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Lee SY. Using Bayesian statistics in confirmatory clinical trials in the regulatory setting: a tutorial review. BMC Med Res Methodol 2024; 24:110. [PMID: 38714936 PMCID: PMC11077897 DOI: 10.1186/s12874-024-02235-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 04/24/2024] [Indexed: 05/12/2024] Open
Abstract
Bayesian statistics plays a pivotal role in advancing medical science by enabling healthcare companies, regulators, and stakeholders to assess the safety and efficacy of new treatments, interventions, and medical procedures. The Bayesian framework offers a unique advantage over the classical framework, especially when incorporating prior information into a new trial with quality external data, such as historical data or another source of co-data. In recent years, there has been a significant increase in regulatory submissions using Bayesian statistics due to its flexibility and ability to provide valuable insights for decision-making, addressing the modern complexity of clinical trials where frequentist trials are inadequate. For regulatory submissions, companies often need to consider the frequentist operating characteristics of the Bayesian analysis strategy, regardless of the design complexity. In particular, the focus is on the frequentist type I error rate and power for all realistic alternatives. This tutorial review aims to provide a comprehensive overview of the use of Bayesian statistics in sample size determination, control of type I error rate, multiplicity adjustments, external data borrowing, etc., in the regulatory environment of clinical trials. Fundamental concepts of Bayesian sample size determination and illustrative examples are provided to serve as a valuable resource for researchers, clinicians, and statisticians seeking to develop more complex and innovative designs.
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Affiliation(s)
- Se Yoon Lee
- Department of Statistics, Texas A &M University, 3143 TAMU, College Station, TX, 77843, USA.
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Wahbi K, Bassez G, Duchateau J, Salort-Campana E, Vicart S, Desaphy JF, Labombarda F, Sellal JM, Deharo JC. Expert opinion on mexiletine treatment in adult patients with myotonic dystrophy. Arch Cardiovasc Dis 2024:S1875-2136(24)00059-7. [PMID: 38677940 DOI: 10.1016/j.acvd.2024.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 03/13/2024] [Accepted: 03/25/2024] [Indexed: 04/29/2024]
Abstract
In France, mexiletine - a class I antiarrhythmic drug - can be prescribed for the symptomatic treatment of myotonia of the skeletal muscles in adult patients with myotonic dystrophy under a compassionate use programme. Mexiletine is used according to its summary of product characteristics, which describes its use for myotonia treatment in adult patients with non-dystrophic myotonia, a different neuromuscular condition without cardiac involvement. A cardiac assessment is required prior to initiation and throughout treatment due to potential proarrhythmic effects. The presence of conduction system disease, the most common cardiac manifestation of myotonic dystrophy, mandates repeated cardiac evaluations in patients with this condition, and becomes even more important when they are given mexiletine. A group of experts, including three neurologists and five cardiologists from French neuromuscular reference centres, were involved in a task force to develop a treatment algorithm to guide mexiletine use in myotonic dystrophy. The recommendations are based on data from a literature review of the safety of mexiletine-treated patients with myotonic dystrophy, the compassionate use protocol for mexiletine and the personal clinical experience of the experts. The main conclusion of the expert group is that, although existing safety data in mexiletine-treated patients with myotonic dystrophy are reassuring, cardiac assessments should be reinforced in such patients compared with mexiletine-treated patients with non-dystrophic myotonia. This expert opinion to guide mexiletine treatment in patients with myotonic dystrophy should help to reduce the risk of severe adverse events and facilitate interactions between specialists involved in the routine care of patients with myotonic dystrophy.
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Affiliation(s)
- Karim Wahbi
- Centre de Référence des Maladies Neuromusculaires Nord/Est/Île-de-France, Cardiology Department, Cochin Hospital, AP-HP, Paris Cité University, 75014 Paris, France; Paris Cardiovascular Research Centre (PARCC), Inserm Unit 970, Georges-Pompidou European Hospital, 75015 Paris, France.
| | - Guillaume Bassez
- Constitutive Reference Centre for Neuromuscular Diseases, Neuro-Myology Department, Pitié-Salpêtrière University Hospital, AP-HP, 75013 Paris, France
| | - Josselin Duchateau
- Department of Cardiology, Electrophysiology and Cardiac Pacing, Haut l'Evêque Cardiology Hospital, CHU de Bordeaux, 33604 Pessac, France
| | - Emmanuelle Salort-Campana
- Reference Centre for Neuromuscular Diseases PACA/Réunion/Rhône Alpes, La Timone Hospital, CHU de Marseille, AP-HM, 13385 Marseille, France; FILNEMUS, Neuromuscular Rare Diseases Healthcare Professional Network, La Timone Hospital, CHU de Marseille, AP-HM, 13385 Marseille, France
| | - Savine Vicart
- Muscle Channelopathies Reference Centre, Neuro-Myology Department, Pitié-Salpêtrière University Hospital, AP-HP, Inserm UMR 974, Institute of Myology, Sorbonne University, 75013 Paris, France
| | - Jean-François Desaphy
- Department of Precision and Regenerative Medicine and Ionian Area, School of Medicine, University of Bari Aldo Moro, 70124 Bari, Italy
| | - Fabien Labombarda
- Cardiology Department, CHU de Caen, UR 4650, UNICAEN, 14000 Caen, France
| | | | - Jean-Claude Deharo
- Cardiology Department, La Timone Hospital, CHU de Marseille, AP-HM, 13385 Marseille, France; C2VN, Aix-Marseille Université, 13005 Marseille, France
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Selman CJ, Lee KJ, Ferguson KN, Whitehead CL, Manley BJ, Mahar RK. Statistical analyses of ordinal outcomes in randomised controlled trials: a scoping review. Trials 2024; 25:241. [PMID: 38582924 PMCID: PMC10998402 DOI: 10.1186/s13063-024-08072-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Accepted: 03/22/2024] [Indexed: 04/08/2024] Open
Abstract
BACKGROUND Randomised controlled trials (RCTs) aim to estimate the causal effect of one or more interventions relative to a control. One type of outcome that can be of interest in an RCT is an ordinal outcome, which is useful to answer clinical questions regarding complex and evolving patient states. The target parameter of interest for an ordinal outcome depends on the research question and the assumptions the analyst is willing to make. This review aimed to provide an overview of how ordinal outcomes have been used and analysed in RCTs. METHODS The review included RCTs with an ordinal primary or secondary outcome published between 2017 and 2022 in four highly ranked medical journals (the British Medical Journal, New England Journal of Medicine, The Lancet, and the Journal of the American Medical Association) identified through PubMed. Details regarding the study setting, design, the target parameter, and statistical methods used to analyse the ordinal outcome were extracted. RESULTS The search identified 309 studies, of which 144 were eligible for inclusion. The most used target parameter was an odds ratio, reported in 78 (54%) studies. The ordinal outcome was dichotomised for analysis in 47 ( 33 % ) studies, and the most common statistical model used to analyse the ordinal outcome on the full ordinal scale was the proportional odds model (64 [ 44 % ] studies). Notably, 86 (60%) studies did not explicitly check or describe the robustness of the assumptions for the statistical method(s) used. CONCLUSIONS The results of this review indicate that in RCTs that use an ordinal outcome, there is variation in the target parameter and the analytical approaches used, with many dichotomising the ordinal outcome. Few studies provided assurance regarding the appropriateness of the assumptions and methods used to analyse the ordinal outcome. More guidance is needed to improve the transparent reporting of the analysis of ordinal outcomes in future trials.
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Affiliation(s)
- Chris J Selman
- Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Parkville, VIC, 3052, Australia.
- Department of Paediatrics, University of Melbourne, Parkville, VIC, 3052, Australia.
| | - Katherine J Lee
- Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Parkville, VIC, 3052, Australia
- Department of Paediatrics, University of Melbourne, Parkville, VIC, 3052, Australia
| | - Kristin N Ferguson
- Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, VIC, 3052, Australia
| | - Clare L Whitehead
- Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, VIC, 3052, Australia
- Department of Maternal Fetal Medicine, The Royal Women's Hospital, Parkville, VIC, 3052, Australia
| | - Brett J Manley
- Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, VIC, 3052, Australia
- Newborn Research, The Royal Women's Hospital, Parkville, VIC, 3052, Australia
- Clinical Sciences, Murdoch Children's Research Institute, Parkville, VIC, 3052, Australia
| | - Robert K Mahar
- Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Parkville, VIC, 3052, Australia
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Parkville, VIC, 3052, Australia
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Zhou L, Schneider J, Arnrich B, Konigorski S. Analyzing population-level trials as N-of-1 trials: An application to gait. Contemp Clin Trials Commun 2024; 38:101282. [PMID: 38533473 PMCID: PMC10964044 DOI: 10.1016/j.conctc.2024.101282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 02/08/2024] [Accepted: 02/28/2024] [Indexed: 03/28/2024] Open
Abstract
Studying individual causal effects of health interventions is important whenever intervention effects are heterogeneous between study participants. Conducting N-of-1 trials, which are single-person randomized controlled trials, is the gold standard for their analysis. As an alternative method, we propose to re-analyze existing population-level studies as N-of-1 trials, and use gait as a use case for illustration. Gait data were collected from 16 young and healthy participants under fatigued and non-fatigued, as well as under single-task (only walking) and dual-task (walking while performing a cognitive task) conditions. As a reference to the N-of-1 trials approach, we first computed standard population-level ANOVA models to evaluate differences in gait parameters (stride length and stride time) across conditions. Then, we estimated the effect of the interventions on gait parameters on the individual level through Bayesian repeated-measures models, viewing each participant as their own trial, and compared the results. The results illustrated that while few overall population-level effects were visible, individual-level analyses revealed differences between participants. Baseline values of the gait parameters varied largely among all participants, and the effects of fatigue and cognitive task were also heterogeneous, with some individuals showing effects in opposite directions. These differences between population-level and individual-level analyses were more pronounced for the fatigue intervention compared to the cognitive task intervention. Following our empirical analysis, we discuss re-analyzing population studies through the lens of N-of-1 trials more generally and highlight important considerations and requirements. Our work encourages future studies to investigate individual effects using population-level data.
