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Sousa AA, Hemez C, Lei L, Traore S, Kulhankova K, Newby GA, Doman JL, Oye K, Pandey S, Karp PH, McCray PB, Liu DR. Systematic optimization of prime editing for the efficient functional correction of CFTR F508del in human airway epithelial cells. Nat Biomed Eng 2024:10.1038/s41551-024-01233-3. [PMID: 38987629 DOI: 10.1038/s41551-024-01233-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Accepted: 06/12/2024] [Indexed: 07/12/2024]
Abstract
Prime editing (PE) enables precise and versatile genome editing without requiring double-stranded DNA breaks. Here we describe the systematic optimization of PE systems to efficiently correct human cystic fibrosis (CF) transmembrane conductance regulator (CFTR) F508del, a three-nucleotide deletion that is the predominant cause of CF. By combining six efficiency optimizations for PE-engineered PE guide RNAs, the PEmax architecture, the transient expression of a dominant-negative mismatch repair protein, strategic silent edits, PE6 variants and proximal 'dead' single-guide RNAs-we increased correction efficiencies for CFTR F508del from less than 0.5% in HEK293T cells to 58% in immortalized bronchial epithelial cells (a 140-fold improvement) and to 25% in patient-derived airway epithelial cells. The optimizations also resulted in minimal off-target editing, in edit-to-indel ratios 3.5-fold greater than those achieved by nuclease-mediated homology-directed repair, and in the functional restoration of CFTR ion channels to over 50% of wild-type levels (similar to those achieved via combination treatment with elexacaftor, tezacaftor and ivacaftor) in primary airway cells. Our findings support the feasibility of a durable one-time treatment for CF.
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Affiliation(s)
- Alexander A Sousa
- Merkin Institute of Transformative Technologies in Healthcare, The Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Department of Chemistry and Chemical Biology, Harvard University, Cambridge, MA, USA
- Howard Hughes Medical Institute, Harvard University, Cambridge, MA, USA
| | - Colin Hemez
- Merkin Institute of Transformative Technologies in Healthcare, The Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Department of Chemistry and Chemical Biology, Harvard University, Cambridge, MA, USA
- Howard Hughes Medical Institute, Harvard University, Cambridge, MA, USA
| | - Lei Lei
- Stead Family Department of Pediatrics and Pappajohn Biomedical Institute, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | - Soumba Traore
- Stead Family Department of Pediatrics and Pappajohn Biomedical Institute, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | - Katarina Kulhankova
- Stead Family Department of Pediatrics and Pappajohn Biomedical Institute, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | - Gregory A Newby
- Merkin Institute of Transformative Technologies in Healthcare, The Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Department of Chemistry and Chemical Biology, Harvard University, Cambridge, MA, USA
- Howard Hughes Medical Institute, Harvard University, Cambridge, MA, USA
- Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Jordan L Doman
- Merkin Institute of Transformative Technologies in Healthcare, The Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Department of Chemistry and Chemical Biology, Harvard University, Cambridge, MA, USA
- Howard Hughes Medical Institute, Harvard University, Cambridge, MA, USA
| | - Keyede Oye
- Merkin Institute of Transformative Technologies in Healthcare, The Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Department of Chemistry and Chemical Biology, Harvard University, Cambridge, MA, USA
- Howard Hughes Medical Institute, Harvard University, Cambridge, MA, USA
| | - Smriti Pandey
- Merkin Institute of Transformative Technologies in Healthcare, The Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Department of Chemistry and Chemical Biology, Harvard University, Cambridge, MA, USA
- Howard Hughes Medical Institute, Harvard University, Cambridge, MA, USA
| | - Philip H Karp
- Department of Internal Medicine and Pappajohn Biomedical Institute, Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA
- Howard Hughes Medical Institute, University of Iowa, Iowa City, IA, USA
| | - Paul B McCray
- Stead Family Department of Pediatrics and Pappajohn Biomedical Institute, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | - David R Liu
- Merkin Institute of Transformative Technologies in Healthcare, The Broad Institute of MIT and Harvard, Cambridge, MA, USA.
- Department of Chemistry and Chemical Biology, Harvard University, Cambridge, MA, USA.
- Howard Hughes Medical Institute, Harvard University, Cambridge, MA, USA.
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Holtrop M, Cosmich S, Lee M, Keller A, Jain R. Sex Differences Persist After Treatment With Ivacaftor in People With Cystic Fibrosis. Chest 2024:S0012-3692(24)00698-6. [PMID: 38871282 DOI: 10.1016/j.chest.2024.05.019] [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: 10/31/2023] [Revised: 05/29/2024] [Accepted: 05/30/2024] [Indexed: 06/15/2024] Open
Abstract
BACKGROUND Historically, studies show that female patients with cystic fibrosis (CF) have worse pulmonary outcomes than male patients, including decreased life expectancy. It is unknown whether this disparity persists in the new era of highly effective modulator therapies. Ivacaftor has been available in the United States for > 10 years, allowing for the opportunity to understand the impact this therapy may have on sex disparities in CF. We hypothesized that female patients will continue to show worse outcomes because we suspect that the disparity is not driven solely by ion channel dysfunction. RESEARCH QUESTION Does a difference in outcomes between male and female patients persist after the initiation of ivacaftor in people with CF? STUDY DESIGN AND METHODS We conducted a retrospective cohort study using the CF Foundation Patient Registry comparing changes in pulmonary exacerbation rate, lung function (FEV1 % predicted), and presence of Pseudomonas aeruginosa among male patients vs female patients before and after initiation of treatment with the highly effective modulator ivacaftor. RESULTS The cohort comprised 1,900 people with CF who were treated with ivacaftor between 2010 and 2017; 928 patients (48.84%) were male and 972 patients (51.16%) were female with a mean age of 33.09 years. Male patients showed a significant decrease in pulmonary exacerbations after ivacaftor treatment (from 0.38 to 0.34; adjusted rate ratio, 0.89; P = .028), whereas female patients did not (from 0.48 to 0.45; adjusted rate ratio, 0.95; P = .174). FEV1 % predicted similarly decreased in both male and female patients before vs after ivacaftor treatment. P aeruginosa prevalence decreased to a similar extent in both male and female patients after ivacaftor treatment. INTERPRETATION Our findings demonstrate that sex disparities in CF persist in those treated with ivacaftor because of differences in pulmonary exacerbations. More research is needed to determine the specific pathophysiologic drivers of this disparity.
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Affiliation(s)
- Melanie Holtrop
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Sophia Cosmich
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - MinJae Lee
- Peter O'Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, Dallas, TX
| | - Ashley Keller
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Raksha Jain
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX.
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3
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Zhou GC, Wang Z, Palipana AK, Andrinopoulou ER, Miranda Afonso P, McPhail GL, Siracusa CM, Gecili E, Szczesniak RD. Predicting lung function decline in cystic fibrosis: the impact of initiating ivacaftor therapy. Respir Res 2024; 25:187. [PMID: 38678203 PMCID: PMC11056050 DOI: 10.1186/s12931-024-02794-2] [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: 02/15/2024] [Accepted: 03/28/2024] [Indexed: 04/29/2024] Open
Abstract
BACKGROUND Modulator therapies that seek to correct the underlying defect in cystic fibrosis (CF) have revolutionized the clinical landscape. Given the heterogeneous nature of lung disease progression in the post-modulator era, there is a need to develop prediction models that are robust to modulator uptake. METHODS We conducted a retrospective longitudinal cohort study of the CF Foundation Patient Registry (N = 867 patients carrying the G551D mutation who were treated with ivacaftor from 2003 to 2018). The primary outcome was lung function (percent predicted forced expiratory volume in 1 s or FEV1pp). To characterize the association between ivacaftor initiation and lung function, we developed a dynamic prediction model through covariate selection of demographic and clinical characteristics. The ability of the selected model to predict a decline in lung function, clinically known as an FEV1-indicated exacerbation signal (FIES), was evaluated both at the population level and individual level. RESULTS Based on the final model, the estimated improvement in FEV1pp after ivacaftor initiation was 4.89% predicted (95% confidence interval [CI]: 3.90 to 5.89). The rate of decline was reduced with ivacaftor initiation by 0.14% predicted/year (95% CI: 0.01 to 0.27). More frequent outpatient visits prior to study entry and being male corresponded to a higher overall FEV1pp. Pancreatic insufficiency, older age at study entry, a history of more frequent pulmonary exacerbations, lung infections, CF-related diabetes, and use of Medicaid insurance corresponded to lower FEV1pp. The model had excellent predictive accuracy for FIES events with an area under the receiver operating characteristic curve of 0.83 (95% CI: 0.83 to 0.84) for the independent testing cohort and 0.90 (95% CI: 0.89 to 0.90) for 6-month forecasting with the masked cohort. The root-mean-square errors of the FEV1pp predictions for these cohorts were 7.31% and 6.78% predicted, respectively, with standard deviations of 0.29 and 0.20. The predictive accuracy was robust across different covariate specifications. CONCLUSIONS The methods and applications of dynamic prediction models developed using data prior to modulator uptake have the potential to inform post-modulator projections of lung function and enhance clinical surveillance in the new era of CF care.
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Affiliation(s)
- Grace C Zhou
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, TN, USA
- Division of Biostatistics & Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Ziyun Wang
- Division of Biostatistics & Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Biostatistics and Data Management, Medpace, Cincinnati, OH, USA
| | - Anushka K Palipana
- Division of Biostatistics & Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Duke University School of Nursing, Durham, NC, USA
| | - Eleni-Rosalina Andrinopoulou
- Departments of Biostatistics and Epidemiology, Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Pedro Miranda Afonso
- Departments of Biostatistics and Epidemiology, Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Gary L McPhail
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA
| | - Christopher M Siracusa
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA
| | - Emrah Gecili
- Division of Biostatistics & Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA
| | - Rhonda D Szczesniak
- Division of Biostatistics & Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA.
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Corrao F, Kelly-Aubert M, Sermet-Gaudelus I, Semeraro M. Unmet challenges in cystic fibrosis treatment with modulators. Expert Rev Respir Med 2024; 18:145-157. [PMID: 38755109 DOI: 10.1080/17476348.2024.2357210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 05/15/2024] [Indexed: 05/18/2024]
Abstract
INTRODUCTION 'Highly effective' modulator therapies (HEMTs) have radically changed the Cystic Fibrosis (CF) therapeutic landscape. AREAS COVERED A comprehensive search strategy was undertaken to assess impact of HEMT in life of pwCF, treatment challenges in specific populations such as very young children, and current knowledge gaps. EXPERT OPINION HEMTs are prescribed for pwCF with definite genotypes. The heterogeneity of variants complicates treatment possibilities and around 10% of pwCF worldwide remains ineligible. Genotype-specific treatments are prompting theratyping and personalized medicine strategies. Improvement in lung function and quality of life increase survival rates, shifting CF from a pediatric to an adult disease. This implies new studies addressing long-term efficacy, side effects, emergence of adult co-morbidities and possible drug-drug interactions. More sensitive and predictive biomarkers for both efficacy and toxicity are warranted. As HEMTs cross the placenta and are found in breast milk, studies addressing the potential consequences of treatment during pregnancy and breastfeeding are urgently needed. Finally, although the treatment and expected outcomes of CF have improved dramatically in high- and middle-income countries, lack of access in low-income countries to these life-changing medicines highlights inequity of care worldwide.
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Affiliation(s)
- Federica Corrao
- Department of Biological, Chemical and Pharmaceutical Sciences and Technologies, University of Palermo, Palermo, Italy
- INSERM, Institut Necker Enfants Malades, Paris, France
| | | | - Isabelle Sermet-Gaudelus
- INSERM, Institut Necker Enfants Malades, Paris, France
- Centre de Référence Maladies Rares Mucoviscidose et maladies apparentées. Site constitutif, Université de Paris, Paris, France
- European Reference Lung Center, Frankfurt, Germany
- Université Paris Cité, Paris, France
| | - Michaela Semeraro
- Université Paris Cité, Paris, France
- Centre Investigation Clinique, Hôpital Necker Enfants Malades, Paris, France
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Seidl E, Licht JC, de Vries R, Ratjen F, Grasemann H. Exhaled Breath Analysis Detects the Clearance of Staphylococcus aureus from the Airways of Children with Cystic Fibrosis. Biomedicines 2024; 12:431. [PMID: 38398033 PMCID: PMC10887307 DOI: 10.3390/biomedicines12020431] [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: 01/12/2024] [Revised: 02/09/2024] [Accepted: 02/12/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Electronic nose (eNose) technology can be used to characterize volatile organic compound (VOC) mixes in breath. While previous reports have shown that eNose can detect lung infections with pathogens such as Staphylococcus aureus (SA) in people with cystic fibrosis (CF), the clinical utility of eNose for longitudinally monitoring SA infection status is unknown. METHODS In this longitudinal study, a cloud-connected eNose, the SpiroNose, was used for the breath profile analysis of children with CF at two stable visits and compared based on changes in SA infection status between visits. Data analysis involved advanced sensor signal processing, ambient correction, and statistics based on the comparison of breath profiles between baseline and follow-up visits. RESULTS Seventy-two children with CF, with a mean (IQR) age of 13.8 (9.8-16.4) years, were studied. In those with SA-positive airway cultures at baseline but SA-negative cultures at follow-up (n = 19), significant signal differences were detected between Baseline and Follow-up at three distinct eNose sensors, i.e., S4 (p = 0.047), S6 (p = 0.014), and S7 (p = 0.014). Sensor signal changes with the clearance of SA from airways were unrelated to antibiotic treatment. No changes in sensor signals were seen in patients with unchanged infection status between visits. CONCLUSIONS Our results demonstrate the potential applicability of the eNose as a non-invasive clinical tool to longitudinally monitor pulmonary SA infection status in children with CF.
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Affiliation(s)
- Elias Seidl
- Division of Respiratory Medicine, Department of Pediatrics, The Hospital for Sick Children, Toronto, ON M5G 1X8, Canada; (E.S.); (J.-C.L.); (F.R.)
- Division of Respiratory Medicine, University Children’s Hospital Zurich, 8032 Zurich, Switzerland
| | - Johann-Christoph Licht
- Division of Respiratory Medicine, Department of Pediatrics, The Hospital for Sick Children, Toronto, ON M5G 1X8, Canada; (E.S.); (J.-C.L.); (F.R.)
| | - Rianne de Vries
- Breathomix BV, Bargelaan 200, 2333 CW Leiden, The Netherlands;
| | - Felix Ratjen
- Division of Respiratory Medicine, Department of Pediatrics, The Hospital for Sick Children, Toronto, ON M5G 1X8, Canada; (E.S.); (J.-C.L.); (F.R.)
- Translational Medicine Program, Research Institute, The Hospital for Sick Children, University of Toronto, Toronto, ON M5G 1X8, Canada
| | - Hartmut Grasemann
- Division of Respiratory Medicine, Department of Pediatrics, The Hospital for Sick Children, Toronto, ON M5G 1X8, Canada; (E.S.); (J.-C.L.); (F.R.)
- Translational Medicine Program, Research Institute, The Hospital for Sick Children, University of Toronto, Toronto, ON M5G 1X8, Canada
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6
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Barry PJ, Burgel PR. Cast no shadow: assessing the disease-modifying effects of elexacaftor/tezacaftor/ivacaftor. Eur Respir J 2023; 62:2302026. [PMID: 38061794 DOI: 10.1183/13993003.02026-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 11/17/2023] [Indexed: 12/18/2023]
Affiliation(s)
- Peter J Barry
- Manchester University NHS Foundation Trust, Manchester, UK
- Division of Immunology, Immunity to Infection and Respiratory Medicine, University of Manchester, Manchester, UK
| | - Pierre-Régis Burgel
- Institut Cochin, Inserm U1016 and Université de Paris, Paris, France
- Department of Respiratory Medicine and National Reference Center for Cystic Fibrosis Cochin Hospital, Assistance Publique, Hôpitaux de Paris, Paris, France
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7
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Daines CL, Tullis E, Costa S, Linnemann RW, Mall MA, McKone EF, Polineni D, Quon BS, Ringshausen FC, Rowe SM, Selvadurai H, Taylor-Cousar JL, Withers NJ, Ahluwalia N, Moskowitz SM, Prieto-Centurion V, Tan YV, Tian S, Weinstock T, Xuan F, Zhang Y, Ramsey B, Griese M. Long-term safety and efficacy of elexacaftor/tezacaftor/ivacaftor in people with cystic fibrosis and at least one F508del allele: 144-week interim results from a 192-week open-label extension study. Eur Respir J 2023; 62:2202029. [PMID: 37945033 PMCID: PMC10701091 DOI: 10.1183/13993003.02029-2022] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 09/27/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND In two pivotal phase 3 trials, up to 24 weeks of treatment with elexacaftor/tezacaftor/ivacaftor (ELX/TEZ/IVA) was efficacious and safe in patients with cystic fibrosis (CF) ≥12 years of age who have at least one F508del allele. The aim of this study is to assess long-term safety and efficacy of ELX/TEZ/IVA in these patients. METHODS In this phase 3, open-label, single-arm extension study, participants with F508del-minimal function (from a 24-week parent study; n=399) or F508del-F508del (from a 4-week parent study; n=107) genotypes receive ELX/TEZ/IVA at the same dose (ELX 200 mg once daily, TEZ 100 mg once daily and IVA 150 mg every 12 h). The primary end-point is safety and tolerability. A prespecified interim analysis was conducted when the last participant reached the Week 144 visit. RESULTS At the Week 144 interim analysis, mean duration of exposure to ELX/TEZ/IVA in the extension study was 151.1 weeks. Exposure-adjusted rates of adverse events (AEs) (586.6 events per 100 participant-years) and serious AEs (22.4 events per 100 participant-years) were lower than in the ELX/TEZ/IVA treatment group in the 24-week parent study (1096.0 and 36.9 events per 100 participant-years, respectively); most participants had AEs classified as mild (16.4% of participants) or moderate (60.3% of participants) in severity. 14 participants (2.8%) had AEs that led to treatment discontinuation. Following initiation of ELX/TEZ/IVA, participants had increases in forced expiratory volume in 1 s (FEV1) percentage predicted, Cystic Fibrosis Questionnaire-Revised respiratory domain score and body mass index, and had decreases in sweat chloride concentration and pulmonary exacerbation rates that were maintained over the interim analysis period. The mean annualised rate of change in FEV1 % pred was +0.07 (95% CI -0.12-0.26) percentage points among the participants. CONCLUSIONS ELX/TEZ/IVA was generally safe and well tolerated, with a safety profile consistent with the 24-week parent study. Participants had sustained improvements in lung function, respiratory symptoms, CF transmembrane conductance regulator function, pulmonary exacerbation rates and nutritional status. These results support the favourable safety profile and durable, disease-modifying clinical benefits of ELX/TEZ/IVA.
