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Heneghan M, Southern KW, Murphy J, Sinha IP, Nevitt SJ. Corrector therapies (with or without potentiators) for people with cystic fibrosis with class II CFTR gene variants (most commonly F508del). Cochrane Database Syst Rev 2023; 11:CD010966. [PMID: 37983082 PMCID: PMC10659105 DOI: 10.1002/14651858.cd010966.pub4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2023]
Abstract
BACKGROUND Cystic fibrosis (CF) is a common life-shortening genetic condition caused by a variant in the cystic fibrosis transmembrane conductance regulator (CFTR) protein. A class II CFTR variant F508del is the commonest CF-causing variant (found in up to 90% of people with CF (pwCF)). The F508del variant lacks meaningful CFTR function - faulty protein is degraded before reaching the cell membrane, where it needs to be to effect transepithelial salt transport. Corrective therapy could benefit many pwCF. This review evaluates single correctors (monotherapy) and any combination of correctors (most commonly lumacaftor, tezacaftor, elexacaftor, VX-659, VX-440 or VX-152) and a potentiator (e.g. ivacaftor) (dual and triple therapies). OBJECTIVES To evaluate the effects of CFTR correctors (with or without potentiators) on clinically important benefits and harms in pwCF of any age with class II CFTR mutations (most commonly F508del). SEARCH METHODS We searched the Cochrane CF Trials Register (28 November 2022), reference lists of relevant articles and online trials registries (3 December 2022). SELECTION CRITERIA Randomised controlled trials (RCTs) (parallel design) comparing CFTR correctors to control in pwCF with class II mutations. DATA COLLECTION AND ANALYSIS Two authors independently extracted data, assessed risk of bias and judged evidence certainty (GRADE); we contacted investigators for additional data. MAIN RESULTS We included 34 RCTs (4781 participants), lasting between 1 day and 48 weeks; an extension of two lumacaftor-ivacaftor studies provided additional 96-week safety data (1029 participants). We assessed eight monotherapy RCTs (344 participants) (4PBA, CPX, lumacaftor, cavosonstat and FDL169), 16 dual-therapy RCTs (2627 participants) (lumacaftor-ivacaftor or tezacaftor-ivacaftor) and 11 triple-therapy RCTs (1804 participants) (elexacaftor-tezacaftor-ivacaftor/deutivacaftor; VX-659-tezacaftor-ivacaftor/deutivacaftor; VX-440-tezacaftor-ivacaftor; VX-152-tezacaftor-ivacaftor). Participants in 21 RCTs had the genotype F508del/F508del, in seven RCTs they had F508del/minimal function (MF), in one RCT F508del/gating genotypes, in one RCT either F508del/F508del genotypes or F508del/residual function genotypes, in one RCT either F508del/gating or F508del/residual function genotypes, and in three RCTs either F508del/F508del genotypes or F508del/MF genotypes. Risk of bias judgements varied across different comparisons. Results from 16 RCTs may not be applicable to all pwCF due to age limits (e.g. adults only) or non-standard designs (converting from monotherapy to combination therapy). Monotherapy Investigators reported no deaths or clinically relevant improvements in quality of life (QoL). There was insufficient evidence to determine effects on lung function. No placebo-controlled monotherapy RCT demonstrated differences in mild, moderate or severe adverse effects (AEs); the clinical relevance of these events is difficult to assess due to their variety and few participants (all F508del/F508del). Dual therapy In a tezacaftor-ivacaftor group there was one death (deemed unrelated to the study drug). QoL scores (respiratory domain) favoured both lumacaftor-ivacaftor and tezacaftor-ivacaftor therapy compared to placebo at all time points (moderate-certainty evidence). At six months, relative change in forced expiratory volume in one second (FEV1) % predicted improved with all dual combination therapies compared to placebo (high- to moderate-certainty evidence). More pwCF reported early transient breathlessness with lumacaftor-ivacaftor (odds ratio (OR) 2.05, 99% confidence interval (CI) 1.10 to 3.83; I2 = 0%; 2 studies, 739 participants; high-certainty evidence). Over 120 weeks (initial study period and follow-up), systolic blood pressure rose by 5.1 mmHg and diastolic blood pressure by 4.1 mmHg with twice-daily 400 mg lumacaftor-ivacaftor (80 participants). The tezacaftor-ivacaftor RCTs did not report these adverse effects. Pulmonary exacerbation rates decreased in pwCF receiving additional therapies to ivacaftor compared to placebo (all moderate-certainty evidence): lumacaftor 600 mg (hazard ratio (HR) 0.70, 95% CI 0.57 to 0.87; I2 = 0%; 2 studies, 739 participants); lumacaftor 400 mg (HR 0.61, 95% CI 0.49 to 0.76; I2 = 0%; 2 studies, 740 participants); and tezacaftor (HR 0.64, 95% CI 0.46 to 0.89; 1 study, 506 participants). Triple therapy No study reported any deaths (high-certainty evidence). All other evidence was low- to moderate-certainty. QoL respiratory domain scores probably improved with triple therapy compared to control at six months (six studies). There was probably a greater relative and absolute change in FEV1 % predicted with triple therapy (four studies each across all combinations). The absolute change in FEV1 % predicted was probably greater for F508del/MF participants taking elexacaftor-tezacaftor-ivacaftor compared to placebo (mean difference 