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Affiliation(s)
- Lin Zhou
- Digital Health - Connected Healthcare, Hasso Plattner Institute, University of Potsdam, Potsdam, Germany
| | - Juliana Schneider
- Digital Health & Machine Learning, Hasso Plattner Institute, University of Potsdam, Potsdam, Germany
| | - Bert Arnrich
- Digital Health - Connected Healthcare, Hasso Plattner Institute, University of Potsdam, Potsdam, Germany
| | - Stefan Konigorski
- Digital Health & Machine Learning, Hasso Plattner Institute, University of Potsdam, Potsdam, Germany
- Department of Statistics, Harvard University, Cambridge, USA
- Hasso Plattner Institute for Digital Health at Mount Sinai, Icahn School of Medicine at Mount Sinai, NY, USA
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Aydin O. Rise of single-case experimental designs: A historical overview of the necessity of single-case methodology. Neuropsychol Rehabil 2024; 34:301-334. [PMID: 36811612 DOI: 10.1080/09602011.2023.2181191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 02/13/2023] [Indexed: 02/24/2023]
Abstract
ABSTRACTWindelband ([1894]1980) advocated that two approaches are used for accumulating scientific knowledge. The first is the idiographic approach that derives knowledge from a single unit, and the second is the nomothetic approach that accumulates knowledge of a group. Given these two approaches, the former matches case studies while the latter is more appropriate with experimental group studies. Scientists have criticized both methodologies for their various limitations. Later, the single-case methodology emerged as an alternative that potentially allays these limitations. In this context, this narrative review aims to describe the historical roots of single-case experimental designs (SCEDs) that have emerged to eliminate the tension of nomothetic and idiographic approaches over time. First, the review focuses on the emergence of SCEDs. Second, the strengths and challenges of SCEDs are reviewed, including those to address the limitations of group experimental and case studies. Third, the use and analyses of SCEDs are outlined, considering their current status. Fourth, this narrative review continues to delineate the dissemination of SCEDs in the modern scientific world. As a result, SCEDs can be evaluated as a method that has the potential to overcome the issues encountered in case description and group experimental research. Thus, that helps accumulate nomothetic and idiographic knowledge in determining evidence-based practices.
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Affiliation(s)
- Orhan Aydin
- Faculty of Education, Erzincan Binali Yildirim University, Erzincan, Türkiye
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Giannuzzi V, Bertolani A, Torretta S, Reggiardo G, Toich E, Bonifazi D, Ceci A. Innovative research methodologies in the EU regulatory framework: an analysis of EMA qualification procedures from a pediatric perspective. Front Med (Lausanne) 2024; 11:1369547. [PMID: 38606157 PMCID: PMC11007141 DOI: 10.3389/fmed.2024.1369547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 03/13/2024] [Indexed: 04/13/2024] Open
Abstract
Introduction The European Medicines Agency (EMA) offers scientific advice to support the qualification procedure of novel methodologies, such as preclinical and in vitro models, biomarkers, and pharmacometric methods, thereby endorsing their acceptability in medicine research and development (R&D). This aspect is particularly relevant to overcome the scarcity of data and the lack of validated endpoints and biomarkers in research fields characterized by small samples, such as pediatrics. Aim This study aimed to analyze the potential pediatric interest in methodologies qualified as "novel methodologies for medicine development" by the EMA. Methods The positive qualification opinions of novel methodologies for medicine development published on the EMA website between 2008 and 2023 were identified. Multi-level analyses were conducted to investigate data with a hierarchical structure and the effects of cluster-level variables and cluster-level variances and to evaluate their potential pediatric interest, defined as the possibility of using the novel methodology in pediatric R&D and the availability of pediatric data. The duration of the procedure, the type of methodology, the specific disease or disease area addressed, the type of applicant, and the availability of pediatric data at the time of the opinion release were also investigated. Results Most of the 27 qualifications for novel methodologies issued by the EMA (70%) were potentially of interest to pediatric patients, but only six of them reported pediatric data. The overall duration of qualification procedures with pediatric interest was longer than that of procedures without any pediatric interest (median time: 7 months vs. 3.5 months, respectively; p = 0.082). In parallel, qualification procedures that included pediatric data lasted for a longer period (median time: 8 months vs. 6 months, respectively; p = 0.150). Nephrology and neurology represented the main disease areas (21% and 16%, respectively), while endpoints, biomarkers, and registries represented the main types of innovative methodologies (32%, 26%, and 16%, respectively). Discussion Our results underscore the importance of implementing innovative methodologies in regulatory-compliant pediatric research activities. Pediatric-dedicated research infrastructures providing regulatory support and strategic advice during research activities could be crucial to the design of ad hoc pediatric methodologies or to extend and validate them for pediatrics.
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Affiliation(s)
- Viviana Giannuzzi
- Department of Research, Fondazione per la Ricerca Farmacologica Gianni Benzi Onlus, Bari, Italy
| | - Arianna Bertolani
- Department of Project Development, Consorzio per Valutazioni Biologiche e Farmacologiche (CVBF), Pavia, Italy
- TEDDY, European Network of Excellence for Paediatric Research, Pavia, Italy
| | - Silvia Torretta
- TEDDY, European Network of Excellence for Paediatric Research, Pavia, Italy
| | - Giorgio Reggiardo
- Department of Project Development, Consorzio per Valutazioni Biologiche e Farmacologiche (CVBF), Pavia, Italy
| | - Eleonora Toich
- Department of Project Development, Consorzio per Valutazioni Biologiche e Farmacologiche (CVBF), Pavia, Italy
| | - Donato Bonifazi
- Department of Project Development, Consorzio per Valutazioni Biologiche e Farmacologiche (CVBF), Pavia, Italy
- TEDDY, European Network of Excellence for Paediatric Research, Pavia, Italy
| | - Adriana Ceci
- Department of Research, Fondazione per la Ricerca Farmacologica Gianni Benzi Onlus, Bari, Italy
- TEDDY, European Network of Excellence for Paediatric Research, Pavia, Italy
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Lloyd A, Rand K, Pike C, Ellis C. Preference-based utility weights for the Individualized Neuromuscular Quality of Life Questionnaire (INQoL), with a focus on non-dystrophic myotonia (NDM). Eur J Health Econ 2024:10.1007/s10198-024-01674-2. [PMID: 38416296 DOI: 10.1007/s10198-024-01674-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 01/18/2024] [Indexed: 02/29/2024]
Abstract
INTRODUCTION The Individualized Neuromuscular Quality of Life Questionnaire (INQoL) is used to measure quality of life in neuromuscular disorders such as non-dystrophic myotonia (NDM). Here we report methods to estimate utilities, with a focus on NDM, from this questionnaire based on two preference elicitation exercises. METHODS Eight items from the INQoL were selected with input from three neuromuscular disorder clinical experts with expertise in treating NDM. A discrete choice experiment (DCE) survey of UK general public respondents (n = 508) described outcomes defined by the INQoL items. The same 8 items were also valued using time trade-off (TTO) face-to-face interviews (n = 200). A hybrid regression modelling approach combined both datasets to inform the utility weights. RESULTS Hybrid modelling of DCE and TTO data in conjunction improved out-of-sample predictive accuracy. The selected INQoL utility model indicates substantial disutility associated with all eight dimensions of health, with the greatest losses associated with subjective items such as pain and depression. DISCUSSION The hybrid modelling approach allows us to combine data from the two methodologies and maximize the information from each to inform the utility weights for the INQoL. The TTO is the more conventional valuation method, but combined with the larger DCE study produced better descriptive coverage. This is a relatively novel method for estimating weights which we think is particularly well suited to economic evaluations of orphan drugs.
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Affiliation(s)
| | - Kim Rand
- Health Services Research Unit, Akershus University Hospital, Lørenskog, Norway
- Maths in Health B.V., Klimmen, The Netherlands
| | - Cleo Pike
- Acaster Lloyd Consulting Ltd, London, UK
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Elettreby AM, Elnaga AAA, Alsaied MA, Ewis DK, Sharkawy AM, Fareed R, Alderbi GM. Effectiveness and safety of mexiletine versus placebo in patients with myotonia: a systematic review and meta-analysis. Neurol Sci 2024:10.1007/s10072-024-07412-z. [PMID: 38403671 DOI: 10.1007/s10072-024-07412-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 02/16/2024] [Indexed: 02/27/2024]
Abstract
BACKGROUND The rare nature of dystrophic and non-dystrophic myotonia has limited the available evidence on the efficacy of mexiletine as a potential treatment. To address this gap, we conducted a systematic review and meta-analysis to evaluate the effectiveness and safety of mexiletine for both dystrophic and non-dystrophic myotonic patients. METHODS The search was conducted on various electronic databases up to March 2023, for randomized clinical trials (RCTs) comparing mexiletine versus placebo in myotonic patients. A risk of bias assessment was carried out, and relevant data was extracted manually into an online sheet. RevMan software (version 5.4) was employed for analysis. RESULTS A total of five studies, comprising 186 patients, were included in the meta-analysis. Our findings showed that mexiletine was significantly more effective than placebo in improving stiffness score (SMD = - 1.19, 95% CI [- 1.53, - 0.85]), as well as in reducing hand grip myotonia (MD = - 1.36 s, 95% CI [- 1.83, - 0.89]). Mexiletine also significantly improved SF-36 Physical and Mental Component Score in patients with non-dystrophic myotonia only. Regarding safety, mexiletine did not significantly alter ECG parameters but was associated with greater gastrointestinal symptoms (GIT) compared to placebo (RR 3.7, 95% CI [1.79, 7.64]). Other adverse events showed no significant differences. CONCLUSION The results support that mexiletine is effective and safe in myotonic patients; however, it is associated with a higher risk of GIT symptoms. Due to the scarcity of published RCTs and the prevalence of GIT symptoms, we recommend further well-designed RCTs testing various drug combinations to reduce GIT symptoms.
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Affiliation(s)
- Abdelrahman Mohammed Elettreby
- Faculty of Medicine, Mansoura University, El Gomhouria St, Mansoura, 35511, Egypt.