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Affiliation(s)
- Cori L Daines
- University of Arizona, Banner University Medical Center, Tucson, AZ, USA
- C.L. Daines and E. Tullis contributed equally to this work
| | - Elizabeth Tullis
- St Michael's Hospital, Toronto, ON, Canada
- C.L. Daines and E. Tullis contributed equally to this work
| | | | | | - Marcus A Mall
- Charité - Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health, Berlin, Germany
- German Center for Lung Research (DZL), Associated Partner Site, Berlin, Germany
| | | | | | | | - Felix C Ringshausen
- Hannover Medical School and German Center for Lung Research (DZL), Hannover, Germany
- European Reference Network Respiratory Diseases (ERN-LUNG), Frankfurt/Main, Germany
| | - Steven M Rowe
- University of Alabama at Birmingham, Birmingham, AL, USA
| | | | | | | | | | | | | | | | - Simon Tian
- Vertex Pharmaceuticals Incorporated, Boston, MA, USA
| | | | - Fengjuan Xuan
- Vertex Pharmaceuticals Incorporated, Boston, MA, USA
| | - Yaohua Zhang
- Vertex Pharmaceuticals Incorporated, Boston, MA, USA
| | - Bonnie Ramsey
- Seattle Children's Hospital, Seattle, WA, USA
- B. Ramsey and M. Griese contributed equally to this work
| | - Matthias Griese
- Ludwig Maximilian University and German Center for Lung Research (DZL), Munich, Germany
- B. Ramsey and M. Griese contributed equally to this work
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8
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Mention K, Cavusoglu-Doran K, Joynt AT, Santos L, Sanz D, Eastman AC, Merlo C, Langfelder-Schwind E, Scallan MF, Farinha CM, Cutting GR, Sharma N, Harrison PT. Use of adenine base editing and homology-independent targeted integration strategies to correct the cystic fibrosis causing variant, W1282X. Hum Mol Genet 2023; 32:3237-3248. [PMID: 37649273 PMCID: PMC10656707 DOI: 10.1093/hmg/ddad143] [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: 05/09/2023] [Revised: 07/21/2023] [Accepted: 08/12/2023] [Indexed: 09/01/2023] Open
Abstract
Small molecule drugs known as modulators can treat ~90% of people with cystic fibrosis (CF), but do not work for premature termination codon variants such as W1282X (c.3846G>A). Here we evaluated two gene editing strategies, Adenine Base Editing (ABE) to correct W1282X, and Homology-Independent Targeted Integration (HITI) of a CFTR superexon comprising exons 23-27 (SE23-27) to enable expression of a CFTR mRNA without W1282X. In Flp-In-293 cells stably expressing a CFTR expression minigene bearing W1282X, ABE corrected 24% of W1282X alleles, rescued CFTR mRNA from nonsense mediated decay and restored protein expression. However, bystander editing at the adjacent adenine (c.3847A>G), caused an amino acid change (R1283G) that affects CFTR maturation and ablates ion channel activity. In primary human nasal epithelial cells homozygous for W1282X, ABE corrected 27% of alleles, but with a notably lower level of bystander editing, and CFTR channel function was restored to 16% of wild-type levels. Using the HITI approach, correct integration of a SE23-27 in intron 22 of the CFTR locus in 16HBEge W1282X cells was detected in 5.8% of alleles, resulting in 7.8% of CFTR transcripts containing the SE23-27 sequence. Analysis of a clonal line homozygous for the HITI-SE23-27 produced full-length mature protein and restored CFTR anion channel activity to 10% of wild-type levels, which could be increased three-fold upon treatment with the triple combination of CF modulators. Overall, these data demonstrate two different editing strategies can successfully correct W1282X, the second most common class I variant, with a concomitant restoration of CFTR function.
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Affiliation(s)
- Karen Mention
- Department of Physiology, University College Cork, College Road, Cork, T12 K8AF, Ireland
- School of Microbiology, University College Cork, College Road, Cork, T12 K8AF, Ireland
| | - Kader Cavusoglu-Doran
- Department of Physiology, University College Cork, College Road, Cork, T12 K8AF, Ireland
| | - Anya T Joynt
- McKusick-Nathans Department of Genetic Medicine, Johns Hopkins University, 3400 N. Charles Street, Baltimore, MD 21218, United States
| | - Lúcia Santos
- Department of Physiology, University College Cork, College Road, Cork, T12 K8AF, Ireland
- Faculty of Sciences, BioISI - Biosystems & Integrative Sciences Institute, University of Lisboa, Campo Grande, C8 bdg, Lisboa 1749-016, Portugal
| | - David Sanz
- Department of Physiology, University College Cork, College Road, Cork, T12 K8AF, Ireland
| | - Alice C Eastman
- McKusick-Nathans Department of Genetic Medicine, Johns Hopkins University, 3400 N. Charles Street, Baltimore, MD 21218, United States
| | - Christian Merlo
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins Hospital, 1800 Orleans St, Baltimore, MD 21287, United States
| | - Elinor Langfelder-Schwind
- The Cystic Fibrosis Center, Lenox Hill Hospital, 100 E. 77th Street, 4E, New York, NY 10075, United States
| | - Martina F Scallan
- School of Microbiology, University College Cork, College Road, Cork, T12 K8AF, Ireland
| | - Carlos M Farinha
- Faculty of Sciences, BioISI - Biosystems & Integrative Sciences Institute, University of Lisboa, Campo Grande, C8 bdg, Lisboa 1749-016, Portugal
| | - Garry R Cutting
- McKusick-Nathans Department of Genetic Medicine, Johns Hopkins University, 3400 N. Charles Street, Baltimore, MD 21218, United States
| | - Neeraj Sharma
- McKusick-Nathans Department of Genetic Medicine, Johns Hopkins University, 3400 N. Charles Street, Baltimore, MD 21218, United States
| | - Patrick T Harrison
- Department of Physiology, University College Cork, College Road, Cork, T12 K8AF, Ireland
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9
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Licht JC, Seidl E, Slingers G, Waters V, de Vries R, Post M, Ratjen F, Grasemann H. Exhaled breath profiles to detect lung infection with Staphylococcus aureus in children with cystic fibrosis. J Cyst Fibros 2023; 22:888-893. [PMID: 36849333 DOI: 10.1016/j.jcf.2023.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 12/23/2022] [Accepted: 02/20/2023] [Indexed: 02/27/2023]
Abstract
BACKGROUND An electronic nose (eNose) can be used to detect volatile organic compounds (VOCs). Exhaled breath contains numerous VOCs and individuals' VOCs mixtures create distinct breath profiles. Previous reports have shown that eNose can detect lung infections. Whether eNose can detect Staphylococcus aureus airway infections in breath of children with cystic fibrosis (CF) is currently unclear. METHODS In this cross-sectional observational study, a cloud-connected eNose was used for breath profile analysis of clinically stable paediatric CF patients with airway microbiology cultures positive or negative for CF pathogens. Data-analysis involved advanced signal processing, ambient correction and statistics based on linear discriminant and receiver operating characteristics (ROC) analyses. RESULTS Breath profiles from 100 children with CF (median predicted FEV1 91%) were obtained and analysed. CF patients with positive airway cultures for any CF pathogen were distinguishable from no CF pathogens (no growth or usual respiratory flora) with accuracy of 79.0% (AUC-ROC 0.791; 95% CI: 0.669-0.913) and between patients positive for Staphylococcus aureus (SA) only and no CF pathogen with accuracy of 74.0% (AUC-ROC 0.797; 95% CI: 0.698-0.896). Similar differences were seen for Pseudomonas aeruginosa (PA) infection vs no CF pathogens (78.0% accuracy, AUC-ROC 0.876, 95% CI: 0.794-0.958). SA- and PA-specific signatures were driven by different sensors in the SpiroNose suggesting pathogen-specific breath signatures. CONCLUSIONS Breath profiles of CF patients with SA in airway cultures are distinct from those with no infection or PA infection, suggesting the utility of eNose technology in the detection of this early CF pathogen in children with CF.
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Affiliation(s)
- Johann-Christoph Licht
- Division of Respiratory Medicine, Department of Pediatrics, Hospital for Sick Children, Toronto, ON M5G 1 X 8, Canada and University of Toronto; Translational Medicine, Research Institute, Hospital for Sick Children, Toronto, ON M5G 1 × 8, Canada
| | - Elias Seidl
- Division of Respiratory Medicine, Department of Pediatrics, Hospital for Sick Children, Toronto, ON M5G 1 X 8, Canada and University of Toronto
| | - Gitte Slingers
- Breathomix BV, Bargelaan 200, 2333 CW Leiden, the Netherlands
| | - Valerie Waters
- Translational Medicine, Research Institute, Hospital for Sick Children, Toronto, ON M5G 1 × 8, Canada; Division of Infectious Diseases, Department of Pediatrics, Hospital for Sick Children, Toronto, ON M5G 1 X 8, Canada and University of Toronto
| | - Rianne de Vries
- Breathomix BV, Bargelaan 200, 2333 CW Leiden, the Netherlands
| | - Martin Post
- Translational Medicine, Research Institute, Hospital for Sick Children, Toronto, ON M5G 1 × 8, Canada
| | - Felix Ratjen
- Division of Respiratory Medicine, Department of Pediatrics, Hospital for Sick Children, Toronto, ON M5G 1 X 8, Canada and University of Toronto; Translational Medicine, Research Institute, Hospital for Sick Children, Toronto, ON M5G 1 × 8, Canada
| | - Hartmut Grasemann
- Division of Respiratory Medicine, Department of Pediatrics, Hospital for Sick Children, Toronto, ON M5G 1 X 8, Canada and University of Toronto; Translational Medicine, Research Institute, Hospital for Sick Children, Toronto, ON M5G 1 × 8, Canada.
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10
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Davis MD, Zein JG, Carraro S, Gaston B. Defining and Promoting Pediatric Pulmonary Health: Developing Biomarkers for Pulmonary Health. Pediatrics 2023; 152:e2023062292C. [PMID: 37656025 PMCID: PMC10484306 DOI: 10.1542/peds.2023-062292c] [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: 06/16/2023] [Indexed: 09/02/2023] Open
Abstract
Children with inherited and/or acquired respiratory disorders often arrive in adolescence and adulthood with diminished lung function that might have been detected and prevented had better mechanisms been available to identify and to assess progression of disease. Fortunately, advances in genetic assessments, low-cost diagnostics, and minimally- invasive novel biomarkers are being developed to detect and to treat respiratory diseases before they give rise to loss of life or lung function. This paper summarizes the Developing Biomarkers for Pulmonary Health sessions of the National Heart, Lung, and Blood Institute- sponsored 2021 Defining and Promoting Pediatric Pulmonary Health workshop. These sessions discussed genetic testing, pulse oximetry, exhaled nitric oxide, and novel biomarkers related to childhood lung diseases.
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Affiliation(s)
- Michael D. Davis
- Wells Center for Pediatric Research and Division of Pulmonology, Allergy, and Sleep Medicine, Riley Hospital for Children at Indiana University, Indianapolis, Indiana
| | - Joe G. Zein
- Department of Pulmonary Medicine, Respiratory Institute and Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Silvia Carraro
- Unit of Pediatric Allergy and Respiratory Medicine, Women’s and Children’s Health Department, University of Padova, Padova, Italy
| | - Benjamin Gaston
- Wells Center for Pediatric Research and Division of Pulmonology, Allergy, and Sleep Medicine, Riley Hospital for Children at Indiana University, Indianapolis, Indiana
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11
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Uytun S, Cinel G, Eryılmaz Polat S, Özkan Tabakçı S, Kiper N, Yalçın E, Ademhan Tural D, Özsezen B, Şen V, Selimoğlu Şen H, Ufuk Altıntaş D, Çokuğraş H, Kılınç AA, Başkan AK, Yazan H, Çollak A, Uzuner S, Ünal G, Yılmaz Aİ, Çağlar HT, Damadoğlu E, Irmak İ, Demir E, Kartal Öztürk G, Bingöl A, Başaran E, Sapan N, Canıtez Y, Tana Aslan A, Asfuroğlu P, Harmancı K, Köse M, Hangül M, Özdemir A, Çobanoğlu N, Özcan G, Keskin Ö, Yüksel H, Özdoğan Ş, Topal E, Çaltepe G, Can D, Korkmaz Ekren P, Kılıç M, Emiralioğlu N, Şişmanlar Eyüboğlu T, Pekcan S, Çakır E, Özçelik U, Doğru D. Patients with cystic fibrosis who could not receive the CFTR modulator treatment: What did they lose in 1 year? Pediatr Pulmonol 2023; 58:2505-2512. [PMID: 37278544 DOI: 10.1002/ppul.26535] [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: 10/09/2022] [Revised: 04/29/2023] [Accepted: 05/29/2023] [Indexed: 06/07/2023]
Abstract
BACKGROUND Cystic fibrosis (CF) is an autosomal recessive disorder caused by CF transmembrane conductance regulator (CFTR) genetic variants. CFTR modulators improve pulmonary function and reduce respiratory infections in CF. This study investigated the clinical and laboratory follow-up parameters over 1 year in patients with CF who could not receive this treatment. METHODS This retrospective cohort study included 2018 and 2019 CF patient data from the CF registry of Turkey. Demographic and clinical characteristics of 294 patients were assessed, who had modulator treatment indications in 2018 but could not reach the treatment. RESULTS In 2019, patients younger than 18 years had significantly lower BMI z-scores than in 2018. During the 1-year follow-up, forced expiratory volumes (FEV1) and FEV1 z-scores a trend toward a decrease. In 2019, chronic Staphylococcus aureus colonization, inhaled antipseudomonal antibiotic use for more than 3 months, oral nutritional supplement requirements, and oxygen support need increased. CONCLUSIONS Patients who had indications for modulator treatments but were unable to obtain them worsened even after a year of follow-up. This study emphasized the importance of using modulator treatments for patients with CF in our country, as well as in many countries worldwide.
