1
|
Gómez-Ganda L, Galván-Blasco P, Fernández-Polo A, Cardona V, García-Palop B, Parramón-Teixidó CJ, Polverino E, Álvarez-Fernández A. Cystic fibrosis: desensitization in delayed hypersensitivity reactions to elexacaftor/tezacaftor/ivacaftor. Front Pharmacol 2024; 15:1392986. [PMID: 38933680 PMCID: PMC11203995 DOI: 10.3389/fphar.2024.1392986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 05/21/2024] [Indexed: 06/28/2024] Open
Abstract
Background: Cystic fibrosis transmembrane conductance regulator modulators are the only available treatment for cystic fibrosis. Although elexacaftor/tezacaftor/ivacaftor (ELX/TEZ/IVA) is well-tolerated, rash has been reported as very frequent. In severe rashes, ELX/TEZ/IVA withdrawal is necessary, leading to clinical deterioration. The objective of the study is to increment the experience of ELX/TEZ/IVA desensitization. Methods: Adult patients who developed a delayed hypersensitivity rash to ELX/TEZ/IVA between December 2021 and February 2023 and required withdrawal due to ineffective rescue medication were included. Skins test for ELX/TEZ/IVA and IVA were conducted to establish hypersensitivity mechanism. Balijepally ELX/TEZ/IVA desensitization protocol was selected. In cases where desensitization had to be discontinued due to rash, an extended desensitization was proposed. Clinical and health-related quality of life parameters were collected before ELX/TEZ/IVA and after desensitization. Results: 162 patients (81 women, 31.2 [23.8-42.5] years) started ELX/TEZ/IVA, developing rash 12 of them (7.4%, six women). Six patients (five women) required stopping ELX/TEZ/IVA and were selected for desensitization. Skin tests indicated delayed type-IV hypersensitivity in one patient. Two patients presented adequate tolerance to desensitization; while, four patients developed rash. Three of these patients, successfully concluded extended desensitization (one patient declined participation). No significant clinical deterioration or quality of life worsening was observed during desensitization; in fact, there was an improvement in practically all mesured parameters. All five patients who resumed ELX/TEZ/IVA are currently receiving therapy with good tolerance. Conclusion: Desensitization to ELX/TEZ/IVA could be a successful and safe strategy for reintroducing this essential treatment in cases of a delayed hypersensitivity rash.
Collapse
Affiliation(s)
- L. Gómez-Ganda
- Pharmacy Department, Vall d’Hebron University Hospital, Barcelona, Spain
| | - P. Galván-Blasco
- Allergology Department, Vall d’Hebron University Hospital, Barcelona, Spain
- Vall Hebron Institut de Recerca (VHIR), Vall d’Hebron University Hospital, Barcelona, Spain
| | - A. Fernández-Polo
- Pharmacy Department, Vall d’Hebron University Hospital, Barcelona, Spain
| | - V. Cardona
- Allergology Department, Vall d’Hebron University Hospital, Barcelona, Spain
- Vall Hebron Institut de Recerca (VHIR), Vall d’Hebron University Hospital, Barcelona, Spain
| | - B. García-Palop
- Pharmacy Department, Vall d’Hebron University Hospital, Barcelona, Spain
| | | | - E. Polverino
- Cystic Fibrosis Unit, Pulmonology Department, Vall d’Hebron University Hospital, Barcelona, Spain
| | - A. Álvarez-Fernández
- Cystic Fibrosis Unit, Pulmonology Department, Vall d’Hebron University Hospital, Barcelona, Spain
| |
Collapse
|
2
|
Manciulli T, Bresci S, Mencarini J, Avarello A, Taccetti G, Terlizzi V. Prevalence of adverse events in cystic fibrosis patients treated with elexacaftor/tezacaftor/ivacaftor: Experience of the regional referral center in Tuscany, Italy. Pediatr Pulmonol 2023; 58:3626-3629. [PMID: 37750598 DOI: 10.1002/ppul.26673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Revised: 08/20/2023] [Accepted: 08/30/2023] [Indexed: 09/27/2023]
Affiliation(s)
- Tommaso Manciulli
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Silvia Bresci
- Infectious and Tropical Diseases Unit, Careggi University Hospital, Florence, Italy
| | - Jessica Mencarini
- Infectious and Tropical Diseases Unit, Careggi University Hospital, Florence, Italy
| | - Angelo Avarello
- Infectious and Tropical Diseases Unit, Careggi University Hospital, Florence, Italy
| | - Giovanni Taccetti
- Department of Paediatric Medicine, Meyer Children's Hospital IRCCS, Cystic Fibrosis Regional Reference Center, Florence, Italy
| | - Vito Terlizzi
- Department of Paediatric Medicine, Meyer Children's Hospital IRCCS, Cystic Fibrosis Regional Reference Center, Florence, Italy
| |
Collapse
|
3
|
Lieu N, Prentice BJ, Field P, Fitzgerald DA. Trials and tribulations of highly effective modulator therapies in cystic fibrosis. Paediatr Respir Rev 2023; 48:10-19. [PMID: 37914566 DOI: 10.1016/j.prrv.2023.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 09/13/2023] [Indexed: 11/03/2023]
Abstract
Highly effective modulator therapies (HEMTs) have revolutionised the management approach of most patients living with cystic fibrosis (CF) who have access to these therapies. Clinical trials have reported significant improvements across multiorgan systems, with patients surviving longer. However, there are accumulating case reports and observational data describing various adverse events following initiation of HEMTs including drug-to-drug interactions, drug induced liver injury, Stevens-Johnson syndrome, and neurocognitive symptoms including psychosis and depression, which have required discontinuation of therapy. Current clinical trials are assessing efficacy in younger patients with CF, yet long-term studies are also required to better understand the safety profile in the real-world setting across all ages and the impact of HEMT dose alteration or discontinuation.