- Medical Research Group of Egypt, Negida Academy LLC, Arlington, MA, 02474, USA.
| | - Ahmed Abdullah Abo Elnaga
- Faculty of Medicine, Mansoura University, El Gomhouria St, Mansoura, 35511, Egypt
- Medical Research Group of Egypt, Negida Academy LLC, Arlington, MA, 02474, USA
| | - Mohamed Ahmed Alsaied
- Faculty of Medicine, Mansoura University, El Gomhouria St, Mansoura, 35511, Egypt
- Medical Research Group of Egypt, Negida Academy LLC, Arlington, MA, 02474, USA
| | - Dalia Kamal Ewis
- Medical Research Group of Egypt, Negida Academy LLC, Arlington, MA, 02474, USA
- Faculty of Medicine, Beni Suef University, Beni Suef, Egypt
| | - Aya Mohammed Sharkawy
- Medical Research Group of Egypt, Negida Academy LLC, Arlington, MA, 02474, USA
- Faculty of Medicine, South Valley University, Qena, Egypt
| | - Rahma Fareed
- Medical Research Group of Egypt, Negida Academy LLC, Arlington, MA, 02474, USA
- Faculty of Pharmacy, Beni Suef University, Beni Suef, Egypt
| | - Gehad Magdy Alderbi
- Medical Research Group of Egypt, Negida Academy LLC, Arlington, MA, 02474, USA
- Faculty of Pharmacy, Beni Suef University, Beni Suef, Egypt
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9
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Müller AR, den Hollander B, van de Ven PM, Roes KCB, Geertjens L, Bruining H, van Karnebeek CDM, Jansen FE, de Wit MCY, Ten Hoopen LW, Rietman AB, Dierckx B, Wijburg FA, Boot E, Brands MMG, van Eeghen AM. Cannabidiol (Epidyolex®) for severe behavioral manifestations in patients with tuberous sclerosis complex, mucopolysaccharidosis type III and fragile X syndrome: protocol for a series of randomized, placebo-controlled N-of-1 trials. BMC Psychiatry 2024; 24:23. [PMID: 38177999 PMCID: PMC10768432 DOI: 10.1186/s12888-023-05422-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 11/29/2023] [Indexed: 01/06/2024] Open
Abstract
BACKGROUND Many rare genetic neurodevelopmental disorders (RGNDs) are characterized by intellectual disability (ID), severe cognitive and behavioral impairments, potentially diagnosed as a comorbid autism spectrum disorder or attention-deficit hyperactivity disorder. Quality of life is often impaired due to irritability, aggression and self-injurious behavior, generally refractory to standard therapies. There are indications from previous (case) studies and patient reporting that cannabidiol (CBD) may be an effective treatment for severe behavioral manifestations in RGNDs. However, clear evidence is lacking and interventional research is challenging due to the rarity as well as the heterogeneity within and between disease groups and interindividual differences in treatment response. Our objective is to examine the effectiveness of CBD on severe behavioral manifestations in three RGNDs, including Tuberous Sclerosis Complex (TSC), mucopolysaccharidosis type III (MPS III), and Fragile X syndrome (FXS), using an innovative trial design. METHODS We aim to conduct placebo-controlled, double-blind, block-randomized, multiple crossover N-of-1 studies with oral CBD (twice daily) in 30 patients (aged ≥ 6 years) with confirmed TSC, MPS III or FXS and severe behavioral manifestations. The treatment is oral CBD up to a maximum of 25 mg/kg/day, twice daily. The primary outcome measure is the subscale irritability of the Aberrant Behavior Checklist. Secondary outcome measures include (personalized) patient-reported outcome measures with regard to behavioral and psychiatric outcomes, disease-specific outcome measures, parental stress, seizure frequency, and adverse effects of CBD. Questionnaires will be completed and study medication will be taken at the participants' natural setting. Individual treatment effects will be determined based on summary statistics. A mixed model analysis will be applied for analyzing the effectiveness of the intervention per disorder and across disorders combining data from the individual N-of-1 trials. DISCUSSION These N-of-1 trials address an unmet medical need and will provide information on the effectiveness of CBD for severe behavioral manifestations in RGNDs, potentially generating generalizable knowledge at an individual-, disorder- and RGND population level. TRIAL REGISTRATION EudraCT: 2021-003250-23, registered 25 August 2022, https://www.clinicaltrialsregister.eu/ctr-search/trial/2021-003250-23/NL .
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Affiliation(s)
- A R Müller
- Department of Pediatrics, Emma Children's Hospital, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- 's Heeren Loo Care Group, Amersfoort, The Netherlands
- Emma Center for Personalized Medicine, Amsterdam UMC, Amsterdam, the Netherlands
| | - B den Hollander
- Department of Pediatrics, Emma Children's Hospital, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Emma Center for Personalized Medicine, Amsterdam UMC, Amsterdam, the Netherlands
- United for Metabolic Diseases, Amsterdam, The Netherlands
| | - P M van de Ven
- Department of Data Science and Biostatistics, University Medical Center Utrecht, Utrecht, The Netherlands
| | - K C B Roes
- Department of Health Evidence, Biostatistics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - L Geertjens
- Child and Adolescent Psychiatry and Psychosocial Care, Amsterdam UMC Location Vrije Universiteit, Amsterdam, The Netherlands
- Amsterdam UMC, Amsterdam Neuroscience, Amsterdam Reproduction and Development, N=You Neurodevelopmental Precision Center, Amsterdam, The Netherlands
| | - H Bruining
- Emma Center for Personalized Medicine, Amsterdam UMC, Amsterdam, the Netherlands
- Child and Adolescent Psychiatry and Psychosocial Care, Amsterdam UMC Location Vrije Universiteit, Amsterdam, The Netherlands
- Amsterdam UMC, Amsterdam Neuroscience, Amsterdam Reproduction and Development, N=You Neurodevelopmental Precision Center, Amsterdam, The Netherlands
- Levvel, Center for Child and Adolescent Psychiatry, Amsterdam, The Netherlands
| | - C D M van Karnebeek
- Department of Pediatrics, Emma Children's Hospital, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Emma Center for Personalized Medicine, Amsterdam UMC, Amsterdam, the Netherlands
- United for Metabolic Diseases, Amsterdam, The Netherlands
- Department of Human Genetics, Amsterdam UMC, Amsterdam, The Netherlands
| | - F E Jansen
- Department of Pediatric Neurology, Brain, University Medical Center Utrecht, Utrecht, The Netherlands
| | - M C Y de Wit
- ENCORE Expertise Center for Neurodevelopmental Disorders, Erasmus University Medical Center, Rotterdam, The Netherlands
- Department of Neurology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - L W Ten Hoopen
- ENCORE Expertise Center for Neurodevelopmental Disorders, Erasmus University Medical Center, Rotterdam, The Netherlands
- Department of Child and Adolescent Psychiatry/Psychology, Sophia Children's Hospital, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - A B Rietman
- ENCORE Expertise Center for Neurodevelopmental Disorders, Erasmus University Medical Center, Rotterdam, The Netherlands
- Department of Child and Adolescent Psychiatry/Psychology, Sophia Children's Hospital, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - B Dierckx
- ENCORE Expertise Center for Neurodevelopmental Disorders, Erasmus University Medical Center, Rotterdam, The Netherlands
- Department of Child and Adolescent Psychiatry/Psychology, Sophia Children's Hospital, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - F A Wijburg
- Department of Pediatrics, Emma Children's Hospital, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - E Boot
- 's Heeren Loo Care Group, Amersfoort, The Netherlands
- The Dalglish Family 22Q Clinic, Toronto, ON, Canada
- Department of Psychiatry & Neuropsychology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - M M G Brands
- Department of Pediatrics, Emma Children's Hospital, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Emma Center for Personalized Medicine, Amsterdam UMC, Amsterdam, the Netherlands
- United for Metabolic Diseases, Amsterdam, The Netherlands
| | - A M van Eeghen
- Department of Pediatrics, Emma Children's Hospital, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands.
- 's Heeren Loo Care Group, Amersfoort, The Netherlands.
- Emma Center for Personalized Medicine, Amsterdam UMC, Amsterdam, the Netherlands.
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10
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Zhai J, Liu AF, Yu W, Guo T. Baduanjin exercise for chronic non-specific low back pain: protocol for a series of N-of-1 trials. BMJ Open 2023; 13:e070703. [PMID: 37963698 PMCID: PMC10649392 DOI: 10.1136/bmjopen-2022-070703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 10/25/2023] [Indexed: 11/16/2023] Open
Abstract
INTRODUCTION Chronic non-specific low back pain (CNLBP) is one of the most common health problems worldwide. According to the clinical guideline released by the American College of Physicians, exercise has been recommended for the treatment of chronic LBP. In recent years, traditional Chinese medicine (TCM) is becoming increasingly popular for the management of chronic LBP. Baduanjin exercise is one of the exercise therapies in TCM. N-of-1 trial is a randomised cross-over self-controlled trial suitable for patients with this chronic disease. A series of similar N-of-1 trials can be pooled to estimate the overall and individual therapeutic effects synchronously by hierarchical Bayesian analysis. And N-of-1 trials are considered as a good tool for evaluating the therapeutic effect of TCM. Therefore, this study aims to conduct a series of N-of-1 trials with hierarchical Bayesian analysis for assessing whether Baduanjin exercise is effective and safe for CNLBP. METHODS AND ANALYSIS This study conducts a series of N-of-1 trials on Baduanjin exercise for the management of CNLBP. Fifty participants will receive 1-3 treatment cycles. They will be randomised into a Baduanjin exercise or waiting list group for a week during the two periods of each treatment cycle. The primary outcome is the 10-point Visual Analogue Scale. The secondary outcomes include the Oswestry Disability Index, the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire and the Short Form Health Survey 12. Statistical analysis will be conducted with WinBUGS V.1.4.3 software. Overall and individual therapeutic effects will be estimated synchronously by hierarchical Bayesian analysis. ETHICS AND DISSEMINATION This study is approved by the Medical Ethics Committee of Tianjin University of TCM (reference number TJUTCM-EC20220005). Our findings will be published in a peer-reviewed journal or international conference. TRIAL REGISTRATION NUMBER ChiCTR2200063307.
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Affiliation(s)
- Jingbo Zhai
- School of Public Health, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Ai Feng Liu
- Department of Orthopaedic Surgery, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Weijie Yu
- Department of Orthopaedic Surgery, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Tianci Guo
- Department of Orthopaedic Surgery, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
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11
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Defelippe VM, J M W van Thiel G, Otte WM, Schutgens REG, Stunnenberg B, Cross HJ, O'Callaghan F, De Giorgis V, Jansen FE, Perucca E, Brilstra EH, Braun KPJ. Toward responsible clinical n-of-1 strategies for rare diseases. Drug Discov Today 2023; 28:103688. [PMID: 37356616 DOI: 10.1016/j.drudis.2023.103688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 06/08/2023] [Accepted: 06/20/2023] [Indexed: 06/27/2023]
Abstract
N-of-1 strategies can provide high-quality evidence of treatment efficacy at the individual level and optimize evidence-based selection of off-label treatments for patients with rare diseases. Given their design characteristics, n-of-1 strategies are considered to lay at the intersection between medical research and clinical care. Therefore, whether n-of-1 strategies should be governed by research or care regulations remains a debated issue. Here, we delineate differences between medical research and optimized clinical care, and distinguish the regulations which apply to either. We also set standards for responsible optimized clinical n-of-1 strategies with (off-label) treatments for rare diseases. Implementing clinical n-of-1 strategies as defined here could aid in optimized treatment selection for such diseases.
