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Huang X. Treatment and management for children with urea cycle disorder in chronic stage. Zhejiang Da Xue Xue Bao Yi Xue Ban 2023; 52:744-750. [PMID: 37807629 PMCID: PMC10764184 DOI: 10.3724/zdxbyxb-2023-0378] [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: 08/14/2023] [Accepted: 09/27/2023] [Indexed: 10/10/2023]
Abstract
Urea cycle disorder (UCD) is a group of inherited metabolic diseases with high disability or fatality rate, which need long-term drug treatment and diet management. Except those with Citrin deficiency or liver transplantation, all pediatric patients require lifelong low protein diet with safe levels of protein intake and adequate energy and lipids supply for their corresponding age; supplementing essential amino acids and protein-free milk are also needed if necessary. The drugs for long-term use include nitrogen scavengers (sodium benzoate, sodium phenylbutyrate, glycerol phenylbutyrate), urea cycle activation/substrate supplementation agents (N-carbamylglutamate, arginine, citrulline), etc. Liver transplantation is recommended for pediatric patients not responding to standard diet and drug treatment, and those with severe progressive liver disease and/or recurrent metabolic decompensations. Gene therapy, stem cell therapy, enzyme therapy and other novel technologies may offer options for treatment in UCD patients. The regular biochemical assessments like blood ammonia, liver function and plasma amino acid profile are needed, and physical growth, intellectual development, nutritional intake should be also evaluated for adjusting treatment in time.
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Affiliation(s)
- Xinwen Huang
- Department of Genetics and Metabolism, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou 310052, China.
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2
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Martín-Hernández E, Quijada-Fraile P, Correcher P, Meavilla S, Sánchez-Pintos P, de las Heras Montero J, Blasco-Alonso J, Dougherty L, Marquez A, Peña-Quintana L, Cañedo E, García-Jimenez MC, Moreno Lozano PJ, Murray Hurtado M, Camprodon Gómez M, Barrio-Carreras D, de los Santos M, del Toro M, Couce ML, Vitoria Miñana I, Morales Conejo M, Bellusci M. Switching to Glycerol Phenylbutyrate in 48 Patients with Urea Cycle Disorders: Clinical Experience in Spain. J Clin Med 2022; 11:jcm11175045. [PMID: 36078975 PMCID: PMC9457033 DOI: 10.3390/jcm11175045] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 08/23/2022] [Accepted: 08/24/2022] [Indexed: 11/30/2022] Open
Abstract
Background and objectives: Glycerol phenylbutyrate (GPB) has demonstrated safety and efficacy in patients with urea cycle disorders (UCDs) by means of its clinical trial program, but there are limited data in clinical practice. In order to analyze the efficacy and safety of GPB in clinical practice, here we present a national Spanish experience after direct switching from another nitrogen scavenger to GPB. Methods: This observational, retrospective, multicenter study was performed in 48 UCD patients (age 11.7 ± 8.2 years) switching to GPB in 13 centers from nine Spanish regions. Clinical, biochemical, and nutritional data were collected at three different times: prior to GPB introduction, at first follow-up assessment, and after one year of GPB treatment. Number of related adverse effects and hyperammonemic crisis 12 months before and after GPB introduction were recorded. Results: GPB was administered at a 247.8 ± 102.1 mg/kg/day dose, compared to 262.6 ± 126.1 mg/kg/day of previous scavenger (46/48 Na-phenylbutyrate). At first follow-up (79 ± 59 days), a statistically significant reduction in ammonia (from 40.2 ± 17.3 to 32.6 ± 13.9 μmol/L, p < 0.001) and glutamine levels (from 791.4 ± 289.8 to 648.6 ± 247.41 μmol/L, p < 0.001) was observed. After one year of GPB treatment (411 ± 92 days), we observed an improved metabolic control (maintenance of ammonia and glutamine reduction, with improved branched chain amino acids profile), and a reduction in hyperammonemic crisis rate (from 0.3 ± 0.7 to less than 0.1 ± 0.3 crisis/patients/year, p = 0.02) and related adverse effects (RAE, from 0.5 to less than 0.1 RAEs/patients/year p < 0.001). Conclusions: This study demonstrates the safety of direct switching from other nitrogen scavengers to GPB in clinical practice, which improves efficacy, metabolic control, and RAE compared to previous treatments.