14.30, 95% CI 12.76 to 15.84; 1 study, 403 participants; moderate-certainty evidence), with similar results for other drug combinations and genotypes. There was little or no difference in adverse events between triple therapy and control (10 studies). No study reported time to next pulmonary exacerbation, but fewer F508del/F508del participants experienced a pulmonary exacerbation with elexacaftor-tezacaftor-ivacaftor at four weeks (OR 0.17, 99% CI 0.06 to 0.45; 1 study, 175 participants) and 24 weeks (OR 0.29, 95% CI 0.14 to 0.60; 1 study, 405 participants); similar results were seen across other triple therapy and genotype combinations. AUTHORS' CONCLUSIONS There is insufficient evidence of clinically important effects from corrector monotherapy in pwCF with F508del/F508del. Additional data in this review reduced the evidence for efficacy of dual therapy; these agents can no longer be considered as standard therapy. Their use may be appropriate in exceptional circumstances (e.g. if triple therapy is not tolerated or due to age). Both dual therapies (lumacaftor-ivacaftor, tezacaftor-ivacaftor) result in similar small improvements in QoL and respiratory function with lower pulmonary exacerbation rates. While the effect sizes for QoL and FEV1 still favour treatment, they have reduced compared to our previous findings. Lumacaftor-ivacaftor was associated with an increase in early transient shortness of breath and longer-term increases in blood pressure (not observed for tezacaftor-ivacaftor). Tezacaftor-ivacaftor has a better safety profile, although data are lacking in children under 12 years. In this population, lumacaftor-ivacaftor had an important impact on respiratory function with no apparent immediate safety concerns, but this should be balanced against the blood pressure increase and shortness of breath seen in longer-term adult data when considering lumacaftor-ivacaftor. Data from triple therapy trials demonstrate improvements in several key outcomes, including FEV1 and QoL. There is probably little or no difference in adverse events for triple therapy (elexacaftor-tezacaftor-ivacaftor/deutivacaftor; VX-659-tezacaftor-ivacaftor/deutivacaftor; VX-440-tezacaftor-ivacaftor; VX-152-tezacaftor-ivacaftor) in pwCF with one or two F508del variants aged 12 years or older (moderate-certainty evidence). Further RCTs are required in children under 12 years and those with more severe lung disease.
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Affiliation(s)
- Matthew Heneghan
- Department of Women's and Children's Health, University of Liverpool, Liverpool, UK
| | - Kevin W Southern
- Department of Women's and Children's Health, University of Liverpool, Liverpool, UK
| | | | - Ian P Sinha
- Department of Women's and Children's Health, University of Liverpool, Liverpool, UK
| | - Sarah J Nevitt
- Department of Health Data Science, University of Liverpool, Liverpool, UK
- Centre for Reviews and Dissemination, University of York, York, UK
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Le Moigne V, Rodriguez Rincon D, Glatigny S, Dupont CM, Langevin C, Ait Ali Said A, Renshaw SA, Floto RA, Herrmann JL, Bernut A. Roscovitine Worsens Mycobacterium abscessus Infection by Reducing DUOX2-mediated Neutrophil Response. Am J Respir Cell Mol Biol 2022; 66:439-451. [PMID: 35081328 PMCID: PMC8990120 DOI: 10.1165/rcmb.2021-0406oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 01/26/2022] [Indexed: 11/24/2022] Open
Abstract
Persistent neutrophilic inflammation associated with chronic pulmonary infection causes progressive lung injury and, eventually, death in individuals with cystic fibrosis (CF), a genetic disease caused by biallelic mutations in the CF transmembrane conductance regulator (CFTR) gene. Therefore, we examined whether roscovitine, a cyclin-dependent kinase inhibitor that (in other conditions) reduces inflammation while promoting host defense, might provide a beneficial effect in the context of CF. Herein, using CFTR-depleted zebrafish larvae as an innovative vertebrate model of CF immunopathophysiology, combined with murine and human approaches, we sought to determine the effects of roscovitine on innate immune responses to tissue injury and pathogens in the CF condition. We show that roscovitine exerts antiinflammatory and proresolution effects in neutrophilic inflammation induced by infection or tail amputation in zebrafish. Roscovitine reduces overactive epithelial reactive oxygen species (ROS)-mediated neutrophil trafficking by reducing DUOX2/NADPH-oxidase activity and accelerates inflammation resolution by inducing neutrophil apoptosis and reverse migration. It is important to note that, although roscovitine efficiently enhances intracellular bacterial killing of Mycobacterium abscessus in human CF macrophages ex vivo, we found that treatment with roscovitine results in worse infection in mouse and zebrafish models. By interfering with DUOX2/NADPH oxidase-dependent ROS production, roscovitine reduces the number of neutrophils at infection sites and, consequently, compromises granuloma formation and maintenance, favoring extracellular multiplication of M. abscessus and more severe infection. Our findings bring important new understanding of the immune-targeted action of roscovitine and have significant therapeutic implications for safely targeting inflammation in CF.