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Affiliation(s)
- Victoria M Defelippe
- Department of Child Neurology, UMCU Brain Center, University Medical Center Utrecht, Universiteitsweg 100, 3584 CG Utrecht, the Netherlands; European Reference Network for Rare and Complex Epilepsies (EpiCare), Department of Paediatric Clinical Epileptology, Sleep Disorders and Functional Neurology, c/o Pr Arzimanoglou, Hôpital Femme Mère Enfant, 59 Boulevard Pinel, 69677 Bron, France.
| | - Ghislaine J M W van Thiel
- Department of Medical Humanities, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Universiteitsweg 100, 3584 CG Utrecht, the Netherlands
| | - Willem M Otte
- Department of Child Neurology, UMCU Brain Center, University Medical Center Utrecht, Universiteitsweg 100, 3584 CG Utrecht, the Netherlands
| | - Roger E G Schutgens
- Van Creveldkliniek, Benign Hematology Center, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands; European Reference Network for Oncological and non-oncological Rare Hematological Diseases (EuroBloodNet), Hôpital St Louis / Université Paris 7, 1 Avenue Claude Vellefaux, 75475 Paris, France
| | - Bas Stunnenberg
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Donders Center for Medical Neuroscience, Radboud University Medical Center, Thomas van Aquinostraat 4, 6525 GD Nijmegen, the Netherlands
| | - Helen J Cross
- European Reference Network for Rare and Complex Epilepsies (EpiCare), Department of Paediatric Clinical Epileptology, Sleep Disorders and Functional Neurology, c/o Pr Arzimanoglou, Hôpital Femme Mère Enfant, 59 Boulevard Pinel, 69677 Bron, France; University College London (UCL) Great Ormond Street, Institute of Child Health, 30 Guilford Street, London WC1N 1EH, UK
| | - Finbar O'Callaghan
- European Reference Network for Rare and Complex Epilepsies (EpiCare), Department of Paediatric Clinical Epileptology, Sleep Disorders and Functional Neurology, c/o Pr Arzimanoglou, Hôpital Femme Mère Enfant, 59 Boulevard Pinel, 69677 Bron, France; Paediatric Neuroscience, UCL Great Ormond Street, Institute of Child Health, 30 Guilford Street, London WC1N 1EH, UK
| | - Valentina De Giorgis
- European Reference Network for Rare and Complex Epilepsies (EpiCare), Department of Paediatric Clinical Epileptology, Sleep Disorders and Functional Neurology, c/o Pr Arzimanoglou, Hôpital Femme Mère Enfant, 59 Boulevard Pinel, 69677 Bron, France; Fondazione Mondino National Institute of Neurology, University of Pavia, Via Mondino 2, 27100 Pavia, Italy
| | - Floor E Jansen
- Department of Child Neurology, UMCU Brain Center, University Medical Center Utrecht, Universiteitsweg 100, 3584 CG Utrecht, the Netherlands; European Reference Network for Rare and Complex Epilepsies (EpiCare), Department of Paediatric Clinical Epileptology, Sleep Disorders and Functional Neurology, c/o Pr Arzimanoglou, Hôpital Femme Mère Enfant, 59 Boulevard Pinel, 69677 Bron, France
| | - Emilio Perucca
- European Reference Network for Rare and Complex Epilepsies (EpiCare), Department of Paediatric Clinical Epileptology, Sleep Disorders and Functional Neurology, c/o Pr Arzimanoglou, Hôpital Femme Mère Enfant, 59 Boulevard Pinel, 69677 Bron, France; Department of Medicine, University of Melbourne (Austin Health), Heidelberg, VIC 3084, Australia; Department of Neuroscience, Monash University, Melbourne, VIC, Australia
| | - Eva H Brilstra
- European Reference Network for Rare and Complex Epilepsies (EpiCare), Department of Paediatric Clinical Epileptology, Sleep Disorders and Functional Neurology, c/o Pr Arzimanoglou, Hôpital Femme Mère Enfant, 59 Boulevard Pinel, 69677 Bron, France; Department of Genetics, Center for Molecular Medicine, University Medical Center Utrecht, Universiteitsweg 100, 3584 CG Utrecht, the Netherlands
| | - Kees P J Braun
- European Reference Network for Rare and Complex Epilepsies (EpiCare), Department of Paediatric Clinical Epileptology, Sleep Disorders and Functional Neurology, c/o Pr Arzimanoglou, Hôpital Femme Mère Enfant, 59 Boulevard Pinel, 69677 Bron, France; Department of Child Neurology, UMCU Brain Center, University Medical Center Utrecht, Universiteitsweg 100, 3584 CG Utrecht, the Netherlands
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12
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Gärtner T, Schneider J, Arnrich B, Konigorski S. Comparison of Bayesian Networks, G-estimation and linear models to estimate causal treatment effects in aggregated N-of-1 trials with carry-over effects. BMC Med Res Methodol 2023; 23:191. [PMID: 37605171 PMCID: PMC10440905 DOI: 10.1186/s12874-023-02012-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 08/07/2023] [Indexed: 08/23/2023] Open
Abstract
BACKGROUND The aggregation of a series of N-of-1 trials presents an innovative and efficient study design, as an alternative to traditional randomized clinical trials. Challenges for the statistical analysis arise when there is carry-over or complex dependencies of the treatment effect of interest. METHODS In this study, we evaluate and compare methods for the analysis of aggregated N-of-1 trials in different scenarios with carry-over and complex dependencies of treatment effects on covariates. For this, we simulate data of a series of N-of-1 trials for Chronic Nonspecific Low Back Pain based on assumed causal relationships parameterized by directed acyclic graphs. In addition to existing statistical methods such as regression models, Bayesian Networks, and G-estimation, we introduce a carry-over adjusted parametric model (COAPM). RESULTS The results show that all evaluated existing models have a good performance when there is no carry-over and no treatment dependence. When there is carry-over, COAPM yields unbiased and more efficient estimates while all other methods show some bias in the estimation. When there is known treatment dependence, all approaches that are capable to model it yield unbiased estimates. Finally, the efficiency of all methods decreases slightly when there are missing values, and the bias in the estimates can also increase. CONCLUSIONS This study presents a systematic evaluation of existing and novel approaches for the statistical analysis of a series of N-of-1 trials. We derive practical recommendations which methods may be best in which scenarios.
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Affiliation(s)
- Thomas Gärtner
- Digital Health Center, Hasso Plattner Institute for Digital Engineering, Potsdam, Germany.
- University of Potsdam, Digital Engineering Faculty, Potsdam, Germany.
| | - Juliana Schneider
- Digital Health Center, Hasso Plattner Institute for Digital Engineering, Potsdam, Germany
- University of Potsdam, Digital Engineering Faculty, Potsdam, Germany
| | - Bert Arnrich
- Digital Health Center, Hasso Plattner Institute for Digital Engineering, Potsdam, Germany
- University of Potsdam, Digital Engineering Faculty, Potsdam, Germany
| | - Stefan Konigorski
- Digital Health Center, Hasso Plattner Institute for Digital Engineering, Potsdam, Germany.
- University of Potsdam, Digital Engineering Faculty, Potsdam, Germany.
- Hasso Plattner Institute for Digital Health at Mount Sinai, Icahn School of Medicine at Mount Sinai, New York, USA.
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13
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Matthews E, Palace J, Ramdas S, Sansone V, Tristani-Firouzi M, Vicart S, Willis T. Care Recommendations for the Investigation and Management of Children With Skeletal Muscle Channelopathies. Pediatr Neurol 2023; 145:102-111. [PMID: 37315339 DOI: 10.1016/j.pediatrneurol.2023.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 05/12/2023] [Accepted: 05/14/2023] [Indexed: 06/16/2023]
Abstract
The field of pediatric skeletal muscle channelopathies has seen major new advances in terms of a wider understanding of clinical presentations and new phenotypes. Skeletal muscle channelopathies cause significant disability and even death in some of the newly described phenotypes. Despite this, there are virtually no data on the epidemiology and longitudinal natural history of these conditions or randomized controlled trial evidence of efficacy or tolerability of any treatment in children, and thus best practice care recommendations do not exist. Clinical history, and to a lesser extent examination, is key to eliciting symptoms and signs that indicate a differential diagnosis of muscle channelopathy. Normal routine investigations should not deter one from the diagnosis. Specialist neurophysiologic investigations have an additional role, but their availability should not delay genetic testing. New phenotypes are increasingly likely to be identified by next-generation sequencing panels. Many treatments or interventions for symptomatic patients are available, with anecdotal data to support their benefit, but we lack trial data on efficacy, safety, or superiority. This lack of trial data in turn can lead to hesitancy in prescribing among doctors or in accepting medication by parents. Holistic management addressing work, education, activity, and additional symptoms of pain and fatigue provides significant benefit. Preventable morbidity and sometimes mortality occurs if the diagnosis and therefore treatment is delayed. Advances in genetic sequencing technology and greater access to testing may help to refine recently identified phenotypes, including histology, as more cases are described. Randomized controlled treatment trials are required to inform best practice care recommendations. A holistic approach to management is essential and should not be overlooked. Good quality data on prevalence, health burden, and optimal treatment are urgently needed.