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Affiliation(s)
- Elena Martín-Hernández
- Centro de Referencia Nacional (CSUR) y Europeo (MetabERN) en Enfermedades Metabólicas, Hospital Universitario 12 de Octubre, Instituto de Investigación i+12, CIBERER, 28041 Madrid, Spain
- Correspondence:
| | - Pilar Quijada-Fraile
- Centro de Referencia Nacional (CSUR) y Europeo (MetabERN) en Enfermedades Metabólicas, Hospital Universitario 12 de Octubre, Instituto de Investigación i+12, CIBERER, 28041 Madrid, Spain
| | - Patricia Correcher
- Centro de Referencia Nacional de Enfermedades Metabólicas (CSUR), Hospital La Fé de Valencia, 46026 Valencia, Spain
| | - Silvia Meavilla
- Centro de Referencia Nacional (CSUR) y Europeo (MetabERN) de Enfermedades Metabólicas, Hospital San Joan de Deu Barcelona, 08950 Esplugues de Llobregat, Spain
| | - Paula Sánchez-Pintos
- Centro de Referencia Nacional (CSUR) y Europeo (MetabERN) de Enfermedades Metabólicas, Hospital Clínico Universitario de Santiago de Compostela, IDIS, CIBERER, 15706 Santiago de Compostela, Spain
| | - Javier de las Heras Montero
- Division of Pediatric Metabolism, CIBERER, MetabERN, Cruces University Hospital, University of the Basque Country (UPV/EHU) and Biocruces-Bizkaia Health Research Institute, 48903 Barakaldo, Spain
| | - Javier Blasco-Alonso
- Sección de Gastroenterología y Nutrición Infantil, Unidad de Enfermedades Metabólicas Hereditarias, Grupo IBIMA Multidisciplinar Pediátrico, Hospital Regional Universitario de Málaga, 29010 Málaga, Spain
| | - Lucy Dougherty
- Centro de Referencia Nacional (CSUR) y Europeo (MetabERN) de Enfermedades Metabólicas, Hospital Vall D’Hebrón, 08035 Barcelona, Spain
| | - Ana Marquez
- Unidad de Gastroenterología y Enfermedades Metabólicas, Hospital de Badajoz, 06002 Badajoz, Spain
| | - Luis Peña-Quintana
- Unidad de Gastroenterología y Nutrición Pediátrica, Complejo Hospitalario Universitario Insular Materno-Infantil de Las Palmas, CIBEROBN, ISCIII, ACIP, Universidad de Las Palmas de Gran Canaria, 35016 Las Palmas de Gran Canaria, Spain
| | - Elvira Cañedo
- Unidad de Gastroenterología y Nutrición, Hospital del Niño Jesús, 28009 Madrid, Spain
| | | | - Pedro Juan Moreno Lozano
- Unidad de Enfermedades Musculares y Metabólicas Hereditarias, Departamento de Medicina Interna, Hospital Clinic, 08036 Barcelona, Spain
| | - Mercedes Murray Hurtado
- Pediatría, Sección de Nutrición y Errores Innatos del Metabolismo, Complejo Hospitalario Universitario de Canarias, 38320 San Cristóbal de La Laguna, Spain
| | - María Camprodon Gómez
- Centro de Referencia Nacional (CSUR) y Europeo (MetabERN) de Enfermedades Metabólicas, Hospital Vall D’Hebrón, 08035 Barcelona, Spain
| | - Delia Barrio-Carreras
- Centro de Referencia Nacional (CSUR) y Europeo (MetabERN) en Enfermedades Metabólicas, Hospital Universitario 12 de Octubre, Instituto de Investigación i+12, CIBERER, 28041 Madrid, Spain
| | - Mariela de los Santos
- Centro de Referencia Nacional (CSUR) y Europeo (MetabERN) de Enfermedades Metabólicas, Hospital San Joan de Deu Barcelona, 08950 Esplugues de Llobregat, Spain
| | - Mireia del Toro
- Centro de Referencia Nacional (CSUR) y Europeo (MetabERN) de Enfermedades Metabólicas, Hospital Vall D’Hebrón, 08035 Barcelona, Spain
| | - María L. Couce
- Centro de Referencia Nacional (CSUR) y Europeo (MetabERN) de Enfermedades Metabólicas, Hospital Clínico Universitario de Santiago de Compostela, IDIS, CIBERER, 15706 Santiago de Compostela, Spain
| | - Isidro Vitoria Miñana
