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Xia D, Zhang P, Chen Y, Liu X, Chen Y. Efficacy of pharmacological treatments for Dravet syndrome: Systematic review and network meta-analysis. Seizure 2024; 117:90-97. [PMID: 38354598 DOI: 10.1016/j.seizure.2024.02.004] [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: 12/05/2023] [Revised: 02/03/2024] [Accepted: 02/05/2024] [Indexed: 02/16/2024] Open
Abstract
BACKGROUND Numerous anti-seizure medications (ASMs) have been developed to treat Dravet syndrome (DS). This network meta-analysis aimed to comprehensively analyse the efficacy of ASMs in DS patients, especially in non-seizure-free patients after treatment. METHODS PubMed, EMBASE, Cochrane Library, and Chinese National Knowledge Infrastructure databases were searched. The treatment efficacy was assessed by the percentage reduction in monthly convulsive seizure frequency (MCSF) from baseline or individuals who achieved at least a 50 % or 75 % reduction from baseline in convulsive seizure frequency (CSF). RESULTS Six randomised controlled trials with 633 participants and seven regimens based on four add-on ASMs-fenfluramine (FFA), stiripentol (STP), cannabidiol (CBD), and soticlestat-were included. All drug regimens were superior to the placebo at achieving at least 50 % and 75 % reductions in CSF, but only STP, 0.4 mg/kg/d FFA (FFA0.4), and 0.7 mg/kg/d FFA (FFA0.7) reduced MCSF. STP (50 mg/kg/d) had the highest correlation with reducing MCSF and achieving at least a 50 % reduction from baseline in CSF, followed by FFA0.4 and FFA0.7. Soticlestat and CBD may also be effective in reducing seizures in DS patients. CONCLUSION STP can be recommended as the first choice among the included drug regimens for reducing seizures in DS patients, while FFA0.4 may be considered the second choice. Other drug regimens can be used as alternative treatments. STP, FFA0.4, and FFA0.7 may consistently present favourable efficacy in most DS patients, while other regimens may present prominent inter-individual variability. Appropriate dose selection and intense monitoring are necessary when treating DS using these drugs.
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Affiliation(s)
- Dujiang Xia
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, 74 Linjiang Road, Yuzhong District, Chongqing, China
| | - Peng Zhang
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, 74 Linjiang Road, Yuzhong District, Chongqing, China
| | - Yankun Chen
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, 74 Linjiang Road, Yuzhong District, Chongqing, China
| | - Xi Liu
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, 74 Linjiang Road, Yuzhong District, Chongqing, China.
| | - Yangmei Chen
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, 74 Linjiang Road, Yuzhong District, Chongqing, China.
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2
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Göldner V, Karst U. Benfluorex metabolism complemented by electrochemistry-mass spectrometry. J Pharm Biomed Anal 2023; 235:115626. [PMID: 37542830 DOI: 10.1016/j.jpba.2023.115626] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 07/31/2023] [Accepted: 08/01/2023] [Indexed: 08/07/2023]
Abstract
The hypolipidemic and hypoglycemic drug benfluorex was widely applied to treat type 2 diabetes mellitus and metabolic syndrome in overweight patients since 1976. However, benfluorex was connected to multiple cases of valvular heart disease and pulmonary arterial hypertension later on. Similar adverse drug reactions were previously found to be associated to the structurally related drug fenfluramine, which was attributed to the formation of its N-deethylated metabolite norfenfluramine. Even though norfenfluramine was known to be a common metabolite of fenfluramine and benfluorex, only fenfluramine was withdrawn from European and United States markets in 1997 while benfluorex remained available until 2009. In this work, the metabolism of benfluorex is simulated by an online hyphenation of electrochemistry and mass spectrometry and the observed transformation products are further characterized using liquid chromatography and high-resolution tandem mass spectrometry. Using this approach, norfenfluramine is found to be the main electrochemical transformation product of benfluorex. Considering the knowledge about norfenfluramine toxicity, rapid metabolite screening using electrochemistry hyphenated to mass spectrometry could have been used to predict the potential of benfluorex for adverse drug reactions early on, showcasing the value of electrochemical metabolism mimicry for rapid drug safety evaluation.
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Affiliation(s)
- Valentin Göldner
- Institute of Inorganic and Analytical Chemistry, University of Münster, Corrensstraße 48, 48149 Münster, Germany; International Graduate School for Battery Chemistry, Characterization, Analysis, Recycling and Application (BACCARA), University of Münster, Corrensstraße 40, 48149 Münster, Germany
| | - Uwe Karst
- Institute of Inorganic and Analytical Chemistry, University of Münster, Corrensstraße 48, 48149 Münster, Germany; International Graduate School for Battery Chemistry, Characterization, Analysis, Recycling and Application (BACCARA), University of Münster, Corrensstraße 40, 48149 Münster, Germany.
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3
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Maki KC, Kirkpatrick CF, Allison DB, Gadde KM. Pharmacotherapy for obesity: recent evolution and implications for cardiovascular risk reduction. Expert Rev Endocrinol Metab 2023; 18:307-319. [PMID: 37199542 DOI: 10.1080/17446651.2023.2209176] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 04/26/2023] [Accepted: 04/27/2023] [Indexed: 05/19/2023]
Abstract
INTRODUCTION Obesity is highly prevalent in the U.S. and is associated with an increased risk of major adverse cardiovascular events (MACE). Modalities for the management of obesity include lifestyle intervention, pharmacotherapy, and bariatric surgery. AREAS COVERED This review describes the evidence on the effects of weight loss therapies on MACE risk. Lifestyle interventions and older antiobesity pharmacotherapies have been associated with <12% body weight reduction and no clear benefit to reduce MACE risk. Bariatric surgery is associated with substantial weight reduction (20-30%) and markedly lower subsequent risk for MACE. Newer antiobesity pharmacotherapies, particularly semaglutide and tirzepatide, have shown greater efficacy for weight reduction compared with older medications and are being evaluated in cardiovascular outcomes trials. EXPERT OPINION Current practice for cardiovascular risk reduction in patients with obesity is lifestyle intervention for weight loss, combined with the treatment of obesity-related cardiometabolic risk factors individually. The use of medications to treat obesity is relatively rare. In part, this reflects concerns about long-term safety and weight loss effectiveness, possible provider bias, as well as lack of clear evidence of MACE risk reduction. If ongoing outcomes trials demonstrate the efficacy of newer agents in reducing MACE risk, this will likely lead to expanded use in obesity management.
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Affiliation(s)
- Kevin C Maki
- Indiana University School of Public Health-Bloomington, Bloomington, IN, USA
- Midwest Biomedical Research, Addison, IL, USA
| | - Carol F Kirkpatrick
- Midwest Biomedical Research, Addison, IL, USA
- Idaho State University, Pocatello, ID, USA
| | - David B Allison
- Indiana University School of Public Health-Bloomington, Bloomington, IN, USA
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4
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Therapeutics in Metabolic Diseases. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2023; 1396:255-273. [DOI: 10.1007/978-981-19-5642-3_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
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5
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Sumińska M, Podgórski R, Bogusz-Górna K, Skowrońska B, Mazur A, Fichna M. Historical and cultural aspects of obesity: From a symbol of wealth and prosperity to the epidemic of the 21st century. Obes Rev 2022; 23:e13440. [PMID: 35238142 DOI: 10.1111/obr.13440] [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: 12/01/2021] [Revised: 01/13/2022] [Accepted: 02/12/2022] [Indexed: 12/17/2022]
Abstract
World Health Organization defines obesity as abnormal or excess adipose tissue accumulation. Nowadays, this condition is a serious threat to the public health in most countries around the world. Obesity adversely affects physical, mental, and in most cultures, social well-being. However, throughout the ages-from ancient times to the 21st century-this condition has been subject to various interpretations. As a matter of fact, obesity has not always been regarded as a disease. For many decades, excessive body weight has been considered rather a symbol of health. It was a marker of wealth and prosperity, as well as a sign of high social status. The centuries that passed on the development of science and medicine have gradually changed its face, but significant progress in understanding the causes and consequences of obesity has been made in the last 30 years. This paper presents the historical outline of obesity and its treatment from ancient times to the present-from its affirmation to the epidemic in the late 20th and 21st century.
