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Jardine S, Anderson S, Babcock S, Leung G, Pan J, Dhingani N, Warner N, Guo C, Siddiqui I, Kotlarz D, Dowling JJ, Melnyk R, Snapper SB, Klein C, Thiagarajah JR, Muise AM. Drug Screen Identifies Leflunomide for Treatment of Inflammatory Bowel Disease Caused by TTC7A Deficiency. Gastroenterology 2020; 158:1000-1015. [PMID: 31743734 PMCID: PMC7062591 DOI: 10.1053/j.gastro.2019.11.019] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 11/03/2019] [Accepted: 11/05/2019] [Indexed: 01/12/2023]
Abstract
BACKGROUND & AIMS Mutations in the tetratricopeptide repeat domain 7A gene (TTC7A) cause intestinal epithelial and immune defects. Patients can become immune deficient and develop apoptotic enterocolitis, multiple intestinal atresia, and recurrent intestinal stenosis. The intestinal disease in patients with TTC7A deficiency is severe and untreatable, and it recurs despite resection or allogeneic hematopoietic stem cell transplant. We screened drugs for those that prevent apoptosis of in cells with TTC7A deficiency and tested their effects in an animal model of the disease. METHODS We developed a high-throughput screen to identify compounds approved by the US Food and Drug Administration that reduce activity of caspases 3 and 7 in TTC7A-knockout (TTC7A-KO) HAP1 (human haploid) cells and reduce the susceptibility to apoptosis. We validated the effects of identified agents in HeLa cells that stably express TTC7A with point mutations found in patients. Signaling pathways in cells were analyzed by immunoblots. We tested the effects of identified agents in zebrafish with disruption of ttc7a, which develop intestinal defects, and colonoids derived from biopsy samples of patients with and without mutations in TTC7A. We performed real-time imaging of intestinal peristalsis in zebrafish and histologic analyses of intestinal tissues from patients and zebrafish. Colonoids were analyzed by immunofluorescence and for ion transport. RESULTS TTC7A-KO HAP1 cells have abnormal morphology and undergo apoptosis, due to increased levels of active caspases 3 and 7. We identified drugs that increased cell viability; leflunomide (used to treat patients with inflammatory conditions) reduced caspase 3 and 7 activity in cells by 96%. TTC7A-KO cells contained cleaved caspase 3 and had reduced levels of phosphorylated AKT and X-linked inhibitor of apoptosis (XIAP); incubation of these cells with leflunomide increased levels of phosphorylated AKT and XIAP and reduced levels of cleaved caspase 3. Administration of leflunomide to ttc7a-/- zebrafish increased gut motility, reduced intestinal tract narrowing, increased intestinal cell survival, increased sizes of intestinal luminal spaces, and restored villi and goblet cell morphology. Exposure of patient-derived colonoids to leflunomide increased cell survival, polarity, and transport function. CONCLUSIONS In a drug screen, we identified leflunomide as an agent that reduces apoptosis and activates AKT signaling in TTC7A-KO cells. In zebrafish with disruption of ttc7a, leflunomide restores gut motility, reduces intestinal tract narrowing, and increases intestinal cell survival. This drug might be repurposed for treatment of TTC7A deficiency.
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Affiliation(s)
- Sasha Jardine
- SickKids Inflammatory Bowel Disease Center, The Hospital for Sick Children, Toronto, ON, Canada
| | - Sierra Anderson
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Boston, MA, USA, Harvard Medical School, Boston, MA, USA
| | - Stephen Babcock
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Boston, MA, USA, Harvard Medical School, Boston, MA, USA
| | - Gabriella Leung
- SickKids Inflammatory Bowel Disease Center, The Hospital for Sick Children, Toronto, ON, Canada
| | - Jie Pan
- SickKids Inflammatory Bowel Disease Center, The Hospital for Sick Children, Toronto, ON, Canada
| | - Neel Dhingani
- SickKids Inflammatory Bowel Disease Center, The Hospital for Sick Children, Toronto, ON, Canada
| | - Neil Warner
- SickKids Inflammatory Bowel Disease Center, The Hospital for Sick Children, Toronto, ON, Canada
| | - Conghui Guo
- SickKids Inflammatory Bowel Disease Center, The Hospital for Sick Children, Toronto, ON, Canada
| | - Iram Siddiqui
- Division of Pathology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Daniel Kotlarz
- Dr. von Hauner Children’s Hospital, Department of Pediatrics, University Hospital, LMU Munich, Munich, Germany
| | - James J Dowling
- Division of Neurology, and Genetics and Genome Biology Program, Research Institute, The Hospital for Sick Children,Molecular Medicine Program, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
| | - Roman Melnyk
- Molecular Medicine Program, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
| | - Scott B Snapper
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Boston, MA, USA, Harvard Medical School, Boston, MA, USA,Division of Gastroenterology, Brigham and Women’s Hospital, Boston, MA, USA
| | - Christoph Klein
- Dr. von Hauner Children’s Hospital, Department of Pediatrics, University Hospital, LMU Munich, Munich, Germany
| | - Jay R Thiagarajah
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Boston, MA, USA, Harvard Medical School, Boston, MA, USA
| | - Aleixo M Muise
- SickKids Inflammatory Bowel Disease Centre, The Hospital for Sick Children, Toronto, Ontario, Canada; Cell Biology Program, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Pediatrics, Institute of Medical Science and Biochemistry, University of Toronto, The Hospital for Sick Children, Toronto, Ontario, Canada.