- Centro de Referencia Nacional de Enfermedades Metabólicas (CSUR), Hospital La Fé de Valencia, 46026 Valencia, Spain
| | - Montserrat Morales Conejo
- Centro de Referencia Nacional (CSUR) y Europeo (MetabERN) en Enfermedades Metabólicas, Hospital Universitario 12 de Octubre, Instituto de Investigación i+12, CIBERER, 28041 Madrid, Spain
| | - Marcello Bellusci
- Centro de Referencia Nacional (CSUR) y Europeo (MetabERN) en Enfermedades Metabólicas, Hospital Universitario 12 de Octubre, Instituto de Investigación i+12, CIBERER, 28041 Madrid, Spain
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3
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Baker J, Hitchins L, Vucko E, Havens K, Becker K, Arduini K. Variable disease manifestations and metabolic management within a single family affected by ornithine transcarbamylase deficiency. Mol Genet Metab Rep 2022; 33:100906. [PMID: 36620388 PMCID: PMC9817479 DOI: 10.1016/j.ymgmr.2022.100906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 07/25/2022] [Accepted: 07/25/2022] [Indexed: 01/11/2023] Open
Abstract
We report on a family with ornithine transcarbamylase (OTC) deficiency, an X-linked urea cycle disorder, with variable disease severity and tailored management strategies based on each family member's biochemical profile and clinical presentation. Our primary patient is a female monozygotic twin who presented to medical care at 10 months of age with acute liver failure, gastrointestinal symptoms, altered mental status, hypoglycemia, and hyperammonemia. The patient's older brother, known to have hemizygous OTC deficiency, died at 8 months of age from cardiac arrest after complications secondary to his diagnosis. Despite her family history, manifestation of symptoms of heterozygous (partial) OTC deficiency went unrecognized by multiple providers based on misconceptions regarding a female's risk for X-linked disease. Despite barriers related to the family's low socioeconomic status, follow-up care by a multidisciplinary metabolic care team, including moderate protein restriction and nitrogen scavenger therapy, led to positive outcomes for the patient. Her twin sister and mother are also heterozygous for variants in OTC and remain controlled on moderate protein restriction. This case illustrates the importance of genotyping all individuals with genetic risk factors for OTC deficiency and the variability in disease manifestation that necessitates tailored treatment approaches for individuals with partial OTC deficiency.
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Key Words
- ALT, alanine aminotransferase
- AST, aspartate transaminase
- CVS, chorionic villus sampling
- DOL, day of life
- EAA, essential amino acid
- GPB, glycerol phenylbutyrate
- HC, head circumference
- IV, intravenous
- Late onset
- Manifesting heterozygote
- NBS, newborn screen
- NORD, National Organization for Rare Disorders
- NaPB, sodium phenylbutyrate
- OTC, ornithine transcarbamylase
- Ornithine transcarbamylase deficiency
- PO, per os, by mouth
- Partial ornithine transcarbamylase deficiency
- UCD, urea cycle disorder
- Urea cycle disorder
- X-linked
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Affiliation(s)
- Joshua Baker
- Division of Genetics, Birth Defects & Metabolism, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E Chicago Ave, Chicago, IL 60611, USA
- Department of Pediatrics (Genetics, Birth Defects, and Metabolism), Northwestern University Feinberg School of Medicine, 420 E Superior St, Chicago, IL 60611, USA
- Corresponding author at: 225 E Chicago Ave, Chicago, IL 60611, USA.
