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Burlina A, Biasucci G, Carbone MT, Cazzorla C, Paci S, Pochiero F, Spada M, Tummolo A, Zuvadelli J, Leuzzi V. Italian national consensus statement on management and pharmacological treatment of phenylketonuria. Orphanet J Rare Dis 2021; 16:476. [PMID: 34784942 PMCID: PMC8594187 DOI: 10.1186/s13023-021-02086-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 10/13/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Phenylketonuria (PKU) is a rare inherited metabolic disorder caused by defects in the phenylalanine-hydroxylase gene (PAH), the enzyme catalyzing the conversion of phenylalanine to tyrosine. PAH impairment causes phenylalanine accumulation in the blood and brain, with a broad spectrum of pathophysiological and neurological consequences for patients. Prevalence of disease varies, with peaks in some regions and countries, including Italy. A recent expert survey described the real-life of clinical practice for PKU in Italy, revealing inhomogeneities in disease management, particularly concerning approach to pharmacotherapy with sapropterin hydrochloride, analogous of the natural PAH co-factor, allowing disease control in a subset of patients. Therefore, the purpose of this paper is to continue the work initiated with the expert survey paper, to provide national guidances aiming to harmonize and optimize patient care at a national level. PARTICIPANTS The Consensus Group, convened by 10 Steering Committee members, consisted of a multidisciplinary crowd of 46 experts in the management of PKU in Italy. CONSENSUS PROCESS The Steering Committee met in a series of virtual meeting in order to discuss on clinical focuses to be developed and analyzed in guidance statements, on the basis of expert practice based evidence, large systematic literature review previously performed in the expert survey paper, and evidence based consensus published. Statements were re-discussed and refined during consensus conferences in the widest audience of experts, and finally submitted to the whole consensus group for a modified-Delphi voting. RESULTS Seventy three statements, divided in two main clinical areas, PKU management and Pharmacotherapy, achieved large consensus in a multidisciplinary group of expert in different aspects of disease. Importantly, these statements involve guidances for the use of sapropterin dihydrochloride, still not sufficiently implemented in Italy, and a set of good practice to approach the use of novel enzyme replacement treatment pegvaliase. CONCLUSIONS This evidence-based consensus provides a minimum set of guidances for disease management to be implemented in all PKU centers. Moreover, these guidances represent the first statement for sapropterin dihydrochloride use, implementation and standardization in Italy, and a guide for approaching pegvaliase treatment at a national level on a consistent basis.
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Affiliation(s)
- Alberto Burlina
- Division of Inherited Metabolic Diseases, Reference Center for Expanded Newborn Screening, DIDAS Servizi Di Diagnostica Integrata, University Hospital Padova, 35128, Padua, Italy
| | - Giacomo Biasucci
- Maternal and Child Health Department, Pediatrics and Neonatology Unit, Guglielmo da Saliceto Hospital, 29121, Piacenza, Italy.
| | - Maria Teresa Carbone
- Pediatric Division, Metabolic and Rare Diseases, Santobono Pausilipon Hospital, 80122, Naples, Italy
| | - Chiara Cazzorla
- Division of Inherited Metabolic Diseases, Reference Center for Expanded Newborn Screening, DIDAS Servizi Di Diagnostica Integrata, University Hospital Padova, 35128, Padua, Italy
| | - Sabrina Paci
- Paediatric Department, ASST Santi Paolo E Carlo, San Paolo Hospital, University of Milan, 20142, Milan, Italy
| | - Francesca Pochiero
- Metabolic and Muscular Unit, A. Meyer Children's Hospital, Florence, Italy
| | - Marco Spada
- Department of Pediatrics, Regina Margherita Children's Hospital, University of Torino, 10126, Turin, Italy
| | - Albina Tummolo
- Metabolic Diseases Department, Clinical Genetics and Diabetology, Giovanni XXIII Children's Hospital, 70126, Bari, Italy
| | - Juri Zuvadelli
- Paediatric Department, ASST Santi Paolo E Carlo, San Paolo Hospital, University of Milan, 20142, Milan, Italy
| | - Vincenzo Leuzzi
- Department of Human Neuroscience, Unit of Child Neurology and Psychiatry, University La Sapienza, 00185, Rome, Italy
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Elsayad MK, Mowafy HA, Zaky AA, Samy AM. Chitosan caged liposomes for improving oral bioavailability of rivaroxaban: in vitro and in vivo evaluation. Pharm Dev Technol 2021; 26:316-327. [PMID: 33356742 DOI: 10.1080/10837450.2020.1870237] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
In this study, chitosan (CS) caged classic liposomes (CLs) and flexible liposomes (FLs) were developed to enhance the oral bioavailability of rivaroxaban (RVX) in the fasted condition. The prepared formulations were subjected to physicochemical characterization included: FTIR, DSC, zeta potential, particle size, polydispersity index, entrapment efficiency, in vitro dissolution, and transmission electron microscope imaging. The selected formulation (RVX-TFL2) composed of PL S100/Tween 80 (85/15% w/w) and coated with CS solution in the strength of (0.2% w/v) had a particle size of 105.67 nm, a zeta potential of +5.67 mV and EE of 96.07%. Compared to RXV suspension, the pharmacokinetic parameters (C max, AUC0-24, and AUC0-∞) of RVX-TFL2 showed no statistically significant difference (P > 0.05) in the fasted and fed test animals. Besides, RVX bioavailability with RVX-TFL2 was improved by 59.66% and 26.97% in the fed and fasted states, respectively, compared to RVX suspension in the fed state. The result highlighted the efficacy of the prepared liquid formulation comprising CS coated liposomes in improving the oral bioavailability of RVX regardless of the fed state. Moreover, the studied liquid formulation could be utilized in developing a liquid dosage form that might be useful as a pediatric formulation of RVX.