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Frequency and Nature of Adverse Drug Reactions Due to Non-Prescription Drugs in Children: A Retrospective Analysis from the French Pharmacovigilance Database. Paediatr Drugs 2018; 20:81-87. [PMID: 28766184 DOI: 10.1007/s40272-017-0255-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Studies that evaluate the safety of non-prescription drugs in children remain scarce. OBJECTIVES The aim of the present study was to compare adverse drug reactions (ADRs) due to prescription versus non-prescription drugs in children. METHODS We conducted a retrospective analysis of ADR notifications for a pediatric population (aged <18 years) registered in the French PharmacoVigilance Database (FPVD) between January 1985 and December 2016 by the Midi-Pyrénées PharmacoVigilance Center (in the south of France). We compared ADR profiles according to drug prescription status using a Chi-squared test. RESULTS We included 2218 notifications concerning 3687 ADRs in the study. Non-prescription drugs were involved in 506 notifications (22.8%). Patients were younger in the non-prescription drug group (6.7 ± 5.3 vs. 8.4 ± 5.7 years in the prescription drug group). No difference by sex was found. Neurological ADRs were more frequent with prescription drugs (21.0%) than with non-prescription drugs (14.2%, p = 0.0008), whereas dermatological disorders (37.2 vs. 29.1%, respectively) and general ADRs (30.8 vs. 20.1%, respectively) were more frequent with non-prescription than with prescription drugs (p = 0.0006 and p < 0.0001, respectively). The frequency of "serious" ADRs was higher with prescription drugs than with non-prescription drugs (40.9 vs. 34.2%, p = 0.007). The non-prescription drugs most frequently implicated with serious ADRs were ibuprofen (n = 37; 4.2%), tuberculosis vaccine (n = 23; 2.6%), aspirin (n = 20, 2.3%), and paracetamol (n = 17; 1.9%). ADRs from prescription drugs involved asparaginase (n = 27; 3.1%), immunoglobulins (n = 25; 2.9%), and amoxicillin (n = 23; 2.4%). CONCLUSIONS Non-prescription drugs, usually considered safe, were frequently responsible for ADR notifications. The non-prescription medication most frequently involved in serious ADRs was ibuprofen.
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Abstract
• On the basis of strong research evidence, children with severe upper gastrointestinal tract bleeding should be treated with intravenous proton pump inhibitors. • On the basis of some research evidence and consensus, children with severe gastrointestinal bleeding should be evaluated by endoscopy. • On the basis of some research evidence and consensus, children in whom endoscopy has not been able to confirm a bleeding source should be considered for capsule endoscopy.
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Affiliation(s)
- Gary A Neidich
- Department of Pediatrics, Sanford School of Medicine of the University of South Dakota, and Sanford Children's Specialty Clinic, Sioux Falls, SD
| | - Sarah R Cole
- Department of Pediatrics, Sanford School of Medicine of the University of South Dakota, and Sanford Children's Specialty Clinic, Sioux Falls, SD
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Abstract
• On the basis of strong research evidence, children with severe upper gastrointestinal tract bleeding should be treated with intravenous proton pump inhibitors. • On the basis of some research evidence and consensus, children with severe gastrointestinal bleeding should be evaluated by endoscopy. • On the basis of some research evidence and consensus, children in whom endoscopy has not been able to confirm a bleeding source should be considered for capsule endoscopy.
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Affiliation(s)
- Gary A Neidich
- Department of Pediatrics, Sanford School of Medicine of the University of South Dakota, and Sanford Children's Specialty Clinic, Sioux Falls, SD
| | - Sarah R Cole
- Department of Pediatrics, Sanford School of Medicine of the University of South Dakota, and Sanford Children's Specialty Clinic, Sioux Falls, SD
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Bianciotto M, Chiappini E, Raffaldi I, Gabiano C, Tovo PA, Sollai S, de Martino M, Mannelli F, Tipo V, Da Cas R, Traversa G, Menniti-Ippolito F. Drug use and upper gastrointestinal complications in children: a case-control study. Arch Dis Child 2013; 98:218-21. [PMID: 23264432 PMCID: PMC3582087 DOI: 10.1136/archdischild-2012-302100] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To evaluate the risk of upper gastrointestinal complications (UGIC) associated with drug use in the paediatric population. METHODS This study is part of a large Italian prospective multicentre study. The study population included children hospitalised for acute conditions through the emergency departments of eight clinical centres. Patients admitted for UGIC (defined as endoscopically confirmed gastroduodenal lesions or clinically defined haematemesis or melena) comprised the case series; children hospitalised for neurological disorders formed the control group. Information on drug and vaccine exposure was collected through parental interview during the children's hospitalisation. Logistic regression was used to estimate ORs for the occurrence of UGIC associated with drug use adjusted for age, clinical centre and concomitant use of any drug. RESULTS 486 children hospitalised for UGIC and 1930 for neurological disorders were enrolled between November 1999 and November 2010. Drug use was higher in cases than in controls (73% vs 54%; p<0.001). UGICs were associated with the use of non-steroidal anti-inflammatory drugs (NSAIDs) (adjusted OR 2.9, 95% CI 2.1 to 4.0), oral steroids (adjusted OR 2.9, 95% CI 1.7 to 4.8) and antibiotics (adjusted OR 2.3, 95% CI 1.8 to 3.1). The duration of use of these drug categories was short (range 1-8 days). Paracetamol showed a lower risk (adjusted OR 2.0, 95% CI 1.5 to 2.6) compared to ibuprofen (adjusted OR 3.7, 95% CI 2.3 to 5.9), although with partially overlapping CIs. CONCLUSIONS NSAIDs, oral steroids and antibiotics, even when administered for a short period, were associated with an increased risk of UGIC.