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Affiliation(s)
- Vincent Le Moigne
- Infection et Inflammation, Inserm/UVSQ, UMR 1173, Université Paris-Saclay, Montigny-le-Bretonneux, France
| | - Daniela Rodriguez Rincon
- Molecular Immunity Unit, Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Simon Glatigny
- Infection et Inflammation, Inserm/UVSQ, UMR 1173, Université Paris-Saclay, Montigny-le-Bretonneux, France
| | - Christian M. Dupont
- Institut de Recherche en Infectiologie de Montpellier, Centre National de la Recherche Scientifique, UMR 9004, Montpellier, France
| | - Christelle Langevin
- Inrae, Infectiologie Expérimentale des Rongeurs et des Poissons, UE 0907, Jouy-en-Josas, France
| | - Amel Ait Ali Said
- Infection et Inflammation, Inserm/UVSQ, UMR 1173, Université Paris-Saclay, Montigny-le-Bretonneux, France
| | - Stephen A. Renshaw
- Department of Infection, Immunity and Cardiovascular Disease, Sheffield Medical School, and
- Firth Court, Bateson Centre, University of Sheffield, Sheffield, United Kingdom
| | - R. Andres Floto
- Molecular Immunity Unit, Department of Medicine, University of Cambridge, Cambridge, United Kingdom
- Cambridge Centre for Lung Infection, Royal Papworth Hospital, Cambridge, United Kingdom; and
| | - Jean-Louis Herrmann
- Infection et Inflammation, Inserm/UVSQ, UMR 1173, Université Paris-Saclay, Montigny-le-Bretonneux, France
- Hôpital Raymond Poincaré, AP-HP, Groupe Hospitalo-universitaire Paris-Saclay, Garches, France
| | - Audrey Bernut
- Infection et Inflammation, Inserm/UVSQ, UMR 1173, Université Paris-Saclay, Montigny-le-Bretonneux, France
- Department of Infection, Immunity and Cardiovascular Disease, Sheffield Medical School, and
- Firth Court, Bateson Centre, University of Sheffield, Sheffield, United Kingdom
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Meijer L, Hery-Arnaud G, Leven C, Nowak E, Hillion S, Renaudineau Y, Durieu I, Chiron R, Prevotat A, Fajac I, Hubert D, Murris-Espin M, Huge S, Danner-Boucher I, Ravoninjatovo B, Leroy S, Macey J, Urban T, Rault G, Mottier D, Berre RL. Safety and pharmacokinetics of Roscovitine (Seliciclib) in cystic fibrosis patients chronically infected with Pseudomonas aeruginosa, a randomized, placebo-controlled study. J Cyst Fibros 2021; 21:529-536. [PMID: 34961705 DOI: 10.1016/j.jcf.2021.10.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 10/17/2021] [Accepted: 10/19/2021] [Indexed: 01/20/2023]
Abstract
BACKGROUND The orally available kinase inhibitor R-roscovitine has undergone clinical trials against various cancers and is currently under clinical evaluation against Cushing disease and rheumatoid arthritis. Roscovitine displays biological properties suggesting potential benefits in CF: it partially corrects F508del-CFTR trafficking, stimulates the bactericidal properties of CF alveolar macrophages, and displays anti-inflammatory properties and analgesic effects. METHODS A phase 2 trial study (ROSCO-CF) was launched to evaluate the safety and effects of roscovitine in Pseudomonas aeruginosa infected adult CF patients carrying two CF causing mutations (at least one F508del-CFTR mutation) and harboring a FEV1 ≥40%. ROSCO-CF was a multicenter, double-blind, placebo-controlled, dose-ranging study (200, 400, 800 mg roscovitine, orally administered daily for 4 days/week/4 weeks). RESULTS Among the 34 volunteers enrolled, randomization assigned 11/8/8/7 to receive the 0 (placebo)/ 200/400/800 mg roscovitine doses, respectively. In these subjects with polypharmacy, roscovitine was relatively safe and well-tolerated, with no significant adverse effects (AEs) other than five serious AEs (SAEs) possibly related to roscovitine. Pharmacokinetics of roscovitine were rather variable among subjects. No significant efficacy, at the levels of inflammation, infection, spirometry, sweat chloride, pain and quality of life, was detected in roscovitine-treated groups compared to the placebo-treated group. CONCLUSION Roscovitine was relatively safe and well-tolerated in CF patients especially at the 200 and 400 mg doses. However, there were 5 subject withdrawals due to SAEs in the roscovitine group and none in the placebo group. The lack of evidence for efficacy of roscovitine (despite encouraging cellular and animal results) may be due to high pharmacokinetics variability, short duration of treatment, and/or inappropriate dosing protocol.