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Affiliation(s)
- Salih Uytun
- Division of Pediatric Pulmonology, Ankara City Hospital, Ankara, Turkey
| | - Güzin Cinel
- Division of Pediatric Pulmonology, Ankara City Hospital, Ankara, Turkey
- Division of Pediatric Pulmonology, Faculty of Medicine, Ankara Yıldırım Beyazıt University, Ankara, Turkey
| | | | | | - Nural Kiper
- Division of Pediatric Pulmonology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Ebru Yalçın
- Division of Pediatric Pulmonology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Dilber Ademhan Tural
- Division of Pediatric Pulmonology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Beste Özsezen
- Division of Pediatric Pulmonology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Velat Şen
- Division of Pediatric Pulmonology, Faculty of Medicine, Dicle University, Diyarbakır, Turkey
| | - Hadice Selimoğlu Şen
- Department of Pulmonology, Faculty of Medicine, Dicle University, Diyarbakır, Turkey
| | - Derya Ufuk Altıntaş
- Division of Pediatric Allergy and Immunology, Faculty of Medicine, Çukurova University, Adana, Turkey
| | - Haluk Çokuğraş
- Division of Pediatric Pulmonology, Cerrahpaşa Faculty of Medicine, İstanbul University-Cerrahpaşa, İstanbul, Turkey
| | - Ayşe Ayzıt Kılınç
- Division of Pediatric Pulmonology, Cerrahpaşa Faculty of Medicine, İstanbul University-Cerrahpaşa, İstanbul, Turkey
| | - Azer Kılıç Başkan
- Division of Pediatric Pulmonology, Cerrahpaşa Faculty of Medicine, İstanbul University-Cerrahpaşa, İstanbul, Turkey
| | - Hakan Yazan
- Division of Pediatric Pulmonology, Faculty of Medicine, Bezmialem Vakıf University, İstanbul, Turkey
| | - Abdulhamit Çollak
- Division of Pediatric Pulmonology, Faculty of Medicine, Bezmialem Vakıf University, İstanbul, Turkey
| | - Selçuk Uzuner
- Division of Pediatric Pulmonology, Faculty of Medicine, Bezmialem Vakıf University, İstanbul, Turkey
| | - Gökçen Ünal
- Division of Pediatric Pulmonology, Meram Faculty of Medicine, Necmettin Erbakan University, Konya, Turkey
| | - Aslı İmran Yılmaz
- Division of Pediatric Pulmonology, Meram Faculty of Medicine, Necmettin Erbakan University, Konya, Turkey
| | - Hanife Tuğçe Çağlar
- Division of Pediatric Pulmonology, Meram Faculty of Medicine, Necmettin Erbakan University, Konya, Turkey
| | - Ebru Damadoğlu
- Department of Pulmonology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - İlim Irmak
- Department of Pulmonology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Esen Demir
- Division of Pediatric Pulmonology, Faculty of Medicine, Ege University, İzmir, Turkey
| | - Gökçen Kartal Öztürk
- Division of Pediatric Pulmonology, Faculty of Medicine, Ege University, İzmir, Turkey
| | - Ayşen Bingöl
- Division of Pediatric Pulmonology, Faculty of Medicine, Akdeniz University, Antalya, Turkey
| | - Erdem Başaran
- Division of Pediatric Pulmonology, Faculty of Medicine, Akdeniz University, Antalya, Turkey
| | - Nihat Sapan
- Division of Pediatric Allergy and Immunology, Faculty of Medicine, Uludağ University, Bursa, Turkey
| | - Yakup Canıtez
- Division of Pediatric Allergy and Immunology, Faculty of Medicine, Uludağ University, Bursa, Turkey
| | - Ayşe Tana Aslan
- Division of Pediatric Pulmonology, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Pelin Asfuroğlu
- Division of Pediatric Pulmonology, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Koray Harmancı
- Division of Pediatric Allergy and Immunology, Faculty of Medicine, Eskişehir Osmangazi University, Eskişehir, Turkey
| | - Mehmet Köse
- Division of Pediatric Pulmonology, Faculty of Medicine, Erciyes University, Kayseri, Turkey
| | - Melih Hangül
- Division of Pediatric Pulmonology, Faculty of Medicine, Erciyes University, Kayseri, Turkey
| | - Ali Özdemir
- Division of Pediatric Pulmonology, Mersin City Training and Research Hospital, Mersin, Turkey
| | - Nazan Çobanoğlu
- Division of Pediatric Pulmonology, Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Gizem Özcan
- Division of Pediatric Pulmonology, Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Özlem Keskin
- Division of Pediatric Allergy and Immunology, Faculty of Medicine, Gaziantep University, Gaziantep, Turkey
| | - Hasan Yüksel
- Division of Pediatric Pulmonology, Allergy and Immunology, Faculty of Medicine, Celal Bayar University, Manisa, Turkey
| | - Şebnem Özdoğan
- Division of Pediatric Pulmonology, Sarıyer Hamidiye Etfal Training and Research Hospital, İstanbul, Turkey
| | - Erdem Topal
- Division of Pediatric Allergy and Immunology, Faculty of Medicine, İnönü University, Malatya, Turkey
| | - Gönül Çaltepe
- Division of Pediatric Gastroenterology, Faculty of Medicine, Ondokuz Mayıs University, Samsun, Turkey
| | - Demet Can
- Division of Pediatric Pulmonology, Faculty of Medicine, Balıkesir University, Balıkesir, Turkey
| | | | - Mehmet Kılıç
- Division of Pediatric Allergy and Immunology, Faculty of Medicine, Fırat University, Elazığ, Turkey
| | - Nagehan Emiralioğlu
- Division of Pediatric Pulmonology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | | | - Sevgi Pekcan
- Division of Pediatric Pulmonology, Meram Faculty of Medicine, Necmettin Erbakan University, Konya, Turkey
| | - Erkan Çakır
- Division of Pediatric Pulmonology, Faculty of Medicine, Bezmialem Vakıf University, İstanbul, Turkey
| | - Uğur Özçelik
- Division of Pediatric Pulmonology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Deniz Doğru
- Division of Pediatric Pulmonology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
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12
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Love AJ, Quon BS. Falling through the Cracks-The Impact of Care Gaps on Lung Function Loss in Cystic Fibrosis. Ann Am Thorac Soc 2023; 20:1235-1236. [PMID: 37655958 PMCID: PMC10502880 DOI: 10.1513/annalsats.202305-459ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/02/2023] Open
Affiliation(s)
- Allison J Love
- Division of Respirology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada; and
| | - Bradley S Quon
- Division of Respirology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada; and
- Centre for Heart Lung Innovation, University of British Columbia and St. Paul's Hospital, Vancouver, British Columbia, Canada
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13
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Stahl M, Roehmel J, Eichinger M, Doellinger F, Naehrlich L, Kopp MV, Dittrich AM, Lee C, Sommerburg O, Tian S, Xu T, Wu P, Joshi A, Ray P, Duncan ME, Wielpütz MO, Mall MA. Effects of Lumacaftor/Ivacaftor on Cystic Fibrosis Disease Progression in Children 2 through 5 Years of Age Homozygous for F508del-CFTR: A Phase 2 Placebo-controlled Clinical Trial. Ann Am Thorac Soc 2023; 20:1144-1155. [PMID: 36943405 PMCID: PMC10405608 DOI: 10.1513/annalsats.202208-684oc] [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: 08/08/2022] [Accepted: 03/21/2023] [Indexed: 03/23/2023] Open
Abstract
Rationale: Lumacaftor/ivacaftor (LUM/IVA) was shown to be safe and well tolerated in children 2 through 5 years of age with cystic fibrosis (CF) homozygous for F508del-CFTR in a Phase 3 open-label study. Improvements in sweat chloride concentration, markers of pancreatic function, and lung clearance index2.5 (LCI2.5), along with increases in growth parameters, suggested the potential for early disease modification with LUM/IVA treatment. Objective: To further assess the effects of LUM/IVA on CF disease progression in children 2 through 5 years of age using chest magnetic resonance imaging (MRI). Methods: This Phase 2 study had two parts: a 48-week, randomized, double-blind, placebo-controlled treatment period in which children 2 through 5 years of age with CF homozygous for F508del-CFTR received either LUM/IVA or placebo (Part 1) followed by an open-label period in which all children received LUM/IVA for an additional 48 weeks (Part 2). The results from Part 1 are reported. The primary endpoint was absolute change from baseline in chest MRI global score at Week 48. Secondary endpoints included absolute change in LCI2.5 through Week 48 and absolute changes in weight-for-age, stature-for-age, and body mass index-for-age z-scores at Week 48. Additional endpoints included absolute changes in sweat chloride concentration, fecal elastase-1 levels, serum immunoreactive trypsinogen, and fecal calprotectin through Week 48. The primary endpoint was analyzed using Bayesian methods, where the actual Bayesian posterior probability of LUM/IVA being superior to placebo in the chest MRI global score at Week 48 was calculated using a vague normal prior distribution; secondary and additional endpoints were analyzed using descriptive summary statistics. Results: Fifty-one children were enrolled and received LUM/IVA (n = 35) or placebo (n = 16). For the change in chest MRI global score at Week 48, the Bayesian posterior probability of LUM/IVA being better than placebo (treatment difference, <0; higher score indicates greater abnormality) was 76%; the mean treatment difference was -1.5 (95% credible interval, -5.5 to 2.6). Treatment with LUM/IVA also led to within-group numerical improvements in LCI2.5, growth parameters, and biomarkers of pancreatic function as well as greater decreases in sweat chloride concentration compared with placebo from baseline through Week 48. Safety data were consistent with the established safety profile of LUM/IVA. Conclusions: This placebo-controlled study suggests the potential for early disease modification with LUM/IVA treatment, including that assessed by chest MRI, in children as young as 2 years of age. Clinical trial registered with www.clinicaltrials.gov (NCT03625466).
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Affiliation(s)
- Mirjam Stahl
- Department of Pediatric Respiratory Medicine, Immunology, and Critical Care Medicine and
- German Center for Lung Research, Associated Partner Site, Berlin, Germany
- Berlin Institute of Health at Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Jobst Roehmel
- Department of Pediatric Respiratory Medicine, Immunology, and Critical Care Medicine and
| | - Monika Eichinger
- Translational Lung Research Center Heidelberg, German Center for Lung Research, Heidelberg, Germany
- Department of Diagnostic and Interventional Radiology
- Department of Diagnostic and Interventional Radiology with Nuclear Medicine, Thoraxklinik, and
| | - Felix Doellinger
- Department of Radiology, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Lutz Naehrlich
- Department of Pediatrics, Justus Liebig University Giessen, Giessen, Germany
- Universities of Giessen and Marburg Lung Center, German Center for Lung Research, Giessen, Germany
| | - Matthias V. Kopp
- Pediatric Respiratory Medicine, Department of Pediatrics, Inselspital, University of Bern, Bern, Switzerland
- Airway Research Center North, German Center for Lung Research, Grosshansdorf, Germany
| | - Anna-Maria Dittrich
- Department for Pediatric Pulmonology, Allergology, and Neonatology and
- BREATH, German Center for Lung Research, Hannover Medical School, Hannover, Germany; and
| | | | - Olaf Sommerburg
- Translational Lung Research Center Heidelberg, German Center for Lung Research, Heidelberg, Germany
- Division of Pediatric Pulmonology and Allergy and Cystic Fibrosis Center, Department of Pediatrics, Heidelberg University Hospital, Heidelberg, Germany
| | - Simon Tian
- Vertex Pharmaceuticals Incorporated, Boston, Massachusetts
| | - Tu Xu
- Vertex Pharmaceuticals Incorporated, Boston, Massachusetts
| | - Pan Wu
- Vertex Pharmaceuticals Incorporated, Boston, Massachusetts
| | - Aniket Joshi
- Vertex Pharmaceuticals Incorporated, Boston, Massachusetts
| | - Partha Ray
- Vertex Pharmaceuticals Incorporated, Boston, Massachusetts
| | | | - Mark O. Wielpütz
- Translational Lung Research Center Heidelberg, German Center for Lung Research, Heidelberg, Germany
- Department of Diagnostic and Interventional Radiology
- Department of Diagnostic and Interventional Radiology with Nuclear Medicine, Thoraxklinik, and
| | - Marcus A. Mall
- Department of Pediatric Respiratory Medicine, Immunology, and Critical Care Medicine and
- German Center for Lung Research, Associated Partner Site, Berlin, Germany
- Berlin Institute of Health at Charité – Universitätsmedizin Berlin, Berlin, Germany
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14
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Lopez A, Daly C, Vega-Hernandez G, MacGregor G, Rubin JL. Elexacaftor/tezacaftor/ivacaftor projected survival and long-term health outcomes in people with cystic fibrosis homozygous for F508del. J Cyst Fibros 2023; 22:607-614. [PMID: 36849331 DOI: 10.1016/j.jcf.2023.02.004] [Citation(s) in RCA: 35] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 01/31/2023] [Accepted: 02/06/2023] [Indexed: 02/27/2023]
Abstract
BACKGROUND A series of phase 3 clinical trials have demonstrated that elexacaftor plus tezacaftor plus ivacaftor (ELX/TEZ/IVA) is safe and efficacious in people with cystic fibrosis (pwCF) aged ≥12 years with ≥1 F508del mutation in the cystic fibrosis transmembrane conductance regulator (CFTR) gene. The impact of this treatment on lifetime clinical outcomes and survival, however, has yet to be assessed. METHODS We used a person-level microsimulation model to estimate the survival and lifetime clinical benefits of ELX/TEZ/IVA treatment versus other CFTR modulator combinations (tezacaftor plus ivacaftor [TEZ/IVA] or lumacaftor plus ivacaftor [LUM/IVA]) or best supportive care (BSC) alone in pwCF aged ≥12 years who are homozygous for F508del-CFTR. Disease progression inputs were derived from published literature; clinical efficacy inputs were derived from an indirect treatment comparison conducted using relevant phase 3 clinical trial data and extrapolations of clinical data. RESULTS The median projected survival for pwCF homozygous for F508del-CFTR treated with ELX/TEZ/IVA was 71.6 years. This was an increase of 23.2 years versus TEZ/IVA, 26.2 years versus LUM/IVA, and 33.5 years versus BSC alone. Treatment with ELX/TEZ/IVA also reduced disease severity as well as the number of pulmonary exacerbations and lung transplants. In a scenario analysis, the median projected survival for pwCF initiating ELX/TEZ/IVA between the ages of 12 and 17 years was 82.5 years, an increase of 45.4 years compared with BSC alone. CONCLUSIONS The results from our model suggest ELX/TEZ/IVA treatment may substantially increase survival for pwCF, with early initiation potentially allowing pwCF to achieve near-normal life expectancy.
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Affiliation(s)
- Andrea Lopez
- Vertex Pharmaceuticals Incorporated, 50 Northern Avenue, Boston, MA 02210, USA.
| | - Conor Daly
- Vertex Pharmaceuticals (Europe) Limited, 2 Kingdom Street, London, W2 6BD, UK
| | | | - Gordon MacGregor
- Department of Respiratory Medicine, NHS Greater Glasgow and Clyde, Glasgow Royal Infirmary, 84 Glasgow Street, Glasgow, G4 0SF, UK
| | - Jaime L Rubin
- Vertex Pharmaceuticals Incorporated, 50 Northern Avenue, Boston, MA 02210, USA
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15
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Szczesniak R, Andrinopoulou ER, Su W, Afonso PM, Burgel PR, Cromwell E, Gecili E, Ghulam E, Goss CH, Mayer-Hamblett N, Keogh RH, Liou TG, Marshall B, Morgan WJ, Ostrenga JS, Pasta DJ, Stanojevic S, Wainwright C, Zhou GC, Fernandez G, Fink AK, Schechter MS. Lung Function Decline in Cystic Fibrosis: Impact of Data Availability and Modeling Strategies on Clinical Interpretations. Ann Am Thorac Soc 2023; 20:958-968. [PMID: 36884219 DOI: 10.1513/annalsats.202209-829oc] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 03/08/2023] [Indexed: 03/09/2023] Open
Abstract
Rationale: Studies estimating the rate of lung function decline in cystic fibrosis have been inconsistent regarding the methods used. How the methodology used impacts the validity of the results and comparability between studies is unknown. Objectives: The Cystic Fibrosis Foundation established a work group whose tasks were to examine the impact of differing approaches to estimating the rate of decline in lung function and to provide analysis guidelines. Methods: We used a natural history cohort of 35,252 individuals with cystic fibrosis aged ⩾6 years in the Cystic Fibrosis Foundation Patient Registry (CFFPR), 2003-2016. Modeling strategies using linear and nonlinear forms of marginal and mixed-effects models, which have previously quantified the rate of forced expiratory volume in 1 second (FEV1) decline (percent predicted per year), were evaluated under clinically relevant scenarios of available lung function data. Scenarios varied by sample size (overall CFFPR, medium-sized cohort of 3,000 subjects, and small-sized cohort of 150), data collection/reporting frequency (encounter, quarterly, and annual), inclusion of FEV1 during pulmonary exacerbation, and follow-up length (<2 yr, 2-5 yr, entire duration). Results: Rate of FEV1 decline estimates (percent predicted per year) differed between linear marginal and mixed-effects models; overall cohort estimates (95% confidence interval) were 1.26 (1.24-1.29) and 1.40 (1.38-1.42), respectively. Marginal models consistently estimated less rapid lung function decline than mixed-effects models across scenarios, except for short-term follow-up (both were ∼1.4). Rate of decline estimates from nonlinear models diverged by age 30. Among mixed-effects models, nonlinear and stochastic terms fit best, except for short-term follow-up (<2 yr). Overall CFFPR analysis from a joint longitudinal-survival model implied that an increase in rate of decline of 1% predicted per year in FEV1 was associated with a 1.52-fold (52%) increase in the hazard of death/lung transplant, but the results exhibited immortal cohort bias. Conclusions: Differences were as high as 0.5% predicted per year between rate of decline estimates, but we found estimates were robust to lung function data availability scenarios, except short-term follow-up and older age ranges. Inconsistencies among previous study results may be attributable to inherent differences in study design, inclusion criteria, or covariate adjustment. Results-based decision points reported herein will support researchers in selecting a strategy to model lung function decline most reflective of nuanced, study-specific goals.
