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Joseph MW, Stein DR, Stein AC. Gastrointestinal challenges in nephropathic cystinosis: clinical perspectives. Pediatr Nephrol 2024:10.1007/s00467-023-06211-6. [PMID: 38393360 DOI: 10.1007/s00467-023-06211-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 10/18/2023] [Accepted: 10/20/2023] [Indexed: 02/25/2024]
Abstract
Gastrointestinal (GI) sequelae, such as vomiting, hyperacidity, dysphagia, dysmotility, and diarrhea, are nearly universal among patients with nephropathic cystinosis. These complications result from disease processes (e.g., kidney disease, cystine crystal accumulation in the GI tract) and side effects of treatments (e.g., cysteamine, immunosuppressive therapy). GI involvement can negatively impact patient well-being and jeopardize disease outcomes by compromising drug absorption and patient adherence to the strict treatment regimen required to manage cystinosis. Given improved life expectancy due to advances in kidney transplantation and the transformative impact of cystine-depleting therapy, nephrologists are increasingly focused on addressing extra-renal complications and quality of life in patients with cystinosis. However, there is a lack of clinical data and guidance to inform GI-related monitoring, interventions, and referrals by nephrologists. Various publications have examined the prevalence and pathophysiology of selected GI complications in cystinosis, but none have summarized the full picture or provided guidance based on the literature and expert experience. We aim to comprehensively review GI sequelae associated with cystinosis and its treatments and to discuss approaches for monitoring and managing these complications, including the involvement of gastroenterology and other disciplines.
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Affiliation(s)
- Mark W Joseph
- Pediatric Nephrology, Oregon Health & Science University and OHSU Doernbecher Children's Hospital, Portland, OR, USA.
| | - Deborah R Stein
- Pediatric Nephrology, Harvard Medical School and Boston Children's Hospital, Boston, MA, USA
| | - Adam C Stein
- Gastroenterology, Northwestern University and Northwestern Medicine, Chicago, IL, USA
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Klank S, van Stein C, Grüneberg M, Ottolenghi C, Rauwolf KK, Grebe J, Reunert J, Harms E, Marquardt T. Enteric-Coated Cysteamine Bitartrate in Cystinosis Patients. Pharmaceutics 2023; 15:1851. [PMID: 37514038 PMCID: PMC10385520 DOI: 10.3390/pharmaceutics15071851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 06/21/2023] [Accepted: 06/25/2023] [Indexed: 07/30/2023] Open
Abstract
Cystinosis is a severe inherited metabolic storage disease caused by the lysosomal accumulation of cystine. Lifelong therapy with the drug cysteamine bitartrate is necessary. Cysteamine cleaves intralysosomal cystine, and thereafter, it can exit from the organelle. The need for frequent dosing every 6 h and the high prevalence of gastrointestinal side effects lead to poor therapy adherence. The purpose of our study was to improve cysteamine treatment by comparing the efficacy of two cysteamine formulas. This is highly relevant for the long-term outcome of cystinosis patients. The cystine and cysteamine levels of 17 patients taking immediate-release cysteamine (IR-cysteamine/Cystagon®) and 6 patients taking encapsulated delayed-release cysteamine (EC-cysteamine) were analyzed. The EC-cysteamine levels showed a near-ideal pharmacokinetic profile indicative of delayed release (longer Tmax and Tmin), and the corresponding cystine levels showed few fluctuations. In addition, the Cmax of IR-cysteamine was greater, which was responsible for unbearable side effects (e.g., nausea, vomiting, halitosis, lethargy). Treatment with EC-cysteamine improves the quality of life of cystinosis patients because the frequency of intake can be reduced to 2-3 times daily and it has a more favorable pharmacokinetic profile than IR-cysteamine. In particular, cystinosis patients with no access to the only approved delayed-release cysteamine Procysbi® could benefit from a cost-effective alternative.
