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Freyer CW, Carulli A, Frey NV, Gill SI, Hexner EO, Martin ME, Luger SM, Porter DL, Stadtmauer EA, Loren AW. Characterization of the calcineurin inhibitor pain syndrome in patients undergoing allogeneic hematopoietic cell transplantation. Leuk Lymphoma 2024; 65:250-256. [PMID: 38264905 DOI: 10.1080/10428194.2023.2281266] [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: 06/30/2023] [Accepted: 11/05/2023] [Indexed: 01/25/2024]
Abstract
Calcineurin inhibitor pain syndrome (CIPS) is a rare complication of graft-vs-host disease prophylaxis following allogeneic hematopoietic cell transplant (alloHCT). CIPS presents as severe bilateral lower extremity pain, and the incidence, risk factors, and management of CIPS are poorly characterized.This is a single center retrospective study of patients who received tacrolimus (TAC) following alloHCT to describe the characteristics and management of CIPS and compare to a cohort who did not develop CIPS.Fifteen of 585 alloHCT patients (2.6%) developed CIPS at a median of 5 days following TAC initiation and a median level of 10.5 ng/mL. Severe bilateral foot, ankle, or leg pain were the primary symptoms. Patients with CIPS were younger and more frequently received myeloablative conditioning and total body irradiation compared to patients without CIPS. Analgesic regimens included dihydropyridine calcium channel blockers, gabapentinoids, topical diclofenac, and opioids.Clinicians should be aware of this uncommon but severe adverse effect.
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Affiliation(s)
- Craig W Freyer
- Department of Pharmacy, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
- Blood and Marrow Transplant and Cellular Therapy Program, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Alison Carulli
- Department of Pharmacy, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
- Blood and Marrow Transplant and Cellular Therapy Program, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Noelle V Frey
- Blood and Marrow Transplant and Cellular Therapy Program, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Saar I Gill
- Blood and Marrow Transplant and Cellular Therapy Program, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Elizabeth O Hexner
- Blood and Marrow Transplant and Cellular Therapy Program, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Mary Ellen Martin
- Blood and Marrow Transplant and Cellular Therapy Program, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Selina M Luger
- Blood and Marrow Transplant and Cellular Therapy Program, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - David L Porter
- Blood and Marrow Transplant and Cellular Therapy Program, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Edward A Stadtmauer
- Blood and Marrow Transplant and Cellular Therapy Program, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Alison W Loren
- Blood and Marrow Transplant and Cellular Therapy Program, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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Cadiou S, Le Gruyer A, Giguet B, Robin F, Milin M, Guennoc X, Guggenbuhl P, De Saint-Riquier M. Calcium pyrophosphate deposition (CPPD) in a liver transplant patient: are hypomagnesemia, tacrolimus or both guilty? A case-based literature review. Rheumatol Int 2021; 42:1105-1112. [PMID: 33709178 DOI: 10.1007/s00296-021-04828-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 03/01/2021] [Indexed: 12/21/2022]
Abstract
Calcium pyrophosphate deposition (CPPD) can be induced by a persistent hypomagnesemia. Tacrolimus is an immunosuppressive treatment especially used in organ transplant, potentially inducer of hypomagnesemia by renal loss. A 53-year-old man, liver transplant 10 months earlier, developed an acute peripheral oligoarthritis of wrist, hip and elbow with fever, associated with acute low back pain. Synovial fluid was sterile, and revealed calcium pyrophosphate crystals. Spinal imaging showed inflammatory changes. Magnesium blood level was low at 0.51 mmol/l, with high fractional excretion in favor of renal loss. Tacrolimus was changed for everolimus, proton pump inhibitor was stopped, and magnesium oral supplementation was started. After 8 months follow-up and slow prednisone tapering, he did not relapse pain. Persistent hypomagnesemia is a rare secondary cause of CPPD. In this entity, drug liability should be investigated such as tacrolimus in organ transplant patient.
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Affiliation(s)
- Simon Cadiou
- Department of Rheumatology, Rennes University Hospital, Rennes 1 University, 35000, Rennes, France.
| | - Antonia Le Gruyer
- Department of Hepato-Gastroenterology, Saint-Brieuc Hospital, 22000, Saint-Brieuc, France
| | - Baptiste Giguet
- Department of Hepato-Gastroenterology, Rennes Univsersity Hospital, Rennes 1 University, 35000, Rennes, France
| | - François Robin
- Department of Rheumatology, Rennes University Hospital, Rennes 1 University, 35000, Rennes, France
| | - Morgane Milin
- Department of Rheumatology, Saint-Brieuc Hospital, 22000, Saint-Brieuc, France
| | - Xavier Guennoc
- Department of Rheumatology, Saint-Brieuc Hospital, 22000, Saint-Brieuc, France
| | - Pascal Guggenbuhl
- Department of Rheumatology, Rennes University Hospital, Rennes 1 University, 35000, Rennes, France
- CHU Rennes, University of Rennes 1, INSERM, Institut NUMECAN (Nutrition Metabolisms and Cancer), UMR INSERM U 1241, 35000, Rennes, France
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