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Affiliation(s)
| | | | | | | | | | - Sara Sollai
- Anna Meyer Children's University Hospital, Florence, Italy
| | | | | | | | - Roberto Da Cas
- National Centre for Epidemiology, Italian National Institute of Health, Rome, Italy
| | - Giuseppe Traversa
- National Centre for Epidemiology, Italian National Institute of Health, Rome, Italy
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Abstract
Fever in a child is one of the most common clinical symptoms managed by pediatricians and other health care providers and a frequent cause of parental concern. Many parents administer antipyretics even when there is minimal or no fever, because they are concerned that the child must maintain a "normal" temperature. Fever, however, is not the primary illness but is a physiologic mechanism that has beneficial effects in fighting infection. There is no evidence that fever itself worsens the course of an illness or that it causes long-term neurologic complications. Thus, the primary goal of treating the febrile child should be to improve the child's overall comfort rather than focus on the normalization of body temperature. When counseling the parents or caregivers of a febrile child, the general well-being of the child, the importance of monitoring activity, observing for signs of serious illness, encouraging appropriate fluid intake, and the safe storage of antipyretics should be emphasized. Current evidence suggests that there is no substantial difference in the safety and effectiveness of acetaminophen and ibuprofen in the care of a generally healthy child with fever. There is evidence that combining these 2 products is more effective than the use of a single agent alone; however, there are concerns that combined treatment may be more complicated and contribute to the unsafe use of these drugs. Pediatricians should also promote patient safety by advocating for simplified formulations, dosing instructions, and dosing devices.
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Southey ER, Soares-Weiser K, Kleijnen J. Systematic review and meta-analysis of the clinical safety and tolerability of ibuprofen compared with paracetamol in paediatric pain and fever. Curr Med Res Opin 2009; 25:2207-22. [PMID: 19606950 DOI: 10.1185/03007990903116255] [Citation(s) in RCA: 83] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE The main aim of this review was to compare the tolerability and safety between ibuprofen and paracetamol when used as anti-pyretic and analgesic agents in children up to 18 years of age. METHODS MEDLINE (1950 to November 2008), EMBASE (1980 to November 2008), The Cochrane Library (2007, Issue 3), ACP Journal Club (1991 to November 2007) and Pascal (1987 to November 2007) were searched for randomised controlled trails (RCTs) (comparing ibuprofen and/or paracetamol with placebo), controlled observational studies and large case series comprised more than 1000 participants. MAIN OUTCOME MEASURES Adverse events (AEs) requiring discontinuation of medication; systemic reactions related to ibuprofen or paracetamol; serious AEs that are fatal, life-threatening or require hospitalisation; and serious AEs not requiring hospitalisation. RESULTS A total of 24 RCTs examined either ibuprofen and/or paracetamol versus placebo for AE data. Twelve other studies meeting our criteria were also included for AE data. Meta-analysis of systemic reactions demonstrated that tolerability and safety of ibuprofen was similar to placebo, as was paracetamol: ibuprofen versus placebo relative risk (RR) 1.39 (95% CI: 0.92, 2.10); paracetamol versus placebo RR 1.57 (95% CI 0.74, 3.33). A total of 2937 systemic AEs occurred in 21,305 patients taking ibuprofen compared with 1,466 systemic AEs in 11,164 patients taking paracetamol: RR 1.03 (95% CI 0.98, 1.10). There was no significant difference between the two groups. Narrative analysis of AE data identified conflicting evidence regarding hepatic injury with paracetamol and group A streptococcal infections with ibuprofen or paracetamol treatment. CONCLUSIONS Ibuprofen, paracetamol and placebo have similar tolerability and safety profiles in terms of gastrointestinal symptoms, asthma and renal adverse effects. While the study data investigated here may not reflect over-the-counter use, these results are still relevant in the context of any safety concerns relating to general ibuprofen or paracetamol treatment in children.
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