Collapse
Affiliation(s)
- Nathan Lieu
- Department of Respiratory Medicine, The Children's Hospital at Westmead, Sydney, New South Wales, Australia, 2145; Discipline of Paediatrics and Child Health, University of Sydney, Sydney, New South Wales, Australia.
| | - Bernadette J Prentice
- Department of Respiratory Medicine, Sydney Children's Hospital, Randwick, Sydney, New South Wales, Australia, 2031; Discipline of Paediatrics and Child Health, UNSW, Sydney, New South Wales, Australia
| | - Penelope Field
- Department of Respiratory Medicine, The Children's Hospital at Westmead, Sydney, New South Wales, Australia, 2145; Department of Respiratory Medicine, Sydney Children's Hospital, Randwick, Sydney, New South Wales, Australia, 2031; Discipline of Paediatrics and Child Health, UNSW, Sydney, New South Wales, Australia
| | - Dominic A Fitzgerald
- Department of Respiratory Medicine, The Children's Hospital at Westmead, Sydney, New South Wales, Australia, 2145; Discipline of Paediatrics and Child Health, University of Sydney, Sydney, New South Wales, Australia
| |
Collapse
|
4
|
Santos AI, Pacheco J, Cemlyn-Jones J, Gamboa F. Triple Therapy for Cystic Fibrosis (Elexacaftor, Tezacaftor, and Ivacaftor): Desensitization After Skin Rash. Cureus 2023; 15:e46228. [PMID: 37905296 PMCID: PMC10613531 DOI: 10.7759/cureus.46228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/29/2023] [Indexed: 11/02/2023] Open
Abstract
Cystic fibrosis (CF) is an autosomal recessive disorder of the CF transmembrane conductance regulator (CFTR) gene. CFTR modulators are novel approved therapies, and triple therapy with elexacaftor/tezacaftor/ivacaftor (ELX/TEZ/IVA) is the current gold standard for patients with at least one F508del mutation. CFTR modulators are usually well-tolerated, but some adverse effects may occur, including skin rash. We report a case of a female patient who developed a severe skin rash after initiating treatment with ELX/TEZ/IVA. Modulator therapy and contraception were discontinued, and consequently, there was a drop in lung function and reappearance of respiratory symptoms. After rash resolution, a gradual reintroduction of ELX/TEZ/IVA was started, and this is the protocol the authors have summarized. Triple therapy with CFTR modulators has a significant impact on lung function and the quality of life of CF patients who have at least one F508del mutation, justifying its reintroduction and desensitization even after a severe adverse effect.
Collapse
Affiliation(s)
- Ana Isabel Santos
- Pulmonology Department, Hospital and University Centre of Coimbra, Coimbra, PRT
| | - Joana Pacheco
- Pulmonology Department, Hospital and University Centre of Coimbra, Coimbra, PRT
| | | | - Fernanda Gamboa
- Pulmonology Department, Hospital and University Centre of Coimbra, Coimbra, PRT
| |
Collapse
|
5
|
Tümmler B. Post-approval studies with the CFTR modulators Elexacaftor-Tezacaftor—Ivacaftor. Front Pharmacol 2023; 14:1158207. [PMID: 37025483 PMCID: PMC10072268 DOI: 10.3389/fphar.2023.1158207] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 03/07/2023] [Indexed: 03/31/2023] Open
Abstract
Triple combination therapy with the CFTR modulators elexacaftor (ELX), tezacaftor (TEZ) and ivacaftor (IVA) has been qualified as a game changer in cystic fibrosis (CF). We provide an overview of the body of literature on ELX/TEZ/IVA published between November 2019 and February 2023 after approval by the regulators. Recombinant ELX/TEZ/IVA-bound Phe508del CFTR exhibits a wild type conformationin vitro, but in patient’s tissue a CFTR glyoisoform is synthesized that is distinct from the wild type and Phe508del isoforms. ELX/TEZ/IVA therapy improved the quality of life of people with CF in the real-life setting irrespective of their anthropometry and lung function at baseline. ELX/TEZ/IVA improved sinonasal and abdominal disease, lung function and morphology, airway microbiology and the basic defect of impaired epithelial chloride and bicarbonate transport. Pregnancy rates were increasing in women with CF. Side effects of mental status changes deserve particular attention in the future.
