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VanDevanter DR, West NE, Sanders DB, Skalland M, Goss CH, Flume PA, Heltshe SL. Antipseudomonal treatment decisions during CF exacerbation management. J Cyst Fibros 2022; 21:753-758. [PMID: 35466039 PMCID: PMC9509480 DOI: 10.1016/j.jcf.2022.04.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 03/01/2022] [Accepted: 04/04/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND Cystic fibrosis (CF) pulmonary exacerbation (PEx) treatment guidelines suggest that Pseudomonas aeruginosa (Pa) airway infection be treated with two antipseudomonal agents. METHODS We retrospectively studied treatment responses for STOP2 PEx treatment trial (NCT02781610) participants with a history of Pa infection. Mean lung function and symptom changes from intravenous (IV) antimicrobial treatment start to Visit 2 (7 to 10 days later) were compared between those receiving one, two, and three+ antipseudomonal classes before Visit 2 by ANCOVA. Odds of PEx retreatment with IV antimicrobials within 30 days and future IV-treated PEx hazard were modeled by logistic and Cox proportional hazards regression, respectively. Sensitivity analyses limited to the most common one-, two-, and three-class regimens, to only IV/oral antipseudomonal treatments, and with more stringent Pa infection definitions were conducted. RESULTS Among 751 participants, 50 (6.7%) were treated with one antipseudomonal class before Visit 2, while 552 (73.5%) and 149 (19.8%) were treated with two and with three+ classes, respectively. Females and participants with a negative Pa culture in the prior month were more likely to be treated with a single class. The most common single, double, and triple class regimens were beta-lactam (BL; n = 42), BL/aminoglycoside (AG; n = 459), and BL/AG/fluoroquinolone (FQ; n = 73). No lung function or symptom response, odds of retreatment, or future PEx hazard differences were observed by number of antipseudomonal classes administered in primary or sensitivity analyses. CONCLUSIONS We were unable to identify additional benefit when multiple antipseudomonal classes are used to treat PEx in people with CF and Pa.
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Affiliation(s)
- D R VanDevanter
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, OH, United States.
| | - N E West
- Department of Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - D B Sanders
- Department of Pediatrics, Indiana University, Indianapolis, IN, United States
| | - M Skalland
- CF Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, WA, United States
| | - C H Goss
- CF Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, WA, United States; Department of Medicine, University of Washington, Seattle, WA, United States; Department of Pediatrics, University of Washington, Seattle, WA, United States
| | - P A Flume
- Departments of Medicine and Pediatrics, Medical University of South Carolina, Charleston, SC, United States
| | - S L Heltshe
- CF Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, WA, United States; Department of Pediatrics, University of Washington, Seattle, WA, United States
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VanDevanter DR, Heltshe SL, Skalland M, West NE, Sanders DB, Goss CH, Flume PA. C-reactive protein (CRP) as a biomarker of pulmonary exacerbation presentation and treatment response. J Cyst Fibros 2021; 21:588-593. [PMID: 34933824 DOI: 10.1016/j.jcf.2021.12.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 11/09/2021] [Accepted: 12/05/2021] [Indexed: 01/05/2023]
Abstract
BACKGROUND C-reactive protein (CRP) has been proposed as a biomarker for pulmonary exacerbation (PEx) diagnosis and treatment response. CRP >75mg/L has been associated with increased risk of PEx treatment failure. We have analyzed CRP measures as biomarkers for clinical response during the STOP2 PEx study (NCT02781610). METHODS CRP measures were collected at antimicrobial treatment start (V1), seven to 10 days later (V2), and two weeks after treatment end (V3). V1 log10CRP concentrations and log10CRP change from V1 to V3 correlations with clinical responses (changes in lung function and symptom score) were assessed by least squares regression. Odds of intravenous (IV) antimicrobial retreatment within 30 days and future PEx hazard associated with V1 and V3 CRP concentrations and V1 CRP >75 mg/L were studied by adjusted logistic regression and proportional hazards modeling, respectively. RESULTS In all, 951 of 982 STOP2 subjects (92.7%) had CRP measures at V1. V1 log10CRP varied significantly by V1 lung function subgroup, symptom score quartile, and sex, but not by age subgroup. V1 log10CRP correlated moderately with log10CRP change at V3 (r2=0.255) but less so with lung function (r2=0.016) or symptom (r2=0.031) changes at V3. Higher V1 CRP was associated with greater response. CRP changes from V1 to V3 only weakly correlated with lung function (r2=0.061) and symptom (r2=0.066) changes. However, V3 log10CRP was associated with increased odds of retreatment (P = .0081) and future PEx hazard (P = .0114). DISCUSSION Despite consistent trends, log10CRP change was highly variable with only limited utility as a biomarker of PEx treatment response.