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Affiliation(s)
- Marta Sumińska
- Department of Pediatric Diabetes and Obesity, Institute of Pediatrics, Poznan University of Medical Sciences, Poznan, Poland
| | - Rafał Podgórski
- Centre for Innovative Research in Medical and Natural Sciences, University of Rzeszow, Rzeszow, Poland.,Department of Biochemistry, Institute of Medical Sciences, Collegium of Medical Sciences, University of Rzeszow, Rzeszow, Poland
| | - Klaudia Bogusz-Górna
- Department of Pediatric Diabetes and Obesity, Institute of Pediatrics, Poznan University of Medical Sciences, Poznan, Poland
| | - Bogda Skowrońska
- Department of Pediatric Diabetes and Obesity, Institute of Pediatrics, Poznan University of Medical Sciences, Poznan, Poland
| | - Artur Mazur
- Department of Pediatrics, Childhood Endocrinology and Diabetes, Collegium of Medical Sciences, University of Rzeszow, Rzeszow, Poland
| | - Marta Fichna
- Department of Endocrinology, Metabolism and Internal Medicine, Poznan University of Medical Sciences, Poznan, Poland
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Li X, Zhang Y, Wang S, Shi C, Wang S, Wang X, Lü X. A review on the potential use of natural products in overweight and obesity. Phytother Res 2022; 36:1990-2015. [DOI: 10.1002/ptr.7426] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Revised: 01/21/2022] [Accepted: 02/05/2022] [Indexed: 12/22/2022]
Affiliation(s)
- Xin Li
- College of Food Science and Engineering Northwest A&F University Yangling China
| | - Yu Zhang
- College of Food Science and Engineering Northwest A&F University Yangling China
| | - Shuxuan Wang
- College of Food Science and Engineering Northwest A&F University Yangling China
| | - Caihong Shi
- College of Food Science and Engineering Northwest A&F University Yangling China
| | - Shuang Wang
- College of Food Science and Engineering Northwest A&F University Yangling China
| | - Xin Wang
- College of Food Science and Engineering Northwest A&F University Yangling China
| | - Xin Lü
- College of Food Science and Engineering Northwest A&F University Yangling China
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7
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Hancu G, Modroiu A. Chiral Switch: Between Therapeutical Benefit and Marketing Strategy. Pharmaceuticals (Basel) 2022; 15:ph15020240. [PMID: 35215352 PMCID: PMC8877306 DOI: 10.3390/ph15020240] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 02/13/2022] [Accepted: 02/16/2022] [Indexed: 11/16/2022] Open
Abstract
Chirality of pharmaceutical substances is an important aspect in drug research because it determines how enantiomers will interact with chiral biological targets. Enantiomers of a chiral drug can have different pharmacokinetic and pharmacological profiles; consequently, using a single pure enantiomer instead of a racemate can enhance the effectiveness and/or safety of the treatment. The tendencies of modern pharmaceutical industry regarding the current market of chiral drugs are divided between the chiral switch of previously used racemates and the development of new enantiopure drugs. The term chiral switch refers to the replacement on the market of a previously approved racemate with its single enantiomer version. The potential advantages of chiral switch can be related to a higher therapeutic index due to better potency, selectivity and fewer adverse effects, faster onset of action and exposure of the patient to lower drug dosages. However, chiral switch is also a strategy that permits manufacturers to keep market exclusivity for chiral pharmaceuticals that have lost their patent protection, even if the pure enantiomers have not demonstrated higher effectiveness or safety profile compared with the racemates.
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8
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Brust JC. Stroke and Substance Abuse. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00039-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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9
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Yao T, He J, Cui Z, Wang R, Bao K, Huang Y, Wang R, Liu T. Central 5-HTR2C in the Control of Metabolic Homeostasis. Front Endocrinol (Lausanne) 2021; 12:694204. [PMID: 34367066 PMCID: PMC8334728 DOI: 10.3389/fendo.2021.694204] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 07/06/2021] [Indexed: 11/29/2022] Open
Abstract
The 5-hydroxytryptamine 2C receptor (5-HTR2C) is a class G protein-coupled receptor (GPCR) enriched in the hypothalamus and the brain stem, where it has been shown to regulate energy homeostasis, including feeding and glucose metabolism. Accordingly, 5-HTR2C has been the target of several anti-obesity drugs, though the associated side effects greatly curbed their clinical applications. Dissecting the specific neural circuits of 5-HTR2C-expressing neurons and the detailed molecular pathways of 5-HTR2C signaling in metabolic regulation will help to develop better therapeutic strategies towards metabolic disorders. In this review, we introduced the regulatory role of 5-HTR2C in feeding behavior and glucose metabolism, with particular focus on the molecular pathways, neural network, and its interaction with other metabolic hormones, such as leptin, ghrelin, insulin, and estrogens. Moreover, the latest progress in the clinical research on 5-HTR2C agonists was also discussed.
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Affiliation(s)
- Ting Yao
- School of Kinesiology, Shanghai University of Sport, Shanghai, China
- Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Xi’an Jiaotong University School of Medicine, Xi’an, China
- *Correspondence: Ting Yao, ; Ru Wang, ; Tiemin Liu,
| | - Jiehui He
- School of Life Sciences, Fudan University, Shanghai, China
| | - Zhicheng Cui
- School of Life Sciences, Fudan University, Shanghai, China
| | - Ruwen Wang
- School of Kinesiology, Shanghai University of Sport, Shanghai, China
| | - Kaixuan Bao
- Human Phenome Institute, Fudan University, Shanghai, China
| | - Yiru Huang
- School of Life Sciences, Fudan University, Shanghai, China
| | - Ru Wang
- School of Kinesiology, Shanghai University of Sport, Shanghai, China
- *Correspondence: Ting Yao, ; Ru Wang, ; Tiemin Liu,
| | - Tiemin Liu
- School of Life Sciences, Fudan University, Shanghai, China
- Human Phenome Institute, Fudan University, Shanghai, China
- State Key Laboratory of Genetic Engineering, Fudan University, Shanghai, China
- State Key Laboratory of Pharmaceutical Biotechnology, Nanjing University, Nanjing, China
- *Correspondence: Ting Yao, ; Ru Wang, ; Tiemin Liu,
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Higgins GA, Fletcher PJ, Shanahan WR. Lorcaserin: A review of its preclinical and clinical pharmacology and therapeutic potential. Pharmacol Ther 2020; 205:107417. [DOI: 10.1016/j.pharmthera.2019.107417] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 09/30/2019] [Indexed: 12/17/2022]
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11
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Fortier JH, Pizzarotti B, Shaw RE, Levy RJ, Ferrari G, Grau J. Drug-associated valvular heart diseases and serotonin-related pathways: a meta-analysis. Heart 2019; 105:1140-1148. [PMID: 31129607 DOI: 10.1136/heartjnl-2018-314403] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 02/25/2019] [Accepted: 03/03/2019] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Serotonergic appetite suppressants and ergot-derived dopamine agonists have been associated with drug-induced valvular heart disease. The purpose of this meta-analysis is to synthesise the current evidence of a link between several medications affecting sertonergic pathways and valvular heart disease. METHODS PubMed was searched to identify studies evaluating an association between medications with serotonergic activity and cardiac valvular pathology. Case reports, uncontrolled studies and in vitro studies were excluded. Relevant studies were assessed for quality and potential bias; those of adequate quality were included in a quantitative synthesis. Sensitivity analyses were conducted, and potential publication bias was examined. RESULTS There was a consistent, significant relationship between certain medications and heart valve disease, including serotonergic medications (OR 3.30, 95% CI 1.99 to 5.49) and dopaminergic medications (OR 2.56, 95% CI 1.68 to 3.91). Subanalyses, including analyses that limited exposure to a single medication or effects to a single heart valve were also consistently significant. Most studies were retrospective or observational in nature, with a higher risk of selection and presentation biases. There was significant heterogeneity and variability between studies, particularly when it came to dose and duration of exposure. CONCLUSIONS There was a consistent, significant association between many medications that affect serotonergic pathways and valvular heart disease. Although many of these medications have been withdrawn from the market, some small studies suggest that recreational drug 3,4-methylenedioxymethamphetamine and widely prescribed selective serotonin reuptake inhibitors may affect similar pathways.