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Affiliation(s)
- Emma Matthews
- Department of Neurology, Atkinson-Morley Neuromuscular Centre, St George's University Hospitals NHS Foundation Trust, and Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK.
| | - Jacqueline Palace
- Clinical Neurology, John Radcliffe Hospital, Oxford University Foundation Trust, Oxford, UK; Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Sithara Ramdas
- Department of Paediatrics, MDUK Neuromuscular Centre, University of Oxford, Oxford, UK; Department of Paediatric Neurology, John Radcliffe Hospital, Oxford, UK
| | - Valeria Sansone
- Neurorehabilitation Unit, Neuromuscular Omnicentre Clinical Center, Niguarda Hospital, University of Milan, Milan, Italy
| | - Martin Tristani-Firouzi
- Nora Eccles Harrison Cardiovascular Research and Training Institute and the Division of Paediatric Cardiology, University of Utah, Salt Lake City, Utah
| | - Savine Vicart
- Reference Centre for Neuromuscular Disorders, APHP, Institute of Myology, Pitié-Salpêtrière Hospital, Paris, France
| | - Tracey Willis
- Robert Jones and Agnes Hunt Orthopaedic Hospital, NHS Foundation Trust, Oswestry, England
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14
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Monfort A, Morin C, Jutras M, Charest S, Leclair G, Ferreira E. Transfer of Mexiletine into Breast Milk: A Case Report. Breastfeed Med 2023. [PMID: 37184533 DOI: 10.1089/bfm.2023.0042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
Background: Mexiletine is a class 1B antiarrhythmic agent, used to treat ventricular arrhythmias, and noncardiac-related problems such as myotonia. Limited safety data are available on the transfer of this drug into breast milk. Case Report: We report the case of a woman diagnosed with myotonia congenita who breastfed two children after two consecutive pregnancies. During the breastfeeding of the first and the second infant, she collected, respectively, five and seven samples at 0, 2, 4, 6, and 8 hours and 0, 1, 2, 3, 4, 6, and 8 hours after taking 200 mg of mexiletine thrice daily for seven doses. One week after the collection, samples were analyzed with a validated liquid chromatography tandem mass spectrometry method. No side effect was observed in either child according to the mother. Results: Using the mean milk concentrations, it is estimated that an exclusively breastfed infant would receive a maximum of 5.14% of the initial pediatric mexiletine dosage. We calculated a maximum of 2.67% for the first infant in our case, considering a nonexclusive breastfeeding. Maximal concentrations were observed 1-2 hours after the dose of mexiletine. Results seem to be in accordance with the two cases previously published. Conclusions: Mexiletine transfers into breast milk in low levels. However, results are obtained from only one woman. Therefore, caution should be used when mexiletine is prescribed to breastfeeding women. More cases are needed to evaluate the interindividual variability and to guide women regarding breastfeeding with mexiletine.
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Affiliation(s)
- Anaëlle Monfort
- Faculté de Pharmacie, Université de Montréal, Montreal, Quebec, Canada
| | - Caroline Morin
- Department of Pharmacy, CHU Sainte-Justine, Montreal, Quebec, Canada
| | - Martin Jutras
- Faculté de Pharmacie, Université de Montréal, Montreal, Quebec, Canada
| | - Stéphane Charest
- Department of Neurology, CIUSSS Mauricie et Centre du Québec, Trois-Rivières, Quebec, Canada
| | - Grégoire Leclair
- Faculté de Pharmacie, Université de Montréal, Montreal, Quebec, Canada
| | - Ema Ferreira
- Faculté de Pharmacie, Université de Montréal, Montreal, Quebec, Canada
- Department of Pharmacy, CHU Sainte-Justine, Montreal, Quebec, Canada
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15
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Yang L, Armijo-Olivo S, Gross DP. Single-Case Experimental Design in Rehabilitation: Basic Concepts, Advantages, and Challenges. Am J Phys Med Rehabil 2023; 102:454-460. [PMID: 36811559 DOI: 10.1097/phm.0000000000002215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
ABSTRACT Single-case experimental design is a family of experimental methods that can be used to examine the efficacy of interventions by testing a small number of patients or cases. This article provides an overview of single-case experimental design research for use in rehabilitation as another option along with traditional group-based research when studying rare cases and rehabilitation interventions of unknown efficacy. Basic concepts related to single-case experimental design and the characteristics of common subtypes ( N-of-1 randomized controlled trial, withdrawal design, multiple-baseline design, multiple-treatment design, changing criterion/intensity design, and alternating treatment design) are introduced. The advantages and disadvantages of each subtype are discussed along with challenges in data analysis and interpretation. Criteria and caveats for interpreting single-case experimental design results and their use in evidence-based practice decisions are discussed. Recommendations are provided for appraising single-case experimental design articles as well as using single-case experimental design principles to improve real-world clinical evaluation.
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Affiliation(s)
- Lujia Yang
- From the Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Canada (LY, SA-O, DPG); and University of Applied Sciences Osnabrück, Faculty of Economics and Social Sciences, Osnabrück, Germany (SA-O)
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16
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Vamos M, Zsigmond EJ, Hohnloser SH. Indications for mexiletine in the new ESC guidelines and beyond. Expert Opin Pharmacother 2023; 24:1403-1407. [PMID: 37306465 DOI: 10.1080/14656566.2023.2223964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 06/05/2023] [Indexed: 06/13/2023]
Abstract
INTRODUCTION Mexiletine is a class IB sodium-channel blocker. Unlike class IA or IC antiarrhythmic drugs, mexiletine rather shortens than prolongs action potential duration; therefore, it is less associated with proarrhythmic effects. AREAS COVERED Recently, new European Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death were published, including a reappraisal of some established older antiarrhythmic drugs. EXPERT OPINION Mexiletine offers a first-line, genotype-specific treatment strategy for LQT3 patients as emphasized by the most recent guidelines. Besides this recommendation, current study reports suggest that in therapy-refractory ventricular tachyarrhythmias and electrical storms adjunctive mexiletine treatment may offer the possibility of stabilizing patients with or without concomitant interventional therapy such as catheter ablation.
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Affiliation(s)
- Mate Vamos
- Cardiac Electrophysiology Division, Department of Internal Medicine, University of Szeged, Szeged, Hungary
| | - Elod-Janos Zsigmond
- Doctoral School of Clinical Medicine, University of Szeged, Szeged, Hungary
- Department of Cardiology, Medical Centre, Hungarian Defence Forces, Budapest, Hungary
| | - Stefan H Hohnloser
- Department of Cardiology, J. W. Goethe University, Frankfurt Am Main, Germany
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17
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Moreno CAI, Kraeva N, Zvaritch E, Jungbluth H, Voermans NC, Riazi S. Oral Dantrolene for Myopathic Symptoms in Malignant Hyperthermia-Susceptible Patients: A 25-Year Retrospective Cohort Study of Adverse Effects and Tolerability. Anesth Analg 2023; 136:569-577. [PMID: 36201369 PMCID: PMC9974786 DOI: 10.1213/ane.0000000000006207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Patients susceptible to malignant hyperthermia (MH) may experience disabling manifestations of an unspecified myopathy outside the context of anesthesia, including myalgia, fatigue, or episodic rhabdomyolysis. Clinical observations suggest that oral dantrolene may relief myopathic symptoms in MH-susceptible (MHS) patients. However, high-dose oral dantrolene has been associated with severe hepatotoxicity. METHODS In a retrospective database review (1994-2018), we investigated a cohort of patients who were diagnosed as MHS by a positive caffeine-halothane contracture test (CHCT), had myopathic manifestations, and received oral dantrolene. Our aim was to investigate the occurrence of serious adverse effects and the adherence to oral dantrolene therapy. We also explored factors associated with self-reported clinical improvement, considering as nonresponders patients with intolerable adverse effects or who reported no improvement 8 weeks after starting treatment. RESULTS Among 476 MHS patients with positive CHCT, 193 had muscle symptoms, 164 started oral dantrolene, 27 refused treatment, and 2 were excluded due to abnormal liver function before starting therapy. There were no serious adverse effects reported. Forty-six of 164 patients (28%; 95% confidence interval [CI], 22%-35%) experienced mild to moderate adverse effects. Twenty-two patients (22/164, 13%; 95% CI, 9%-19%) discontinued treatment, among which 16 due to adverse effects and 6 due to lack of improvement. One hundred forty-two patients (87%; 95% CI, 80%-90%) adhered to therapy and reported improvement of myalgia (n = 78), fatigue (n = 32), or rhabdomyolysis/hiperCKemia (n = 32). The proportion of responders was larger among patients with MH history than among those referred due to a clinical myopathy with nonpertinent anesthetic history (97% vs 79%, respectively; 95% CI of the difference, 8.5-28; P < .001). Patients with a sarcoplasmic reticulum Ca2+ release channel ryanodine receptor gene ( RYR1 ) variant had higher odds of responding to dantrolene treatment (OR, 6.4; 95% CI, 1.3-30.9; P = .013). Dantrolene median dose was 50 (25-400) and 200 (25-400) mg·day -1 in responders and nonresponders, respectively. CONCLUSIONS We found that oral dantrolene produced no serious adverse effects within the reported dose range, and was well tolerated by most MH-susceptible patients presenting myopathic symptoms. Our study provides dosing and adverse effect data as a basis for further randomized controlled clinical trials to determine the efficacy of oral dantrolene for symptomatic relief in MHS-related myopathies.
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Affiliation(s)
- Carlos A. Ibarra Moreno
- Department of Anesthesiology and Pain Medicine, Malignant Hyperthermia Investigation Unit, Toronto General Hospital–University Health Network, Toronto, Ontario, Canada
| | - Natalia Kraeva
- Department of Anesthesiology and Pain Medicine, Malignant Hyperthermia Investigation Unit, Toronto General Hospital–University Health Network, Toronto, Ontario, Canada
| | - Elena Zvaritch
- Department of Anesthesiology and Pain Medicine, Malignant Hyperthermia Investigation Unit, Toronto General Hospital–University Health Network, Toronto, Ontario, Canada
| | - Heinz Jungbluth
- Department of Paediatric Neurology, Neuromuscular Service, Evelina Children’s Hospital, Guy’s and St Thomas’ Hospital NHS Foundation Trust, London, United Kingdom, Randall Centre for Cell and Molecular Biophysics, Muscle Signalling Section, Faculty of Life Sciences and Medicine, King’s College, London, United Kingdom
| | - Nicol C. Voermans
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Sheila Riazi
- Department of Anesthesiology and Pain Medicine, Malignant Hyperthermia Investigation Unit, Toronto General Hospital–University Health Network, Toronto, Ontario, Canada
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18
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Altamura C, Saltarella I, Campanale C, Laghetti P, Desaphy JF. Drug repurposing in skeletal muscle ion channelopathies. Curr Opin Pharmacol 2023; 68:102329. [PMID: 36512979 DOI: 10.1016/j.coph.2022.102329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 10/26/2022] [Accepted: 11/02/2022] [Indexed: 12/14/2022]
Abstract
Skeletal muscle ion channelopathies are rare genetic diseases mainly characterized by myotonia (muscle stiffness) or periodic paralysis (muscle weakness). Here, we reviewed the available therapeutic options in non-dystrophic myotonias (NDM) and periodic paralyses (PP), which consists essentially in drug repositioning to address stiffness or weakness attacks. Empirical use followed by successful randomized clinical trials eventually led to the orphan drug designation and marketing authorization granting of mexiletine for NDM and dichlorphenamide for PP. Yet, these treatments neither consider the genetic cause of the diseases nor address the individual variability in drug response. Thus, ongoing research aims at the identification of repurposed drugs alternative to mexiletine and dichlorphenamide to allow personalization of treatment. This review highlights how drug repurposing may represent an efficient strategy in rare diseases, allowing reduction of drug development time and costs in a context in which the return on investment may be particularly challenging.