| | - Lauren Hitchins
- Division of Genetics, Birth Defects & Metabolism, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E Chicago Ave, Chicago, IL 60611, USA
| | - Erika Vucko
- Division of Genetics, Birth Defects & Metabolism, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E Chicago Ave, Chicago, IL 60611, USA
| | - Kirsten Havens
- Division of Genetics, Birth Defects & Metabolism, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E Chicago Ave, Chicago, IL 60611, USA
| | - Karen Becker
- Division of Genetics, Birth Defects & Metabolism, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E Chicago Ave, Chicago, IL 60611, USA
| | - Katherine Arduini
- Division of Genetics, Birth Defects & Metabolism, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E Chicago Ave, Chicago, IL 60611, USA
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4
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Mao X, Chen H, Lin AZ, Kim S, Burczynski ME, Na E, Halasz G, Sleeman MW, Murphy AJ, Okamoto H, Cheng X. Glutaminase 2 knockdown reduces hyperammonemia and associated lethality of urea cycle disorder mouse model. J Inherit Metab Dis 2022; 45:470-480. [PMID: 34988999 PMCID: PMC9302672 DOI: 10.1002/jimd.12474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 12/29/2021] [Accepted: 01/04/2022] [Indexed: 11/12/2022]
Abstract
Amino acids, the building blocks of proteins in the cells and tissues, are of fundamental importance for cell survival, maintenance, and proliferation. The liver plays a critical role in amino acid metabolism and detoxication of byproducts such as ammonia. Urea cycle disorders with hyperammonemia remain difficult to treat and eventually necessitate liver transplantation. In this study, ornithine transcarbamylase deficient (Otcspf-ash ) mouse model was used to test whether knockdown of a key glutamine metabolism enzyme glutaminase 2 (GLS2, gene name: Gls2) or glutamate dehydrogenase 1 (GLUD1, gene name: Glud1) could rescue the hyperammonemia and associated lethality induced by a high protein diet. We found that reduced hepatic expression of Gls2 but not Glud1 by AAV8-mediated delivery of a short hairpin RNA in Otcspf-ash mice diminished hyperammonemia and reduced lethality. Knockdown of Gls2 but not Glud1 in Otcspf-ash mice exhibited reduced body weight loss and increased plasma glutamine concentration. These data suggest that Gls2 hepatic knockdown could potentially help alleviate risk for hyperammonemia and other clinical manifestations of patients suffering from defects in the urea cycle.
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Affiliation(s)
- Xia Mao
- Regeneron PharmaceuticalsTarrytownNew YorkUSA
| | - Helen Chen
- Regeneron PharmaceuticalsTarrytownNew YorkUSA
| | | | - Sun Kim
- Regeneron PharmaceuticalsTarrytownNew YorkUSA
| | | | - Erqian Na
- Regeneron PharmaceuticalsTarrytownNew YorkUSA
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5
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Ficicioglu C, Liu N, Sun Q, Burdett A, Hata A, Porter M, Sutton VR. Perceptions and use of phenylbutyrate metabolite testing in urea cycle disorders: Results of a clinician survey and analysis of a centralized testing database. Mol Genet Metab 2022; 135:35-41. [PMID: 34980542 DOI: 10.1016/j.ymgme.2021.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 12/13/2021] [Accepted: 12/14/2021] [Indexed: 11/24/2022]
Abstract
The nitrogen scavengers sodium and glycerol phenylbutyrate (PB), approved for chronic treatment of urea cycle disorders (UCDs), undergo hepatic conversion to phenylacetate (PAA), which conjugates glutamine to form phenylacetylglutamine for urinary nitrogen excretion. Elevated PAA has been associated with reversible neurological toxicity, with symptoms similar to hyperammonemia. Plasma PB metabolite analysis can assess for toxicity and therapeutic drug levels. An online survey was undertaken to assess US clinician perceptions and use of the test in addition to an analysis of centralized US laboratory records. Survey responses from 52 clinicians were analyzed, including 58% who reported using plasma PB metabolite testing. Test users reported managing more UCD patients than nonusers. Users rated the test as "often helpful" for ruling out PAA toxicity (44%), informing PB dosing decisions (42%), and assessing adherence (28%). Test results were reported as most often unremarkable (61%) or suggestive of poor adherence (13%); 46% of users had never encountered results indicative of PAA toxicity. Analyses of laboratory records for 1668 plasma metabolite tests determined that only 5% of samples had plasma PAA-to-phenylacetylglutamine ratios associated with increased risk of PAA toxicity. Nearly half of surveyed clinicians were unsure of metabolite targets; those conducting ad hoc (versus regular) testing were significantly more likely to be unsure of targets. One-fifth of test users identified uncertainties, including questions about test validation, timing, and interpretation. Increased awareness of published PB metabolite data and further clinician education on test interpretation may help to inform the use of metabolite testing to optimize UCD care.