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Affiliation(s)
- Maged K Elsayad
- Department of Pharmaceutics and Industrial Pharmacy, Faculty of Pharmacy, Al-Azhar University, Cairo, Egypt
| | - Hammam A Mowafy
- Department of Pharmaceutics and Industrial Pharmacy, Faculty of Pharmacy, Al-Azhar University, Cairo, Egypt
| | - Alaa A Zaky
- Department of Pharmaceutics and Industrial Pharmacy, Faculty of Pharmacy, Al-Azhar University, Cairo, Egypt
| | - Ahmed M Samy
- Department of Pharmaceutics and Industrial Pharmacy, Faculty of Pharmacy, Al-Azhar University, Cairo, Egypt
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Smith N, Longo N, Levert K, Hyland K, Blau N. Phase I clinical evaluation of CNSA-001 (sepiapterin), a novel pharmacological treatment for phenylketonuria and tetrahydrobiopterin deficiencies, in healthy volunteers. Mol Genet Metab 2019; 126:406-412. [PMID: 30922814 DOI: 10.1016/j.ymgme.2019.02.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 02/07/2019] [Accepted: 02/07/2019] [Indexed: 01/14/2023]
Abstract
Tetrahydrobiopterin (BH4) is the natural cofactor of aromatic amino acid hydroxylases and essential for degradation of phenylalanine and synthesis of catecholamines and serotonin. It can be synthesized either de novo from GTP or through the salvage pathway from sepiapterin. Sepiapterin, a natural precursor of BH4, is a more stable molecule and is transported more efficiently across cellular membranes, thus having potentially significant advantage over BH4 as a pharmacological agent for diseases associated with BH4-deficient conditions. We report the results of a first-in-humans, randomized, double-blind, placebo-controlled, dose-ranging, Phase I clinical trial in 83 healthy volunteers of CNSA-001, a novel formulation of sepiapterin. Single oral doses of 2.5-80 mg/kg CNSA-001 caused dose-related increases in plasma sepiapterin (mean Cmax 0.58-2.92 ng/mL) and BH4 (mean Cmax 57-312 ng/mL). Maximum plasma concentrations were achieved in about 1-2 h (sepiapterin) or about 4 h (BH4) after CNSA-001 oral intake. Increases in plasma BH4 were substantially larger in absolute terms and on a dose-for-dose basis following treatment with CNSA-001 vs. sapropterin dihydrochloride, a synthetic form of BH4. The pharmacokinetics of plasma sepiapterin and BH4 were similar before and after seven days of repeat daily dosing with CNSA-001 at 5, 20 or 60 mg/kg indicating little or no drug accumulation. Oral administration of CNSA-001 resulted in higher concentrations of sepiapterin in fasted vs. fed subjects, but overall BH4 plasma exposure following CNSA-001 intake increased by 1.7-1.8-fold in fed subjects. CNSA-001 was well tolerated, with no clear dose-relationship for adverse events (AE), no serious AE and no study discontinuations for AE. These data indicate that CNSA-001 is rapidly and efficiently converted to BH4 in humans supporting further clinical evaluation of CNSA-001 for the management of PKU, primary BH4 deficiencies and other diseases associated with deficient BH4 metabolism.