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Affiliation(s)
- Rhonda Szczesniak
- Division of Biostatistics & Epidemiology and
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics and
| | | | - Weiji Su
- Division of Biostatistics & Epidemiology and
- Department of Mathematical Sciences, University of Cincinnati, Cincinnati, Ohio
- Eli Lilly and Company, Indianapolis, Indiana
| | - Pedro M Afonso
- Department of Biostatistics and
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Pierre-Régis Burgel
- Cochin Hospital, Assistance Publique Hôpitaux de Paris, Paris, France
- Respiratory Medicine and Cystic Fibrosis National Reference Center, Cochin Hospital, Assistance Publique Hôpitaux de Paris, Paris, France
- European Reference Network for Rare Lung Diseases (ERN-LUNG), Frankfurt, Germany
| | | | - Emrah Gecili
- Division of Biostatistics & Epidemiology and
- Department of Pediatrics and
| | - Enas Ghulam
- Division of Biostatistics & Epidemiology and
- Basic Science Department, College of Science and Health Professions, King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | | | - Nicole Mayer-Hamblett
- Department of Pediatrics, and
- Department of Biostatistics, University of Washington School of Medicine, Seattle, Washington
- Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, Washington
| | - Ruth H Keogh
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Theodore G Liou
- Division of Respiratory, Critical Care and Occupational Pulmonary Medicine, Department of Internal Medicine, School of Medicine, and
- Center for Quantitative Biology, University of Utah, Salt Lake City, Utah
| | | | - Wayne J Morgan
- Department of Pediatrics, University of Arizona, Tucson, Arizona
| | | | - David J Pasta
- formerly ICON Clinical Research, San Francisco, California
| | - Sanja Stanojevic
- Department of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Claire Wainwright
- Children's Health Queensland Hospital and Health Service, Brisbane, Queensland, Australia
- Child Health Research Centre, The University of Queensland, South Brisbane, Queensland, Australia; and
| | - Grace C Zhou
- Division of Biostatistics & Epidemiology and
- Department of Mathematical Sciences, University of Cincinnati, Cincinnati, Ohio
| | | | | | - Michael S Schechter
- Childrens Hospital of Richmond at Virginia Commonwealth University, Richmond, Virginia
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16
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Desai S, Zhang W, Sutherland JM, Singer J, Quon BS. Factors associated with frequent high-cost individuals with cystic fibrosis and their healthcare utilization and cost patterns. Sci Rep 2023; 13:8910. [PMID: 37264136 DOI: 10.1038/s41598-023-35942-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 05/26/2023] [Indexed: 06/03/2023] Open
Abstract
Cystic fibrosis (CF) is a progressive multi-organ disease with significant morbidity placing extensive demands on the healthcare system. Little is known about those individuals with CF who continually incur high costs over multiple years. Understanding their characteristics may help inform opportunities to improve management and care, and potentially reduce costs. The purpose of this study was to identify and understand the clinical and demographic attributes of frequent high-costing CF individuals and characterize their healthcare utilization and costs over time. A longitudinal study of retrospective data was completed in British Columbia, Canada by linking the Canadian CF Registry with provincial healthcare administrative databases for the period between 2009 and 2017. Multivariable Cox regression models were employed to identify baseline factors associated with becoming a frequent high-cost CF user (vs. not a frequent high-cost CF user) in the follow-up period. We found that severe lung impairment (Hazard Ratio [HR]: 3.71, 95% confidence interval [CI], 1.49-9.21), lung transplantation (HR: 4.23, 95% CI, 1.68-10.69), liver cirrhosis with portal hypertension (HR: 10.96, 95% CI: 3.85-31.20) and female sex (HR: 1.97, 95% CI: 1.13-3.44) were associated with becoming a frequent high-cost CF user. Fifty-nine (17% of cohort) frequent high-cost CF users accounted for more than one-third of the overall total healthcare costs, largely due to inpatient hospitalization and outpatient medication costs.
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Affiliation(s)
- Sameer Desai
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Wei Zhang
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
- Centre for Health Evaluation and Outcome Sciences, St. Paul's Hospital, Vancouver, BC, Canada
| | - Jason M Sutherland
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
- Centre for Health Services and Policy Research, University of British Columbia, Vancouver, BC, Canada
| | - Joel Singer
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
- Centre for Health Evaluation and Outcome Sciences, St. Paul's Hospital, Vancouver, BC, Canada
| | - Bradley S Quon
- Centre for Heart Lung Innovation, University of British Columbia, St. Paul's Hospital, #166 - 1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.
- Division of Respiratory Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada.
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17
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Lee T, Sawicki GS, Altenburg J, Millar SJ, Geiger JM, Jennings MT, Lou Y, McGarry LJ, Van Brunt K, Linnemann RW. EFFECT OF ELEXACAFTOR/TEZACAFTOR/IVACAFTOR ON ANNUAL RATE OF LUNG FUNCTION DECLINE IN PEOPLE WITH CYSTIC FIBROSIS. J Cyst Fibros 2023; 22:402-406. [PMID: 36581485 DOI: 10.1016/j.jcf.2022.12.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 12/06/2022] [Accepted: 12/18/2022] [Indexed: 12/28/2022]
Abstract
Elexacaftor/tezacaftor/ivacaftor (ELX/TEZ/IVA) was shown to be safe and efficacious in people with cystic fibrosis (CF) with ≥ 1 F508del-CFTR allele in Phase 3 clinical trials. ELX/TEZ/IVA treatment led to improved lung function, with increases in percent predicted forced expiratory volume in 1 second (ppFEV1) and Cystic Fibrosis Questionnaire-Revised respiratory domain score. Here, we evaluated the impact of ELX/TEZ/IVA on the rate of lung function decline over time by comparing changes in ppFEV1 in participants from the Phase 3 trials with a matched group of people with CF from the US Cystic Fibrosis Foundation Patient Registry not eligible for cystic fibrosis transmembrane conductance regulator (CFTR) modulator therapy. Participants treated with ELX/TEZ/IVA had on average no loss of pulmonary function over a 2-year period (mean annualized rate of change in ppFEV1, +0.39 percentage points [95% CI, -0.06 to 0.85]) compared with a 1.92 percentage point annual decline (95% CI, -2.16 to -1.69) in ppFEV1 in untreated controls. ELX/TEZ/IVA is the first CFTR modulator therapy shown to halt lung function decline over an extended time period.
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Affiliation(s)
- Tim Lee
- Leeds Children's Hospital, Leeds, United Kingdom of Great Britain and Northern Ireland United Kingdom.
| | | | - Josje Altenburg
- Amsterdam University Medical Centres, Amsterdam, the Netherlands.
| | | | | | - Mark T Jennings
- Vertex Pharmaceuticals Incorporated, Boston, MA, United States of America.
| | - Yiyue Lou
- Vertex Pharmaceuticals Incorporated, Boston, MA, United States of America.
| | - Lisa J McGarry
- Vertex Pharmaceuticals Incorporated, Boston, MA, United States of America.
| | - Kate Van Brunt
- Vertex Pharmaceuticals Incorporated, Boston, MA, United States of America.
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18
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McGarry LJ, Bhaiwala Z, Lopez A, Chandler C, Pelligra CG, Rubin JL, Liou TG. Calibration and validation of modeled 5-year survival predictions among people with cystic fibrosis treated with the cystic fibrosis transmembrane conductance regulator modulator ivacaftor using United States registry data. PLoS One 2023; 18:e0283479. [PMID: 37043485 PMCID: PMC10096446 DOI: 10.1371/journal.pone.0283479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 03/09/2023] [Indexed: 04/13/2023] Open
Abstract
OBJECTIVES Cystic fibrosis (CF) is a rare genetic disease characterized by life-shortening lung function decline. Ivacaftor, a CF transmembrane conductance regulator modulator (CFTRm), was approved in 2012 for people with CF with specific gene mutations. We used real-world evidence of 5-year mortality impacts of ivacaftor in a US registry population to validate a CF disease-progression model that estimates the impact of ivacaftor on survival. METHODS The model projects the impact of ivacaftor vs. standard care in people with CF aged ≥6 years with CFTR gating mutations by combining parametric equations fitted to historical registry survival data, with mortality hazards adjusted for fixed and time-varying person-level characteristics. Disease progression with standard care was derived from published registry studies and the expected impact of ivacaftor on clinical characteristics was derived from clinical trials. Individual-level baseline characteristics of the registry ivacaftor-treated population were entered into the model; 5-year model-projected mortality with credible intervals (CrIs) was compared with registry mortality to evaluate the model's validity. RESULTS Post-calibration 5-year mortality projections closely approximated registry mortality in populations treated with standard care (6.4% modeled [95% CrI: 5.3% to 7.6%] vs. 6.0% observed) and ivacaftor (3.4% modeled [95% CrI: 2.7% to 4.4%] vs. 3.1% observed). The model accurately predicted 5-year relative risk of mortality (0.53 modeled [0.47 to 0.60] vs. 0.51 observed) in people treated with ivacaftor vs. standard care. CONCLUSIONS Modeled 5-year survival projections for people with CF initiating ivacaftor vs. standard care align closely with real-world registry data. Findings support the validity of modeling CF to predict long-term survival and estimate clinical and economic outcomes of CFTRm.
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Affiliation(s)
- Lisa J. McGarry
- Vertex Pharmaceuticals Incorporated, Boston, MA, United States of America
| | - Zahra Bhaiwala
- Vertex Pharmaceuticals Incorporated, Boston, MA, United States of America
| | - Andrea Lopez
- Vertex Pharmaceuticals Incorporated, Boston, MA, United States of America
| | | | | | - Jaime L. Rubin
- Vertex Pharmaceuticals Incorporated, Boston, MA, United States of America
| | - Theodore G. Liou
- Adult CF Center, University of Utah, Salt Lake City, UT, United States of America
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19
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O'Carroll M. Advanced Cystic Fibrosis Lung Disease and Lung Transplantation in the Era of Cystic Fibrosis Transmembrane Conductance Regulator Modulators. Semin Respir Crit Care Med 2023; 44:260-268. [PMID: 36893762 DOI: 10.1055/s-0042-1758731] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/11/2023]
Abstract
Cystic fibrosis transmembrane conductance regulator (CFTR) modulators have changed the clinical landscape of cystic fibrosis (CF) by improving clinically significant outcome measures and quality of life of people with CF (pwCF). There are now long-term data showing improved 5-year survival with the use of ivacaftor, and the field continues to evolve at a rapid pace with the continued development of highly effective CFTR modulators. While the randomized controlled trials of CFTR modulators excluded patients with severe lung disease (forced expiratory volume in 1 second <40% predicted), observational data based on case reports and registry data show similar benefits in those with advanced lung disease. This has altered clinical practice particularly as it pertains to the role of lung transplantation in CF. This article describes the impact of highly effective modulator therapy (HEMT) on the natural history of CF and the influence on the timing of referral and consideration of listing for lung transplantation. CF clinicians play a pivotal role to ensure that the impetus of the CF foundation consensus guidelines to facilitate timely referral for lung transplantation is not lost among the excitement of anticipated sustained benefit from HEMT. While the widespread availability of elexacaftor/tezacaftor/ivacaftor over the past 2 years has been associated with a sharp drop in the number of people referred for consideration for lung transplantation and the number of people wait-listed for lung transplantation, it is difficult to accurately determine the true impact due to the confounding effect of the coronavirus disease 2019 pandemic. It is expected that lung transplantation will remain an important treatment for a smaller number of pwCF. Lung transplantation offers survival benefits in CF, and there remains an imperative to ensure timely consideration of lung transplantation in patients with advanced disease to further reduce the number of pwCF dying without consideration of lung transplant.
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Affiliation(s)
- Mark O'Carroll
- Respiratory Services, Auckland City Hospital, Te Toka Tumai, Te Whatu Ora - Health New Zealand, Auckland, New Zealand
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20
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Zampoli M, Morrow BM, Paul G. Real-world disparities and ethical considerations with access to CFTR modulator drugs: Mind the gap! Front Pharmacol 2023; 14:1163391. [PMID: 37050905 PMCID: PMC10083423 DOI: 10.3389/fphar.2023.1163391] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 03/09/2023] [Indexed: 03/29/2023] Open
Abstract
The third Sustainable Development Goal (SDG), to ensure healthy lives and promote well-being for all at all ages, has particular relevance and implementation challenges amongst people living with rare diseases such as cystic fibrosis (CF). Although the treatment and projected outcome of CF has significantly improved with the advent of CF transmembrane conductance regulator protein modulator (CFTRm) therapy, there remains significant global inequality with regards to access to these life-saving and life-altering drugs. Elexacaftor, tezacaftor, and ivacaftor (ETI) triple combination therapy, first licensed in the United States in 2019, has rapidly become the standard of care for children aged 6 years and older in most high-income countries for individuals with CFTR variants responsive to ETI. Negotiated agreements for access to ETI are currently in place in North America,Europe, Israel ,Australia and New Zealand. However, less priority has been given to negotiate agreements for access to CFTRm in low-middle income countries(LMIC) with significant CF populations such as Central and South America, India, the Middle East, and Southern Africa. These countries and individuals living with CF are therefore effectively being left behind, in direct conflict with the stated principle of the 2030 SDGs. In this review, we highlight the current global inequity in access to CFTRm drugs and its impact on widening disparities between high-income countries and LMIC in CF outcomes and survival. We further discuss the reasons for this inequity and explore the ethical- and human rights-based principles and dilemmas that clinicians, families, governments, and healthcare funders must consider when prioritizing fair and affordable access to expensive CFTRm drugs. Lastly, we propose possible solutions to overcoming the barriers to accessing affordable CFTRm drugs in LMIC and illustrate with examples how access to drug therapies for other conditions have been successfully negotiated in LMIC through innovative partnerships between governments and pharmaceutical industries.
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Affiliation(s)
- M. Zampoli
- Department of Paediatrics and Child Health and Red Cross War Memorial Children’s Hospital, University of Cape Town, Cape Town, South Africa
- *Correspondence: M. Zampoli,
| | - B. M Morrow
- Department of Paediatrics and Child Health and Red Cross War Memorial Children’s Hospital, University of Cape Town, Cape Town, South Africa
| | - G Paul
- Division of Pulmonary Medicine, Nationwide Children’s Hospital, Columbus, OH, United States
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21
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Vijaykumar K, Rowe SM. Lessons from other fields of medicine, Part 2: Cystic fibrosis. HANDBOOK OF CLINICAL NEUROLOGY 2023; 192:119-130. [PMID: 36796937 DOI: 10.1016/b978-0-323-85538-9.00006-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
Cystic fibrosis (CF), first described in 1938, is a common, life-limiting monogenetic disease. The discovery of the cystic fibrosis transmembrane conductance regulator (CFTR) gene in 1989 was crucial in advancing our understanding of disease pathogenesis and paving the road for treatment aimed at the fundamental molecular defect. With the delineation of over 2000 variations in the CFTR gene, a sound understanding of the individual variations in cell biology, and electrophysiological abnormalities conferred by the most common defects propelled the advent of targeted disease-modifying therapeutics beginning in 2012. Since then, CF care has transformed beyond just symptomatic treatment to include a variety of small-molecule therapies that address the basic electrophysiologic defect and cause profound improvements in physiology, clinical manifestations, and long-term outcomes, designed to differentially address six genetic/molecular subtypes. This chapter illustrates the progress made toward how fundamental science and translational initiatives enabled personalized, mutation specific treatment. We highlight the importance of preclinical assays and mechanistically-driven development strategies that were coupled with sensitive biomarkers and a clinical trial cooperative to provide a platform for successful drug development. This convergence of academic and private partnerships, and formation of multidisciplinary care teams directed by evidence-based initiatives provide a seminal example of addressing the needs of individuals with a rare, but fatal genetic disease.
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Affiliation(s)
- Kadambari Vijaykumar
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, United States; The Gregory Fleming James Cystic Fibrosis Research Center, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Steven M Rowe
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, United States; The Gregory Fleming James Cystic Fibrosis Research Center, University of Alabama at Birmingham, Birmingham, AL, United States.
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22
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Stransky OM, Benipal S, Pam M, Taylor-Cousar JL, Documet P, Kazmerski TM. "Find ways to work parenting into cystic fibrosis": A PhotoVoice exploration of being a parent and having CF. Pediatr Pulmonol 2023; 58:1527-1534. [PMID: 36808716 DOI: 10.1002/ppul.26355] [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: 10/20/2022] [Revised: 01/24/2023] [Accepted: 02/11/2023] [Indexed: 02/20/2023]
Abstract
BACKGROUND As more people with cystic fibrosis (CF) consider their reproductive futures, the impact of parenthood on CF must be better understood. In the context of chronic disease, deciding if, when, and how to become a parent is complex. Little research has investigated how parents with CF balance their role as parents with its associated health impacts and demands of CF. METHODS PhotoVoice is a research methodology that utilizes photography to generate discussion about community issues. We recruited parents with CF with at least 1 child <10 years old and divided them into three cohorts. Each cohort met five times. Cohorts developed photography prompts, took photographs between sessions, and reflected on the photos at subsequent meetings. At the final meeting, participants selected 2-3 pictures, wrote captions, and as a group organized the photographs into thematic groups. Secondary thematic analysis identified metathemes. RESULTS Participants (n = 18) generated a total of 202 photographs. Each cohort identified 3-4 themes (n = 10) which secondary analysis grouped into 3 metathemes: (1) It is important for parents with CF to pay attention to the joyful aspects of parenting and to cultivate positive experiences; (2) Parenting with CF requires balancing your own needs with those of your child, and creativity and flexibility can be key; (3) Parenting with CF consists of competing priorities and expectations often with no clear "correct" choice. CONCLUSIONS Parents with CF identified unique challenges to their existence as both parents and patients as well as ways in which parenting has enhanced their lives.