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Affiliation(s)
- Concetta Altamura
- Section of Pharmacology, Department of Precision and Regenerative Medicine, School of Medicine, University of Bari Aldo Moro, Piazza Giulo Cesare, 70124, Bari, Italy
| | - Ilaria Saltarella
- Section of Pharmacology, Department of Precision and Regenerative Medicine, School of Medicine, University of Bari Aldo Moro, Piazza Giulo Cesare, 70124, Bari, Italy
| | - Carmen Campanale
- Section of Pharmacology, Department of Precision and Regenerative Medicine, School of Medicine, University of Bari Aldo Moro, Piazza Giulo Cesare, 70124, Bari, Italy
| | - Paola Laghetti
- Section of Pharmacology, Department of Precision and Regenerative Medicine, School of Medicine, University of Bari Aldo Moro, Piazza Giulo Cesare, 70124, Bari, Italy
| | - Jean-François Desaphy
- Section of Pharmacology, Department of Precision and Regenerative Medicine, School of Medicine, University of Bari Aldo Moro, Piazza Giulo Cesare, 70124, Bari, Italy.
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19
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De Bellis M, Boccanegra B, Cerchiara AG, Imbrici P, De Luca A. Blockers of Skeletal Muscle Na v1.4 Channels: From Therapy of Myotonic Syndrome to Molecular Determinants of Pharmacological Action and Back. Int J Mol Sci 2023; 24:ijms24010857. [PMID: 36614292 PMCID: PMC9821513 DOI: 10.3390/ijms24010857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 12/28/2022] [Accepted: 12/30/2022] [Indexed: 01/05/2023] Open
Abstract
The voltage-gated sodium channels represent an important target for drug discovery since a large number of physiological processes are regulated by these channels. In several excitability disorders, including epilepsy, cardiac arrhythmias, chronic pain, and non-dystrophic myotonia, blockers of voltage-gated sodium channels are clinically used. Myotonia is a skeletal muscle condition characterized by the over-excitability of the sarcolemma, resulting in delayed relaxation after contraction and muscle stiffness. The therapeutic management of this disorder relies on mexiletine and other sodium channel blockers, which are not selective for the Nav1.4 skeletal muscle sodium channel isoform. Hence, the importance of deepening the knowledge of molecular requirements for developing more potent and use-dependent drugs acting on Nav1.4. Here, we review the available treatment options for non-dystrophic myotonia and the structure-activity relationship studies performed in our laboratory with a focus on new compounds with potential antimyotonic activity.
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Vivekanandam V, Jayaseelan D, Hanna MG. Muscle channelopathies. Handb Clin Neurol 2023; 195:521-532. [PMID: 37562884 DOI: 10.1016/b978-0-323-98818-6.00006-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/12/2023]
Abstract
Muscle channelopathies encompass a wide range of mainly episodic conditions that are characterized by muscle stiffness and weakness. The myotonic conditions, characterized predominantly by stiffness, include myotonia congenita, paramyotonia congenita, and sodium channel myotonia. The periodic paralysis conditions include hypokalemic periodic paralysis, hyperkalemic periodic paralysis, and Andersen-Tawil syndrome. Clinical history is key, and diagnosis is confirmed by next-generation genetic sequencing of a panel of known genes but can also be supplemented by neurophysiology studies and MRI. As genetic testing expands, so have the spectrum of phenotypes seen including pediatric presentations and congenital myopathies. Management of these conditions requires a multidisciplinary approach with extra support needed when patients require anesthetics or when pregnant. Patients with Andersen-Tawil syndrome will also need cardiac input. Diagnosis is important as symptomatic treatment is available for all of these conditions but need to be tailored to the gene and variant of the patient.
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Affiliation(s)
- Vinojini Vivekanandam
- Centre for Neuromuscular Disorders, Queen Square UCL Institute of Neurology, London, United Kingdom
| | | | - Michael G Hanna
- Centre for Neuromuscular Disorders, Queen Square UCL Institute of Neurology, London, United Kingdom.
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21
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Trivedi JR. Muscle Channelopathies. Continuum (Minneap Minn) 2022; 28:1778-1799. [PMID: 36537980 DOI: 10.1212/con.0000000000001183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
PURPOSE OF REVIEW This article describes the clinical features, diagnosis, pathophysiology, and management of nondystrophic myotonia and periodic paralysis. RECENT FINDINGS An increasing awareness exists about the genotype-phenotype overlap in skeletal muscle channelopathies, and thus genetic testing is needed to make a definitive diagnosis. Electrodiagnostic testing in channelopathies is highly specialized with significant overlap in various mutation subtypes. Randomized clinical trials have now been conducted in these disorders with expanded treatment options for patients with muscle channelopathies. SUMMARY Skeletal muscle channelopathies are rare heterogeneous conditions characterized by lifelong symptoms that require a comprehensive management plan that includes pharmacologic and nonpharmacologic interventions. The significant variability in biophysical features of various mutations, coupled with the difficulties of performing clinical trials in rare diseases, makes it challenging to design and implement treatment trials for muscle channelopathies.
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22
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Goyal P, Safford M, Hilmer SN, Steinman MA, Matlock D, Maurer MS, Lachs M, Kronish IM. N-of-1 trials to facilitate evidence-based deprescribing: Rationale and case study. Br J Clin Pharmacol 2022; 88:4460-4473. [PMID: 35705532 PMCID: PMC9464693 DOI: 10.1111/bcp.15442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 05/24/2022] [Accepted: 05/26/2022] [Indexed: 11/30/2022] Open
Abstract
Deprescribing has emerged as an important aspect of patient-centred medication management but is vastly underutilized in clinical practice. The current narrative review will describe an innovative patient-centred approach to deprescribing-N-of-1 trials. N-of-1 trials involve multiple-period crossover design experiments conducted within individual patients. They enable patients to compare the effects of two or more treatments or, in the case of deprescribing N-of-1 trials, continuation with a current treatment versus no treatment or placebo. N-of-1 trials are distinct from traditional between-patient studies such as parallel-group or crossover designs which provide an average effect across a group of patients and obscure differences between individuals. By generating data on the effect of an intervention for the individual rather than the population, N-of-1 trials can promote therapeutic precision. N-of-1 trials are a particularly appealing strategy to inform deprescribing because they can generate individual-level evidence for deprescribing when evidence is uncertain, and can thus allay patient and physician concerns about discontinuing medications. To illustrate the use of deprescribing N-of-1 trials, we share a case example of an ongoing series of N-of-1 trials that compare maintenance versus deprescribing of beta-blockers in patients with heart failure with preserved ejection fraction. By providing quantifiable data on patient-reported outcomes, promoting personalized pharmacotherapy, and facilitating shared decision making, N-of-1 trials represent a potentially transformative strategy to address polypharmacy.
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Affiliation(s)
- Parag Goyal
- Division of Cardiology, Weill Cornell Medicine (New York, NY)
- Division of General Internal Medicine, Weill Cornell Medicine (New York, NY)
| | - Monika Safford
- Division of General Internal Medicine, Weill Cornell Medicine (New York, NY)
| | - Sarah N. Hilmer
- Kolling Institute, University of Sydney and Royal North Shore Hospital (Sydney, Australia)
| | - Michael A. Steinman
- Division of Geriatrics, University of California San Francisco (San Francisco, CA)
| | - Daniel Matlock
- Division of Geriatrics, University of Colorado (Denver, CO)
| | - Mathew S. Maurer
- Department of Medicine, Columbia University Irving Medical Center (New York, NY)
| | - Mark Lachs
- Division of Geriatrics, Weill Cornell Medicine (New York, NY)
| | - Ian M. Kronish
- Center for Behavioral Cardiovascular Health, Columbia University, (New York, NY)
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23
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van der Ree MH, van Dussen L, Rosenberg N, Stolwijk N, van den Berg S, van der Wel V, Jacobs BAW, Wilde AAM, Hollak CEM, Postema PG. Effectiveness and safety of mexiletine in patients at risk for (recurrent) ventricular arrhythmias: a systematic review. Europace 2022; 24:1809-1823. [PMID: 36036670 DOI: 10.1093/europace/euac087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 05/12/2022] [Indexed: 11/15/2022] Open
Abstract
While mexiletine has been used for over 40 years for prevention of (recurrent) ventricular arrhythmias and for myotonia, patient access has recently been critically endangered. Here we aim to demonstrate the effectiveness and safety of mexiletine in the treatment of patients with (recurrent) ventricular arrhythmias, emphasizing the absolute necessity of its accessibility. Studies were included in this systematic review (PROSPERO, CRD42020213434) if the efficacy or safety of mexiletine in any dose was evaluated in patients at risk for (recurrent) ventricular arrhythmias with or without comparison with alternative treatments (e.g. placebo). A systematic search was performed in Ovid MEDLINE, Embase, and in the clinical trial registry databases ClinicalTrials.gov and ICTRP. Risk of bias were assessed and tailored to the different study designs. Large heterogeneity in study designs and outcome measures prompted a narrative synthesis approach. In total, 221 studies were included reporting on 8970 patients treated with mexiletine. Age ranged from 0 to 88 years. A decrease in ventricular arrhythmias of >50% was observed in 72% of the studies for pre-mature ventricular complexes, 64% for ventricular tachycardia, and 33% for ventricular fibrillation. Electrocardiographic effects of mexiletine were small; only in a subset of patients with primary arrhythmia syndromes, a relative (desired) QTc decrease was reproducibly observed. As for adverse events, gastrointestinal complaints were most frequently observed (33% of the patients). In this systematic review, we present all the currently available knowledge of mexiletine in patients at risk for (recurrent) ventricular arrhythmias and show that mexiletine is both effective and safe.