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Affiliation(s)
- Neil Smith
- Censa Pharmaceuticals Inc., Wellesley, MA, USA.
| | - Nicola Longo
- Division of Medical Genetics, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | | | | | - Nenad Blau
- Dietmar-Hopp-Metabolic Center, University Children's Hospital, Heidelberg, Germany; Division of Metabolism, University Children's Hospital, Zurich, Switzerland.
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Muntau AC, du Moulin M, Feillet F. Diagnostic and therapeutic recommendations for the treatment of hyperphenylalaninemia in patients 0-4 years of age. Orphanet J Rare Dis 2018; 13:173. [PMID: 30268140 PMCID: PMC6162894 DOI: 10.1186/s13023-018-0911-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Accepted: 09/12/2018] [Indexed: 12/17/2023] Open
Abstract
BACKGROUND Treatment of phenylketonuria (PKU) with sapropterin dihydrochloride in responsive patients from an early age can have many advantages for the patient over dietary restriction alone. Accordingly, approval of sapropterin in the European Union was extended in 2015 to include patients aged 0-4 years, bringing the treatment age range in line with that in the USA and providing an additional treatment option for those patients with PKU who are responsive or partially responsive to treatment with sapropterin. Subsequently, European guidelines have been published on the diagnosis and management of patients with PKU. However, testing for PKU can be demanding and requires particular expertise. We have compiled experience-based, real-world guidance in an algorithmic format to complement the published guidelines, with the overall aim to achieve optimized and individualized care for patients with PKU. RESULTS Our guidance covers aspects such as how to perform, monitor and interpret appropriate biochemical measures to achieve effective patient management and desired outcomes, how to perform a tetrahydrobiopterin (BH4) loading test to assess responsiveness in newborns, and how to initiate sapropterin treatment in patients from birth. We also provide our expert opinion on starting pharmacotherapy in patients who were previously managed by diet alone. CONCLUSIONS Real-world-based guidance is particularly important in managing therapeutic strategies in newborns with PKU to achieve optimal long-term outcomes and will serve as a complement to the other published guidelines.
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Affiliation(s)
- Ania C. Muntau
- University Children’s Hospital, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marcel du Moulin
- University Children’s Hospital, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Francois Feillet
- Department of Pediatrics, Hôpital d’Enfants Brabois, CHU Nancy, Vandoeuvre les Nancy, France
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Xue X, Cao M, Ren L, Qian Y, Chen G. Preparation and Optimization of Rivaroxaban by Self-Nanoemulsifying Drug Delivery System (SNEDDS) for Enhanced Oral Bioavailability and No Food Effect. AAPS PharmSciTech 2018; 19:1847-1859. [PMID: 29637496 DOI: 10.1208/s12249-018-0991-6] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Accepted: 03/13/2018] [Indexed: 11/30/2022] Open
Abstract
In this paper, a novel self-nanoemulsifying drug delivery system (SNEDDS) was used to improve the oral bioavailability in fasted state and diminish the food effect for rivaroxaban. Oil, surfactant, and co-surfactant were selected by saturated solubility study. IPM, Tween80, and 1,2-propanediol were finally selected as oil, surfactant, and co-surfactant, respectively. The pseudo-ternary-phase diagram was utilized to optimize the preliminary composition of SNEDDS formulation. The optimized rivaroxaban-SNEDDS formulation was selected by central composite design (CCD) of response surface methodology. Optimized SNEDDS formulation was evaluated for drug content, self-emulsifying time, droplet size, zeta potential, polydispersity index, Fourier transform-infrared (FTIR) spectroscopy, and transmission electron microscope (TEM). The drug dissolution profile compared to the commercial formulation Xarelto® (20 mg rivaroxaban) was determined in four different media (pH 1.2HCl, pH 4.5NaAc-HAc, pH 6.8PBS, and water). The result indicated that the SNEDDS formulation had successfully increased the drug solubility in four different media. A HPLC-MS method that indicated a high sensitivity, strong attribute, and high accuracy characteristic was built to measure the drug concentration in plasma. The fast/fed in vivo pharmacokinetics studies of SNEDDS formulation and Xarelto® were carried out in adult beagle dog, rivaroxaban with no food effect was achieved in SNEDDS formulation compared with Xarelto® in fed state. The result suggested that SNEDDS formulation in this study is useful to increase the oral bioavailability and diminish the food effect in fasted state.