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Affiliation(s)
- Sabrina Klank
- Department of Paediatrics, Metabolic Diseases, University of Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany
| | - Christina van Stein
- Department of Paediatrics, Metabolic Diseases, University of Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany
| | - Marianne Grüneberg
- Department of Paediatrics, Metabolic Diseases, University of Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany
| | - Chris Ottolenghi
- UMR 1163, Université Paris Descartes, Sorbonne Paris Cité, Institut IMAGINE, 24 Boulevard du Montparnasse, 75015 Paris, France
- Biochimie Métabolomique et Protéomique, Hôpital Necker-Enfants Malades, 149 Rue de Sèvres, 75015 Paris, France
| | - Kerstin K Rauwolf
- Department of Pediatric Hematology and Oncology, University of Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany
- Division of Pediatric Oncology, University Children's Hospital Zürich, Steinwiesstraße 75, 8032 Zürich, Switzerland
| | - Jürgen Grebe
- Department of Paediatrics, Metabolic Diseases, University of Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany
| | - Janine Reunert
- Department of Paediatrics, Metabolic Diseases, University of Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany
| | - Erik Harms
- Department of Paediatrics, Metabolic Diseases, University of Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany
| | - Thorsten Marquardt
- Department of Paediatrics, Metabolic Diseases, University of Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany
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Thuy Nguyen H, Van Duong T, Taylor YS. Enteric coating of tablets containing an amorphous solid dispersion of an enteric polymer and a weakly basic drug: a strategy to enhance in vitro release. Int J Pharm 2023:123139. [PMID: 37311499 PMCID: PMC10390825 DOI: 10.1016/j.ijpharm.2023.123139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 06/06/2023] [Accepted: 06/09/2023] [Indexed: 06/15/2023]
Abstract
Recent work has highlighted that amorphous solid dispersions (ASDs) containing delamanid (DLM) and an enteric polymer, hypromellose phthalate (HPMCP), appear to be susceptible to crystallization during immersion in simulated gastric fluids. The goal of this study was to minimize contact of the ASD particles with the acidic media via application of an enteric coating to tablets containing the ASD intermediate, and improve the subsequent drug release at higher pH conditions. DLM ASDs were prepared with HPMCP and formulated into a tablet that was then coated with a methacrylic acid copolymer (Acryl EZE II®). Drug release was studied in vitro using a two-stage dissolution test where the pH of the gastric compartment was altered to reflect physiological variations. The medium was subsequently switched to simulated intestinal fluid. The gastric resistance time of the enteric coating was probed over the pH range of 1.6-5.0. The enteric coating was found to be effective at protecting the drug against crystallization in pH conditions where HPMCP was insoluble. Consequently, the variability in drug release following gastric immersion under pH conditions reflecting different prandial states was notably reduced when compared to the reference product. These findings support closer examination of the potential for drug crystallization from ASDs in the gastric environment where acid-insoluble polymers may be less effective as crystallization inhibitors. Further, addition of a protective enteric coating appears to provide a promising remediation strategy to prevent crystallization at low pH environments, and may mitigate variability associated with prandial state that arises due to pH changes.
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Affiliation(s)
- Hanh Thuy Nguyen
- Department of Industrial and Physical Pharmacy, College of Pharmacy, Purdue University, West Lafayette, Indiana 47907, United States
| | - Tu Van Duong
- Department of Industrial and Physical Pharmacy, College of Pharmacy, Purdue University, West Lafayette, Indiana 47907, United States
| | - Ynne S Taylor
- Department of Industrial and Physical Pharmacy, College of Pharmacy, Purdue University, West Lafayette, Indiana 47907, United States.
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Wu KW, Zheng K, Tian L, Xia L, Hwang SY, Nwakama PE, Sun WJ, Kim MJ, Tampal N, Xu X, Boyce H, Feng X. The effect of food vehicles on in vitro performance of pantoprazole sodium delayed release sprinkle formulation. Int J Pharm 2023; 635:122737. [PMID: 36801362 DOI: 10.1016/j.ijpharm.2023.122737] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 02/10/2023] [Accepted: 02/13/2023] [Indexed: 02/18/2023]
Abstract
Certain patient populations, including children, the elderly or people with dysphagia, find swallowing whole medications such as tablets and capsules difficult. To facilitate oral administration of drugs in such patients, a common practice is to sprinkle the drug products (e.g., usually after crushing the tablet or opening the capsule) on food vehicles before consumption which improves swallowability. Thus, evaluation of the impact of food vehicles on the potency and stability of the administered drug product is important. The aim of the current study was to evaluate the physicochemical properties (viscosity, pH, and water content) of common food vehicles used for sprinkle administration (e.g., apple juice, applesauce, pudding, yogurt, and milk) and their impacts on the in vitro performance (i.e., dissolution) of pantoprazole sodium delayed release (DR) drug products. The food vehicles evaluated exhibited marked difference in viscosity, pH and water content. Notably, the pH of the food as well as the interaction between food vehicle pH and drug-food contact time were the most significant factors affecting the in vitro performance of pantoprazole sodium DR granules. For example, the dissolution of pantoprazole sodium DR granules sprinkled on food vehicles of low pH (e.g., apple juice or applesauce) for short durations remained unchanged compared with the control group (i.e., without mixing with food vehicles). However, use of high pH food vehicles (e.g., milk) with prolonged contact time (e.g., 2 h) resulted in accelerated pantoprazole release, drug degradation and loss of potency. Overall, a thorough assessment of physicochemical properties of food vehicles and formulation characteristics are a necessary part of the development of sprinkle formulations.
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Affiliation(s)
- Kai-Wei Wu
- Office of Testing and Research, Office of Pharmaceutical Quality, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD 20993, United States
| | - Kai Zheng
- Office of Testing and Research, Office of Pharmaceutical Quality, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD 20993, United States
| | - Li Tian
- Office of Testing and Research, Office of Pharmaceutical Quality, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD 20993, United States
| | - Li Xia
- Office of Bioequivalence, Office of Generic Drugs, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD 20993, United States
| | - Sung-Yong Hwang
- Office of Bioequivalence, Office of Generic Drugs, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD 20993, United States
| | - Patrick E Nwakama
- Office of Bioequivalence, Office of Generic Drugs, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD 20993, United States
| | - Wei-Jhe Sun
- Office of Research and Standards, Office of Generic Drugs, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD 20993, United States
| | - Myong-Jin Kim
- Office of Research and Standards, Office of Generic Drugs, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD 20993, United States
| | - Nilufer Tampal
- Office of Bioequivalence, Office of Generic Drugs, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD 20993, United States
| | - Xiaoming Xu
- Office of Testing and Research, Office of Pharmaceutical Quality, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD 20993, United States
| | - Heather Boyce
- Office of Research and Standards, Office of Generic Drugs, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD 20993, United States
| | - Xin Feng
- Office of Testing and Research, Office of Pharmaceutical Quality, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD 20993, United States.