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Affiliation(s)
- Olivia M Stransky
- Center for Innovative Research on Gender Health Equity (CONVERGE), University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Savvy Benipal
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah, USA
| | - Molly Pam
- Cystic Fibrosis Reproductive and Sexual Health Collaborative, Seattle, Washington, USA
| | - Jennifer L Taylor-Cousar
- Divisions of Pulmonary, Critical Care and Sleep Medicine and Pediatric Pulmonary Medicine, National Jewish Health, Denver, Colorado, USA
| | - Patricia Documet
- Behavioral and Community Health Sciences, University of Pittsburgh School of Public Health, Pittsburgh, Pennsylvania, USA
| | - Traci M Kazmerski
- Center for Innovative Research on Gender Health Equity (CONVERGE), University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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23
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Boat T, Hente E, Hardie W, Szczesniak R, Gecili E, Zhou G, Taylor J, Amin R. Body composition and functional correlates of CF youth experiencing pulmonary exacerbation and recovery. Pediatr Pulmonol 2023; 58:457-464. [PMID: 36271603 DOI: 10.1002/ppul.26207] [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: 04/28/2022] [Revised: 09/22/2022] [Accepted: 10/11/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND Youth with cystic fibrosis (CF) and pulmonary exacerbation (PEx) often experience weight loss, then rapid weight gain. Little is known about body composition and its relationship to functional outcomes during this critical period. METHODS Twenty CF youth experiencing PEx were assessed on the day following admission and 7-17 days later at discharge for body mass index (BMI), fat mass index (FMI), lean mass index (LMI), skeletal muscle mass index (SMMI), and functional measures: percent predicted forced expiratory volume in 1 second (FEV1) (ppFEV1), maximal inspiratory and expiratory pressures (MIPs and MEPs), and handgrip strength (HGS). Changes from admission to discharge and correlations among body composition indices and functional measures at both times are reported. RESULTS Upon admission, participant BMI percentile and ppFEV1 varied from 2 to 97 and 29 to 113, respectively. Thirteen had an LMI below the 25th percentile and nine had a percent body fat above the 75th percentile. BMI and FMI increased significantly (p = 0.03, 0.003) during hospitalization. LMI and SMMI did not change. FEV1 and MIPS increased (p = 0.0003, 0.007), independent of weight gain, during treatment. HGS did not improve. CONCLUSIONS Many youth with CF, independent of BMI, frequently carried a small muscle mass and disproportionate fat at the time of PEx. During hospital treatment, weight gain largely represented fat deposition; muscle mass and strength did not improve. A need for trials of interventions designed to augment muscle mass and function, and limit fat mass accretion, at the time of PEx is suggested by these observations.
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Affiliation(s)
- Thomas Boat
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Elizabeth Hente
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - William Hardie
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Rhonda Szczesniak
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Division of Epidemiology and Biostatistics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Emrah Gecili
- Division of Epidemiology and Biostatistics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Grace Zhou
- Division of Epidemiology and Biostatistics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Jacqueline Taylor
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Raouf Amin
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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24
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Toward a Broader Understanding of Cystic Fibrosis Epidemiology and Its Impact on Clinical Manifestations. Clin Chest Med 2022; 43:579-590. [PMID: 36344067 DOI: 10.1016/j.ccm.2022.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The incidence of cystic fibrosis remains constant in North America and Western Europe is 1 in 3500 live births, but survival and quality of life have improved. The cystic fibrosis population has shifted toward the adult age range with a concomitant shift in the spectrum of complications. Survival increased because of aggressive symptomatic therapy, earlier diagnosis by newborn screening, and the introduction of modulators of the cystic fibrosis transmembrane conductance regulator, so that predicted median survival age is now about 50 years. In the United States, members of low socioeconomic status populations or members of racial or ethnic minorities have benefitted less from these advances.
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25
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Gifford AH, Taylor-Cousar JL, Davies JC, McNally P. Update on Clinical Outcomes of Highly Effective Modulator Therapy. Clin Chest Med 2022; 43:677-695. [PMID: 36344074 DOI: 10.1016/j.ccm.2022.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Based on the cystic fibrosis transmembrane conductance regulator (CFTR) genotype, approximately 90% of people with cystic fibrosis (CF) are candidates for highly effective modulator therapy (HEMT). Clinical trials conducted over the last 11 years have shown that these oral therapies substantially restore CFTR function, leading to improvements in lung function, nutritional status, and health-related quality of life. Here, we review safety and efficacy data from phase 3 clinical trials and observational studies which support the use of HEMT in most adults and children with CF. We also discuss opportunities for additional investigation in groups underrepresented or excluded from phase 3 clinical trials, and challenges in the evaluation of the safety and efficacy of HEMT at increasingly earlier stages of CFTR-mediated pathophysiology.
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Affiliation(s)
- Alex H Gifford
- Division of Pulmonary, Critical Care, and Sleep Medicine, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Bolwell Building 6174, Cleveland, OH 44106, USA; Rainbow Babies and Children's Hospital, Cleveland, OH, USA.
| | - Jennifer L Taylor-Cousar
- Department of Internal Medicine, National Jewish Medical Center, Denver, CO, USA; Department of Pediatrics, National Jewish Medical Center, Denver, CO, USA
| | - Jane C Davies
- National Heart and Lung Institute, Imperial College London, England, United Kingdom; Royal Brompton & Harefield Hospital, Guys & St Thomas' Trust, London, United Kingdom
| | - Paul McNally
- Department of Paediatrics, RCSI University of Medicine and Health Sciences, Dublin, Ireland; Cystic Fibrosis Center, Children's Health Ireland, Dublin, Ireland
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26
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Carnovale V, Iacotucci P, Qiao D, Ferrillo L, Somma J, Buonaurio S, Marcella d’Ippolito, Celardo A, Savi D. Clinical outcomes of digital health in adults with cystic fibrosis. Respir Med 2022; 202:106970. [DOI: 10.1016/j.rmed.2022.106970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 07/26/2022] [Accepted: 08/24/2022] [Indexed: 11/29/2022]
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27
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Balfour-Lynn IM, King JA. CFTR modulator therapies - Effect on life expectancy in people with cystic fibrosis. Paediatr Respir Rev 2022; 42:3-8. [PMID: 32565113 PMCID: PMC7255286 DOI: 10.1016/j.prrv.2020.05.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 05/14/2020] [Indexed: 12/13/2022]
Abstract
CFTR modulators have dramatically changed the clinical course of CF in those fortunate enough to receive them. Inevitably, randomised controlled trials during the development of these drugs are too short to use mortality as an outcome. Evidence for their effect on life expectancy are best gained from real world registry studies specifically looking at mortality, but these are only available for ivacaftor to date. Therefore, indirect evidence must be obtained by looking at outcomes known to affect mortality and seeing the effect of these drugs on those outcomes.
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Affiliation(s)
- I M Balfour-Lynn
- Department of Paediatric Respiratory Medicine, Royal Brompton Hospital, London, UK.
| | - J A King
- Department of Paediatric Respiratory Medicine, Royal Brompton Hospital, London, UK
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28
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Newsome SJ, Daniel RM, Carr SB, Bilton D, Keogh RH. Using Negative Control Outcomes and Difference-in-Differences Analysis to Estimate Treatment Effects in an Entirely Treated Cohort: The Effect of Ivacaftor in Cystic Fibrosis. Am J Epidemiol 2022; 191:505-515. [PMID: 34753177 PMCID: PMC8914944 DOI: 10.1093/aje/kwab263] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Revised: 09/26/2021] [Accepted: 10/27/2021] [Indexed: 11/15/2022] Open
Abstract
When an entire cohort of patients receives a treatment, it is difficult to estimate the treatment effect in the treated because there are no directly comparable untreated patients. Attempts can be made to find a suitable control group (e.g., historical controls), but underlying differences between the treated and untreated can result in bias. Here we show how negative control outcomes combined with difference-in-differences analysis can be used to assess bias in treatment effect estimates and obtain unbiased estimates under certain assumptions. Causal diagrams and potential outcomes are used to explain the methods and assumptions. We apply the methods to UK Cystic Fibrosis Registry data to investigate the effect of ivacaftor, introduced in 2012 for a subset of the cystic fibrosis population with a particular genotype, on lung function and annual rate (days/year) of receiving intravenous (IV) antibiotics (i.e., IV days). We consider 2 negative control outcomes: outcomes measured in the pre-ivacaftor period and outcomes among persons ineligible for ivacaftor because of their genotype. Ivacaftor was found to improve lung function in year 1 (an approximately 6.5–percentage-point increase in ppFEV1), was associated with reduced lung function decline (an approximately 0.5–percentage-point decrease in annual ppFEV1 decline, though confidence intervals included 0), and reduced the annual rate of IV days (approximately 60% over 3 years).
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Affiliation(s)
| | | | | | | | - Ruth H Keogh
- Correspondence to Dr. Ruth H. Keogh, Department of Medical Statistics, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, United Kingdom (e-mail: )
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29
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McBennett KA, Davis PB, Konstan MW. Increasing life expectancy in cystic fibrosis: Advances and challenges. Pediatr Pulmonol 2022; 57 Suppl 1:S5-S12. [PMID: 34672432 PMCID: PMC9004282 DOI: 10.1002/ppul.25733] [Citation(s) in RCA: 38] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 09/30/2021] [Accepted: 10/03/2021] [Indexed: 01/14/2023]
Abstract
Since the first description of cystic fibrosis in 1938, there have been significant advances in both quality of life and longevity for people living with this disease. In this article we describe the milestones of the last 80 years and what we perceive to be the remaining barriers to normalcy for this population.
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Affiliation(s)
- Kimberly A McBennett
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.,Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
| | - Pamela B Davis
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Michael W Konstan
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.,Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
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Sawicki GS, Chilvers M, McNamara J, Naehrlich L, Saunders C, Sermet-Gaudelus I, Wainwright CE, Ahluwalia N, Campbell D, Harris RS, Paz-Diaz H, Shih JL, Davies JC. A Phase 3, open-label, 96-week trial to study the safety, tolerability, and efficacy of tezacaftor/ivacaftor in children ≥ 6 years of age homozygous for F508del or heterozygous for F508del and a residual function CFTR variant. J Cyst Fibros 2022; 21:675-683. [DOI: 10.1016/j.jcf.2022.02.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 01/26/2022] [Accepted: 02/05/2022] [Indexed: 01/03/2023]
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Woodley FW, Gecili E, Szczesniak RD, Shrestha CL, Nemastil CJ, Kopp BT, Hayes D. Sweat metabolomics before and after intravenous antibiotics for pulmonary exacerbation in people with cystic fibrosis. Respir Med 2022; 191:106687. [PMID: 34864373 PMCID: PMC8810598 DOI: 10.1016/j.rmed.2021.106687] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 11/06/2021] [Accepted: 11/20/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND People with cystic fibrosis (PWCF) suffer from acute unpredictable reductions in pulmonary function associated with a pulmonary exacerbation (PEx) that may require hospitalization. PEx symptoms vary between PWCF without universal diagnostic criteria for diagnosis and response to treatment. RESEARCH QUESTION We characterized sweat metabolomes before and after intravenous (IV) antibiotics in PWCF hospitalized for PEx to determine feasibility and define biological alterations by IV antibiotics for PEx. STUDY DESIGN AND METHODS PWCF with PEx requiring hospitalization for IV antibiotics were recruited from clinic. Sweat samples were collected using the Macroduct® Sweat Collection System at admission prior to initiation of IV antibiotics and after completion prior to discharge. Samples were analyzed for metabolite changes using ultra-high-performance liquid chromatography/tandem accurate mass spectrometry. RESULTS Twenty-six of 29 hospitalized PWCF completed the entire study. A total of 326 compounds of known identity were detected in sweat samples. Of detected metabolites, 147 were significantly different between pre-initiation and post-completion of IV antibiotics for PEx (average treatment 14 days). Global sweat metabolomes changed from before and after IV antibiotic treatment. We discovered specific metabolite profiles predictive of PEx status as well as enriched biologic pathways associated with PEx. However, metabolomic changes were similar in PWCF who failed to return to baseline pulmonary function and those who did not. INTERPRETATION Our findings demonstrate the feasibility of non-invasive sweat metabolomic profiling in PWCF and the potential for sweat metabolomics as a prospective diagnostic and research tool to further advance our understanding of PEx in PWCF.
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Affiliation(s)
- Frederick W. Woodley
- Division of Gastroenterology, Hepatology and Nutrition, Nationwide Children’s Hospital and The Ohio State University College of Medicine, Columbus, OH, USA
| | - Emrah Gecili
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Rhonda D. Szczesniak
- Division of Pulmonary Medicine, Cincinnati Children’s Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, OH, USA,Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Chandra L. Shrestha
- Center for Microbial Pathogenesis, The Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, OH, USA
| | - Christopher J. Nemastil
- Division of Pulmonary Medicine, Nationwide Children’s Hospital and The Ohio State University College of Medicine, Columbus, OH, USA
| | - Benjamin T. Kopp
- Division of Pulmonary Medicine, Nationwide Children’s Hospital and The Ohio State University College of Medicine, Columbus, OH, USA,Center for Microbial Pathogenesis, The Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, OH, USA
| | - Don Hayes
- Division of Pulmonary Medicine, Cincinnati Children’s Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Graeber SY, Vitzthum C, Pallenberg ST, Naehrlich L, Stahl M, Rohrbach A, Drescher M, Minso R, Ringshausen FC, Rueckes-Nilges C, Klajda J, Berges J, Yu Y, Scheuermann H, Hirtz S, Sommerburg O, Dittrich AM, Tümmler B, Mall MA. Effects of Elexacaftor/Tezacaftor/Ivacaftor Therapy on CFTR Function in Patients with Cystic Fibrosis and One or Two F508del Alleles. Am J Respir Crit Care Med 2021; 205:540-549. [PMID: 34936849 DOI: 10.1164/rccm.202110-2249oc] [Citation(s) in RCA: 77] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE The CFTR modulator combination elexacaftor/tezacaftor/ivacaftor (ELX/TEZ/IVA) was shown to improve clinical outcomes and sweat chloride concentration (SCC) in patients with cystic fibrosis (CF) and one or two F508del alleles. However, the effect of ELX/TEZ/IVA on CFTR function in the airways and intestine has not been studied. OBJECTIVES To assess the effect of ELX/TEZ/IVA on CFTR function in airway and intestinal epithelia in patients with CF and one or two F508del alleles aged 12 years and older. METHODS This prospective observational multicenter study assessed clinical outcomes including FEV1 %predicted and body mass index, and the CFTR biomarkers SCC, nasal potential difference (NPD) and intestinal current measurement (ICM) before and 8-16 weeks after initiation of ELX/TEZ/IVA. MEASUREMENTS AND MAIN RESULTS A total of 107 patients with CF including 55 patients with one F508del and a minimal function mutation and 52 F508del homozygous patients were enrolled in this study. In patients with one F508del allele, NPD and ICM showed that ELX/TEZ/IVA improved CFTR function in nasal epithelia to a level of 46.5% (IQR, 27.5-72.4; P<0.001) and in intestinal epithelia to 41.8% of normal (IQR, 25.1-57.6; P<0.001). In F508del homozygous patients, ELX/TEZ/IVA exceeded improvement of CFTR function observed with TEZ/IVA and increased CFTR-mediated Cl- secretion to a level of 47.4% of normal (IQR, 19.3-69.2; P<0.001) in nasal and to 45.9% (IQR, 19.7-66.6; P<0.001) in intestinal epithelia. CONCLUSIONS Treatment with ELX/TEZ/IVA results in effective improvement of CFTR function in airway and intestinal epithelia in patients with CF and one or two F508del alleles.