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Affiliation(s)
- Jacqueline H Fortier
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | | | | | - Robert J Levy
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Giovanni Ferrari
- Department of Surgery, Columbia University, New York City, New York, USA
| | - Juan Grau
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
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Brigo F, Striano P, Balagura G, Belcastro V. Emerging drugs for the treatment of Dravet syndrome. Expert Opin Emerg Drugs 2018; 23:261-269. [DOI: 10.1080/14728214.2018.1552937] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Francesco Brigo
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
- Division of Neurology, “Franz Tappeiner” Hospital, Merano, Italy
| | - Pasquale Striano
- Pediatric Neurology and Muscular Diseases Unit, Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, “G. Gaslini” Institute, Genova, Italy
| | - Ganna Balagura
- Pediatric Neurology and Muscular Diseases Unit, Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, “G. Gaslini” Institute, Genova, Italy
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Lu CW, Chang CJ, Yang YC, Lin WY, Huang KC. Multicentre, placebo-controlled trial of lorcaserin for weight management in Chinese population. Obes Res Clin Pract 2018; 12:465-471. [DOI: 10.1016/j.orcp.2018.07.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 06/12/2018] [Accepted: 07/09/2018] [Indexed: 02/05/2023]
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14
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Chao AM, Wadden TA, Berkowitz RI. The safety of pharmacologic treatment for pediatric obesity. Expert Opin Drug Saf 2018; 17:379-385. [PMID: 29411652 DOI: 10.1080/14740338.2018.1437143] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Pediatric obesity is a serious public health concern. Five medications have been approved by the Food and Drug Administration (FDA) for chronic weight management in adults with obesity, when used as an adjunct to lifestyle modification. Orlistat is the only FDA-approved medication for pediatric patients aged 12 years and above. AREAS COVERED This paper summarizes safety and efficacy data from clinical trials of weight loss medications conducted among pediatric samples. Relevant studies were identified through searches in PubMed. EXPERT OPINION Orlistat, as an adjunct to lifestyle modification, results in modest weight losses and may be beneficial for some pediatric patients with obesity. However, gastrointestinal side effects are common and may limit use. In adults taking orlistat, rare but severe adverse events, including liver and renal events, have been reported. Recent pediatric pharmacokinetic studies of liraglutide have demonstrated similar safety and tolerability profiles as found in adults, with gastrointestinal disorders being the most common adverse events. Clinical trials are needed of liraglutide, as well as other medications for obesity, that systematically evaluate their risks and benefits in pediatric patients.
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Affiliation(s)
- Ariana M Chao
- a Department of Biobehavioral Health Sciences , University of Pennsylvania School of Nursing , Philadelphia , PA , USA.,b Department of Psychiatry , Perelman School of Medicine at the University of Pennsylvania , Philadelphia , PA , USA
| | - Thomas A Wadden
- b Department of Psychiatry , Perelman School of Medicine at the University of Pennsylvania , Philadelphia , PA , USA
| | - Robert I Berkowitz
- b Department of Psychiatry , Perelman School of Medicine at the University of Pennsylvania , Philadelphia , PA , USA.,c Department of Child and Adolescent Psychiatry and Behavioral Science , The Children's Hospital of Philadelphia , Philadelphia , PA , USA
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15
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Schoonjans AS, Marchau F, Paelinck BP, Lagae L, Gammaitoni A, Pringsheim M, Keane MG, Ceulemans B. Cardiovascular safety of low-dose fenfluramine in Dravet syndrome: a review of its benefit-risk profile in a new patient population. Curr Med Res Opin 2017; 33:1773-1781. [PMID: 28704161 DOI: 10.1080/03007995.2017.1355781] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Dravet syndrome (DS) is a rare, treatment-resistant epilepsy syndrome for which current treatment regimens are often ineffective. Fenfluramine is currently in development for treatment of DS, based on reports in the 1980s and 1990s of its anti-epileptic activity in pediatric patients with intractable epilepsy. However, fenfluramine was withdrawn from global markets in 1997 following reports of its association with pulmonary hypertension and heart valve disease in adult patients treated for obesity. This review was conducted to assess cardiac safety of fenfluramine when used at lower doses for treatment of DS. METHODS Pubmed was searched for clinical studies of fenfluramine in obese adults who reported incidence of heart valve disease. These data were reviewed against published results from Belgian patients with DS who have been treated with low-dose fenfluramine for up to 28 years. RESULTS Nine controlled studies of fenfluramine and related compounds (dexfenfluramine and/or phentermine) which assessed incidence and severity of cardiac valve disease in 3,268 treated patients and 2,017 control subjects have been reported. Mild or greater aortic valve regurgitation was found in 9.6% of treated patients compared with 3.9% of control subjects, and moderate or greater mitral valve regurgitation was found in 3.1% of treated patients and 2.5% of control subjects. Nineteen DS patients have been treated for up to 28 years with 10-20 mg/day fenfluramine, with no clinical signs or symptoms of cardiac valve disease or pulmonary hypertension. Slight and clinically unimportant changes in valve structure have been seen on echocardiography in five patients at some time during the observation period. CONCLUSIONS A different benefit-risk relationship appears to be emerging when fenfluramine is used at low doses for extended periods in young patients with DS. Continued cardiac assessments during ongoing Phase 3 clinical trials will provide additional safety information for this potential new and effective treatment.
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Affiliation(s)
- An-Sofie Schoonjans
- a Department of Paediatric Neurology , Antwerp University Hospital, University of Antwerp , Antwerp , Belgium
| | - Fabienne Marchau
- b Department of Paediatric Cardiology , Antwerp University Hospital, University of Antwerp , Antwerp , Belgium
| | - Bernard P Paelinck
- c Department of Cardiology , Antwerp University Hospital, University of Antwerp , Antwerp , Belgium
| | - Lieven Lagae
- d Department of Development and Regeneration , Section of Paediatric Neurology, University Hospitals Gasthuisberg , Leuven , Belgium
| | | | - Milka Pringsheim
- f Department of Pediatric Cardiology , German Heart Centre Munich , Munich , Germany
- g Pediatric Neurology, Schön Klinik Vogtareuth , Vogtareuth , Germany
| | | | - Berten Ceulemans
- a Department of Paediatric Neurology , Antwerp University Hospital, University of Antwerp , Antwerp , Belgium
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16
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Albertson TE, Murin S, Sutter ME, Chenoweth JA. The Salford Lung Study: a pioneering comparative effectiveness approach to COPD and asthma in clinical trials. Pragmat Obs Res 2017; 8:175-181. [PMID: 29033625 PMCID: PMC5614786 DOI: 10.2147/por.s144157] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
The Salford Lung Study (SLS) of patients with asthma and chronic obstructive pulmonary disease (COPD) is a practical, community-based, randomized, open-label pragmatic study on the efficacy and safety of the once-daily dry powder inhaler that combines the inhaled corticosteroid fluticasone furoate (FF) with the long-acting beta2 agonist vilanterol (VI). The asthma component of the SLS is not yet reported but the COPD component, done over a 12-month period, found a statistically significant 8.4% reduction in COPD exacerbations when compared to usual care. No differences in adverse events, including serious adverse events and pneumonia, were noted. The importance of real-world findings, such as those found in the SLS COPD trial with inhaled FF/VI, is discussed in comparison to classical randomized controlled trials (RCTs) with inhaled FF/VI in COPD patients. The real-world, community-based pragmatic RCT like the SLS provides additional generalizable data with direct clinical applicability and potential usefulness in the development of practice guidelines. The results from the SLS, along with those of large and small RCTs, are supportive of the use of once-daily FF/VI in COPD maintenance therapy.
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Affiliation(s)
- Timothy E Albertson
- Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, School of Medicine, University of California, Davis, Sacramento.,Department of Medicine, Veterans Administration Northern California Healthcare System, Mather.,Department of Emergency Medicine, School of Medicine, University of California, Davis, Sacramento, CA, USA
| | - Susan Murin
- Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, School of Medicine, University of California, Davis, Sacramento.,Department of Medicine, Veterans Administration Northern California Healthcare System, Mather
| | - Mark E Sutter
- Department of Medicine, Veterans Administration Northern California Healthcare System, Mather.,Department of Emergency Medicine, School of Medicine, University of California, Davis, Sacramento, CA, USA
| | - James A Chenoweth
- Department of Medicine, Veterans Administration Northern California Healthcare System, Mather.,Department of Emergency Medicine, School of Medicine, University of California, Davis, Sacramento, CA, USA
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Abstract
Dravet syndrome (DS) is an intractable pediatric epilepsy syndrome, starting in early childhood. This disorder typically manifests with febrile status epilepticus, and progresses to a multifocal epilepsy with febrile and non-febrile seizures with encephalopathy. Most cases are due to a mutation in the SCN1A gene. This article reviews treatments for DS, with an emphasis on pharmacotherapy. While many medications are used in treating the seizures associated with DS, these patients typically have medically refractory epilepsy, and polytherapy is often required. First-line agents include valproate and clobazam, although there are supportive data for topiramate, levetiracetam, stiripentol and the ketogenic diet. Other agents such as fenfluramine are promising therapies for Dravet syndrome. Sodium channel-blocking anticonvulsants such as carbamazepine and lamotrigine are generally contraindicated in this syndrome. Nonpharmacologic therapies (such as neurostimulation or surgery) are understudied in DS. Because DS is a global encephalopathy, pharmacologic treatment of non-epileptic manifestations of the disease is often necessary. Attention-deficit hyperactivity disorder is often encountered in patients with DS, and psychostimulants can be helpful for this indication. Other psychoactive drugs are less studied in this context. Extrapyramidal and gait disorders are often encountered in DS as well. While DS is a severe epileptic encephalopathy with a high (up to 15 %) mortality rate in childhood, careful pharmacologic management can improve these patients' clinical picture and quality of life.