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Reverter E, Mesonero F, Seijo S, Martínez J, Abraldes JG, Peñas B, Berzigotti A, Deulofeu R, Bosch J, Albillos A, García-Pagán JC. Effects of Sapropterin on Portal and Systemic Hemodynamics in Patients With Cirrhosis and Portal Hypertension: A Bicentric Double-Blind Placebo-Controlled Study. Am J Gastroenterol 2015; 110:985-92. [PMID: 26077176 DOI: 10.1038/ajg.2015.185] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Accepted: 03/03/2015] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Tetrahydrobiopterin (BH4), a cofactor of nitric oxide synthase, might have a role in the treatment of portal hypertension (PHT) as its administration improves endothelial nitric oxide generation and hepatic endothelial dysfunction, and reduces portal pressure in experimental models of cirrhosis. Sapropterin is an oral synthetic analogue of BH4 recently approved for the treatment of phenylketonuria. This study evaluated the safety and effects of sapropterin on hepatic and systemic hemodynamics in patients with cirrhosis and PHT. METHODS Forty patients with cirrhosis and PHT (hepatic venous pressure gradient (HVPG) ≥10 mm Hg) were randomly allocated to receive sapropterin (n=19) for 2 weeks (5 mg/kg/day increased to 10 at day 8) or placebo (n=21) in a double-blind multicenter clinical trial. Randomization was stratified according to concomitant treatment with β-adrenergic blockers. We studied at baseline and post-treatment splanchnic (HVPG and hepatic blood flow (HBF)) and systemic hemodynamics, endothelial dysfunction and oxidative stress markers (von Willebrand factor and malondialdehyde), liver function tests, and safety variables. RESULTS HVPG was not modified by either sapropterin (16.0±4.4 vs. 15.8±4.7 mm Hg) or placebo (16.0±4.6 vs. 15.5±4.9 mm Hg). HBF, systemic hemodynamics, endothelial dysfunction markers, and liver function tests remained unchanged. Sapropterin was well tolerated (no patient required dose adjustment or withdrawal), and adverse events were mild and similar between groups. CONCLUSIONS Sapropterin, an oral synthetic analogue of BH4, at the used dose did not reduce portal pressure in patients with cirrhosis. Sapropterin was safe and no serious adverse effects or deleterious systemic hemodynamic effects were observed.
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Affiliation(s)
- Enric Reverter
- 1] Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Barcelona, Spain [2] Centro de Investigaciones Biomédicas en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Francisco Mesonero
- 1] Centro de Investigaciones Biomédicas en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain [2] Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, University of Alcalá, Madrid, Spain
| | - Susana Seijo
- 1] Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Barcelona, Spain [2] Centro de Investigaciones Biomédicas en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Javier Martínez
- 1] Centro de Investigaciones Biomédicas en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain [2] Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, University of Alcalá, Madrid, Spain
| | - Juan G Abraldes
- 1] Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Barcelona, Spain [2] Centro de Investigaciones Biomédicas en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Beatriz Peñas
- 1] Centro de Investigaciones Biomédicas en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain [2] Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, University of Alcalá, Madrid, Spain
| | - Annalisa Berzigotti
- 1] Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Barcelona, Spain [2] Centro de Investigaciones Biomédicas en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Ramon Deulofeu
- 1] Centro de Investigaciones Biomédicas en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain [2] Department of Biochemistry and Molecular Genetics, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Barcelona, Spain
| | - Jaume Bosch
- 1] Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Barcelona, Spain [2] Centro de Investigaciones Biomédicas en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Agustín Albillos
- 1] Centro de Investigaciones Biomédicas en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain [2] Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, University of Alcalá, Madrid, Spain
| | - Joan Carles García-Pagán
- 1] Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Barcelona, Spain [2] Centro de Investigaciones Biomédicas en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
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Camp KM, Parisi MA, Acosta PB, Berry GT, Bilder DA, Blau N, Bodamer OA, Brosco JP, Brown CS, Burlina AB, Burton BK, Chang CS, Coates PM, Cunningham AC, Dobrowolski SF, Ferguson JH, Franklin TD, Frazier DM, Grange DK, Greene CL, Groft SC, Harding CO, Howell RR, Huntington KL, Hyatt-Knorr HD, Jevaji IP, Levy HL, Lichter-Konecki U, Lindegren ML, Lloyd-Puryear MA, Matalon K, MacDonald A, McPheeters ML, Mitchell JJ, Mofidi S, Moseley KD, Mueller CM, Mulberg AE, Nerurkar LS, Ogata BN, Pariser AR, Prasad S, Pridjian G, Rasmussen SA, Reddy UM, Rohr FJ, Singh RH, Sirrs SM, Stremer SE, Tagle DA, Thompson SM, Urv TK, Utz JR, van Spronsen F, Vockley J, Waisbren SE, Weglicki LS, White DA, Whitley CB, Wilfond BS, Yannicelli S, Young JM. Phenylketonuria Scientific Review Conference: state of the science and future research needs. Mol Genet Metab 2014; 112:87-122. [PMID: 24667081 DOI: 10.1016/j.ymgme.2014.02.013] [Citation(s) in RCA: 133] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2014] [Revised: 02/25/2014] [Accepted: 02/26/2014] [Indexed: 01/17/2023]