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Affiliation(s)
- Can Ficicioglu
- Perelman School of Medicine, The University of Pennsylvania, Philadelphia, PA, USA; Division of Human Genetics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Ning Liu
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA; Baylor Genetics, Houston, TX, USA
| | - Qin Sun
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA; Baylor Genetics, Houston, TX, USA
| | | | | | | | - V Reid Sutton
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA; Baylor Genetics, Houston, TX, USA; Inborn Errors of Metabolism Service, Texas Children's Hospital, Houston, TX, USA.
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6
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Dunmore BJ, Jones RJ, Toshner MR, Upton PD, Morrell NW. Approaches to treat pulmonary arterial hypertension by targeting bmpr2 - from cell membrane to nucleus. Cardiovasc Res 2021; 117:2309-2325. [PMID: 33399862 DOI: 10.1093/cvr/cvaa350] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 11/06/2020] [Accepted: 12/15/2020] [Indexed: 12/12/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is estimated to affect between 10-50 people per million worldwide. The lack of cure and devastating nature of the disease means that treatment is crucial to arrest rapid clinical worsening. Current therapies are limited by their focus on inhibiting residual vasoconstriction rather than targeting key regulators of the cellular pathology. Potential disease-modifying therapies may come from research directed towards causal pathways involved in the cellular and molecular mechanisms of disease. It is widely acknowledged, that targeting reduced expression of the critical bone morphogenetic protein type-2 receptor (BMPR2) and its associated signalling pathways is a compelling therapeutic avenue to explore. In this review we highlight the advances that have been made in understanding this pathway and the therapeutics that are being tested in clinical trials and the clinic to treat PAH.
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Affiliation(s)
- Benjamin J Dunmore
- Department of Medicine, University of Cambridge School of Clinical Medicine, Addenbrooke's and Royal Papworth Hospitals, Cambridge, UK
| | - Rowena J Jones
- Department of Medicine, University of Cambridge School of Clinical Medicine, Addenbrooke's and Royal Papworth Hospitals, Cambridge, UK
| | - Mark R Toshner
- Department of Medicine, University of Cambridge School of Clinical Medicine, Addenbrooke's and Royal Papworth Hospitals, Cambridge, UK
| | - Paul D Upton
- Department of Medicine, University of Cambridge School of Clinical Medicine, Addenbrooke's and Royal Papworth Hospitals, Cambridge, UK
| | - Nicholas W Morrell
- Department of Medicine, University of Cambridge School of Clinical Medicine, Addenbrooke's and Royal Papworth Hospitals, Cambridge, UK
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7
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Longo N, Diaz GA, Lichter-Konecki U, Schulze A, Inbar-Feigenberg M, Conway RL, Bannick AA, McCandless SE, Zori R, Hainline B, Ah Mew N, Canavan C, Vescio T, Kok T, Porter MH, Berry SA. Glycerol phenylbutyrate efficacy and safety from an open label study in pediatric patients under 2 months of age with urea cycle disorders. Mol Genet Metab 2021; 132:19-26. [PMID: 33388234 PMCID: PMC8655853 DOI: 10.1016/j.ymgme.2020.12.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 12/08/2020] [Accepted: 12/09/2020] [Indexed: 01/25/2023]
Abstract