Collapse
Affiliation(s)
- Burkhard Tümmler
- Department of Pediatric Pneumology, Allergology and Neonatology, Hannover Medical School, Hannover, Germany
- Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), German Center for Lung Research, Hannover Medical School, Hannover, Germany
- *Correspondence: Burkhard Tümmler,
| |
Collapse
|
6
|
Li Pomi F, Di Bartolomeo L, Vaccaro M, Lentini M, Cristadoro S, Lucanto MC, Lombardo M, Costa S, Borgia F. Malassezia Folliculitis following Triple Therapy for Cystic Fibrosis. Medicina (B Aires) 2022; 58:medicina58091204. [PMID: 36143881 PMCID: PMC9503821 DOI: 10.3390/medicina58091204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 08/28/2022] [Accepted: 08/30/2022] [Indexed: 11/27/2022] Open
Abstract
Triple-combination therapy with elexacaftor, tezacaftor and ivacaftor has been recently approved for cystic fibrosis patients with at least one F508del mutation in the transmembrane conductance regulator of the cystic fibrosis gene. Among the adverse events of elexacaftor, tezacaftor and ivacaftor, the cutaneous ones have been rarely reported, mainly dealing with urticarial-like rashes. On this topic, we report two cases of Malassezia folliculitis following triple therapy administration in two young females. In the first patient, a papulopustular rush appeared before the folliculitis while in the second patient it was not preceded by other skin manifestations. The diagnosis was confirmed both by dermoscopy and histology. The prompt response to systemic antimycotic drugs provided further evidence for the causative role of Malassezia, requiring no discontinuation of cystic fibrosis therapy. We could hypothesize that the triple regimen treatment may induce changes in the skin microbiome, potentially able to favor colonization and proliferation of Malassezia species. Physicians should be aware of such associations to allow prompt diagnosis and early interventions, avoiding useless drug removal.
Collapse
Affiliation(s)
- Federica Li Pomi
- Department of Clinical and Experimental Medicine, Section of Dermatology, University of Messina, 98122 Messina, Italy
| | - Luca Di Bartolomeo
- Department of Clinical and Experimental Medicine, Section of Dermatology, University of Messina, 98122 Messina, Italy
| | - Mario Vaccaro
- Department of Clinical and Experimental Medicine, Section of Dermatology, University of Messina, 98122 Messina, Italy
| | - Maria Lentini
- Department of Human Pathology of Adult and Childhood Gaetano Barresi, University of Messina, 98122 Messina, Italy
| | - Simona Cristadoro
- Cystic Fibrosis Center, Gastroenterology and Cystic Fibrosis Unit, Department of Human Pathology of Adult and Childhood Gaetano Barresi, University of Messina, 98122 Messina, Italy
| | - Maria Cristina Lucanto
- Cystic Fibrosis Center, Gastroenterology and Cystic Fibrosis Unit, Department of Human Pathology of Adult and Childhood Gaetano Barresi, University of Messina, 98122 Messina, Italy
| | - Mariangela Lombardo
- Cystic Fibrosis Center, Gastroenterology and Cystic Fibrosis Unit, Department of Human Pathology of Adult and Childhood Gaetano Barresi, University of Messina, 98122 Messina, Italy
| | - Stefano Costa
- Cystic Fibrosis Center, Gastroenterology and Cystic Fibrosis Unit, Department of Human Pathology of Adult and Childhood Gaetano Barresi, University of Messina, 98122 Messina, Italy
| | - Francesco Borgia
- Department of Clinical and Experimental Medicine, Section of Dermatology, University of Messina, 98122 Messina, Italy
- Correspondence:
| |
Collapse
|
7
|
Autry E, Kuhn R. Pharmacist to the Rescue: Overcoming Obstacles for Select Patients. J Pediatr Pharmacol Ther 2022; 27:407-408. [PMID: 35845564 PMCID: PMC9268107 DOI: 10.5863/1551-6776-27.5.407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 05/05/2022] [Indexed: 09/01/2024]
Affiliation(s)
- Elizabeth Autry
- Department of Pharmacy, University of Kentucky Healthcare, Lexington, KY, USA and the Department of Pharmacy Practice and Science, College of Pharmacy (EA, RK), University of Kentucky. Lexington, KY USA
| | - Robert Kuhn
- Department of Pharmacy, University of Kentucky Healthcare, Lexington, KY, USA and the Department of Pharmacy Practice and Science, College of Pharmacy (EA, RK), University of Kentucky. Lexington, KY USA
| |
Collapse
|