Abstract
New developments in the treatment and management of phenylketonuria (PKU) as well as advances in molecular testing have emerged since the National Institutes of Health 2000 PKU Consensus Statement was released. An NIH State-of-the-Science Conference was convened in 2012 to address new findings, particularly the use of the medication sapropterin to treat some individuals with PKU, and to develop a research agenda. Prior to the 2012 conference, five working groups of experts and public members met over a 1-year period. The working groups addressed the following: long-term outcomes and management across the lifespan; PKU and pregnancy; diet control and management; pharmacologic interventions; and molecular testing, new technologies, and epidemiologic considerations. In a parallel and independent activity, an Evidence-based Practice Center supported by the Agency for Healthcare Research and Quality conducted a systematic review of adjuvant treatments for PKU; its conclusions were presented at the conference. The conference included the findings of the working groups, panel discussions from industry and international perspectives, and presentations on topics such as emerging treatments for PKU, transitioning to adult care, and the U.S. Food and Drug Administration regulatory perspective. Over 85 experts participated in the conference through information gathering and/or as presenters during the conference, and they reached several important conclusions. The most serious neurological impairments in PKU are preventable with current dietary treatment approaches. However, a variety of more subtle physical, cognitive, and behavioral consequences of even well-controlled PKU are now recognized. The best outcomes in maternal PKU occur when blood phenylalanine (Phe) concentrations are maintained between 120 and 360 μmol/L before and during pregnancy. The dietary management treatment goal for individuals with PKU is a blood Phe concentration between 120 and 360 μmol/L. The use of genotype information in the newborn period may yield valuable insights about the severity of the condition for infants diagnosed before maximal Phe levels are achieved. While emerging and established genotype-phenotype correlations may transform our understanding of PKU, establishing correlations with intellectual outcomes is more challenging. Regarding the use of sapropterin in PKU, there are significant gaps in predicting response to treatment; at least half of those with PKU will have either minimal or no response. A coordinated approach to PKU treatment improves long-term outcomes for those with PKU and facilitates the conduct of research to improve diagnosis and treatment. New drugs that are safe, efficacious, and impact a larger proportion of individuals with PKU are needed. However, it is imperative that treatment guidelines and the decision processes for determining access to treatments be tied to a solid evidence base with rigorous standards for robust and consistent data collection. The process that preceded the PKU State-of-the-Science Conference, the conference itself, and the identification of a research agenda have facilitated the development of clinical practice guidelines by professional organizations and serve as a model for other inborn errors of metabolism.
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Affiliation(s)
- Kathryn M Camp
- Office of Dietary Supplements, National Institutes of Health, Bethesda, MD 20982, USA.
| | - Melissa A Parisi
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD 20892, USA.
| | | | - Gerard T Berry
- Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, USA.
| | - Deborah A Bilder
- Department of Psychiatry, University of Utah, Salt Lake City, UT 84108, USA.
| | - Nenad Blau
- University Children's Hospital, Heidelberg, Germany; University Children's Hospital, Zürich, Switzerland.
| | - Olaf A Bodamer
- University of Miami Miller School of Medicine, Miami, FL 33136, USA.
| | - Jeffrey P Brosco
- University of Miami Mailman Center for Child Development, Miami, FL 33101, USA.
| | | | | | - Barbara K Burton
- Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL 60611, USA.
| | - Christine S Chang
- Agency for Healthcare Research and Quality, Rockville, MD 20850, USA.
| | - Paul M Coates
- Office of Dietary Supplements, National Institutes of Health, Bethesda, MD 20982, USA.
| | - Amy C Cunningham
- Tulane University Medical School, Hayward Genetics Center, New Orleans, LA 70112, USA.
| | | | - John H Ferguson
- Office of Rare Diseases Research, National Center for Advancing Translational Sciences, National Institutes of Health, Bethesda, MD 20982, USA.
| | | | | | - Dorothy K Grange
- Washington University School of Medicine, St. Louis Children's Hospital, St. Louis, MO 63110, USA.
| | - Carol L Greene
- University of Maryland School of Medicine, Baltimore, MD 21201, USA.