BACKGROUND/AIMS Neonatal onset Urea cycle disorders (UCDs) can be life threatening with severe hyperammonemia and poor neurological outcomes. Glycerol phenylbutyrate (GPB) is safe and effective in reducing ammonia levels in patients with UCD above 2 months of age. This study assesses safety, ammonia control and pharmacokinetics (PK) of GPB in UCD patients below 2 months of age. METHODS This was an open-label study in UCD patients aged 0 - 2 months, consisting of an initiation/transition period (1 - 4 days) to GPB, followed by a safety extension period (6 months to 2 years). Patients presenting with a hyperammonemic crisis (HAC) did not initiate GPB until blood ammonia levels decreased to below 100 µmol/L while receiving sodium phenylacetate/sodium benzoate and/or hemodialysis. Ammonia levels, PK analytes and safety were evaluated during transition and monthly during the safety extension for 6 months and every 3 months thereafter. RESULTS All 16 patients with UCD (median age 0.48 months, range 0.1 to 2.0 months) successfully transitioned to GPB within 3 days. Average plasma ammonia level excluding HAC was 94.3 µmol/L at baseline and 50.4 µmol/L at the end of the transition period (p = 0.21). No patient had a HAC during the transition period. During the safety extension, the majority of patients had controlled ammonia levels, with mean plasma ammonia levels lower during GPB treatment than baseline. Mean glutamine levels remained within normal limits throughout the study. PK analyses indicate that UCD patients <2 months are able to hydrolyze GPB with subsequent absorption of phenylbutyric acid (PBA), metabolism to phenylacetic acid (PAA) and conjugation with glutamine. Plasma concentrations of PBA, PAA, and phenylacetylglutamine (PAGN) were stable during the safety extension phase and mean plasma phenylacetic acid: phenylacetylglutamine ratio remained below 2.5 suggesting no accumulation of GPB. All patients reported at least 1 treatment emergent adverse event with gastroesophageal reflux disease, vomiting, hyperammonemia, diaper dermatitis (37.5% each), diarrhea, upper respiratory tract infection and rash (31.3% each) being the most frequently reported. CONCLUSIONS This study supports safety and efficacy of GPB in UCD patients aged 0 -2 months who cannot be managed by dietary protein restriction and/or amino acid supplementation alone. GPB undergoes intestinal hydrolysis with no accumulation in this population.
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Affiliation(s)
| | - George A Diaz
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Andreas Schulze
- Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | | | | | | | - Shawn E McCandless
- University of Colorado Anschutz Medical Campus and Children's Hospital Colorado, Aurora, CO, USA
| | | | - Bryan Hainline
- Indiana University School of Medicine, Indianapolis, IN, USA
| | | | | | | | - Teresa Kok
- Horizon Therapeutics plc, Deerfield, IL, USA.
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8
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Cavino K, Sung B, Su Q, Na E, Kim J, Cheng X, Gromada J, Okamoto H. Glucagon Receptor Inhibition Reduces Hyperammonemia and Lethality in Male Mice with Urea Cycle Disorder. Endocrinology 2021; 162:5988952. [PMID: 33206168 DOI: 10.1210/endocr/bqaa211] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Indexed: 12/14/2022]
Abstract
The liver plays a critical role in maintaining ammonia homeostasis. Urea cycle defects, liver injury, or failure and glutamine synthetase (GS) deficiency result in hyperammonemia, serious clinical conditions, and lethality. In this study we used a mouse model with a defect in the urea cycle enzyme ornithine transcarbamylase (Otcspf-ash) to test the hypothesis that glucagon receptor inhibition using a monoclonal blocking antibody will reduce the hyperammonemia and associated lethality induced by a high-protein diet, which exacerbates disease. We found reduced expression of glutaminase, which degrades glutamine and increased expression of GS in livers of Otcspf-ash mice treated with the glucagon receptor blocking antibody. The gene expression changes favor ammonia consumption and were accompanied by increased circulating glutamine levels and diminished hyperammonemia. Otcspf-ash mice treated with the glucagon receptor-blocking antibody gained lean and body mass and had increased survival. These data suggest that glucagon receptor inhibition using a monoclonal antibody could reduce the risk for hyperammonemia and other clinical manifestations of patients suffering from defects in the urea cycle, liver injury, or failure and GS deficiency.