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Affiliation(s)
- Simon Y Graeber
- Charité Universitätsmedizin Berlin, 14903, Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine and Cystic Fibrosis Center, Berlin, Germany.,Berlin Institute of Health, 522475, Berlin, Germany.,German Center for Lung Research, 542891, associated partner, Berlin, Germany
| | - Constanze Vitzthum
- Charité Universitätsmedizin Berlin, 14903, Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine and Cystic Fibrosis Center, Berlin, Germany.,German Center for Lung Research, 542891, associated partner, Berlin, Germany
| | - Sophia T Pallenberg
- Hannover Medical School, 9177, Department of Pediatric Pneumology, Allergology and Neonatology, Hannover, Germany.,German Center for Lung Research, 542891, Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Hannover, Germany
| | - Lutz Naehrlich
- Justus-Liebig-University Giessen, Department of Pediatrics, Giessen, Germany.,German Center for Lung Research, 542891, Universities of Giessen and Marburg Lung Center (UGMLC), Giessen, Germany
| | - Mirjam Stahl
- Charité Universitätsmedizin Berlin, 14903, Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine and Cystic Fibrosis Center, Berlin, Germany.,Berlin Institute of Health, 522475, Berlin, Germany.,German Center for Lung Research, 542891, associated partner, Berlin, Germany
| | - Alexander Rohrbach
- Charité Universitätsmedizin Berlin, 14903, Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine and Cystic Fibrosis Center, Berlin, Germany
| | - Marika Drescher
- Charité Universitätsmedizin Berlin, 14903, Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine and Cystic Fibrosis Center, Berlin, Germany.,German Center for Lung Research, 542891, associated partner, Berlin, Germany
| | - Rebecca Minso
- Hannover Medical School, 9177, Department of Pediatric Pneumology, Allergology and Neonatology, Hannover, Germany
| | - Felix C Ringshausen
- Hannover Medical School, 9177, Department of Respiratory Medicine, Hannover, Germany.,German Center for Lung Research, 542891, Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Hannover, Germany
| | | | - Jan Klajda
- Justus-Liebig-University Giessen, Department of Pediatrics, Giessen, Germany
| | - Julian Berges
- University of Heidelberg, 9144, Department of Pediatrics, Division of Pediatric Pulmonology and Allergy and Cystic Fibrosis Center, Heidelberg, Germany.,University of Heidelberg, 9144, Department of Translational Pulmonology, Translational Lung Research Center Heidelberg (TLRC), German Center for Lung Research (DZL), Heidelberg, Germany
| | - Yin Yu
- University of Heidelberg, 9144, Department of Pediatrics, Division of Pediatric Pulmonology and Allergy and Cystic Fibrosis Center, Heidelberg, Germany.,University of Heidelberg, 9144, German Centre for Lung Research (DZL), Translational Lung Research Center Heidelberg (TLRC), Department of Translational Pulmonology, Heidelberg, Germany
| | - Heike Scheuermann
- University of Heidelberg, 9144, Department of Pediatrics, Division of Pediatric Pulmonology and Allergy and Cystic Fibrosis Center, Heidelberg, Germany.,University of Heidelberg, 9144, Department of Translational Pulmonology, Translational Lung Research Center Heidelberg (TLRC), German Center for Lung Research (DZL), Heidelberg, Germany
| | - Stephanie Hirtz
- University of Heidelberg, 9144, Department of Pediatrics, Division of Pediatric Pulmonology and Allergy and Cystic Fibrosis Center, Heidelberg, Germany.,University of Heidelberg, 9144, Department of Translational Pulmonology, Translational Lung Research Center Heidelberg (TLRC), German Center for Lung Research (DZL), Heidelberg, Germany
| | - Olaf Sommerburg
- University of Heidelberg, 9144, Department of Pediatrics, Division of Pediatric Pulmonology and Allergy and Cystic Fibrosis Center, Heidelberg, Germany.,University of Heidelberg, 9144, Department of Translational Pulmonology, Translational Lung Research Center Heidelberg (TLRC), German Center for Lung Research (DZL), Heidelberg, Germany
| | - Anna-Maria Dittrich
- Hannover Medical School, 9177, Department of Pediatric Pneumology, Allergology and Neonatology, Hannover, Germany.,German Center for Lung Research, 542891, Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Hannover, Germany
| | - Burkhard Tümmler
- Hannover Medical School, 9177, Department of Pediatric Pneumology, Allergology and Neonatology, Hannover, Germany.,German Center for Lung Research, 542891, Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Hannover, Germany
| | - Marcus A Mall
- Charité Universitätsmedizin Berlin, 14903, Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine and Cystic Fibrosis Center, Berlin, Germany.,Berlin Institute of Health, 522475, Berlin, Germany.,German Center for Lung Research, 542891, associated partner, Berlin, Germany;
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Nichols DP, Paynter AC, Heltshe SL, Donaldson SH, Frederick CA, Freedman SD, Gelfond D, Hoffman LR, Kelly A, Narkewicz MR, Pittman JE, Ratjen F, Rosenfeld M, Sagel SD, Schwarzenberg SJ, Singh PK, Solomon GM, Stalvey MS, Clancy JP, Kirby S, Van Dalfsen JM, Kloster MH, Rowe SM. Clinical Effectiveness of Elexacaftor/Tezacftor/Ivacaftor in People with Cystic Fibrosis. Am J Respir Crit Care Med 2021; 205:529-539. [PMID: 34784492 PMCID: PMC8906485 DOI: 10.1164/rccm.202108-1986oc] [Citation(s) in RCA: 149] [Impact Index Per Article: 49.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Rationale The cystic fibrosis (CF) modulator drug, elexacaftor/tezacaftor/ivacaftor (ETI), proved highly effective in controlled clinical trials for individuals with at least one F508del allele, which occurs in at least 85% of people with CF. Objectives PROMISE is a postapproval study to understand the broad effects of ETI through 30 months’ clinical use in a more diverse U.S. patient population with planned analyses after 6 months. Methods Prospective, observational study in 487 people with CF age 12 years or older with at least one F508del allele starting ETI for the first time. Assessments occurred before and 1, 3, and 6 months into ETI therapy. Outcomes included change in percent predicted FEV1 (ppFEV1), sweat chloride concentration, body mass index (BMI), and self-reported respiratory symptoms. Measurements and Main Results Average age was 25.1 years, and 44.1% entered the study using tezacaftor/ivacaftor or lumacaftor/ivacaftor, whereas 6.7% were using ivacaftor, consistent with F508del homozygosity and G551D allele, respectively. At 6 months into ETI therapy, ppFEV1 improved 9.76 percentage points (95% confidence interval [CI], 8.76 to 10.76) from baseline, cystic fibrosis questionnaire–revised respiratory domain score improved 20.4 points (95% CI, 18.3 to 22.5), and sweat chloride decreased −41.7 mmol/L (95% CI, −43.8 to −39.6). BMI also significantly increased. Changes were larger in those naive to modulators but substantial in all groups, including those treated with ivacaftor at baseline. Conclusions ETI by clinical prescription provided large improvements in lung function, respiratory symptoms, and BMI in a diverse population naive to modulator drug therapy, using existing two-drug combinations, or using ivacaftor alone. Each group also experienced significant reductions in sweat chloride concentration, which correlated with improved ppFEV1 in the overall study population. Clinical trial registered with www.clinicaltrials.gov (NCT NCT04038047).
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Affiliation(s)
- David P Nichols
- University of Washington School of Medicine, 12353, Pediatrics, Seattle, Washington, United States.,Seattle Children's Hospital, 7274, Pediatric Pulmonology, Seattle, Washington, United States;
| | - Alex C Paynter
- Seattle Children's Research Institute, 145793, Seattle, Washington, United States
| | - Sonya L Heltshe
- Seattle Children's Research Institute, Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle, Washington, United States.,University of Washington School of Medicine, Pediatrics, Seattle, Washington, United States
| | | | - Carla A Frederick
- University at Buffalo Jacobs School of Medicine and Biomedical Sciences, 12291, Buffalo, New York, United States
| | - Steven D Freedman
- Beth Israel Deaconess Medical Center, Gastroenterology, Boston, Massachusetts, United States
| | - Daniel Gelfond
- Western New York Pediatric Gastroenterology, Batavia, New York, United States
| | - Lucas R Hoffman
- University of Washington School of Medicine, 12353, Seattle, Washington, United States.,Seattle Children's Hospital, 7274, Seattle, Washington, United States
| | - Andrea Kelly
- The Children's Hospital of Philadelphia, 6567, Pediatrics, Division of Endocrinology & Diabetes, Philadelphia, Pennsylvania, United States
| | - Michael R Narkewicz
- Children's Hospital Colorado and University of Colorado School of Medicine, Digestive Health Institute and Pediatrics, Aurora, Colorado, United States
| | - Jessica E Pittman
- Washington University in Saint Louis School of Medicine, 12275, Department of Pediatrics, Saint Louis, Missouri, United States
| | - Felix Ratjen
- University of Toronto HSC, Division of Respiratory Medicine, Toronto, Ontario, Canada
| | - Margaret Rosenfeld
- Seattle Children's, Pediatrics / Pulmonary, Seattle, Washington, United States
| | - Scott D Sagel
- University of Colorado School of Medicine, Pediatrics, Aurora, Colorado, United States
| | - Sarah Jane Schwarzenberg
- University of Minnesota Masonic Children's Hospital, 501779, Pediatrics, Minneapolis, Minnesota, United States
| | - Pradeep K Singh
- University of Washington, 7284, Department of Microbiology and Medicine, Seattle, Washington, United States
| | - George M Solomon
- University of Alabama at Birmingham, 9968, Medicine, Gregory Fleming James Cystic Fibrosis Research Center, Birmingham, Alabama, United States
| | - Michael S Stalvey
- The University of Alabama at Birmingham School of Medicine, 9967, Birmingham, Alabama, United States
| | - John P Clancy
- Cincinnati Children's Hospital Medical Center, 2518, Department of Pediatrics, Cincinnati, Ohio, United States.,Cincinnati Children's Hospital Medical Center, 2518, Division of Pulmonary Medicine, Cincinnati, Ohio, United States
| | - Shannon Kirby
- Seattle Children's Research Institute, 145793, Seattle, Washington, United States
| | - Jill M Van Dalfsen
- Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, Washington, United States
| | - Margaret H Kloster
- Seattle Children's Research Institute, Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle, Washington, United States
| | - Steven M Rowe
- University of Alabama at Birmingham, Medicine, Cystic Fibrosis Center, Birmingham, Alabama, United States
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Breuer O, Shoseyov D, Koretz S, Alyan N, Reiter J, Cohen-Cymberknoh M, Wexler I, Kerem E. Ethical Dilemma: Elexacaftor-Tezacaftor-Ivacaftor or Lung Transplantation in Cystic Fibrosis and End-Stage Lung Disease? Chest 2021; 161:773-780. [PMID: 34506793 DOI: 10.1016/j.chest.2021.08.073] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 08/03/2021] [Accepted: 08/31/2021] [Indexed: 11/25/2022] Open
Abstract
Cystic fibrosis (CF) is caused by mutations in the cystic fibrosis transmembrane conductance regulator gene (CFTR). Novel, highly effective, modulator therapies correcting and potentiating CFTR function are changing the course of this disease. We present an ethical dilemma involving an 11-year-old child with CF and end-stage lung disease. Shortly after starting treatment with elexacaftor-tezacaftor-ivacaftor, the family received notification that a matched donor lung had been allocated. Clinical decision-making in this case is challenging as definitive data to medically support one treatment option over the other are limited. A survey of CF center team members was conducted for the purpose of this article. Ethical principles that may guide us in these situations are discussed. Overall, results of the survey present a lack of agreement as to the best approach in this situation. Physicians, when compared with other team members, are more likely to provide a specific recommendation vs presenting the information to the family and letting them decide (OR, 4.0; 95% CI, 1.2-12.8; P = .021). A shared decision-making model, stressing our moral obligation as physicians to respect autonomy by appreciating family values, while offering to participate in the decision-making process and ensuring nonmaleficence, is presented. In summary, CFTR modulators affect the outcomes of CF disease and influence clinical decision-making. The current lack of data on long-term outcomes, in young patients with CF receiving effective modulator therapy, should not preclude CF team participation in decision-making. Shared decision-making, which is focused on respecting autonomy, is our preferred approach in these situations.
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Affiliation(s)
- Oded Breuer
- Department of Pediatrics, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel; Department of Pediatric Pulmonology and CF Center, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.
| | - David Shoseyov
- Department of Pediatrics, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Shifra Koretz
- Department of Pediatric Pulmonology and CF Center, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel; Department of Social Work Services, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Nadia Alyan
- Department of Pediatrics, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel; Department of Social Work Services, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Joel Reiter
- Department of Pediatrics, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel; Department of Pediatric Pulmonology and CF Center, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Malena Cohen-Cymberknoh
- Department of Pediatrics, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Isaiah Wexler
- Department of Pediatrics, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Eitan Kerem
- Department of Pediatrics, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel; Department of Pediatric Pulmonology and CF Center, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
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Edmondson C, Course CW, Doull I. Cystic fibrosis transmembrane conductance regulator modulators for cystic fibrosis: a new dawn? Arch Dis Child 2021; 106:941-945. [PMID: 33785533 DOI: 10.1136/archdischild-2020-320680] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 02/24/2021] [Accepted: 03/01/2021] [Indexed: 02/04/2023]
Abstract
Cystic fibrosis (CF) is the most common life-limiting inherited condition in Caucasians. It is a multisystem autosomal recessive disorder caused by variants in the gene for cystic fibrosis transmembrane conductance regulator (CFTR) protein, a cell-surface localised chloride channel that regulates absorption and secretion of salt and water across epithelia. Until recently, the treatment for CF was predicated on ameliorating and preventing the downstream symptoms of CFTR dysfunction, primarily recurrent respiratory infections and pancreatic exocrine failure. But a new class of therapy-the CFTR modulators, which treat the basic defect and decrease the complications of CF, leads to significantly improved pulmonary function, decreased respiratory infections and improved nutrition. The newest agent, a combination of elexacaftor, tezacaftor and ivacaftor, will be suitable for approximately 90% of all people with CF and is likely to decrease the morbidity and significantly increase the life expectancy for most people with CF. The major barrier to their widespread introduction has been their cost, with many countries unwilling or unable to fund them. Nevertheless, such is their therapeutic efficacy and their likely potent effect on life expectancy that their advent has wider societal implications for the care of children and adults with CF.
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Affiliation(s)
- Claire Edmondson
- Respiratory Medicine and Specialised Cystic Fibrosis Unit, Children's Hospital for Wales, Cardiff, UK
| | | | - Iolo Doull
- Respiratory Medicine and Specialised Cystic Fibrosis Unit, Children's Hospital for Wales, Cardiff, UK
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36
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Elborn JS, Konstan MW, Taylor-Cousar JL, Fajac I, Horsley A, Sutharsan S, Aaron SD, Daines CL, Uluer A, Downey DG, Lucidi VV, Ahuja S, Springman E, Mershon J, Grosswald R, Rowe SM. Empire-CF study: A phase 2 clinical trial of leukotriene A4 hydrolase inhibitor acebilustat in adult subjects with cystic fibrosis. J Cyst Fibros 2021; 20:1026-1034. [PMID: 34538755 DOI: 10.1016/j.jcf.2021.08.007] [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: 12/15/2020] [Revised: 08/15/2021] [Accepted: 08/16/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Cystic fibrosis (CF) is characterized by neutrophilic inflammation in the airways. Leukotriene B4 (LTB4) is a neutrophil chemoattractant and has been implicated in CF pathogenesis. Acebilustat, a novel, synthetic, small-molecule leukotriene A4 hydrolase inhibitor, reduces LTB4 production. We report findings from a randomized placebo-controlled trial of acebilustat in adult subjects with mild-to-moderate lung disease. METHODS Subjects were randomized (1:1:1) to once-daily acebilustat 50 mg, 100 mg or placebo for 48 weeks, concomitantly with their current therapeutic regimen. Subjects were stratified by use of concomitant CF transmembrane conductance regulator (CFTR) modulators, baseline percent predicted forced expiratory volume in 1 second (ppFEV1) 50-75 and >75, and number of pulmonary exacerbations in the past year (1 or >1). Primary endpoints were the change from baseline in ppFEV1 and safety. Secondary endpoints included the rate of pulmonary exacerbations. RESULTS Overall, 199 subjects were randomized and dosed (acebilustat 50 mg, n=67; acebilustat 100 mg, n=66; placebo, n=66). Baseline demographics and disease profile were well balanced among treatment groups. Acebilustat had no statistically significant effect on the primary endpoint of change in ppFEV1 at week 48 or the secondary endpoint pulmonary exacerbations. There was a trend towards reduced pulmonary exacerbations in subjects receiving acebilustat in pre-specified populations with ppFEV1>75 (35% rate reduction) and those on concomitant CFTR modulator therapy (20% rate reduction). Acebilustat was well tolerated. CONCLUSIONS Acebilustat did not improve lung function. A trend towards reduced pulmonary exacerbations in subjects with an earlier stage of lung disease suggests a potential effect in this population.
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Affiliation(s)
- J Stuart Elborn
- Faculty of Medicine Health and Life sciences Queens University School of Medicine, Belfast, UK
| | - Michael W Konstan
- Department of Pediatrics, Case Western Reserve University School of Medicine and Rainbow Babies & Children's Hospital, Cleveland, OH, USA
| | | | - Isabelle Fajac
- Physiology Department, Cochin Hospital, APHP Centre, Paris, France; Université de Paris, Paris, France
| | - Alexander Horsley
- Division of Infection, Immunity and Respiratory Medicine, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Sivagurunathan Sutharsan
- Division of Cystic Fibrosis, Department of Pulmonary Medicine, University Medicine EssenRuhrlandklinik, University of DuisburgEssen, Essen, Germany
| | - Shawn D Aaron
- Ottawa Health Research Institute, Ottawa, Ontario, Canada
| | - Cori L Daines
- Department of Pediatrics, University of Arizona, Tucson, AZ, USA
| | - Ahmet Uluer
- Department of Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Damian G Downey
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Vincenzina V Lucidi
- Cystic Fibrosis Center, Children's Hospital and Research Institute, Bambino Gesu, Rome, Italy
| | | | | | | | | | - Steven M Rowe
- Gregory Fleming James Cystic Fibrosis Research Center and Department of Medicine, University of Alabama at Birmingham, 1918 University Blvd, MCLM 804, Birmingham 35294, AL, USA.
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Granger E, Davies G, Keogh RH. Treatment patterns in people with cystic fibrosis: have they changed since the introduction of ivacaftor? J Cyst Fibros 2021; 21:316-322. [PMID: 34497037 PMCID: PMC9097695 DOI: 10.1016/j.jcf.2021.08.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 06/11/2021] [Accepted: 08/18/2021] [Indexed: 11/28/2022]
Abstract
Longitudinal treatment patterns among the ivacaftor-treated cystic fibrosis population in the UK differ from those seen in a contemporary cohort of individuals untreated due to their genotype, despite minimal differences between the genotype groups prior to the introduction of ivacaftor. People who are treated with ivacaftor were less likely to continue other treatments such as inhaled antibiotics, dornase alfa, hypertonic saline, chronic oral antibiotics and supplementary feeding, compared to people who are not treated with ivacaftor. The differences in use of dornase alfa and hypertonic saline solution between ivacaftor-treated and non-ivacaftor-treated people, are larger for people with higher lung function.