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Coloma PM, de Ridder M, Bezemer I, Herings RMC, Gini R, Pecchioli S, Scotti L, Rijnbeek P, Mosseveld M, van der Lei J, Trifirò G, Sturkenboom M. Risk of cardiac valvulopathy with use of bisphosphonates: a population-based, multi-country case-control study. Osteoporos Int 2016; 27:1857-67. [PMID: 26694594 PMCID: PMC4839043 DOI: 10.1007/s00198-015-3441-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Accepted: 11/23/2015] [Indexed: 01/25/2023]
Abstract
UNLABELLED Analyses of healthcare data from 30 million individuals in three countries showed that current use of bisphosphonates may be associated with a small increased risk of cardiac valvulopathy (vs. those not exposed within the previous year), although confounding cannot be entirely ruled out. The observed tendency for decreased valvulopathy risk with cumulative duration of bisphosphonate use >6 months may even indicate a protective effect with prolonged use. Further studies are still needed to evaluate whether bisphosphonates increase or decrease the risk of valvulopathy. INTRODUCTION A signal of cardiac valve disorders with use of bisphosphonates was identified in the literature and EudraVigilance database, which contains reports of suspected adverse drug reactions from worldwide sources. The aim of this study was to evaluate the association using population-based healthcare data. METHODS This was a case-control study among users of bisphosphonates and other drugs for osteoporosis in six healthcare databases covering over 30 million individuals in Italy, Netherlands and the UK from 1996 to 2012. Prescriptions/dispensations were used to assess drug exposure. Newly diagnosed cases of cardiac valvulopathy were identified via disease codes/free-text search. Controls were matched to each case by age, sex, database and index date. Adjusted odds ratios (ORs) were estimated using conditional logistic regression for the pooled data and meta-analysis of individual database risk estimates. RESULTS A small but statistically significant association was found between exposure to bisphosphonates as a class and risk of valvulopathy. Overall risk was 18 % higher (95 % CI 12-23 %) in those currently exposed to any bisphosphonate (mainly alendronate and risedronate) vs. those not exposed within the previous year. Risk of valve regurgitation was 14 % higher (95 % CI 7-22 %). Decreased valvulopathy risk was observed with longer cumulative duration of bisphosphonate use, compared to use of less than 6 months. Meta-analyses of database-specific estimates confirmed results from pooled analyses. CONCLUSIONS The observed increased risks of cardiac valvulopathy with bisphosphonate use, although statistically significant, were quite small and unlikely to be clinically significant. Further studies are still needed to evaluate whether bisphosphonates increase or decrease the risk of valvulopathy and to investigate possible mechanisms for the association.
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Affiliation(s)
- P M Coloma
- Department of Medical Informatics, Erasmus MC University Medical Center Rotterdam, 3000 CA, Rotterdam, The Netherlands.
| | - M de Ridder
- Department of Medical Informatics, Erasmus MC University Medical Center Rotterdam, 3000 CA, Rotterdam, The Netherlands
| | - I Bezemer
- PHARMO Institute NV, 3528 AE, Utrecht, The Netherlands
| | - R M C Herings
- PHARMO Institute NV, 3528 AE, Utrecht, The Netherlands
| | - R Gini
- Agenzia Regionale di Sanità della Toscana, 50141, Florence, Italy
| | - S Pecchioli
- Società Italiana di Medicina Generale, 50141, Florence, Italy
| | - L Scotti
- Università di Milano-Bicocca, 20126, Milan, Italy
| | - P Rijnbeek
- Department of Medical Informatics, Erasmus MC University Medical Center Rotterdam, 3000 CA, Rotterdam, The Netherlands
| | - M Mosseveld
- Department of Medical Informatics, Erasmus MC University Medical Center Rotterdam, 3000 CA, Rotterdam, The Netherlands
| | - J van der Lei
- Department of Medical Informatics, Erasmus MC University Medical Center Rotterdam, 3000 CA, Rotterdam, The Netherlands
| | - G Trifirò
- Department of Medical Informatics, Erasmus MC University Medical Center Rotterdam, 3000 CA, Rotterdam, The Netherlands
- Department of Clinical and Experimental Medicine, University of Messina, 98122, Messina, Italy
| | - M Sturkenboom
- Department of Medical Informatics, Erasmus MC University Medical Center Rotterdam, 3000 CA, Rotterdam, The Netherlands
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Acute pergolide exposure stiffens engineered valve interstitial cell tissues and reduces contractility in vitro. Cardiovasc Pathol 2016; 25:316-324. [PMID: 27174867 DOI: 10.1016/j.carpath.2016.04.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Revised: 03/30/2016] [Accepted: 04/20/2016] [Indexed: 01/11/2023] Open
Abstract
Medications based on ergoline-derived dopamine and serotonin agonists are associated with off-target toxicities that include valvular heart disease (VHD). Reports of drug-induced VHD resulted in the withdrawal of appetite suppressants containing fenfluramine and phentermine from the US market in 1997 and pergolide, a Parkinson's disease medication, in 2007. Recent evidence suggests that serotonin receptor activity affected by these medications modulates cardiac valve interstitial cell activation and subsequent valvular remodeling, which can lead to cardiac valve fibrosis and dysfunction similar to that seen in carcinoid heart disease. Failure to identify these risks prior to market and continued use of similar drugs reaffirm the need to improve preclinical evaluation of drug-induced VHD. Here, we present two complimentary assays to measure stiffness and contractile stresses generated by engineered valvular tissues in vitro. As a case study, we measured the effects of acute (24 h) pergolide exposure to engineered porcine aortic valve interstitial cell (AVIC) tissues. Pergolide exposure led to increased tissue stiffness, but it decreased both basal and active contractile tone stresses generated by AVIC tissues. Pergolide exposure also disrupted AVIC tissue organization (i.e., tissue anisotropy), suggesting that the mechanical properties and contractile functionality of these tissues are governed by their ability to maintain their structure. We expect further use of these assays to identify off-target drug effects that alter the phenotypic balance of AVICs, disrupt their ability to maintain mechanical homeostasis, and lead to VHD.
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Jiménez-Urbieta H, Gago B, de la Riva P, Delgado-Alvarado M, Marin C, Rodriguez-Oroz MC. Dyskinesias and impulse control disorders in Parkinson's disease: From pathogenesis to potential therapeutic approaches. Neurosci Biobehav Rev 2015. [PMID: 26216865 DOI: 10.1016/j.neubiorev.2015.07.010] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Dopaminergic treatment in Parkinson's disease (PD) reduces the severity of motor symptoms of the disease. However, its chronic use is associated with disabling motor and behavioral side effects, among which levodopa-induced dyskinesias (LID) and impulse control disorders (ICD) are the most common. The underlying mechanisms and pathological substrate of these dopaminergic complications are not fully understood. Recently, the refinement of imaging techniques and the study of the genetics and molecular bases of LID and ICD indicate that, although different, they could share some features. In addition, animal models of parkinsonism with LID have provided important knowledge about mechanisms underlying such complications. In contrast, animal models of parkinsonism and abnormal impulsivity, although useful regarding some aspects of human ICD, do not fully resemble the clinical phenotype of ICD in patients with PD, and until now have provided limited information. Studies on animal models of addiction could complement the previous models and provide some insights into the background of these behavioral complications given that ICD are regarded as behavioral addictions. Here we review the most relevant advances in relation to imaging, genetics, biochemistry and pharmacological interventions to treat LID and ICD in patients with PD and in animal models with a view to better understand the overlapping and unique maladaptations to dopaminergic therapy that are associated with LID and ICD.
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Affiliation(s)
- Haritz Jiménez-Urbieta
- Biodonostia Research Institute, 20014 San Sebastián, Spain; Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas (CIBERNED), Spain.
| | - Belén Gago
- Biodonostia Research Institute, 20014 San Sebastián, Spain; Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas (CIBERNED), Spain.
| | | | - Manuel Delgado-Alvarado
- Biodonostia Research Institute, 20014 San Sebastián, Spain; Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas (CIBERNED), Spain.
| | - Concepció Marin
- INGENIO, IRCE, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) , 08036 Barcelona, Spain.
| | - María C Rodriguez-Oroz
- Biodonostia Research Institute, 20014 San Sebastián, Spain; Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas (CIBERNED), Spain; University Hospital Donostia, 20014 San Sebastián, Spain; Ikerbasque (Basque Foundation for Science), 48011 Bilbao, Spain.