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Affiliation(s)
- Katie Cavino
- Regeneron Pharmaceuticals, Tarrytown, New York USA
| | - Biin Sung
- Regeneron Pharmaceuticals, Tarrytown, New York USA
| | - Qi Su
- Regeneron Pharmaceuticals, Tarrytown, New York USA
| | - Erqian Na
- Regeneron Pharmaceuticals, Tarrytown, New York USA
| | - Jinrang Kim
- Regeneron Pharmaceuticals, Tarrytown, New York USA
| | - Xiping Cheng
- Regeneron Pharmaceuticals, Tarrytown, New York USA
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9
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Zheng K, Xiao G, Guo T, Ding Y, Wang C, Loh TP, Wu X. Intermolecular Reductive Heck Reaction of Unactivated Aliphatic Alkenes with Organohalides. Org Lett 2020; 22:694-699. [DOI: 10.1021/acs.orglett.9b04474] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- Kewang Zheng
- Institute of Advanced Synthesis, School of Chemistry and Molecular Engineering, Nanjing Tech University, Nanjing 211816, P. R. China
| | - Guanlin Xiao
- Institute of Advanced Synthesis, School of Chemistry and Molecular Engineering, Nanjing Tech University, Nanjing 211816, P. R. China
| | - Tao Guo
- Institute of Advanced Synthesis, School of Chemistry and Molecular Engineering, Nanjing Tech University, Nanjing 211816, P. R. China
| | - Yalan Ding
- Institute of Advanced Synthesis, School of Chemistry and Molecular Engineering, Nanjing Tech University, Nanjing 211816, P. R. China
| | - Chengdong Wang
- Institute of Advanced Synthesis, School of Chemistry and Molecular Engineering, Nanjing Tech University, Nanjing 211816, P. R. China
| | - Teck-Peng Loh
- Institute of Advanced Synthesis, School of Chemistry and Molecular Engineering, Nanjing Tech University, Nanjing 211816, P. R. China
- Division of Chemistry and Biological Chemistry, School of Physical and Mathematical Sciences, Nanyang Technological University, Singapore 637616
| | - Xiaojin Wu
- Institute of Advanced Synthesis, School of Chemistry and Molecular Engineering, Nanjing Tech University, Nanjing 211816, P. R. China
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10
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Diaz GA, Schulze A, Longo N, Rhead W, Feigenbaum A, Wong D, Merritt JL, Berquist W, Gallagher RC, Bartholomew D, McCandless SE, Smith WE, Harding CO, Zori R, Lichter-Konecki U, Vockley J, Canavan C, Vescio T, Holt RJ, Berry SA. Long-term safety and efficacy of glycerol phenylbutyrate for the management of urea cycle disorder patients. Mol Genet Metab 2019; 127:336-345. [PMID: 31326288 DOI: 10.1016/j.ymgme.2019.07.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 06/20/2019] [Accepted: 07/09/2019] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Glycerol phenylbutyrate (GPB) is currently approved for use in the US and Europe for patients of all ages with urea cycle disorders (UCD) who cannot be managed with protein restriction and/or amino acid supplementation alone. Currently available data on GPB is limited to 12 months exposure. Here, we present long-term experience with GPB. METHODS This was an open-label, long-term safety study of GPB conducted in the US (17 sites) and Canada (1 site) monitoring the use of GPB in UCD patients who had previously completed 12 months of treatment in the previous safety extension studies. Ninety patients completed the previous studies with 88 of these continuing into the long-term evaluation. The duration of therapy was open ended until GPB was commercially available. The primary endpoint was the rate of adverse events (AEs). Secondary endpoints were venous ammonia levels, number and causes of hyperammonemic crises (HACs) and neuropsychological testing. RESULTS A total of 45 pediatric patients between the ages of 1 to 17 years (median 7 years) and 43 adult patients between the ages of 19 and 61 years (median 30 years) were enrolled. The treatment emergent adverse events (TEAE) reported in ≥10% of adult or pediatric patients were consistent with the TEAEs reported in the previous safety extension studies with no increase in the overall incidence of TEAEs and no new TEAEs that indicated a new safety signal. Mean ammonia levels remained stable and below the adult upper limit of normal (<35 µmol/L) through 24 months of treatment in both the pediatric and adult population. Over time, glutamine levels decreased in the overall population. The mean annualized rate of HACs (0.29) established in the previously reported 12-month follow-up study was maintained with continued GPB exposure. CONCLUSION Following the completion of 12-month follow-up studies with GPB treatment, UCD patients were followed for an additional median of 1.85 (range 0 to 5.86) years in the present study with continued maintenance of ammonia control, similar rates of adverse events, and no new adverse events identified.