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Affiliation(s)
- Martijn H van der Ree
- Department of Clinical Cardiology, Heart Center, Amsterdam UMC-University of Amsterdam, Cardiovascular Sciences, Meibergdreef 9, Amsterdam, The Netherlands
| | - Laura van Dussen
- Department of Endocrinology and Metabolism, Amsterdam UMC-University of Amsterdam, Meibergdreef 15, 1105 AZ Amsterdam, The Netherlands
- Medicine for Society, Platform at Amsterdam UMC-University of Amsterdam, Amsterdam, The Netherlands
| | - Noa Rosenberg
- Department of Endocrinology and Metabolism, Amsterdam UMC-University of Amsterdam, Meibergdreef 15, 1105 AZ Amsterdam, The Netherlands
- Medicine for Society, Platform at Amsterdam UMC-University of Amsterdam, Amsterdam, The Netherlands
| | - Nina Stolwijk
- Department of Endocrinology and Metabolism, Amsterdam UMC-University of Amsterdam, Meibergdreef 15, 1105 AZ Amsterdam, The Netherlands
- Medicine for Society, Platform at Amsterdam UMC-University of Amsterdam, Amsterdam, The Netherlands
| | - Sibren van den Berg
- Department of Endocrinology and Metabolism, Amsterdam UMC-University of Amsterdam, Meibergdreef 15, 1105 AZ Amsterdam, The Netherlands
- Medicine for Society, Platform at Amsterdam UMC-University of Amsterdam, Amsterdam, The Netherlands
| | - Vincent van der Wel
- Medicine for Society, Platform at Amsterdam UMC-University of Amsterdam, Amsterdam, The Netherlands
| | - Bart A W Jacobs
- Medicine for Society, Platform at Amsterdam UMC-University of Amsterdam, Amsterdam, The Netherlands
- Department of Pharmacy, Amsterdam UMC-University of Amsterdam, Meibergdreef 15, 1105 AZ Amsterdam, The Netherlands
| | - Arthur A M Wilde
- Department of Clinical Cardiology, Heart Center, Amsterdam UMC-University of Amsterdam, Cardiovascular Sciences, Meibergdreef 9, Amsterdam, The Netherlands
| | - Carla E M Hollak
- Department of Endocrinology and Metabolism, Amsterdam UMC-University of Amsterdam, Meibergdreef 15, 1105 AZ Amsterdam, The Netherlands
- Medicine for Society, Platform at Amsterdam UMC-University of Amsterdam, Amsterdam, The Netherlands
| | - Pieter G Postema
- Department of Clinical Cardiology, Heart Center, Amsterdam UMC-University of Amsterdam, Cardiovascular Sciences, Meibergdreef 9, Amsterdam, The Netherlands
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Altamura C, Conte E, Campanale C, Laghetti P, Saltarella I, Camerino GM, Imbrici P, Desaphy JF. Chaperone activity of niflumic acid on ClC-1 chloride channel mutants causing myotonia congenita. Front Pharmacol 2022; 13:958196. [PMID: 36034862 PMCID: PMC9403836 DOI: 10.3389/fphar.2022.958196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 07/08/2022] [Indexed: 11/14/2022] Open
Abstract
Myotonia congenita (MC) is an inherited rare disease characterized by impaired muscle relaxation after contraction, resulting in muscle stiffness. It is caused by loss-of-function mutations in the skeletal muscle chloride channel ClC-1, important for the stabilization of resting membrane potential and for the repolarization phase of action potentials. Thanks to in vitro functional studies, the molecular mechanisms by which ClC-1 mutations alter chloride ion influx into the cell have been in part clarified, classifying them in “gating-defective” or “expression-defective” mutations. To date, the treatment of MC is only palliative because no direct ClC-1 activator is available. An ideal drug should be one which is able to correct biophysical defects of ClC-1 in the case of gating-defective mutations or a drug capable to recover ClC-1 protein expression on the plasma membrane for trafficking-defective ones. In this study, we tested the ability of niflumic acid (NFA), a commercial nonsteroidal anti-inflammatory drug, to act as a pharmacological chaperone on trafficking-defective MC mutants (A531V, V947E). Wild-type (WT) or MC mutant ClC-1 channels were expressed in HEK293 cells and whole-cell chloride currents were recorded with the patch-clamp technique before and after NFA incubation. Membrane biotinylation assays and western blot were performed to support electrophysiological results. A531V and V947E mutations caused a decrease in chloride current density due to a reduction of ClC-1 total protein level and channel expression on the plasma membrane. The treatment of A531V and V947E-transfected cells with 50 µM NFA restored chloride currents, reaching levels similar to those of WT. Furthermore, no significant difference was observed in voltage dependence, suggesting that NFA increased protein membrane expression without altering the function of ClC-1. Indeed, biochemical experiments confirmed that V947E total protein expression and its plasma membrane distribution were recovered after NFA incubation, reaching protein levels similar to WT. Thus, the use of NFA as a pharmacological chaperone in trafficking defective ClC-1 channel mutations could represent a good strategy in the treatment of MC. Because of the favorable safety profile of this drug, our study may easily open the way for confirmatory human pilot studies aimed at verifying the antimyotonic activity of NFA in selected patients carrying specific ClC-1 channel mutations.
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Affiliation(s)
- Concetta Altamura
- Dept. of Biomedical Sciences and Human Oncology, School of Medicine, University of Bari Aldo Moro, Bari, Italy
- *Correspondence: Concetta Altamura,
| | - Elena Conte
- Dept. of Pharmacy-Drug Sciences, University of Bari Aldo Moro, Bari, Italy
| | - Carmen Campanale
- Dept. of Biomedical Sciences and Human Oncology, School of Medicine, University of Bari Aldo Moro, Bari, Italy
| | - Paola Laghetti
- Dept. of Biomedical Sciences and Human Oncology, School of Medicine, University of Bari Aldo Moro, Bari, Italy
| | - Ilaria Saltarella
- Dept. of Biomedical Sciences and Human Oncology, School of Medicine, University of Bari Aldo Moro, Bari, Italy
| | | | - Paola Imbrici
- Dept. of Pharmacy-Drug Sciences, University of Bari Aldo Moro, Bari, Italy
| | - Jean-François Desaphy
- Dept. of Biomedical Sciences and Human Oncology, School of Medicine, University of Bari Aldo Moro, Bari, Italy
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Janssen Daalen JM, Meinders MJ, Giardina F, Roes KCB, Stunnenberg BC, Mathur S, Ainslie PN, Thijssen DHJ, Bloem BR. Multiple N-of-1 trials to investigate hypoxia therapy in Parkinson's disease: study rationale and protocol. BMC Neurol 2022; 22:262. [PMID: 35836147 PMCID: PMC9281145 DOI: 10.1186/s12883-022-02770-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 06/24/2022] [Indexed: 11/30/2022] Open
Abstract
Background Parkinson’s disease (PD) is a neurodegenerative disease, for which no disease-modifying therapies exist. Preclinical and clinical evidence suggest that hypoxia-based therapy might have short- and long-term benefits in PD. We present the contours of the first study to assess the safety, feasibility and physiological and symptomatic impact of hypoxia-based therapy in individuals with PD. Methods/Design In 20 individuals with PD, we will investigate the safety, tolerability and short-term symptomatic efficacy of continuous and intermittent hypoxia using individual, double-blind, randomized placebo-controlled N-of-1 trials. This design allows for dose finding and for including more individualized outcomes, as each individual serves as its own control. A wide range of exploratory outcomes is deployed, including the Movement Disorders Society Unified Parkinson’s Disease Rating scale (MDS-UPDRS) part III, Timed Up & Go Test, Mini Balance Evaluation Systems (MiniBES) test and wrist accelerometry. Also, self-reported impression of overall symptoms, motor and non-motor symptoms and urge to take dopaminergic medication will be assessed on a 10-point Likert scale. As part of a hypothesis-generating part of the study, we also deploy several exploratory outcomes to probe possible underlying mechanisms of action, including cortisol, erythropoietin and platelet-derived growth factor β. Efficacy will be assessed primarily by a Bayesian analysis. Discussion This evaluation of hypoxia therapy could provide insight in novel pathways that may be pursued for PD treatment. This trial also serves as a proof of concept for deploying an N-of-1 design and for including individualized outcomes in PD research, as a basis for personalized treatment approaches. Trial registration ClinicalTrials.gov Identifier: NCT05214287 (registered January 28, 2022).
Supplementary Information The online version contains supplementary material available at 10.1186/s12883-022-02770-7.
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Affiliation(s)
- Jules M Janssen Daalen
- Center of Expertise for Parkinson & Movement Disorders; Nijmegen, the Netherlands, Department of Neurology, Donders Institute for Brain, Cognition and Behavior, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marjan J Meinders
- Center of Expertise for Parkinson & Movement Disorders; Nijmegen, the Netherlands, Department of Neurology, Donders Institute for Brain, Cognition and Behavior, Radboud University Medical Center, Nijmegen, The Netherlands.,IQ Healthcare, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Federica Giardina
- Department of Health Evidence, Radboud Institute for Health Sciences, Radboud University Medical Center, Section Biostatistics, Nijmegen, The Netherlands
| | - Kit C B Roes
- Department of Health Evidence, Radboud Institute for Health Sciences, Radboud University Medical Center, Section Biostatistics, Nijmegen, The Netherlands
| | - Bas C Stunnenberg
- Department of Neurology, Donders Institute for Brain, Cognition and Behavior, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Neurology, Rijnstate Hospital, Arnhem, Netherlands
| | | | - Philip N Ainslie
- Center for Heart, Lung and Vascular Health, School of Health and Exercise Sciences, University of British Columbia, Kelowna, Canada
| | - Dick H J Thijssen
- Department of Physiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Bastiaan R Bloem
- Center of Expertise for Parkinson & Movement Disorders; Nijmegen, the Netherlands, Department of Neurology, Donders Institute for Brain, Cognition and Behavior, Radboud University Medical Center, Nijmegen, The Netherlands.