Background In late 2012, ivacaftor became available in the UK for people with cystic fibrosis (CF) aged 6 years and over with a G551D mutation. Long-term changes in treatment patterns have not previously been reported. We investigated long-term treatment patterns in people with CF with a G551D mutation who took ivacaftor and compared these with non-ivacaftor-treated cohorts using the UK Cystic Fibrosis Registry. Methods Using 2007-2018 data we compared treatment patterns between four cohorts: 1: ivacaftor-treated; 2: ivacaftor era (2013-2018), ineligible genotype (no G551D mutation); 3: pre-ivacaftor era (2007-2012), eligible genotype (G551D mutation); 4: pre-ivacaftor era, ineligible genotype. Treatments included: inhaled antibiotics, dornase alfa, hypertonic saline, chronic oral antibiotics and supplementary feeding. Results Up to 2012 the percentages of people taking each treatment were similar between the two cohorts defined by genotype and tended to increase by year with a similar slope. Once ivacaftor was introduced, the use of other treatments tended to decrease or remain stable by year for the ivacaftor-treated cohort, whereas it remained stable or increased in the non-ivacaftor-treated cohort. This led to differences in treatment use between the two cohorts in the ivacaftor-era, which became more marked over time. Conclusions We have shown a clear divergence in treatment patterns since the introduction of ivacaftor in a number of key treatments widely used in CF. Further research is needed to investigate whether the differences in treatment patterns are associated with changes in health outcomes.
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Affiliation(s)
- Emily Granger
- Department of Medical Statistics, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, Keppel St, Bloomsbury, London WC1E 7HT, United Kingdom.
| | - Gwyneth Davies
- Population, Policy and Practice Research and Teaching Department, UCL Great Ormond Street Institute of Child Health (UCL GOS ICH), London WC1N 1EH, United Kingdom
| | - Ruth H Keogh
- Department of Medical Statistics, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, Keppel St, Bloomsbury, London WC1E 7HT, United Kingdom; Centre for Statistical Methodology, London School of Hygiene and Tropical Medicine, Keppel St, Bloomsbury, London WC1E 7HT, United Kingdom
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Zemanick ET, Taylor-Cousar JL, Davies J, Gibson RL, Mall MA, McKone EF, McNally P, Ramsey BW, Rayment JH, Rowe SM, Tullis E, Ahluwalia N, Chu C, Ho T, Moskowitz SM, Noel S, Tian S, Waltz D, Weinstock TG, Xuan F, Wainwright CE, McColley SA. A Phase 3 Open-Label Study of Elexacaftor/Tezacaftor/Ivacaftor in Children 6 through 11 Years of Age with Cystic Fibrosis and at Least One F508del Allele. Am J Respir Crit Care Med 2021; 203:1522-1532. [PMID: 33734030 PMCID: PMC8483230 DOI: 10.1164/rccm.202102-0509oc] [Citation(s) in RCA: 139] [Impact Index Per Article: 46.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Rationale: Elexacaftor/tezacaftor/ivacaftor (ELX/TEZ/IVA) was shown to be efficacious and safe in patients ≥12 years of age with cystic fibrosis and at least one F508del-CFTR (cystic fibrosis transmembrane conductance regulator) allele, but it has not been evaluated in children <12 years of age. Objectives: To assess the safety, pharmacokinetics, and efficacy of ELX/TEZ/IVA in children 6 through 11 years of age with F508del–minimal function or F508del-F508del genotypes. Methods: In this 24-week open-label phase 3 study, children (N = 66) weighing <30 kg received 50% of the ELX/TEZ/IVA adult daily dose (ELX 100 mg once daily, TEZ 50 mg once daily, and IVA 75 mg every 12 h) whereas children weighing ⩾30 kg received the full adult daily dose (ELX 200 mg once daily, TEZ 100 mg once daily, and IVA 150 mg every 12 h). Measurements and Main Results: The primary endpoint was safety and tolerability. The safety and pharmacokinetic profiles of ELX/TEZ/IVA were generally consistent with those observed in older patients. The most commonly reported adverse events included cough, headache, and pyrexia; in most of the children who had adverse events, these were mild or moderate in severity. Through Week 24, ELX/TEZ/IVA treatment improved the percentage of predicted FEV1 (10.2 percentage points; 95% confidence interval [CI], 7.9 to 12.6), Cystic Fibrosis Questionnaire–Revised respiratory domain score (7.0 points; 95% CI, 4.7 to 9.2), lung clearance index2.5 (−1.71 units; 95% CI, −2.11 to −1.30), and sweat chloride (−60.9 mmol/L; 95% CI, −63.7 to −58.2); body mass index-for-age z-score increased over the 24-week treatment period when compared with the pretreatment baseline. Conclusions: Our results show ELX/TEZ/IVA is safe and efficacious in children 6 through 11 years of age with at least one F508del-CFTR allele, supporting its use in this patient population. Clinical trial registered with www.clinicaltrials.gov (NCT03691779).
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Affiliation(s)
- Edith T Zemanick
- Department of Pediatrics, University of Colorado Anschutz Medical Campus and Children's Hospital Colorado, Aurora, Colorado
| | | | - Jane Davies
- National Heart and Lung Institute, Imperial College London, National Institute for Health Research Imperial Biomedical Research Centre and Royal Brompton and Harefield National Health Service Foundation Trust, London, United Kingdom
| | - Ronald L Gibson
- University of Washington/Seattle Children's Hospital, Seattle, Washington
| | - Marcus A Mall
- Department of Pediatric Pulmonology, Immunology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health, Berlin, Germany.,German Center for Lung Research, Berlin, Germany
| | - Edward F McKone
- St. Vincent's University Hospital and University College, Dublin, Ireland
| | - Paul McNally
- Children's Health Ireland and Royal College of Surgeons in Ireland University of Medicine and Health Sciences, Dublin, Ireland
| | - Bonnie W Ramsey
- University of Washington/Seattle Children's Hospital, Seattle, Washington
| | - Jonathan H Rayment
- British Columbia Children's Hospital, Vancouver, British Columbia, Canada
| | - Steven M Rowe
- University of Alabama at Birmingham, Birmingham, Alabama
| | | | - Neil Ahluwalia
- Vertex Pharmaceuticals Incorporated, Boston, Massachusetts
| | - Chenghao Chu
- Vertex Pharmaceuticals Incorporated, Boston, Massachusetts
| | - Thang Ho
- Vertex Pharmaceuticals Incorporated, Boston, Massachusetts
| | | | - Sabrina Noel
- Vertex Pharmaceuticals Incorporated, Boston, Massachusetts
| | - Simon Tian
- Vertex Pharmaceuticals Incorporated, Boston, Massachusetts
| | - David Waltz
- Vertex Pharmaceuticals Incorporated, Boston, Massachusetts
| | | | - Fengjuan Xuan
- Vertex Pharmaceuticals Incorporated, Boston, Massachusetts
| | | | - Susanna A McColley
- Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois; and.,Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Mayer-Hamblett N, Nichols DP, Odem-Davis K, Riekert KA, Sawicki GS, Donaldson SH, Ratjen F, Konstan MW, Simon N, Rosenbluth DB, Retsch-Bogart G, Clancy JP, VanDalfsen JM, Buckingham R, Gifford AH. Evaluating the Impact of Stopping Chronic Therapies after Modulator Drug Therapy in Cystic Fibrosis: The SIMPLIFY Clinical Trial Study Design. Ann Am Thorac Soc 2021; 18:1397-1405. [PMID: 33465316 PMCID: PMC8513667 DOI: 10.1513/annalsats.202010-1336sd] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 01/15/2021] [Indexed: 12/31/2022] Open
Abstract
The care for individuals with cystic fibrosis (CF) with at least one F508del mutation will greatly change as a result of the unparalleled clinical benefits observed with the new triple-combination CFTR (CF transmembrane regulator)-modulator therapy elexacaftor/tezacaftor/ivacaftor (ETI). Incorporating ETI into the standard of care creates new motivation and opportunity to consider reductions in overall treatment burden and evaluate whether other chronic medications can now be safely discontinued without loss of clinical benefit. SIMPLIFY is a master protocol poised to test the impact of discontinuing versus continuing two commonly used chronic therapies in people with CF who are at least 12 years of age or older and stable on ETI therapy. The protocol is composed of two concurrent randomized controlled trials designed to evaluate the independent short-term effects of discontinuing hypertonic saline or dornase alfa, enabling individuals on both therapies to participate in one or both trials. The primary objective for each trial is to determine whether discontinuing treatment is noninferior to continuing treatment after establishment of ETI, as measured by the 6-week absolute change in the percent-predicted forced expiratory volume in 1 second. Developing this study required a balance between ideal study-design principles and feasibility. SIMPLIFY will be the largest multicenter, randomized, controlled medication-withdrawal study in CF. This study is uniquely positioned to provide timely evidence on whether the daily treatment burden can be reduced among individuals on CFTR-modulator therapy. Clinical trial registered with www.clinicaltrials.gov (NCT04378153).
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Affiliation(s)
- Nicole Mayer-Hamblett
- Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children's Hospital, Seattle, Washington
- Department of Pediatrics and
- Department of Biostatistics, University of Washington, Seattle, Washington
| | - David P Nichols
- Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children's Hospital, Seattle, Washington
- Department of Pediatrics and
| | - Katherine Odem-Davis
- Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children's Hospital, Seattle, Washington
| | - Kristin A Riekert
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Greg S Sawicki
- Division of General Pediatrics and Respiratory Diseases, Boston Children's Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | | | - Felix Ratjen
- Division of Respiratory Translational Medicine Program, SickKids Research Institute, Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Michael W Konstan
- Department of Pediatrics, Rainbow Babies and Children's Hospital and School of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Noah Simon
- Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children's Hospital, Seattle, Washington
- Department of Biostatistics, University of Washington, Seattle, Washington
| | - Daniel B Rosenbluth
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, School of Medicine, Washington University, St. Louis, Missouri
| | - George Retsch-Bogart
- Division of Pediatric Pulmonology, University of North Carolina, Chapel Hill, Chapel Hill, North Carolina
| | - John P Clancy
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Cystic Fibrosis Foundation, Bethesda, Maryland
| | - Jill M VanDalfsen
- Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children's Hospital, Seattle, Washington
| | - Rachael Buckingham
- Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children's Hospital, Seattle, Washington
| | - Alex H Gifford
- Pulmonary and Critical Care Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; and
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire
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DiMango E, Simpson K, Menten E, Keating C, Fan W, Leu CS. Health Disparities among adults cared for at an urban cystic fibrosis program. Orphanet J Rare Dis 2021; 16:332. [PMID: 34332588 PMCID: PMC8325847 DOI: 10.1186/s13023-021-01965-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Accepted: 07/19/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Evidence is conflicting regarding differential health outcomes in racial and ethnic minorities with cystic fibrosis (CF), a rare genetic disease affecting approximately 28,000 Americans. We performed a cross-sectional analysis of health outcomes in Black/Latinx patients compared with non-Hispanic Caucasian patients cared for in a CF center in New York City. Adult patients enrolled in the CF Foundation Patient Registry at the Columbia University Adult CF Program and seen at least once during 2019 were included. Health metrics were compared between Black/Latinx and non-Hispanic Caucasian patients. RESULTS 262 patients were eligible. 39 patients (15%) identified as Black/Latinx or non-Hispanic Caucasian. Descriptive statistics are reported with mean (standard deviation). Current age was 35.9 (13.3) years for non-Hispanic Caucasian and 32.0 (9.3) years for Black/Latinx patients (p = 0.087). Age of diagnosis did not differ between groups; 9.56 (15.96) years versus 11.59 (15.8) years for non-Hispanic Caucasian versus Black/Latinx respectively (p = 0.464). Pulmonary function, measured as mean forced expiratory volume in one second (FEV1) was 70.6 (22.5) percent predicted in non-Hispanic Caucasian versus 59.50 (27.9) percent predicted in Black/Latinx patients (p = 0.010). Number of visits to the CF clinic were similar between groups. When controlled for age, gender, co-morbidities, median income, and insurance status, there was a continued association between minority status and lower FEV1. CONCLUSIONS Minorities with CF have significantly lower pulmonary function, the major marker of survival, than non-Hispanic Caucasians, even when controlled for a variety of demographic and socioeconomic factors that are known to affect health status in CF. Significant health disparities based on race and ethnicity exist at a single CF center in New York City, despite apparent similarities in access to guideline based care at an accredited CF Center. This data confirms the importance of design of culturally appropriate preventative and management strategies to better understand how to direct interventions to this vulnerable population with a rare disease.
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Affiliation(s)
- Emily DiMango
- Columbia University Irving Medical Center, 622 West 168th Street, New York, NY, 10032, USA.
| | - Kaitlyn Simpson
- Columbia University Irving Medical Center, 622 West 168th Street, New York, NY, 10032, USA
| | - Elizabeth Menten
- Columbia University Irving Medical Center, 622 West 168th Street, New York, NY, 10032, USA
| | - Claire Keating
- Columbia University Irving Medical Center, 622 West 168th Street, New York, NY, 10032, USA
| | - Weijia Fan
- Columbia University Mailman School of Public Health, 722 West 168th Street, New York, NY, 10032, USA
| | - Cheng-Shiun Leu
- Columbia University Mailman School of Public Health, 722 West 168th Street, New York, NY, 10032, USA
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Mingora CM, Flume PA. Pulmonary Complications in Cystic Fibrosis: Past, Present, and Future. Chest 2021; 160:1232-1240. [PMID: 34147501 DOI: 10.1016/j.chest.2021.06.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 03/14/2021] [Accepted: 06/14/2021] [Indexed: 12/22/2022] Open
Abstract
Cystic fibrosis (CF) is an autosomal recessive genetic condition with multisystemic disease manifestations, the most prominent of which occur in the respiratory system. Despite significant developments in disease understanding and therapeutics, each contributing to improved lung function and survival in patients with CF, several pulmonary complications, including pneumothorax, massive hemoptysis, and respiratory failure, continue to occur. In this review, we briefly describe each of these complications and their management and discuss how they impact the care and disease trajectory of individuals in whom they occur. Finally, we discuss the evolving role that palliative care and CF transmembrane conductance regular modulator therapies play in the natural disease course and care of patients with CF.
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Affiliation(s)
- Christina M Mingora
- Department of Medicine, Medical University of South Carolina, Charleston, SC.
| | - Patrick A Flume
- Department of Medicine, Medical University of South Carolina, Charleston, SC
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42
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Henen S, Denton C, Teckman J, Borowitz D, Patel D. Review of Gastrointestinal Motility in Cystic Fibrosis. J Cyst Fibros 2021; 20:578-585. [PMID: 34147362 DOI: 10.1016/j.jcf.2021.05.016] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 05/24/2021] [Accepted: 05/25/2021] [Indexed: 02/07/2023]
Abstract
Gastrointestinal manifestations in patients with cystic fibrosis (CF) are extremely common and have recently become a research focus. Gastrointestinal (GI) dysfunction is poorly understood in the CF population, despite many speculations including the role of luminal pH, bacterial overgrowth, and abnormal microbiome. Nevertheless, dysmotility is emerging as a possible key player in CF intestinal symptoms. Our review article aims to explore the sequelae of defective cystic fibrosis transmembrane conductance regulator (CFTR) genes on the GI tract as studied in both animals and humans, describe various presentations of intestinal dysmotility in CF, review newer diagnostic motility techniques including intraluminal manometry, and review the current literature regarding the potential role of dysmotility in CF-related intestinal pathologies.
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Affiliation(s)
- Sara Henen
- Saint Louis University School of Medicine, SSM Health Cardinal Glennon Children's Hospital, 1465 S Grand Blvd, St. Louis, MO 63104.
| | - Christine Denton
- Saint Louis University School of Medicine, SSM Health Cardinal Glennon Children's Hospital, 1465 S Grand Blvd, St. Louis, MO 63104
| | - Jeff Teckman
- Interim Chair, Department of Pediatrics, Professor of Pediatrics and Biochemistry, Saint Louis University School of Medicine, SSM Health Cardinal Glennon Children's Hospital, 1465 S Grand BLVD, St. Louis, MO 63104.
| | - Drucy Borowitz
- Emeritus Professor of Clinical Pediatrics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, NY, 1001 Main Street, Buffalo, NY, 14203.
| | - Dhiren Patel
- Associate Professor and Medical Director, Neurogastroenterology and Motility Program, Department of Pediatrics, Saint Louis University School of Medicine, SSM Health Cardinal Glennon Children's Hospital, 1465 S Grand Blvd, St. Louis, MO 63104.
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43
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Perkins RC, Shah M, Sawicki GS. An evaluation of healthcare utilization and clinical charges in children and adults with cystic fibrosis. Pediatr Pulmonol 2021; 56:928-938. [PMID: 33621440 DOI: 10.1002/ppul.25251] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 12/23/2020] [Accepted: 12/25/2020] [Indexed: 01/09/2023]
Abstract
BACKGROUND Prior studies have estimated healthcare costs for cystic fibrosis (CF) of $8000-$131,000, but do not account for impacts of CF modulator therapy. This study aims to assess utilization patterns and cost of CF care in a center in the United States. METHODS Care utilization patterns and costs at a large pediatric-adult CF center were examined from November 2017 to November 2018. Subjects were stratified by age and cost (excluding pharmacy costs) were calculated based on hospital-derived utilization charges. RESULTS A total of 166 patients were reviewed with mean clinical charges of $28,755. Lower lung function ($23,032 normal lung function, $62,293 moderate reduction, $186,786 severe reduction; p = .05), hospitalizations ($85,452 yes, $6362 no; p = .0001), Pseudomonas positive culture ($48,660 positive, $22,013 negative, p = .0001), and CF-related diabetes ($161,892 CFRD, $22,153 no CFRD; p = .001) were associated with increased charges. Patients utilizing Ivacaftor had lower charges compared to lumacaftor-ivacaftor ($6633 vs. $33,039; p = .05) and tezacaftor-ivacaftor ($6633 vs. $64,434; p = .002). CONCLUSION Our study characterized utilization and care charges among a CF cohort. Lower lung function, hospitalizations, and CFRD were associated with increased charges.