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Affiliation(s)
- George A Diaz
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Andreas Schulze
- University of Toronto and The Hospital for Sick Children, Toronto, ON, Canada
| | | | | | - Annette Feigenbaum
- University of Toronto and The Hospital for Sick Children, Toronto, ON, Canada
| | - Derek Wong
- David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | | | - William Berquist
- Stanford University Medical Center & Lucile Packard Children's Hospital, Stanford, CA, USA
| | | | - Dennis Bartholomew
- Ohio State University and Nationwide Children's Hospital, Columbus, OH, USA
| | - Shawn E McCandless
- Children's Hospital Colorado and University of Colorado Denver, Aurora, CO, USA
| | | | | | | | | | - Jerry Vockley
- Children's Hospital of Pittsburgh, Pittsburgh, PA, USA; University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Berry SA, Vockley J, Vinks AA, Dong M, Diaz GA, McCandless SE, Smith WE, Harding CO, Zori R, Ficicioglu C, Lichter-Konecki U, Perdok R, Robinson B, Holt RJ, Longo N. Pharmacokinetics of glycerol phenylbutyrate in pediatric patients 2 months to 2 years of age with urea cycle disorders. Mol Genet Metab 2018; 125:251-257. [PMID: 30217721 DOI: 10.1016/j.ymgme.2018.09.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2018] [Revised: 07/27/2018] [Accepted: 09/02/2018] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Glycerol phenylbutyrate (GPB) is approved in the US and EU for the chronic management of patients ≥2 months of age with urea cycle disorders (UCDs) who cannot be managed by dietary protein restriction and/or amino acid supplementation alone. GPB is a pre-prodrug, hydrolyzed by lipases to phenylbutyric acid (PBA) that upon absorption is beta-oxidized to the active nitrogen scavenger phenylacetic acid (PAA), which is conjugated to glutamine (PAGN) and excreted as urinary PAGN (UPAGN). Pharmacokinetics (PK) of GPB were examined to see if hydrolysis is impaired in very young patients who may lack lipase activity. METHODS Patients 2 months to <2 years of age with UCDs from two open label studies (n = 17, median age 10 months) predominantly on stable doses of nitrogen scavengers (n = 14) were switched to GPB. Primary assessments included traditional plasma PK analyses of PBA, PAA, and PAGN, using noncompartmental methods with WinNonlin™. UPAGN was collected periodically throughout the study up to 12 months. RESULTS PBA, PAA and PAGN rapidly appeared in plasma after GPB dosing, demonstrating evidence of GPB cleavage with subsequent PBA absorption. Median concentrations of PBA, PAA and PAGN did not increase over time and were similar to or lower than the values observed in older UCD patients. The median PAA/PAGN ratio was well below one over time, demonstrating that conjugation of PAA with glutamine to form PAGN did not reach saturation. Covariate analyses indicated that age did not influence the PK parameters, with body surface area (BSA) being the most significant covariate, reinforcing current BSA based dosing recommendations as seen in older patients. CONCLUSION These observations demonstrate that UCD patients aged 2 months to <2 years have sufficient lipase activity to adequately convert the pre-prodrug GPB to PBA. PBA is then converted to its active moiety (PAA) providing successful nitrogen scavenging even in very young children.
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Affiliation(s)
- Susan A Berry
- University of Minnesota Department of Pediatrics, Minneapolis, MN, USA
| | - Jerry Vockley
- University of Pittsburgh School of Medicine and the Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Alexander A Vinks
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA
| | - Min Dong
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA
| | - George A Diaz
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Shawn E McCandless
- University of Colorado Denver School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | | | | | | | - Can Ficicioglu
- Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | | | | | | | - Robert J Holt
- Horizon Pharma USA, Inc, Lake Forest, IL, USA; University of Illinois-Chicago, Chicago, IL, USA.
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