| | - Stephen C Groft
- Office of Rare Diseases Research, National Center for Advancing Translational Sciences, National Institutes of Health, Bethesda, MD 20982, USA.
| | - Cary O Harding
- Oregon Health & Science University, Portland, OR 97239, USA.
| | - R Rodney Howell
- University of Miami Miller School of Medicine, Miami, FL 33136, USA.
| | | | - Henrietta D Hyatt-Knorr
- Office of Rare Diseases Research, National Center for Advancing Translational Sciences, National Institutes of Health, Bethesda, MD 20982, USA.
| | - Indira P Jevaji
- Office of Research on Women's Health, National Institutes of Health, Bethesda, MD 20817, USA.
| | - Harvey L Levy
- Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, USA.
| | - Uta Lichter-Konecki
- George Washington University, Children's National Medical Center, Washington, DC 20010, USA.
| | | | | | | | | | - Melissa L McPheeters
- Vanderbilt Evidence-based Practice Center, Institute for Medicine and Public Health, Nashville, TN 37203, USA.
| | - John J Mitchell
- McGill University Health Center, Montreal, Quebec H3H 1P3, Canada.
| | - Shideh Mofidi
- Maria Fareri Children's Hospital of Westchester Medical Center, Valhalla, NY 10595, USA.
| | - Kathryn D Moseley
- University of Southern California Keck School of Medicine, Los Angeles, CA 90033, USA.
| | - Christine M Mueller
- Office of Orphan Products Development, U.S. Food and Drug Administration, Silver Spring, MD 20993, USA.
| | - Andrew E Mulberg
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD 20993, USA.
| | - Lata S Nerurkar
- Office of Rare Diseases Research, National Center for Advancing Translational Sciences, National Institutes of Health, Bethesda, MD 20982, USA.
| | - Beth N Ogata
- University of Washington, Seattle, WA 98195, USA.
| | - Anne R Pariser
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD 20993, USA.
| | - Suyash Prasad
- BioMarin Pharmaceutical Inc., San Rafael, CA 94901, USA.
| | - Gabriella Pridjian
- Tulane University Medical School, Hayward Genetics Center, New Orleans, LA 70112, USA.
| | | | - Uma M Reddy
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD 20892, USA.
| | | | | | - Sandra M Sirrs
- Vancouver General Hospital, University of British Columbia, Vancouver V5Z 1M9, Canada.
| | | | - Danilo A Tagle
- National Center for Advancing Translational Sciences, National Institutes of Health, Bethesda, MD 20892, USA.
| | - Susan M Thompson
- The Children's Hospital at Westmead, Sydney, NSW 2145, Australia.
| | - Tiina K Urv
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD 20892, USA.
| | - Jeanine R Utz
- University of Minnesota, Minneapolis, MN 55455, USA.
| | - Francjan van Spronsen
- University of Groningen, University Medical Center of Groningen, Beatrix Children's Hospital, Netherlands.
| | - Jerry Vockley
- University of Pittsburgh, Pittsburgh, PA 15224, USA.
| | - Susan E Waisbren
- Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, USA.
| | - Linda S Weglicki
- National Institute of Nursing Research, National Institutes of Health, Bethesda, MD 20892, USA.
| | - Desirée A White
- Department of Psychology, Washington University, St. Louis, MO 63130, USA.
| | | | - Benjamin S Wilfond
- Seattle Children's Research Institute, University of Washington School of Medicine, Seattle, WA 98101, USA.
| | | | - Justin M Young
- The Young Face, Facial Plastic and Reconstructive Surgery, Cumming, GA 30041, USA.
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Abstract
INTRODUCTION Phenylketonuria (PKU) is caused by mutation of the enzyme, phenylalanine (Phe) hydroxylase (PAH). The hyperphenylalaninemia characteristic of PKU causes devastating neurological damage if not identified and treated at birth with a Phe-restricted diet. Sapropterin dihydrochloride, a pharmaceutical formulation of the natural cofactor for PAH (6R-tetrahydrobiopterin; BH4), is now available for the management of hyperphenylalaninemia in some PKU patients, including BH4 deficiencies. Sapropterin dihydrochloride improves dietary Phe tolerance in about 20% of patients with PKU. AREAS COVERED This evaluation describes the identification of patients suitable for treatment of sapropterin dihydrochloride, together with its indications, therapeutic properties and efficacy. Furthermore, the article reviews its safety and tolerability in patients with PKU or BH4 deficiency. EXPERT OPINION A reduction in blood Phe of at least 30% occurred in ∼ 20 - 30% of sapropterin-treated PKU patients (mostly with milder forms of PKU). Treatment with sapropterin resulted in clinically significant and sustained reductions in blood Phe concentrations and increased dietary Phe tolerance in well-designed clinical studies in PKU patients who responded to BH4. Successful treatment with sapropterin may lead to a relaxation of the Phe-restricted diet, although continued monitoring of blood Phe is required. Sapropterin was well tolerated.