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Higgins GA, Fletcher PJ. Therapeutic Potential of 5-HT2C Receptor Agonists for Addictive Disorders. ACS Chem Neurosci 2015; 6:1071-88. [PMID: 25870913 DOI: 10.1021/acschemneuro.5b00025] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
The neurotransmitter 5-hydroxytryptamine (5-HT; serotonin) has long been associated with the control of a variety of motivated behaviors, including feeding. Much of the evidence linking 5-HT and feeding behavior was obtained from studies of the effects of the 5-HT releaser (dex)fenfluramine in laboratory animals and humans. Recently, the selective 5-HT2C receptor agonist lorcaserin received FDA approval for the treatment of obesity. This review examines evidence to support the use of selective 5-HT2C receptor agonists as treatments for conditions beyond obesity, including substance abuse (particularly nicotine, psychostimulant, and alcohol dependence), obsessive compulsive, and excessive gambling disorder. Following a brief survey of the early literature supporting a role for 5-HT in modulating food and drug reinforcement, we propose that intrinsic differences between SSRI and serotonin releasers may have underestimated the value of serotonin-based pharmacotherapeutics to treat clinical forms of addictive behavior beyond obesity. We then highlight the critical involvement of the 5-HT2C receptor in mediating the effect of (dex)fenfluramine on feeding and body weight gain and the evidence that 5-HT2C receptor agonists reduce measures of drug reward and impulsivity. A recent report of lorcaserin efficacy in a smoking cessation trial further strengthens the idea that 5-HT2C receptor agonists may have potential as a treatment for addiction. This review was prepared as a contribution to the proceedings of the 11th International Society for Serotonin Research Meeting held in Hermanus, South Africa, July 9-12, 2014.
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Affiliation(s)
- Guy A. Higgins
- InterVivo Solutions Inc., 120 Carlton Street, Toronto, ON M5A
4K2, Canada
- Department of Pharmacology & Toxicology, University of Toronto, Toronto, ON M5S 1A8, Canada
| | - Paul J. Fletcher
- Section of Biopsychology
and Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, 250 College Street, Toronto, ON M5T 1R8, Canada
- Departments of Psychiatry & Psychology, University of Toronto, Toronto, ON M5T 1R8, Canada
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Abstract
Worldwide obesity prevalence has nearly doubled since 1980. Due to numerous co-morbidities, obesity represents a serious health and socioeconomic problem worldwide. Pharmacotherapy should be an integral part of comprehensive obesity management. Drug therapy can assist in weight loss and its maintenance in those individuals who do not achieve appropriate weight loss through lifestyle interventions alone. After the withdrawal of sibutramine from the market in 2010, orlistat, a lipase inhibitor, was the only remaining prescription drug approved for the long-term treatment of obesity. In 2012, phentermine/topiramate extended-release (PHEN/TPM ER) combination and lorcaserin were approved by the US FDA as novel medications for long-term weight management. Three major phase III trials conducted with each drug confirmed their efficacy in terms of weight loss/maintenance and improvement of cardiometabolic risks. No head-to-head studies between the two new anti-obesity drugs have been carried out. However, in the existing studies PHEN/TPM ER had a superior weight loss profile to lorcaserin but the incidence of adverse effects was lower with lorcaserin. Both drugs were well-tolerated, and adverse events were modest in intensity, dose dependent, rather rare, and tended to decrease with the duration of treatment. Major safety concerns regarding PHEN/TPM ER include elevations in resting pulse rate, teratogenicity, mild metabolic acidosis, and psychiatric and cognitive adverse events. Valvulopathy, cognitive impairment, psychiatric disorders, and hypoglycemia represent major safety concerns for lorcaserin. Although existing trials have not demonstrated any significant issues with PHEN/TPM ER-induced heart rate elevation and lorcaserin-induced valvulopathy, all safety concerns should be seriously taken into account in patients treated with either of these novel anti-obesity medications.
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Aronne L, Shanahan W, Fain R, Glicklich A, Soliman W, Li Y, Smith S. Safety and Efficacy of Lorcaserin: A Combined Analysis of the BLOOM and BLOSSOM Trials. Postgrad Med 2015; 126:7-18. [DOI: 10.3810/pgm.2014.10.2817] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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25
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Halpern B, Halpern A. Safety assessment of FDA-approved (orlistat and lorcaserin) anti-obesity medications. Expert Opin Drug Saf 2015; 14:305-15. [DOI: 10.1517/14740338.2015.994502] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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26
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Maréchaux S, Rusinaru D, Jobic Y, Ederhy S, Donal E, Réant P, Arnalsteen E, Boulanger J, Garban T, Ennezat PV, Jeu A, Szymanski C, Tribouilloy C. Food and Drug Administration criteria for the diagnosis of drug-induced valvular heart disease in patients previously exposed to benfluorex: a prospective multicentre study. ACTA ACUST UNITED AC 2014; 16:158-65. [DOI: 10.1093/ehjci/jeu212] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Bays HE. Lorcaserin and adiposopathy: 5-HT2c agonism as a treatment for ‘sick fat’ and metabolic disease. Expert Rev Cardiovasc Ther 2014; 7:1429-45. [DOI: 10.1586/erc.09.123] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Abstract
The metabolic syndrome (MS), a cluster of metabolic abnormalities with insulin resistance as its central component, is increasing in prevalence and is associated with an increased risk of cardiovascular disease and Type 2 diabetes mellitus (T2DM). Current evidence supports an aggressive intervention approach that comprises lifestyle modification in conjunction with drug treatment of the MS components. Healthier eating and regular exercise greatly reduce waistline and body mass index, lower blood pressure and improve lipid profile. Lifestyle modification has been proven to prevent T2DM development. Nevertheless, appropriate treatment of MS components often requires pharmacologic intervention with insulin-sensitizing agents, such as metformin and thiazolidinediones, while statins and fibrates, or angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers are the first-line lipid-modifying or antihypertensive drugs. Only severely obese patients require specific drug treatments. Very often, drug combinations will be necessary to manage multiple risk factors. As we progress in the understanding of the pathophysiology of the MS, new targets for therapies will probably be identified and new treatments will prove to be even more efficacious than those currently available for the management of this life-threatening condition.
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Affiliation(s)
- Cristina Bianchi
- University of Pisa, Department of Endocrinology and Metabolism, Cisanello University Hospital, Pisa, Italy.
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29
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Borer JS. Drug-induced valve disease and considerations of benefit versus risk. Eur Heart J 2013; 34:3535-7. [DOI: 10.1093/eurheartj/eht323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Kelly AS, Barlow SE, Rao G, Inge TH, Hayman LL, Steinberger J, Urbina EM, Ewing LJ, Daniels SR. Severe obesity in children and adolescents: identification, associated health risks, and treatment approaches: a scientific statement from the American Heart Association. Circulation 2013; 128:1689-712. [PMID: 24016455 DOI: 10.1161/cir.0b013e3182a5cfb3] [Citation(s) in RCA: 697] [Impact Index Per Article: 63.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Severe obesity afflicts between 4% and 6% of all youth in the United States, and the prevalence is increasing. Despite the serious immediate and long-term cardiovascular, metabolic, and other health consequences of severe pediatric obesity, current treatments are limited in effectiveness and lack widespread availability. Lifestyle modification/behavior-based treatment interventions in youth with severe obesity have demonstrated modest improvement in body mass index status, but participants have generally remained severely obese and often regained weight after the conclusion of the treatment programs. The role of medical management is minimal, because only 1 medication is currently approved for the treatment of obesity in adolescents. Bariatric surgery has generally been effective in reducing body mass index and improving cardiovascular and metabolic risk factors; however, reports of long-term outcomes are few, many youth with severe obesity do not qualify for surgery, and access is limited by lack of insurance coverage. To begin to address these challenges, the purposes of this scientific statement are to (1) provide justification for and recommend a standardized definition of severe obesity in children and adolescents; (2) raise awareness of this serious and growing problem by summarizing the current literature in this area in terms of the epidemiology and trends, associated health risks (immediate and long-term), and challenges and shortcomings of currently available treatment options; and (3) highlight areas in need of future research. Innovative behavior-based treatment, minimally invasive procedures, and medications currently under development all need to be evaluated for their efficacy and safety in this group of patients with high medical and psychosocial risks.
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Tribouilloy C, Maréchaux S, Jobic Y, Jeu A, Ederhy S, Donal E, Réant P, Arnalsteen E, Boulanger J, Garban T, Ennezat PV, Andréjak M, Rusinaru D. Frequency of drug-induced valvular heart disease in patients previously exposd to benfluorex: a multicentre prospective study. Eur Heart J 2013; 34:3580-7. [PMID: 24014218 DOI: 10.1093/eurheartj/eht266] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
AIMS The epidemiologic link between benfluorex use and an increased global frequency of left heart valve regurgitation has been well documented. However, no data linking previous drug exposure to the frequency of diagnosis of drug-induced valvular heart disease (DI-VHD) are available. The present study was conducted to address this issue. METHODS AND RESULTS This echocardiography reader-blinded, controlled study conducted in 10 centres between February 2010 and February 2012 prospectively included 835 subjects previously exposed to benfluorex referred by primary care physicians for echocardiography. Based on blinded off-line analysis, echocardiography findings were classified as: (i) DI-VHD⁺ for patients with an echocardiographic diagnosis of DI-VHD, (ii) inconclusive, and (iii) DI-VHD⁻ for patients without signs of DI-VHD. Fifty-seven (6.8%) patients exposed to benfluorex were classified as DI-VHD⁺, 733 (87.8%) patients were classified as DI-VHD⁻, and 45 (5.4%) were classified as inconclusive. Mitral and aortic DI-VHD were reported in 43 patients (5.1%) and 30 (3.6%) patients, respectively. Longer duration of exposure, female gender, smoking, and lower BMI were independently associated with a diagnosis of DI-VHD. Good inter-observer reproducibility was observed for the echocardiography classification (Kappa = 0.83, P < 0.00001). CONCLUSIONS About 7% of patients without a history of heart valve disease previously exposed to benfluorex present echocardiography features of DI-VHD. Further studies are needed to study the natural history of DI-VHD and to identify risk factors for the development of drug-induced valve lesions.