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Gaillard S, Roche L, Deschênes G, Morin D, Vianey-Saban C, Acquaviva-Bourdain C, Nony P, Subtil F, Mercier C, Cochat P, Bertholet-Thomas A, Cornu C, Kassai B. Collaboration between academics, small pharmaceutical company and patient organizations in the development of a new formulation of cysteamine in nephropathic cystinosis: A successful story. Therapie 2020; 75:169-173. [PMID: 32248985 DOI: 10.1016/j.therap.2020.02.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 11/15/2019] [Indexed: 11/19/2022]
Abstract
Rare diseases usually concern small and disseminated population. Implementing clinical research with the right design, outcomes measures and the recruitment of patients are challenges. Collaborations, training and multidisciplinary approach are often required. In this article, we provide an overview of a successful collaboration in nephropathic cystinosis (NC), focusing on what was the key of success, the interactions between academics, the pharmaceutical company and patients organizations. NC is considered as a very rare disease. In 2010, a new formulation of cysteamine, the only available treatment to improve renal outcome of the disease, was proposed by a small American company. Studies were implemented in France under the coordination of an expert of the disease and the clinical investigation center of Lyon. The collaboration resulted in a good recruitment and retention of the patients in the study and most of all in the availability of the new formulation in France. Patients could have facilitated the research by being involved in the early stages of the studies. Involving patients and public early in the process is particularly important in rare diseases as the patient is a great source of knowledge and has his own expectations. Priorities of research, design, conduct and reporting of clinical trials can be defined in collaboration with adults but also with young patients or public, the first concerned in rare diseases. This concept is still to be developed and improved especially with paediatric patients.
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Affiliation(s)
- Ségolène Gaillard
- Hospices civils de Lyon, EPICIME-CIC 1407 de Lyon, Inserm, department of clinical epidemiology, CHU-Lyon, 69677 Bron, France; Université de Lyon 1, 69000 Lyon, France.
| | - Laurent Roche
- Université de Lyon 1, 69000 Lyon, France; CNRS, UMR 5558, laboratoire de biométrie et biologie évolutive, 69622 Villeurbanne, France; Hospices civils de Lyon, service de biostatistiques, 69324 Lyon, France
| | - Georges Deschênes
- AP-HP, hôpital Robert-Debré, service de néphrologie pédiatrique, 75019 Paris, France
| | - Denis Morin
- CHU Montpellier, service de néphrologie et endocrinologie pédiatrique, 34295 Montpellier, France
| | - Christine Vianey-Saban
- Hospices civils de Lyon, service biochimie et biologie moléculaire, UF maladies héréditaires du métabolisme, 69500 Bron, France
| | - Cécile Acquaviva-Bourdain
- Hospices civils de Lyon, service biochimie et biologie moléculaire, UF maladies héréditaires du métabolisme, 69500 Bron, France
| | - Patrice Nony
- Hospices civils de Lyon, EPICIME-CIC 1407 de Lyon, Inserm, department of clinical epidemiology, CHU-Lyon, 69677 Bron, France; Université de Lyon 1, 69000 Lyon, France
| | - Fabien Subtil
- Université de Lyon 1, 69000 Lyon, France; Hospices civils de Lyon, service de biostatistiques, 69324 Lyon, France
| | - Catherine Mercier
- Université de Lyon 1, 69000 Lyon, France; Hospices civils de Lyon, service de biostatistiques, 69324 Lyon, France
| | - Pierre Cochat
- Hospices civils de Lyon, service de néphrologie pédiatrique, et centre de référence maladies rénales et phosphocalciques rares - Néphrogones - Filière ORKiD, 69500 Bron, France
| | - Aurélia Bertholet-Thomas
- Hospices civils de Lyon, service de néphrologie pédiatrique, et centre de référence maladies rénales et phosphocalciques rares - Néphrogones - Filière ORKiD, 69500 Bron, France
| | - Catherine Cornu
- Hospices civils de Lyon, EPICIME-CIC 1407 de Lyon, Inserm, department of clinical epidemiology, CHU-Lyon, 69677 Bron, France; Université de Lyon 1, 69000 Lyon, France
| | - Behrouz Kassai
- Hospices civils de Lyon, EPICIME-CIC 1407 de Lyon, Inserm, department of clinical epidemiology, CHU-Lyon, 69677 Bron, France; Université de Lyon 1, 69000 Lyon, France
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