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Affiliation(s)
- Nenad Blau
- University Children's Hospital, Division of Inborn Metabolic Diseases, Department of General Pediatrics, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany.
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Bélanger-Quintana A, Burlina A, Harding CO, Muntau AC. Up to date knowledge on different treatment strategies for phenylketonuria. Mol Genet Metab 2011; 104 Suppl:S19-25. [PMID: 21967857 PMCID: PMC4437510 DOI: 10.1016/j.ymgme.2011.08.009] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2011] [Revised: 07/23/2011] [Accepted: 08/05/2011] [Indexed: 11/18/2022]
Abstract
Dietary management for phenylketonuria was established over half a century ago, and has rendered an immense success in the prevention of the severe mental retardation associated with the accumulation of phenylalanine. However, the strict low-phenylalanine diet has several shortcomings, not the least of which is the burden it imposes on the patients and their families consequently frequent dietary non-compliance. Imperfect neurological outcome of patients in comparison to non-PKU individuals and nutritional deficiencies associated to the PKU diet are other important reasons to seek alternative therapies. In the last decade there has been an impressive effort in the investigation of other ways to treat PKU that might improve the outcome and quality of life of these patients. These studies have lead to the commercialization of sapropterin dihydrochloride, but there are still many questions regarding which patients to challenge with sapropterin what is the best challenge protocol and what could be the implications of this treatment in the long-term. Current human trials of PEGylated phenylalanine ammonia lyase are underway, which might render an alternative to diet for those patients non-responsive to sapropterin dihydrochloride. Preclinical investigation of gene and cell therapies for PKU is ongoing. In this manuscript, we will review the current knowledge on novel pharmacologic approaches to the treatment of phenylketonuria.
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Affiliation(s)
- Amaya Bélanger-Quintana
- Division of Metabolic Diseases, Pediatrics Department, Ramon y Cajal Hospital, Madrid, Spain.
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Mütze U, Roth A, Weigel JFW, Beblo S, Baerwald CG, Bührdel P, Kiess W. Transition of young adults with phenylketonuria from pediatric to adult care. J Inherit Metab Dis 2011; 34:701-9. [PMID: 21305352 DOI: 10.1007/s10545-011-9284-x] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2010] [Revised: 01/15/2011] [Accepted: 01/18/2011] [Indexed: 11/28/2022]
Abstract
BACKGROUND Transition from pediatric to adult health care is a particularly vulnerable period for patients with inborn metabolic diseases. Aim of the present study was to evaluate the current transition situation of patients with phenylketonuria (PKU) in Leipzig, Germany, by analysis of the medical care, metabolic control, patients' satisfaction, socio-economic and psychosocial status, in order to identify areas of weakness and potential improvement. METHODS Patients who had been transferred from pediatric to adult medical care between 2005 and 2008 were identified. An interview was performed using a questionnaire. Pediatric case notes and the present physician's case notes were analyzed retrospectively. Socio-demographic data were compared to data derived from the annual statistics of the city of Leipzig, Germany in 2008. RESULTS seventy two transferred patients were identified and included in the study, 48 patients responded to the questionnaire, the data of 24 non-responders were analysed retrospectively. About 90% of the responding patients with PKU were satisfied with the current transition situation. However, they agreed to several suggestions of improvement. Most specifically an interdisciplinary appointment before the definite transfer to the adult clinics was asked for. At the time of transition, most of the patients were in good metabolic control according to current treatment guidelines (median dried blood phenylalanine concentration 853 μmol/l before versus 690 μmol/l after transition). Of the interviewed patients 92% were still on a low phenylalanine diet in combination with the intake of a phenylalanine free amino acid mixture. Of the interviewees 77% carried a secondary school certificate or a secondary modern school qualification, but only 19% had achieved senior high school diploma (controls 38.2%). Marital status was comparable with the population of Leipzig. However, fewer patients with PKU had children (15% versus 37%). CONCLUSION Transition of patients with PKU from pediatric to adult care seems to be successful in Leipzig. Patients were mostly satisfied with the transition situation. Still, some suggestions for improvements appeared to be desirable. During transition medical care and metabolic control were stable. However, with regard to psychosocial and socioeconomic data differences to the control population were detected.