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Affiliation(s)
- D R VanDevanter
- Case Western Reserve Univ. School of Medicine, Cleveland OH, USA.
| | - S L Heltshe
- Univ. of Washington, Seattle WA, USA; CFF TDNCC, Seattle Children's Hospital, Seattle WA, USA
| | - M Skalland
- CFF TDNCC, Seattle Children's Hospital, Seattle WA, USA
| | - N E West
- Johns Hopkins University, Baltimore MD, USA
| | - D B Sanders
- Indiana Univ. School of Medicine, Indianapolis IN, USA
| | - C H Goss
- Univ. of Washington, Seattle WA, USA
| | - P A Flume
- Medical Univ. of South Carolina, Charleston SC, USA
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Kopp BT, Joseloff E, Goetz D, Ingram B, Heltshe SL, Leung DH, Ramsey BW, McCoy K, Borowitz D. Urinary metabolomics reveals unique metabolic signatures in infants with cystic fibrosis. J Cyst Fibros 2018; 18:507-515. [PMID: 30477895 DOI: 10.1016/j.jcf.2018.10.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 10/25/2018] [Accepted: 10/28/2018] [Indexed: 12/25/2022]
Abstract
BACKGROUND Biologic pathways and metabolic mechanisms underpinning early systemic disease in cystic fibrosis (CF) are poorly understood. The Baby Observational and Nutrition Study (BONUS) was a prospective multi-center study of infants with CF with a primary aim to examine the current state of nutrition in the first year of life. Its secondary aim was to prospectively explore concurrent nutritional, metabolic, respiratory, infectious, and inflammatory characteristics associated with early CF anthropometric measurements. We report here metabolomics differences within the urine of these infants as compared to infants without CF. METHODS Urine metabolomics was performed for 85 infants with predefined clinical phenotypes at approximately one year of age enrolled in BONUS via Ultrahigh Performance Liquid Chromatography-Tandem Mass Spectroscopy (UPLC-MS/MS). Samples were stratified by disease status (non-CF controls (n = 22); CF (n = 63, All-CF)) and CF clinical phenotype: respiratory hospitalization (CF Resp, n = 22), low length (CF LL, n = 23), and low weight (CF LW, n = 15). RESULTS Global urine metabolomics profiles in CF were heterogeneous, however there were distinct metabolic differences between the CF and non-CF groups. Top pathways altered in CF included tRNA charging and methionine degradation. ADCYAP1 and huntingtin were identified as predicted unique regulators of altered metabolic pathways in CF compared to non-CF. Infants with CF displayed alterations in metabolites associated with bile acid homeostasis, pentose sugars, and vitamins. CONCLUSIONS Predicted metabolic pathways and regulators were identified in CF infants compared to non-CF, but metabolic profiles were unable to discriminate between CF phenotypes. Targeted metabolomics provides an opportunity for further understanding of early CF disease. TRIAL REGISTRATION United States ClinicalTrials.Gov registry NCT01424696 (clinicaltrials.gov).
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Affiliation(s)
- B T Kopp
- Division of Pulmonary Medicine, Nationwide Children's Hospital, Columbus, OH, USA; Center for Microbial Pathogenesis, Nationwide Children's Hospital, Columbus, OH, USA.
| | - E Joseloff
- Cystic Fibrosis Foundation, Bethesda, MD, USA
| | - D Goetz
- Department of Pediatrics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | | | - S L Heltshe
- Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, WA, USA; University of Washington, Department of Pediatrics, Division of Pulmonary and Sleep Medicine, Seattle, WA, USA
| | - D H Leung
- Department of Pediatrics, Baylor College of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, Texas Children's Hospital, Houston, TX, USA
| | - B W Ramsey
- Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, WA, USA; University of Washington, Department of Pediatrics, Division of Pulmonary and Sleep Medicine, Seattle, WA, USA
| | - K McCoy
- Division of Pulmonary Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - D Borowitz
- Cystic Fibrosis Foundation, Bethesda, MD, USA; Department of Pediatrics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
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Mayer-Hamblett N, Polineni D, Heltshe SL. In statistics we trust: Towards the careful derivation and interpretation of meaningful survival estimates in cystic fibrosis. J Cyst Fibros 2018; 17:133-134. [PMID: 29396024 PMCID: PMC6445384 DOI: 10.1016/j.jcf.2018.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/14/2018] [Indexed: 10/18/2022]
Affiliation(s)
- N Mayer-Hamblett
- University of Washington, Seattle Children's Hospital, Seattle, WA, USA.