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Affiliation(s)
- Laurent Meijer
- ManRos Therapeutics, Presqu'île de Perharidy, Roscoff 29680, France.
| | - Geneviève Hery-Arnaud
- Unité de Bactériologie, Hôpital de la Cavale Blanche, CHRU Brest, Brest cedex 29609, France; Univ Brest, Inserm, EFS, UMR 1078, GGB, Brest 29200, France
| | - Cyril Leven
- Département de Biochimie et Pharmaco-Toxicologie, CHRU Brest, Brest cedex 29609, France; Univ Brest, EA 3878, GETBO, Brest 29200, France
| | - Emmanuel Nowak
- INSERM CIC 1412, Brest University Hospital, Brest cedex 29609, France
| | - Sophie Hillion
- Laboratoire d'Immunologie et Immunothérapie, CHRU de Brest, INSERM U1227, 2 avenue Foch, BP824, 29609 Brest cedex, France
| | - Yves Renaudineau
- Laboratoire d'Immunologie et Immunothérapie, CHRU de Brest, INSERM U1227, 2 avenue Foch, BP824, 29609 Brest cedex, France
| | - Isabelle Durieu
- Research on Healthcare Performance (RESHAPE), INSERM U1290, Claude Bernard Lyon 1 University, 8 Avenue Rockefeller, 69003 Lyon, France; Department of Internal Medicine, Cystic Fibrosis Center, Hospices Civils de Lyon, Pierre-Bénite 69495, France
| | - Raphaël Chiron
- CHU Montpellier, Maladies Respiratoires, Hôpital Arnaud de Villeneuve, 371, avenue du Doyen Gaston Giraud, Montpellier 34295, France
| | - Anne Prevotat
- Service de pneumologie, CHR - Hôpital Calmette, Boulevard du Pr. Leclercq, Lille 59037, France
| | - Isabelle Fajac
- APHP.Centre - Université de Paris, 27 rue du Faubourg Saint-Jacques, Paris 75014, France
| | - Dominique Hubert
- APHP.Centre - Université de Paris, 27 rue du Faubourg Saint-Jacques, Paris 75014, France
| | - Marlène Murris-Espin
- CHU Toulouse, CRCM adulte, Service de Pneumologie, Clinique des Voies Respiratoires. Hôpital Larrey, 24 chemin de Pouvourville, Toulouse 31059, France
| | - Sandrine Huge
- Centre Hospitalier Bretagne Atlantique, CRCM Mixte 56, 20 Boulevard du général Maurice Guillaudot, Vannes cedex 56017, France
| | - Isabelle Danner-Boucher
- CHU de Nantes, Service de Pneumologie, Hôpital Nord Laennec, Boulevard Jacques-Monod, Nantes 44093, Saint-Herblain, France
| | - Bruno Ravoninjatovo
- Centre de Ressources et de Compétences de la Mucoviscidose, Maladies Respiratoires et Allergiques, Hôpital Maison Blanche - CHU Reims, 45 rue Cognacq-Jay, 51100 Reims, France
| | - Sylvie Leroy
- CHU de Nice, Hôpital Pasteur, Service de Pneumologie, Oncologie Thoracique et Soins Intensifs Respiratoires, 30 Voie Romaine, CS 51069, Nice cedex 1 06001, France
| | - Julie Macey
- CHU Bordeaux, Hôpital Haut-Lévêque, Service de Pneumologie, Avenue de Magellan, Pessac cedex 33604, France
| | - Thierry Urban
- Département de Pneumologie, CHU Angers, Site de Larrey, 4 rue de Larrey, Angers cedex 49933, France
| | - Gilles Rault
- Fondation Ildys, Centre de Perharidy, Roscoff cedex 29684, France
| | - Dominique Mottier
- Département de Biochimie et Pharmaco-Toxicologie, CHRU Brest, Brest cedex 29609, France
| | - Rozenn Le Berre
- Univ Brest, Inserm, EFS, UMR 1078, GGB, Brest 29200, France; Département de Médecine Interne et Pneumologie, CHRU Brest, Brest cedex 29609, France
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