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Affiliation(s)
- Ulrike Mütze
- University Hospital for Children and Adolescents, University Hospital, University of Leipzig, Liebigstrasse 20 a, 04103 Leipzig, Germany.
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Enns GM, Koch R, Brumm V, Blakely E, Suter R, Jurecki E. Suboptimal outcomes in patients with PKU treated early with diet alone: revisiting the evidence. Mol Genet Metab 2010; 101:99-109. [PMID: 20678948 DOI: 10.1016/j.ymgme.2010.05.017] [Citation(s) in RCA: 128] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2010] [Revised: 05/27/2010] [Accepted: 05/28/2010] [Indexed: 11/22/2022]
Abstract
BACKGROUND The National Institute of Health (NIH) published a Consensus Statement on the screening and management of Phenylketonuria (PKU) in 2000. The panel involved in the development of this consensus statement acknowledged the lack of data regarding the potential for more subtle suboptimal outcomes and the need for further research into treatment options. In subsequent years, the approval of new treatment options for PKU and outcome data for patients treated from the newborn period by dietary therapy alone have become available. We hypothesized that a review of the PKU literature since 2000 would provide further evidence related to neurocognitive, psychosocial, and physical outcomes that could serve as a basis for reassessment of the 2000 NIH Consensus Statement. METHODS A systematic review of literature residing in PubMed, Scopus and PsychInfo was performed in order to assess the outcome data over the last decade in diet-alone early-treated PKU patients to assess the need for new recommendations and validity of older recommendations in light of new evidence. RESULTS The majority of publications (140/150) that contained primary outcome data presented at least one suboptimal outcome compared to control groups or standardized norms/reference values in at least one of the following areas: neurocognitive/psychosocial (N=60; 58 reporting suboptimal outcomes); quality of life (N=6; 4 reporting suboptimal outcomes); brain pathology (N=32; 30 reporting suboptimal outcomes); growth/nutrition (N=34; 29 reporting suboptimal outcomes); bone pathology (N=9; 9 reporting suboptimal outcomes); and/or maternal PKU (N=19; 19 reporting suboptimal outcomes). CONCLUSIONS Despite the remarkable success of public health programs that have instituted newborn screening and early introduction of dietary therapy for PKU, there is a growing body of evidence that suggests that neurocognitive, psychosocial, quality of life, growth, nutrition, bone pathology and maternal PKU outcomes are suboptimal. The time may be right for revisiting the 2000 NIH Consensus Statement in order to address a number of important issues related to PKU management, including treatment advancements for metabolic control in PKU, blood Phe variability, neurocognitive and psychological assessments, routine screening measures for nutritional biomarkers, and bone pathology.
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Affiliation(s)
- G M Enns
- Division of Medical Genetics, Department of Pediatrics, Lucile Packard Children's Hospital, Stanford University, Stanford, CA 94305-5208,USA.
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Blau N. Sapropterin dihydrochloride for phenylketonuria and tetrahydrobiopterin deficiency. Expert Rev Endocrinol Metab 2010; 5:483-494. [PMID: 30780801 DOI: 10.1586/eem.10.39] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Sapropterin dihydrochloride is the first registered synthetic form of the naturally occurring cofactor and cosubstrate, tetrahydrobiopterin (BH4). It is essential for the conversion of phenylalanine (Phe) by phenylalanine-4-hydroxylase (PAH) to tyrosine. BH4 is also the co-factor of rate-limiting enzymes involved in the synthesis of monoamine neurotransmitters. Phenylketonuria (PKU) is an inherited disorder of PAH, characterized by elevated Phe concentrations (hyperphenylalaninemia) in the blood and brain, with toxic neurological consequences. Sapropterin dihydrochloride is approved for treating patients (of all ages in the USA and >4 years old in Europe) with PKU who are BH4 responsive, and those with BH4 deficiency (Europe). It decreases blood Phe concentration and increases dietary Phe tolerance in some patients with PKU on a low-Phe diet, allowing dietary adjustment or even discontinuation of a low-Phe diet. This article reviews sapropterin dihydrochloride for the management of PKU - aimed at improving clinical outcomes and quality of life - and it considers the potential for incorporating such information into international consensus guidelines.
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Affiliation(s)
- Nenad Blau
- a Zürich Center for Integrative Human Physiology (ZIHP), Division of Clinical Chemistry and Biochemistry, University Children's Hospital, Steinwiesstrasse 75, CH-8032 Zürich, Switzerland.
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