| | - D Polineni
- University of Kansas Medical Center, Kansas City, KS, USA
| | - S L Heltshe
- University of Washington, Seattle Children's Hospital, Seattle, WA, USA
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Heltshe SL, Khan U, Beckett V, Baines A, Emerson J, Sanders DB, Gibson RL, Morgan W, Rosenfeld M. Longitudinal development of initial, chronic and mucoid Pseudomonas aeruginosa infection in young children with cystic fibrosis. J Cyst Fibros 2017; 17:341-347. [PMID: 29110966 DOI: 10.1016/j.jcf.2017.10.008] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Revised: 10/02/2017] [Accepted: 10/11/2017] [Indexed: 01/11/2023]
Abstract
BACKGROUND While the emergence of chronic and mucoid Pseudomonas aeruginosa (Pa) infection are both associated with poorer outcomes among CF patients, their relationship is poorly understood. We examined the longitudinal relationship of incident, chronic and mucoid Pa in a contemporary, young CF cohort in the current era of Pa eradication therapy. METHODS This retrospective cohort was comprised of patients in the U.S. CF Foundation Patient Registry born 2006-2015, diagnosed before age 2, and with at least 3 respiratory cultures annually. Incidence and age-specific prevalence of Pa infection stages (initial and chronic [≥ 3Pa+cultures in prior year]) and of mucoid Pa were summarized. Transition times and the interaction between Pa stage and acquisition of mucoid Pa were examined via Cox models. RESULTS Among the 5592 CF patients in the cohort followed to a mean age of 5.5years, 64% (n=3580) acquired Pa. Of those, 13% (n=455) developed chronic Pa and 17% (n=594) cultured mucoid Pa. Among those with mucoid Pa, 36% (211/594) had it on their first recorded Pa+culture, while mucoid Pa emerged at or after entering the chronic stage in 12% (73/594). Mucoidy was associated with significantly increased risk of transition to chronic Pa infection (HR=2.59, 95% CI 2.11, 3.19). CONCLUSIONS Two-thirds of early-diagnosed young children with CF acquired Pa during a median 5.6years of follow up, among whom 13% developed chronic Pa and 17% acquired mucoid Pa. Contrary to our hypothesis, 87% of young children who developed mucoid Pa did so before becoming chronically infected.
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Affiliation(s)
- S L Heltshe
- CFF Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, WA 98105, USA; Division of Pediatric Pulmonology, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA 98121, USA.
| | - U Khan
- CFF Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, WA 98105, USA
| | - V Beckett
- CFF Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, WA 98105, USA
| | - A Baines
- CFF Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, WA 98105, USA
| | - J Emerson
- Division of Pediatric Pulmonology, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA 98121, USA
| | - D B Sanders
- Department of Pediatrics, Riley Hospital for Children, School of Medicine, Indiana University, Indiana, IN 46202, USA
| | - R L Gibson
- Division of Pediatric Pulmonology, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA 98121, USA
| | - W Morgan
- Department of Pediatrics, University of Arizona, Tucson, AZ, USA
| | - M Rosenfeld
- Division of Pediatric Pulmonology, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA 98121, USA
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VanDevanter DR, Heltshe SL, Spahr J, Beckett VV, Daines CL, Dasenbrook EC, Gibson RL, Raksha J, Sanders DB, Goss CH, Flume PA. Rationalizing endpoints for prospective studies of pulmonary exacerbation treatment response in cystic fibrosis. J Cyst Fibros 2017; 16:607-615. [PMID: 28438499 DOI: 10.1016/j.jcf.2017.04.004] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Revised: 03/08/2017] [Accepted: 04/04/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Given the variability in pulmonary exacerbation (PEx) management within and between Cystic Fibrosis (CF) Care Centers, it is possible that some approaches may be superior to others. A challenge with comparing different PEx management approaches is lack of a community consensus with respect to treatment-response metrics. In this analysis, we assess the feasibility of using different response metrics in prospective randomized studies comparing PEx treatment protocols. METHODS Response parameters were compiled from the recent STOP (Standardized Treatment of PEx) feasibility study. Pulmonary function responses (recovery of best prior 6-month and 12-month FEV1% predicted and absolute and relative FEV1% predicted improvement from treatment initiation) and sign and symptom recovery from treatment initiation (measured by the Chronic Respiratory Infection Symptom Score [CRISS]) were studied as categorical and continuous variables. The proportion of patients retreated within 30days after the end of initial treatment was studied as a categorical variable. Sample sizes required to adequately power prospective 1:1 randomized superiority and non-inferiority studies employing candidate endpoints were explored. RESULTS The most sensitive endpoint was mean change in CRISS from treatment initiation, followed by mean absolute FEV1% predicted change from initiation, with the two responses only modestly correlated (R2=.157; P<0.0001). Recovery of previous best FEV1 was a problematic endpoint due to missing data and a substantial proportion of patients beginning PEx treatment with FEV1 exceeding their previous best measures (12.1% >12-month best, 19.6% >6-month best). Although mean outcome measures deteriorated approximately 2-weeks post-treatment follow-up, the effect was non-uniform: 62.7% of patients experienced an FEV1 worsening versus 49.0% who experienced a CRISS worsening. CONCLUSIONS Results from randomized prospective superiority and non-inferiority studies employing mean CRISS and FEV1 change from treatment initiation should prove compelling to the community. They will need to be large, but appear feasible.
