvitelli", Naples, Italy
| | - Alessandra Eva
- Laboratory of Molecular Biology, IRCCS Istituto Giannina Gaslini, Via Gerolamo Gaslini 5, 16147 Genova, Italy
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