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Affiliation(s)
- Ryan C Perkins
- Division of Pulmonary Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Mahek Shah
- Institute for Strategy and Competitiveness, Harvard Business School, Boston, Massachusetts, USA
| | - Gregory S Sawicki
- Division of Pulmonary Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
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44
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Barreda CB, Farrell PM, Laxova A, Eickhoff JC, Braun AT, Coller RJ, Rock MJ. Newborn screening alone insufficient to improve pulmonary outcomes for cystic fibrosis. J Cyst Fibros 2021; 20:492-498. [PMID: 32546430 PMCID: PMC7736297 DOI: 10.1016/j.jcf.2020.06.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 05/30/2020] [Accepted: 06/01/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND The Wisconsin Cystic Fibrosis Neonatal Screening Project was a randomized clinical trial (RCT) revealing that children receiving an early diagnosis of CF via newborn screening (NBS) had improved nutritional outcomes but similar lung disease severity compared to those who presented clinically. Because the evaluations of these subjects by protocol ended in 2012, our objective was to assess long-term pulmonary and mortality outcomes. METHODS Retrospective analysis of the RCT cohort utilized longitudinal outcome measures obtained from the Cystic Fibrosis Foundation Patient Registry (CFFPR). Data included screening assignment, clinical characteristics, percent predicted forced expiratory volume in 1 s (ppFEV1) and mortality. A random intercept model was used to compare the ppFEV1 decline of subjects between the two groups up to age 26 years. Mortality was analyzed using the Kaplan-Meier method. RESULTS Of the 145 subjects who consented to the original study, 104 subjects met inclusion criteria and had adequate data in the CFFPR. Of 57 subjects in the screened group and 47 in the control group, the rates of ppFEV1 decline were 1.76%/year (95% CI 1.62 to 1.91%) and 1.43%/year (95% CI 1.26 to 1.60%), respectively (p<0.0002). Pseudomonas aeruginosa acquired before 2 years was partially responsible. There was no difference in mortality between the two groups. CONCLUSIONS NBS alone does not improve pulmonary outcomes in CF, particularly when other risk factors supervene. In an era prior to strict infection control and current therapies, NBS for CF may be associated with worse pulmonary outcomes.
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Affiliation(s)
- Christina B Barreda
- Department of Pediatrics, University of Wisconsin-Madison School of Medicine and Public Health, 600 Highland Ave, Madison, WI 53792, USA.
| | - Philip M Farrell
- Department of Pediatrics, University of Wisconsin-Madison School of Medicine and Public Health, 600 Highland Ave, Madison, WI 53792, USA.
| | - Anita Laxova
- Department of Pediatrics, University of Wisconsin-Madison School of Medicine and Public Health, 600 Highland Ave, Madison, WI 53792, USA.
| | - Jens C Eickhoff
- Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison School of Medicine and Public Health, 600 Highland Ave, Madison, WI 53792, USA.
| | - Andrew T Braun
- Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, 600 Highland Ave, Madison, WI 53792, USA.
| | - Ryan J Coller
- Department of Pediatrics, University of Wisconsin-Madison School of Medicine and Public Health, 600 Highland Ave, Madison, WI 53792, USA.
| | - Michael J Rock
- Department of Pediatrics, University of Wisconsin-Madison School of Medicine and Public Health, 600 Highland Ave, Madison, WI 53792, USA.
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Hodos RA, Strub MD, Ramachandran S, Meleshkevitch EA, Boudko DY, Bridges RJ, Dudley JT, McCray PB. Integrative chemogenomic analysis identifies small molecules that partially rescue ΔF508-CFTR for cystic fibrosis. CPT Pharmacometrics Syst Pharmacol 2021; 10:500-510. [PMID: 33934548 PMCID: PMC8129714 DOI: 10.1002/psp4.12626] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 03/15/2021] [Accepted: 03/22/2021] [Indexed: 12/14/2022] Open
Abstract
Rare diseases affect 10% of the first-world population, yet over 95% lack even a single pharmaceutical treatment. In the present age of information, we need ways to leverage our vast data and knowledge to streamline therapeutic development and lessen this gap. Here, we develop and implement an innovative informatic approach to identify therapeutic molecules, using the Connectivity Map and LINCS L1000 databases and disease-associated transcriptional signatures and pathways. We apply this to cystic fibrosis (CF), the most common genetic disease in people of northern European ancestry leading to chronic lung disease and reduced lifespan. We selected and tested 120 small molecules in a CF cell line, finding 8 with activity, and confirmed 3 in primary CF airway epithelia. Although chemically diverse, the transcriptional profiles of the hits suggest a common mechanism associated with the unfolded protein response and/or TNFα signaling. This study highlights the power of informatics to help identify new therapies and reveal mechanistic insights while moving beyond target-centric drug discovery.
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Affiliation(s)
- Rachel A. Hodos
- Institute for Next Generation HealthcareMount Sinai School of MedicineNew YorkNYUSA
- Courant Institute for Mathematical SciencesNew York UniversityNew YorkNYUSA
- Present address:
BenevolentAINew YorkNYUSA
| | - Matthew D. Strub
- Department of PediatricsUniversity of IowaCarver College of MedicineIowa CityIAUSA
- Interdisciplinary Graduate Program in GeneticsUniversity of IowaIowa CityIAUSA
| | | | - Ella A. Meleshkevitch
- Department of Physiology and BiophysicsRosalind Franklin UniversityNorth ChicagoILUSA
| | - Dmitri Y. Boudko
- Department of Physiology and BiophysicsRosalind Franklin UniversityNorth ChicagoILUSA
| | - Robert J. Bridges
- Department of Physiology and BiophysicsRosalind Franklin UniversityNorth ChicagoILUSA
| | - Joel T. Dudley
- Institute for Next Generation HealthcareMount Sinai School of MedicineNew YorkNYUSA
| | - Paul B. McCray
- Department of PediatricsUniversity of IowaCarver College of MedicineIowa CityIAUSA
- Interdisciplinary Graduate Program in GeneticsUniversity of IowaIowa CityIAUSA
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Long-Term Impact of Ivacaftor on Healthcare Resource Utilization Among People with Cystic Fibrosis in the United States. Pulm Ther 2021; 7:281-293. [PMID: 33913076 PMCID: PMC8137794 DOI: 10.1007/s41030-021-00154-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 03/19/2021] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION Ivacaftor was first approved in 2012 for the treatment of a select population of individuals with cystic fibrosis (CF), a rare, life-shortening genetic disease. Reductions in healthcare resource utilization (HCRU) associated with ivacaftor have been observed during limited follow-up and for selected outcomes in real-world studies. This study aimed to further describe the long-term impact of ivacaftor treatment on multiple measures of HCRU among people with CF (pwCF). METHODS This retrospective study used US commercial and Medicaid claims data from 2011-2018. We included pwCF ≥ 6 years of age with ≥ 1 claim for ivacaftor and 12 months of continuous health plan enrollment before ivacaftor initiation ("pre-ivacaftor" period) who also had 36 months of continuous enrollment and persistent ivacaftor use (i.e., no gap ≥ 90 days between refills) following initiation ("post-ivacaftor" period). We compared comorbidities occurring pre-ivacaftor versus the last 12 months post-ivacaftor. HCRU outcomes included medication use, inpatient admissions, and outpatient office visits. We compared medication use pre-ivacaftor versus the last 12 months post-ivacaftor and inpatient admissions and outpatient office visits pre-ivacaftor versus the post-ivacaftor period annualized across 36 months. RESULTS Seventy-nine pwCF met all criteria, including persistent ivacaftor use during the post-ivacaftor period. Ivacaftor treatment was associated with a significant reduction in pneumonia prevalence (10.1% vs. 26.6%; p < 0.001) and significantly fewer mean [SD] antibiotics claims (8.0 [7.3] vs. 12.3 [11.1]; p < 0.001) in the last 12 months post-ivacaftor versus pre-ivacaftor. In comparing the 36-month post-ivacaftor period to the pre-ivacaftor period, we also observed fewer mean [SD] annual inpatient admissions (0.2 [0.4] vs. 0.4 [0.7]), CF-related inpatient admissions (0.1 [0.2] vs. 0.2 [0.5]), and outpatient office visits (8.8 [4.9] vs. 9.9 [5.4]) (all, p < 0.05). CONCLUSION Long-term ivacaftor treatment reduced HCRU, consistent with trends observed in prior real-world studies. Our results support the sustained, long-term value of ivacaftor treatment in reducing CF burden.
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Lopes-Pacheco M, Pedemonte N, Veit G. Discovery of CFTR modulators for the treatment of cystic fibrosis. Expert Opin Drug Discov 2021; 16:897-913. [PMID: 33823716 DOI: 10.1080/17460441.2021.1912732] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Cystic fibrosis (CF) is a life-threatening inherited disease caused by mutations in the gene encoding the CF transmembrane conductance regulator (CFTR) protein, an anion channel expressed at the apical membrane of secretory epithelia. CF leads to multiorgan dysfunction with progressive deterioration of lung function being the major cause of untimely death. Conventional CF therapies target only symptoms and consequences downstream of the primary genetic defect and the current life expectancy and quality of life of these individuals are still very limited. AREA COVERED CFTR modulator drugs are novel-specialized therapies that enhance or even restore functional expression of CFTR mutants and have been approved for clinical use for individuals with specific CF genotypes. This review summarizes classical approaches used for the pre-clinical development of CFTR correctors and potentiators as well as emerging strategies aiming to accelerate modulator development and expand theratyping efforts. EXPERT OPINION Highly effective CFTR modulator drugs are expected to deeply modify the disease course for the majority of individuals with CF. A multitude of experimental approaches have been established to accelerate the development of novel modulators. CF patient-derived specimens are valuable cell models to predict therapeutic effectiveness of existing (and novel) modulators in a precision medicine approach.
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Affiliation(s)
| | | | - Guido Veit
- Department of Physiology, McGill University, Montréal, Canada
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48
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Duckers J, Lesher B, Thorat T, Lucas E, McGarry LJ, Chandarana K, De Iorio F. Real-World Outcomes of Ivacaftor Treatment in People with Cystic Fibrosis: A Systematic Review. J Clin Med 2021; 10:1527. [PMID: 33917386 PMCID: PMC8038673 DOI: 10.3390/jcm10071527] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 03/24/2021] [Accepted: 03/26/2021] [Indexed: 12/20/2022] Open
Abstract
Cystic fibrosis (CF) is a rare, progressive, multi-organ genetic disease. Ivacaftor, a small-molecule CF transmembrane conductance regulator modulator, was the first medication to treat the underlying cause of CF. Since its approval, real-world clinical experience on the use of ivacaftor has been documented in large registries and smaller studies. Here, we systematically review data from real-world observational studies of ivacaftor treatment in people with CF (pwCF). Searches of MEDLINE and Embase identified 368 publications reporting real-world studies that enrolled six or more pwCF treated with ivacaftor published between January 2012 and September 2019. Overall, 75 publications providing data from 57 unique studies met inclusion criteria and were reviewed. Studies reporting within-group change for pwCF treated with ivacaftor consistently showed improvements in lung function, nutritional parameters, and patient-reported respiratory and sino-nasal symptoms. Benefits were evident as early as 1 month following ivacaftor initiation and were sustained over long-term follow-up. Decreases in pulmonary exacerbations, Pseudomonas aeruginosa prevalence, and healthcare resource utilization also were reported for up to 66 months following ivacaftor initiation. In studies comparing ivacaftor treatment to modulator untreated comparator groups, clinical benefits similarly were reported as were decreases in mortality, organ-transplantation, and CF-related complications. The safety profile of ivacaftor observed in these real-world studies was consistent with the well-established safety profile based on clinical trial data. Our systematic review of real-world studies shows ivacaftor treatment in pwCF results in highly consistent and sustained clinical benefit in both pulmonary and non-pulmonary outcomes across various geographies, study designs, patient characteristics, and follow-up durations, confirming and expanding upon evidence from clinical trials.
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Affiliation(s)
- Jamie Duckers
- All Wales Adult Cystic Fibrosis Centre, University Hospital Llandough, Cardiff CF64 2XX, UK
| | - Beth Lesher
- Pharmerit—An OPEN Health Company, 4350 East-West Highway, Suite 1100, Bethesda, MD 20814, USA; (B.L.); (E.L.)
| | - Teja Thorat
- Vertex Pharmaceuticals Incorporated, Boston, MA 02210, USA; (T.T.); (L.J.M.); (K.C.)
| | - Eleanor Lucas
- Pharmerit—An OPEN Health Company, 4350 East-West Highway, Suite 1100, Bethesda, MD 20814, USA; (B.L.); (E.L.)
| | - Lisa J. McGarry
- Vertex Pharmaceuticals Incorporated, Boston, MA 02210, USA; (T.T.); (L.J.M.); (K.C.)
| | - Keval Chandarana
- Vertex Pharmaceuticals Incorporated, Boston, MA 02210, USA; (T.T.); (L.J.M.); (K.C.)
| | - Fosca De Iorio
- Vertex Pharmaceuticals (Europe) Limited, London W2 6BD, UK;
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Real-world use of ivacaftor in Canada: A retrospective analysis using the Canadian Cystic Fibrosis Registry. J Cyst Fibros 2021; 20:1040-1045. [PMID: 33810992 DOI: 10.1016/j.jcf.2021.03.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 03/08/2021] [Accepted: 03/09/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Ivacaftor is a CFTR potentiator with demonstrated efficacy in clinical trials and has been rapidly adopted within the CF community. Given the uptake of ivacaftor in eligible people, identifying a comparator group not on modulators to measure effectiveness is difficult. We evaluated health outcomes in individuals with G551D and non-G551D genotypes on ivacaftor using real-world longitudinal data. METHODS This population-based observational study compared clinical trajectories pre-post ivacaftor using the Canadian CF Registry from 2006 to 01-01 through 2018-12-31. Piece-wise linear mixed-effects models were used to compare lung function, nutritional status, pulmonary exacerbations, and Pseudomonas colonization pre- and post-ivacaftor. Multivariable models were used to adjust for confounding factors. RESULTS Forced expiratory volume in 1 second (FEV1) increased significantly by 5.7 percent predicted (95% confidence interval (CI) 3.9, 7.5; p<0.001) after initiation of ivacaftor. FEV1 decline rate was attenuated to -0.30% (95% CI -0.9, 0.29; p = 0.32) predicted/year post-ivacaftor, compared with -0.75% (95% CI -1.12, -0.37; p<0.001) predicted/year pre-ivacaftor, although this difference did not reach statistical significance. BMI percentiles also increased post-ivacaftor (6.57 percentiles, 95% CI 3.91, 9.24; p<0.001). Pulmonary exacerbations showed a nonsignificant reduction of 18% (RR 0.82, 95% CI 0.61, 1.11; p = 0.19) and the odds of a positive sputum culture for Pseudomonas aeruginosa decreased in the post-ivacaftor period (odds ratio 0.44, 95% CI 0.30, 0.63; p<0.001). CONCLUSIONS This real-world, observational study demonstrated improvement in health outcomes in a broad population of people with CF. Additional studies are needed to evaluate the impact of ivacaftor on quality of life and survival.
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Veit G, Vaccarin C, Lukacs GL. Elexacaftor co-potentiates the activity of F508del and gating mutants of CFTR. J Cyst Fibros 2021; 20:895-898. [PMID: 33775603 DOI: 10.1016/j.jcf.2021.03.011] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 03/11/2021] [Accepted: 03/14/2021] [Indexed: 12/16/2022]
Abstract
Trikafta, the combination of elexacaftor (VX-445), tezacaftor (VX-661) and ivacaftor (VX-770), was approved for therapy of cystic fibrosis (CF) patients with at least one allele of the CFTR mutation F508del. While the corrector function of VX-445 is well established, here we investigated the putative potentiator activity of VX-445 alone and in combination with VX-770. Acute addition of VX-445 increased the VX-770-potentiated F508del- and G551D-CFTR current by ~24% and >70%, respectively, in human bronchial and nasal epithelia. Combinatorial profiling and cluster analysis of G551D- and G1244E-CFTR channel activation with potentiator pairs indicated a distinct VX-445 mechanism of action that is, at least, additive to previously identified potentiator classes, including the VX-770. Since VX-770 only partially normalizes the G551D-CFTR channel function and adult G551D patients still experience progressive loss of lung function, VX-445+VX-770 combination therapy could provide clinical benefit to CF patients with the G551D and other dual potentiator responsive mutants.
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Affiliation(s)
- Guido Veit
- Department of Physiology, McGill University, Montréal, Canada.
| | - Christian Vaccarin
- Department of Pharmaceutical and Pharmacological Sciences, University of Padova, Padova, Italy
| | - Gergely L Lukacs
- Department of Physiology, McGill University, Montréal, Canada; Department of Biochemistry, McGill University, Montréal, Canada..
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