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Affiliation(s)
- D R VanDevanter
- Case Western Reserve University School of Medicine, Cleveland, OH 44106, USA.
| | - S L Heltshe
- University of Washington, Seattle, WA 98121, USA; CFF Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, WA 98105, USA
| | - J Spahr
- Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA 15224, USA
| | - V V Beckett
- CFF Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, WA 98105, USA
| | - C L Daines
- University of Arizona, Tucson, AZ 85724, USA
| | - E C Dasenbrook
- Case Western Reserve University School of Medicine, Cleveland, OH 44106, USA
| | - R L Gibson
- CFF Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, WA 98105, USA
| | - Jain Raksha
- University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
| | - D B Sanders
- University of Wisconsin, Madison, WI 53792, USA
| | - C H Goss
- University of Washington, Seattle, WA 98121, USA; CFF Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, WA 98105, USA
| | - P A Flume
- Medical University of South Carolina, Charleston, SC 29425, USA
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Konstan MW, Döring G, Heltshe SL, Lands LC, Hilliard KA, Koker P, Bhattacharya S, Staab A, Hamilton A. A randomized double blind, placebo controlled phase 2 trial of BIIL 284 BS (an LTB4 receptor antagonist) for the treatment of lung disease in children and adults with cystic fibrosis. J Cyst Fibros 2014; 13:148-55. [PMID: 24440167 DOI: 10.1016/j.jcf.2013.12.009] [Citation(s) in RCA: 99] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2013] [Revised: 11/20/2013] [Accepted: 12/23/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND Airway inflammation, mediated in part by LTB4, contributes to lung destruction in patients with cystic fibrosis (CF). LTB(4)-receptor inhibition may reduce airway inflammation. We report the results of a randomized, double-blind, placebo-controlled study of the efficacy and safety of the leukotriene B(4) (LTB(4))-receptor antagonist BIIL 284 BS in CF patients. METHODS CF patients aged ≥6 years with mild to moderate lung disease were randomized to oral BIIL 284 BS or placebo once daily for 24 weeks. Co-primary endpoints were change in FEV(1) and incidence of pulmonary exacerbation. RESULTS After 420 (155 children, 265 adults) of the planned 600 patients were randomized, the trial was terminated after a planned interim analysis revealed a significant increase in pulmonary related serious adverse events (SAEs) in adults receiving BIIL 284 BS. Final analysis revealed SAEs in 36.1% of adults receiving BIIL 284 BS vs. 21.2% receiving placebo (p = 0.007), and in 29.6% of children receiving BIIL 284 BS vs. 22.9% receiving placebo (p = 0.348). In adults, the incidence of protocol-defined pulmonary exacerbation was greater in those receiving BIIL 284 BS than in those receiving placebo (33.1% vs. 18.2% respectively; p = 0.005). In children, the incidence of protocol-defined pulmonary exacerbation was 19.8% in the BIIL 284 BS arm, and 25.7% in the placebo arm (p = 0.38). CONCLUSIONS While the cause of increased SAEs and exacerbations due to BIIL 284 BS is unknown, the outcome of this trial provides a cautionary tale for the administration of potent anti-inflammatory compounds to individuals with chronic infections, as the potential to significantly suppress the inflammatory response may increase the risk of infection-related adverse events.
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Affiliation(s)
- M W Konstan
- Rainbow Babies & Children's Hospital, Cleveland, OH, USA; Case Western Reserve University, Cleveland, OH, USA.
| | - G Döring
- Institute of Medical Microbiology and Hygiene, University of Tübingen, Tübingen, Germany
| | - S L Heltshe
- Seattle Children's Hospital, Seattle, WA, USA
| | - L C Lands
- Research Institute of the McGill University Health Centre, Montreal Children's Hospital, Montreal, QC, Canada
| | - K A Hilliard
- Case Western Reserve University, Cleveland, OH, USA
| | | | | | - A Staab
- Boehringer Ingelheim, Germany
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