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Affiliation(s)
- Christophe Tribouilloy
- Pôle cardiovasculaire et thoracique, Centre Hospitalier Universitaire Amiens, Amiens, France
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Ljungvall I, Höglund K, Lilliehöök I, Oyama MA, Tidholm A, Tvedten H, Häggström J. Serum serotonin concentration is associated with severity of myxomatous mitral valve disease in dogs. J Vet Intern Med 2013; 27:1105-12. [PMID: 23865457 DOI: 10.1111/jvim.12137] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2012] [Revised: 04/26/2013] [Accepted: 05/28/2013] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND The neurotransmitter serotonin (5-hydroxytryptamine, 5-HT) has recently been suggested to play a role in the development of naturally acquired myxomatous mitral valve disease (MMVD) in dogs. AIM To investigate the association between serum 5-HT concentration and MMVD severity in dogs, and to assess potential associations between serum 5-HT concentrations and dog characteristics, echocardiographic variables, heart rate, systolic blood pressure, presence of macrothrombocytosis, and plateletcrit. ANIMALS A total of 120 client-owned dogs. MATERIAL AND METHODS Dogs were prospectively recruited and were classified by standard echocardiography into healthy (dogs of breeds predisposed to MMVD, but without echocardiographic evidence of the disease), mild, moderate, or severe MMVD groups. Serum 5-HT concentrations were analyzed using an ELISA. RESULTS Dogs with severe MMVD had lower serum 5-HT concentrations than healthy dogs (P = .0025) and dogs with mild MMVD (P = .0011). Unilinear and multiple regression analyses showed that serum 5-HT concentrations decreased with increasing left atrial to aortic root ratio (LA/Ao), were higher in Cavalier King Charles Spaniel (CKCS) dogs compared to dogs of other breeds, and were higher in female dogs than in male dogs. The LA/Ao was the variable most strongly associated with serum 5-HT concentration. CONCLUSIONS AND CLINICAL IMPORTANCE The finding of higher serum 5-HT concentrations in dogs of breeds predisposed to the early onset of MMVD (CKCS) and dogs with mild MMVD suggests that alterations in 5-HT signaling might play a role in progression of early stages of MMVD.
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Affiliation(s)
- I Ljungvall
- Department of Clinical Sciences, Faculty of Veterinary Medicine and Animal Science, Swedish University of Agricultural Sciences, Uppsala, Sweden
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Tribouilloy C, Rusinaru D, Maréchaux S, Jeu A, Ederhy S, Donal E, Réant P, Arnalsteen E, Boulanger J, Ennezat PV, Garban T, Jobic Y. Increased risk of left heart valve regurgitation associated with benfluorex use in patients with diabetes mellitus: a multicenter study. Circulation 2012; 126:2852-8. [PMID: 23143159 DOI: 10.1161/circulationaha.112.111260] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Benfluorex was withdrawn from European markets in June 2010 after reports of an association with heart valve lesions. The link between benfluorex and valve regurgitations was based on small observational studies and retrospective estimations. We therefore designed an echocardiography-based multicenter study to compare the frequency of left heart valve regurgitations in diabetic patients exposed to benfluorex for at least 3 months and in diabetic control subjects never exposed to the drug. METHODS AND RESULTS This reader-blinded, controlled study conducted in 10 centers in France between February 2010 and September 2011 prospectively included 376 diabetic subjects previously exposed to benfluorex who were referred by primary care physicians for echocardiography and 376 diabetic control subjects. Through the use of propensity scores, 293 patients and 293 control subjects were matched for age, sex, body mass index, smoking, dyslipidemia, hypertension, and coronary artery disease. The main outcome measure was the frequency of mild or greater left heart valve regurgitations. In the matched sample, the frequency and relative risk (odds ratio) of mild or greater left heart valve regurgitations were significantly increased in benfluorex patients compared with control subjects: 31.0% versus 12.9% (odds ratio, 3.55; 95% confidence interval, 2.03-6.21) for aortic and/or mitral regurgitation, 19.8% versus 4.7% (odds ratio, 5.29; 95% confidence interval, 2.46-11.4) for aortic regurgitation, and 19.4% versus 9.6% (odds ratio, 2.38; 95% confidence interval, 1.27-4.45) for mitral regurgitation. CONCLUSIONS Our results indicate that the use of benfluorex is associated with a significant increase in the frequency of left heart valve regurgitations in diabetic patients. The natural history of benfluorex-induced valve abnormalities needs further research.
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Affiliation(s)
- Christophe Tribouilloy
- INSERM U 1088 and University Hospital, Amiens, France, Department of Cardiology, Avenue René Laënnec, 80054 Amiens Cedex 1, France.
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Fournier A, Zureik M. Response to the letter by Acar. Pharmacoepidemiol Drug Saf 2012. [DOI: 10.1002/pds.3344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Yao W, Mu W, Zeifman A, Lofti M, Remillard CV, Makino A, Perkins DL, Garcia JG, Yuan JXJ, Zhang W. Fenfluramine-induced gene dysregulation in human pulmonary artery smooth muscle and endothelial cells. Pulm Circ 2012; 1:405-18. [PMID: 22140631 PMCID: PMC3224433 DOI: 10.4103/2045-8932.87310] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Fenfluramine is prescribed either alone or in combination with phentermine as part of Fen-Phen, an anti-obesity medication. Fenfluramine was withdrawn from the US market in 1997 due to reports of heart valvular disease, pulmonary arterial hypertension, and cardiac fibrosis. Particularly, idiopathic pulmonary arterial hypertension (IPAH), previously referred to as primary pulmonary hypertension (PPH), was found to be associated with the use of Fen-Phen, fenfluramine, and fenfluramine derivatives. The underlying mechanism of fenfluramine-associated pulmonary hypertension is still largely unknown. We reasoned that investigating drug-induced gene dysregulation would enhance our understanding of the fenfluramine-associated pathogenic mechanism of IPAH. Whole-genome gene expression profiles in fenfluramine-treated human pulmonary artery smooth muscle (PASMC) and endothelial (PAEC) cells (isolated from normal subjects) were compared with baseline expression in untreated cells. Fenfluramine treatment caused dysregulation in a substantial number of genes involved in a variety of pathways and biological processes. In addition to several common pathways and biological processes such as "MAPK signaling pathway," "inflammation response," and "calcium signaling pathway" shared between both cell types, pathways and biological processes such as "blood circulation," "muscle system process," and "immune response" were enriched among the dysregulated genes in PASMC. Pathways and biological processes such as those related to cell cycle, however, were enriched among the dysregulated genes in PAEC, indicating that fenfluramine could affect unique pathways (or differentially) in different types of pulmonary artery cells. While awaiting validation in a larger cohort, these results strongly suggested that fenfluramine could induce significant dysregulation of genes in multiple biological processes and pathways critical for normal pulmonary vascular functions and structure. The transcriptional and posttranscriptional changes in these genes may, therefore, contribute to the pathogenesis of fenfluramine-associated IPAH.
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Affiliation(s)
- Weijuan Yao
- Department of Medicine, University of California, San Diego, La Jolla, California, USA
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McElroy SL, Guerdjikova AI, Mori N, O’Melia AM. Pharmacological management of binge eating disorder: current and emerging treatment options. Ther Clin Risk Manag 2012; 8:219-41. [PMID: 22654518 PMCID: PMC3363296 DOI: 10.2147/tcrm.s25574] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Growing evidence suggests that pharmacotherapy may be beneficial for some patients with binge eating disorder (BED), an eating disorder characterized by repetitive episodes of uncontrollable consumption of abnormally large amounts of food without inappropriate weight loss behaviors. In this paper, we provide a brief overview of BED and review the rationales and data supporting the effectiveness of specific medications or medication classes in treating patients with BED. We conclude by summarizing these data, discussing the role of pharmacotherapy in the BED treatment armamentarium, and suggesting future areas for research.
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Affiliation(s)
- Susan L McElroy
- Lindner Center of HOPE, Mason, and Department of Psychiatry, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Anna I Guerdjikova
- Lindner Center of HOPE, Mason, and Department of Psychiatry, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Nicole Mori
- Lindner Center of HOPE, Mason, and Department of Psychiatry, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Anne M O’Melia
- Lindner Center of HOPE, Mason, and Department of Psychiatry, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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37
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Heal DJ, Gosden J, Smith SL. A review of late-stage CNS drug candidates for the treatment of obesity. Int J Obes (Lond) 2012; 37:107-17. [PMID: 22410963 DOI: 10.1038/ijo.2012.26] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Obesity is an important causative factor in morbidity, disability and premature death. Increasing levels of obesity will impose enormous health, financial and social burdens on worldwide society unless effective interventions are implemented. For many obese individuals, diet and behavioural modification need to be supplemented by pharmacotherapy. Preclinical research has revealed a greater understanding of the complex nature of the hypothalamic regulation of food intake and has generated a wide range of new molecular targets for the development of drug candidates for obesity treatment. As shown by the clinical results that have been obtained with this next generation of therapies, some approaches, for example, fixed-dose drug combinations, have already demonstrated an ability to deliver levels of efficacy that are not achievable with the current antiobesity drug therapies. The regulatory and marketing landscape for development, registration and commercialisation of novel centrally acting drugs for treatment of obesity and related metabolic disorders has changed substantially in recent years. Now a much greater emphasis is placed on tolerability and safety, as well as efficacy. In this review we briefly describe the therapeutic approaches to tackle obesity that are in late-stage clinical development. We then discuss drugs in late-stage development for the treatment of obesity and also future directions.
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Affiliation(s)
- D J Heal
- RenaSci Consultancy Limited, Biocity, Nottingham, UK.
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38
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Fournier A, Zureik M. Estimate of deaths due to valvular insufficiency attributable to the use of benfluorex in France. Pharmacoepidemiol Drug Saf 2012; 21:343-51. [PMID: 22318872 DOI: 10.1002/pds.3213] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2011] [Revised: 12/12/2011] [Accepted: 12/13/2011] [Indexed: 11/10/2022]
Abstract
PURPOSE To estimate the number of deaths from valvular insufficiency caused by the use of the fenfluramine-derivative benfluorex during the period 1976-2009 in France. METHODS Our calculation was based on (i) the exposure level to benfluorex in the French population, derived from sales figures for the period 1976-2009 and from the main characteristics of benfluorex use provided by the French health products safety agency; (ii) the relative risk of hospitalization for valvular insufficiency among exposed compared with unexposed individuals with diabetes, originating from a cohort study based on a French medico-administrative database, with benfluorex exposure assessed in 2006; (iii) the incidence of hospitalization for valvular insufficiency among exposed individuals, originating from the same database; and (iv) the mortality associated with valvular heart disease. RESULTS In France, use of benfluorex during the period 1976-2009 is likely to be responsible for around 3100 hospitalizations and 1300 deaths due to valvular insufficiency. These figures may be underestimations. CONCLUSIONS The grave consequences benfluorex use have had for many people lend support to the public investigation, which has been set to understand the reasons that have contributed to the delay in withdrawing benfluorex from the French market.
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Affiliation(s)
- Agnès Fournier
- INSERM, CESP Centre for Research in Epidemiology and Population Health, U1018, Nutrition, Hormones and Women's Health Team, Villejuif, France
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39
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Pérez-Rodríguez JV, González López-Valcárcel B. Does innovation in obesity drugs affect stock markets? An event study analysis. GACETA SANITARIA 2012; 26:352-9. [PMID: 22244267 DOI: 10.1016/j.gaceta.2011.07.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/08/2011] [Revised: 07/12/2011] [Accepted: 07/13/2011] [Indexed: 11/17/2022]
Abstract
OBJECTIVE This study empirically analyzes the effects of public information about the pharmaceutical R&D process on the market valuation of the sponsoring firm. We examined the market's response to scientific news and regulatory decisions about an antiobesity drug, rimonabant, and the effects on the sponsoring company (Sanofi-Aventis) and its incumbent competitors (Abbott and Roche). METHODS Event study methodology was used to test the null hypothesis of no market response. We covered the full life cycle of rimonabant (1994-2008), using a data set of daily closing price and volume. RESULTS The results suggest that scientific news in the initial stages of the drug R&D process (i.e., drug discovery, preclinical and clinical trials) had no significant effects. However, news related to regulatory decisions, such as recall or safety warning, had significant negative effects on the company's market value. No spillover/contagion effects on competitor firms were detected. CONCLUSION Market reactions occur at the time when the regulator takes decisions about drugs. Scientific news, even those of high-impact, may pass unnoticed.
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Affiliation(s)
- Jorge V Pérez-Rodríguez
- Department of Quantitative Methods in Economics and Business, University of Las Palmas de Gran Canaria, Las Palmas (Canary Islands), Spain.
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40
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Kushner RF. Pharmacologic management of obesity. Pediatr Blood Cancer 2012; 58:140-3. [PMID: 22009632 DOI: 10.1002/pbc.23366] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2011] [Accepted: 09/06/2011] [Indexed: 11/06/2022]
Abstract
Recent discoveries of processes that govern regulation of body weight and energy expenditure have led to development of new anti-obesity pharmacological agents. This article will inform health professionals of new anti-obesity medications that target neuronal systems within the central nervous system (CNS) and peripheral humoral proteins that send signals to the CNS. An emerging theme of new therapies is to use combination medications that are directed toward several targets or leverage existing gastrointestinal satiety hormonal signals. By using combination therapies, it is anticipated that greater weight loss will be achieved compared to monotherapy.
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Affiliation(s)
- Robert F Kushner
- Northwestern University Feinberg School of Medicine, Chicago, Illinois 60611, USA.
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41
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Abstract
Obesity is a major health problem worldwide. It is associated with cardiovascular diseases, diabetes mellitus and decreased longevity. In managing obesity, diet and exercise are essential; pharmacological therapy may be added for obese patients or overweight patients with cardiovascular risk factors. Sibutramine is a serotonergic and adrenergic drug that reduces food intake and increases thermogenesis. It reduces bodyweight by about 4.2 kg after 12 months, and improves blood glucose and lipids; however, it can increase heart rate and blood pressure. In the SCOUT (Sibutramine Cardiovascular OUTcomes) study, sibutramine increased serious cardiovascular events, such as stroke or myocardial infarction, compared with placebo, and was consequently withdrawn from the market. The lesson learnt from this is the importance of patient selection, limiting the duration of treatment and stopping treatment in non-responders. Currently, phentermine and amfepramone (diethylpropion) are approved for short-term treatment of obesity (up to 3 months) and orlistat is approved for longer-term treatment; however, the gastrointestinal adverse effects of orlistat may be intolerable for some patients. There is now a clear need to find anti-obesity drugs that are effective and safe in the long term.
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42
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Hainer V. Comparative efficiency and safety of pharmacological approaches to the management of obesity. Diabetes Care 2011; 34 Suppl 2:S349-54. [PMID: 21525481 PMCID: PMC3632205 DOI: 10.2337/dc11-s255] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Vojtech Hainer
- Institute of Endocrinology, Obesity Management Center, Prague, Czech Republic.
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43
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Daws LC, Gould GG. Ontogeny and regulation of the serotonin transporter: providing insights into human disorders. Pharmacol Ther 2011; 131:61-79. [PMID: 21447358 DOI: 10.1016/j.pharmthera.2011.03.013] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2011] [Accepted: 03/11/2011] [Indexed: 12/17/2022]
Abstract
Serotonin (5-hydroxytryptamine, 5-HT) was one of the first neurotransmitters for which a role in development was identified. Pharmacological and gene knockout studies have revealed a critical role for 5-HT in numerous processes, including cell division, neuronal migration, differentiation and synaptogenesis. An excess in brain 5-HT appears to be mechanistically linked to abnormal brain development, which in turn is associated with neurological disorders. Ambient levels of 5-HT are controlled by a vast orchestra of proteins, including a multiplicity of pre- and post-synaptic 5-HT receptors, heteroreceptors, enzymes and transporters. The 5-HT transporter (SERT, 5-HTT) is arguably the most powerful regulator of ambient extracellular 5-HT. SERT is the high-affinity uptake mechanism for 5-HT and exerts tight control over the strength and duration of serotonergic neurotransmission. Perturbation of its expression level or function has been implicated in many diseases, prominent among them are psychiatric disorders. This review synthesizes existing information on the ontogeny of SERT during embryonic and early postnatal development though adolescence, along with factors that influence its expression and function during these critical developmental windows. We integrate this knowledge to emphasize how inappropriate SERT expression or its dysregulation may be linked to the pathophysiology of psychiatric, cardiovascular and gastrointestinal diseases.
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Affiliation(s)
- Lynette C Daws
- Department of Physiology, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, MC 7756, San Antonio, TX 78229-3900, USA.
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44
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Abstract
Oleoyl-estrone (OE) is a powerful slimming agent that is also present in plasma and adipose tissue, where it is synthesized. It acts through the formation of a derivative W. OE effects (and W levels) are proportional to the dose. OE reduces food intake but maintains energy expenditure (thermogenesis). The energy gap is fulfilled with adipose tissue fat, sparing body protein and maintaining glycemia (and glycogen) with lower insulin and leptin levels. OE (in fact W) acts through specific receptors, different from those of estrogen. OE increases cholesterol catabolism, reducing hypercholesterolemia in obese rats. The main metabolic effect on adipose tissue is lowering of lipid synthesis, maintaining unchanged the intracellular lipolytic processes; the imbalance favors the progressive loss of fat, which is largely used by the muscle. OE administration induces additive effects with other antiobesity agents, such as β(3)-adrenergic agonists, forcing a massive loss of lipid. Corticosteroids markedly limit OE action by altering the liver control of lipogenesis. OE also inhibits the action of 17β-hydroxysteroid dehydrogenase, decreasing the synthesis of β-estradiol and testosterone. Discontinuous treatment allows for maximal efficacy both in rats and humans. OE has the advantage that the loss of fat is maintained and does not require additional dietary limitations.
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Affiliation(s)
- Xavier Remesar
- Department of Nutrition and Food Science, Faculty of Biology, University of Barcelona, Barcelona, Spain
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45
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Stroke and Substance Abuse. Stroke 2011. [DOI: 10.1016/b978-1-4160-5478-8.10042-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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46
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Le Ven F, Tribouilloy C, Habib G, Gueffet JP, Maréchaux S, Eicher JC, Blanchard-Lemoine B, Rousseau J, Hénon P, Jobic Y, Etienne Y. Valvular heart disease associated with benfluorex therapy: results from the French multicentre registry. EUROPEAN JOURNAL OF ECHOCARDIOGRAPHY 2010; 12:265-71. [PMID: 21193484 DOI: 10.1093/ejechocard/jeq172] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
AIMS The aim of this paper is to report clinical characteristics, consequences, echocardiographic features, and pathological findings encountered in patients suffering from valvular disease associated with benfluorex exposure in a multicentre French registry. METHODS AND RESULTS Forty patients suffering from unexplained restrictive valvular disease with a previous exposition to benfluorex, a fenfluramine derivative, were identified from eight French university hospitals. Patients were mostly women (87.5%) with a mean age of 57 ± 9 years and high body mass index of 30 ± 7 kg/m²; 37.5% of them presented with severe heart failure symptoms (NYHA class III and IV). Benfluorex mean daily dose was 415 ± 131 mg with total therapy duration of 72 ± 53 months. Resulting cumulative dose was 910 ± 675 g. Common echocardiographic findings were leaflets and sub-valvular apparatus thickening and retraction. Aortic and mitral valve regurgitations resulting from leaflets loss of coaptation were the most frequent findings (87.5 and 82.5%) and were severe in 29 patients (72.5%). Multiple valve involvements were present in 31 cases (77.5%). Pulmonary arterial hypertension was identified in 20 cases (50%). Histopathological examination demonstrated abundant extra cellular matrix encasing the leaflets without modification of valve architecture. Fifteen patients (37.5%) underwent valvular surgery. CONCLUSION Benfluorex-related valvulopathy shares numerous characteristics with other drug-induced valvular disease. Clinical consequences may be serious with severe heart failure symptoms that may lead to surgical treatment.
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Affiliation(s)
- Florent Le Ven
- Department of Cardiology, University Hospital Brest, Brest, France.
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47
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Yosefy C, Beeri R. Phentermine cardiovascular safety II: response to Rothman Hendricks Int J Cardiol. 2009 epub Mar 19. Int J Cardiol 2010; 145:407-408. [PMID: 20471119 DOI: 10.1016/j.ijcard.2010.04.044] [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: 03/15/2010] [Accepted: 04/16/2010] [Indexed: 11/27/2022]
Affiliation(s)
- Chaim Yosefy
- Non Invasive Cardiology Unit, Barzilai Medical Center Campus, Ben-Gurion University, Ashkelon, Israel.
| | - Ronen Beeri
- Cardiovascular Research Center, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
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48
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Raja SG, Bhattacharyya S, Davar J, Dreyfus GD. Surgery for carcinoid heart disease: current outcomes, concerns and controversies. Future Cardiol 2010; 6:647-55. [DOI: 10.2217/fca.10.87] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Cardiac involvement in patients with carcinoid disease is a well-recognized pathology. Early reports described right-sided heart involvement. More recently, both right- and left-sided heart disease have been reported. Progress of the treatment of carcinoid disease is leading to an increase in the number of patients presenting for surgery to treat valvular dysfunction. owing to improvements in the prognosis of the basic disease, valve replacement surgery is now a reasonable option in patients with severe valvular dysfunction. This article provides an overview of carcinoid heart disease with an emphasis on current outcomes, concerns and controversies associated with the surgical management of this disease.
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Affiliation(s)
- Shahzad G Raja
- Department of Cardiothoracic Surgery, Harefield Hospital, London, UB9 6JH, UK
| | - Sanjeev Bhattacharyya
- Carcinoid Heart Disease Clinic, Department of Cardiology, Royal Free Hospital, London, UK
| | - Joseph Davar
- Carcinoid Heart Disease Clinic, Department of Cardiology, Royal Free Hospital, London, UK
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49
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Heal DJ, Gosden J, Smith SL. Regulatory challenges for new drugs to treat obesity and comorbid metabolic disorders. Br J Clin Pharmacol 2010; 68:861-74. [PMID: 20002080 DOI: 10.1111/j.1365-2125.2009.03549.x] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Obesity is a major cause of morbidity and mortality through cardio- and cerebrovascular diseases and cancer. The metabolic consequences of obesity include dyslipidaemia, hypertension, proinflammatory atherogenesis, pre-diabetes and Type 2 diabetes. For a significant proportion of patients, pharmacotherapy to tackle obesity is required as adjunctive support to diet, exercise and lifestyle modification. To this end, the pharmaceutical industry is pursuing many novel drug targets. Although this view is probably not justified, the recent tribulations of rimonabant have created a perception that the regulatory bar for the approval of antiobesity drugs has been raised. Although >5% of placebo-subtracted weight loss maintained over 1 year is the primary efficacy end-point, it is improvements in cardiovascular risk factors that the Food and Drug Administration (FDA) and European Medicines Agency (EMEA) require to grant approval. Safety aspects are also critical in this indication. Many companies are now switching development of their antiobesity drug candidates into other metabolic disorders. Type 2 diabetes is accepted by the industry and FDA, but not EMEA, as the most appropriate alternative. On the other hand, improvements in plasma lipids produced by antiobesity drugs are moderate compared with established therapies, suggesting dyslipidaemia is not a viable development option. Metabolic Syndrome is not accepted by FDA or EMEA as a discrete disease and the agencies will not licence antiobesity drugs for its treatment. The regulatory environment for antiobesity drugs and the spectrum of indications for which they can be approved could change dramatically if positive data for sibutramine emerge from the SCOUT outcome trial.
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Affiliation(s)
- David J Heal
- RenaSci Consultancy Ltd, BioCity, Nottingham, UK.
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50
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Bays H, Rodbard HW, Schorr AB, González-Campoy JM. Adiposopathy: treating pathogenic adipose tissue to reduce cardiovascular disease risk. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2010; 9:259-71. [PMID: 17761111 DOI: 10.1007/s11936-007-0021-6] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Excessive adipose tissue is potentially pathogenic due to its mass effects and through adverse metabolic/immune responses, which may lead to cardiovascular disease risk factors (eg, type 2 diabetes mellitus, hypertension, dyslipidemia, and possibly atherosclerosis itself). Positive caloric balance in genetically/environmentally susceptible patients may result in adipocyte hypertrophy, visceral adipose tissue accumulation, and ectopic fat deposition, all causally associated with metabolic disease, and all anatomic manifestations of "adiposopathy" (a term used to describe adipose tissue pathology). Weight loss through improved nutrition, increased physical activity, and weight loss agents (ie, orlistat and sibutramine) improves adiposopathy and improves many metabolic diseases whose prevalence are directly associated with an increase in body fat and sedentary lifestyle. Cannabinoid receptor antagonists improve adiposopathy through weight reduction and favorable metabolic effects upon multiple body organs (including adipocytes). Peroxisome proliferator-activated receptor-gamma agonists may improve adiposopathy through recruitment of functional fat cells and apoptosis of dysfunctional fat cells.
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Affiliation(s)
- Harold Bays
- L-MARC Research Center, 3288 Illinois Avenue, Louisville, KY 40213, USA.
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