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Wadman RI, Rheenen WV, van der Pol WL, van den Berg LH. Major advances in neuromuscular disorders in the past two decades. Lancet Neurol 2022; 21:585-587. [DOI: 10.1016/s1474-4422(22)00190-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 04/28/2022] [Indexed: 01/10/2023]
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Watkins B, Schuster HM, Gerwin L, Schoser B, Kröger S. The effect of methocarbamol and mexiletine on murine muscle spindle function. Muscle Nerve 2022; 66:96-105. [PMID: 35373353 DOI: 10.1002/mus.27546] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 02/23/2022] [Accepted: 02/25/2022] [Indexed: 11/10/2022]
Abstract
INTRODUCTION/AIMS The muscle relaxant methocarbamol and the antimyotonic drug mexiletine are widely used for the treatment of muscle spasms, myotonia, and pain syndromes. To determine whether these drugs affect muscle spindle function, we studied their effect on the resting discharge and on stretch-induced action potential frequencies of proprioceptive afferent neurons. METHODS Single unit action potential frequencies of proprioceptive afferents from muscle spindles in the murine extensor digitorum longus muscle of adult C57BL/6J mice were recorded under resting conditions and during ramp-and-hold stretches. Maximal tetanic force of the same muscle after direct stimulation was determined. High-resolution confocal microscopy analysis was performed to determine the distribution of Nav 1.4 channels, a potential target for both drugs. RESULTS Methocarbamol and mexiletine inhibited the muscle spindle resting discharge in a dose-dependent manner with IC50 values around 300 μM and 6 μM, respectively. With increasing concentrations of both drugs, the response to stretch was also affected, with the static sensitivity first followed by the dynamic sensitivity. At high concentrations, both drugs completely blocked muscle spindle afferent output. Both drugs also reversibly reduced the specific force of the extensor digitorum longus muscle after tetanic stimulation. Finally, we present evidence for the presence and specific localization of the voltage-gated sodium channel Nav 1.4 in intrafusal fibers. DISCUSSION In this study we demonstrate that both muscle relaxants affect muscle spindle function, suggesting impaired proprioception as a potential side effect of both drugs. Moreover, our results provide additional evidence of a peripheral activity of methocarbamol and mexiletine.
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Affiliation(s)
- Bridgette Watkins
- Department of Physiological Genomics, Biomedical Center, Ludwig-Maximilians-University, Planegg-Martinsried, Germany
| | - Hedwig M Schuster
- Department of Physiological Genomics, Biomedical Center, Ludwig-Maximilians-University, Planegg-Martinsried, Germany
| | - Laura Gerwin
- Department of Physiological Genomics, Biomedical Center, Ludwig-Maximilians-University, Planegg-Martinsried, Germany
| | - Benedikt Schoser
- Department of Neurology, LMU Klinikum, Friedrich-Baur-Institute, Ludwig-Maximilians-University, Munich, Germany
| | - Stephan Kröger
- Department of Physiological Genomics, Biomedical Center, Ludwig-Maximilians-University, Planegg-Martinsried, Germany
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Li Y, Li M, Wang Z, Yang F, Wang H, Bai X, Sun B, Chen S, Huang X. Clinical and molecular characteristics of myotonia congenita in China: Case series and a literature review. Channels (Austin) 2022; 16:35-46. [PMID: 35170402 PMCID: PMC8855856 DOI: 10.1080/19336950.2022.2041292] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Myotonia congenita (MC) is a rare genetic disease caused by mutations in the skeletal muscle chloride channel gene (CLCN1), encoding the voltage-gated chloride channel ClC-1 in skeletal muscle. Our study reported the clinical and molecular characteristics of six patients with MC and systematically review the literature on Chinese people. We retrospectively analyzed demographics, clinical features, family history, creatine kinase (CK), electromyography (EMG), treatment, and genotype data of our patients and reviewed the clinical data and CLCN1 mutations in literature. The median ages at examination and onset were 26.5 years (range 11–50 years) and 6.5 years (range 1.5–11 years), respectively, in our patients, and 21 years (range 3.5–65 years, n = 45) and 9 years (range 0.5–26 years, n = 50), respectively, in literature. Similar to previous reports, myotonia involved limb, lids, masticatory, and trunk muscles to varying degrees. Warm-up phenomenon (5/6), percussion myotonia (3/5), and grip myotonia (6/6) were common. Menstruation triggered myotonia in females, not observed in Chinese patients before. The proportion of abnormal CK levels (4/5) was higher than data from literature. Electromyography performed in six patients revealed myotonic changes (100%). Five novel CLCN1 mutations, including a splicing mutation (c.853 + 4A>G), a deletion mutation (c.2010_2014del), and three missense mutations (c.2527C>T, c.1727C>T, c.2017 G > C), were identified. The c.892 G > A (p.A298T) mutation was the most frequent mutation in the Chinese population. Our study expanded the clinical and genetic spectrum of patients with MC in the China. The MC phenotype in Chinese people is not different from that found in the West, while the genotype is different.
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Affiliation(s)
- Yifan Li
- Geriatric Neurological Department of the Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese Pla General Hospital, Beijing, China
| | - Mao Li
- Department of Neurology of the First Medical Center, Chinese Pla General Hospital, Beijing, China
| | - Zhenfu Wang
- Geriatric Neurological Department of the Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese Pla General Hospital, Beijing, China
| | - Fei Yang
- Department of Neurology of the First Medical Center, Chinese Pla General Hospital, Beijing, China
| | - Hongfen Wang
- Department of Neurology of the First Medical Center, Chinese Pla General Hospital, Beijing, China
| | - Xiujuan Bai
- Geriatric Neurological Department of the Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese Pla General Hospital, Beijing, China
| | - Bo Sun
- Geriatric Neurological Department of the Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese Pla General Hospital, Beijing, China
| | - Siyu Chen
- Geriatric Neurological Department of the Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese Pla General Hospital, Beijing, China
| | - Xusheng Huang
- Department of Neurology of the First Medical Center, Chinese Pla General Hospital, Beijing, China
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Boegle AK, Narayanaswami P. Treatment and Management of Disorders of Neuromuscular Hyperexcitability and Periodic Paralysis. Neuromuscul Disord 2022. [DOI: 10.1016/b978-0-323-71317-7.00018-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Partington G, Cro S, Mason A, Phillips R, Cornelius V. Design and analysis features used in small population and rare disease trials: A targeted review. J Clin Epidemiol 2021; 144:93-101. [PMID: 34910979 DOI: 10.1016/j.jclinepi.2021.12.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 11/24/2021] [Accepted: 12/07/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Frequentist trials in Rare disease/small population trials often require unfeasibly large sample size to detect minimum clinically important differences. A targeted review was performed investigating what design and analysis methods these trials use when facing restricted recruitment. STUDY DESIGN AND SETTING Targeted Review searching EMBASE and MEDLINE for Phase II-IV RCTs reporting 'rare' disease or 'small population' within title or abstract, since 2009. RESULTS A total of 6,128 articles were screened with 64 trials eligible (4 Bayesian, 60 frequentist trials). Frequentists trials had planned power ranging 72-90% (median: 80%) but reported recruiting a mean of 6.6% below the planned sample size (n=38) [median 0%, IQR (-5%, 5%)], most used standard type 1 error (52 used 5% and 1 used 1%), and the average standardised effect was high (0.7) with 50% missing their assumed level. Of the 4 Bayesian trials, 3 used informed priors, 2 and 1 trials performed sensitivity analysis for the impact of priors on design and analysis respectively. Historical data, expert consensus, or both were used to construct informative priors. Bayesian trials required 30%-2400% less participants than using frequentist frameworks. CONCLUSION Bayesian trials required lower sample size through use of informative priors. Most frequentists didn't achieve their target sample size. Bayesian methods offer promising solutions for such trials but are underutilised.
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Affiliation(s)
- Giles Partington
- Imperial Clinical Trials Unit, Imperial College London, 1st Floor Stadium House, 68 Wood Lane, London, United Kingdom W12 7RH.
| | - Suzie Cro
- Imperial Clinical Trials Unit, Imperial College London, 1st Floor Stadium House, 68 Wood Lane, London, United Kingdom W12 7RH
| | - Alexina Mason
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, Keppel Street, London, United Kingdom WC1E 7HT
| | - Rachel Phillips
- Imperial Clinical Trials Unit, Imperial College London, 1st Floor Stadium House, 68 Wood Lane, London, United Kingdom W12 7RH
| | - Victoria Cornelius
- Imperial Clinical Trials Unit, Imperial College London, 1st Floor Stadium House, 68 Wood Lane, London, United Kingdom W12 7RH
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Stunnenberg BC, Merkus EC, Raaphorst J, Saris CG, Groenewoud H, Statland J, Weijma R, van Vlijmen B, Griggs R, van Engelen BGM, van der Wilt GJ. N-of-1 trial of salbutamol in hyperkalaemic periodic paralysis. J Neurol Neurosurg Psychiatry 2021; 92:1352-1353. [PMID: 34112717 DOI: 10.1136/jnnp-2021-326347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 05/15/2021] [Indexed: 11/04/2022]
Affiliation(s)
- Bas C Stunnenberg
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Donders Center for Medical Neuroscience, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Esther C Merkus
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Donders Center for Medical Neuroscience, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Joost Raaphorst
- Department of Neurology, Amsterdam UMC, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Christiaan Gj Saris
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Donders Center for Medical Neuroscience, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Hans Groenewoud
- Department for Health Evidence, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jeffrey Statland
- Department of Neurology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Robyn Weijma
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Donders Center for Medical Neuroscience, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Bas van Vlijmen
- Department of Pharmacy, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Robert Griggs
- Department of Neurology, University of Rochester Medical Center, Rochester, New York, USA
| | - Baziel G M van Engelen
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Donders Center for Medical Neuroscience, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Gert Jan van der Wilt
- Department for Health Evidence, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
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Nicole S, Lory P. New Challenges Resulting From the Loss of Function of Na v1.4 in Neuromuscular Diseases. Front Pharmacol 2021; 12:751095. [PMID: 34671263 PMCID: PMC8521073 DOI: 10.3389/fphar.2021.751095] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Accepted: 09/16/2021] [Indexed: 11/13/2022] Open
Abstract
The voltage-gated sodium channel Nav1.4 is a major actor in the excitability of skeletal myofibers, driving the muscle force in response to nerve stimulation. Supporting further this key role, mutations in SCN4A, the gene encoding the pore-forming α subunit of Nav1.4, are responsible for a clinical spectrum of human diseases ranging from muscle stiffness (sodium channel myotonia, SCM) to muscle weakness. For years, only dominantly-inherited diseases resulting from Nav1.4 gain of function (GoF) were known, i.e., non-dystrophic myotonia (delayed muscle relaxation due to myofiber hyperexcitability), paramyotonia congenita and hyperkalemic or hypokalemic periodic paralyses (episodic flaccid muscle weakness due to transient myofiber hypoexcitability). These last 5 years, SCN4A mutations inducing Nav1.4 loss of function (LoF) were identified as the cause of dominantly and recessively-inherited disorders with muscle weakness: periodic paralyses with hypokalemic attacks, congenital myasthenic syndromes and congenital myopathies. We propose to name this clinical spectrum sodium channel weakness (SCW) as the mirror of SCM. Nav1.4 LoF as a cause of permanent muscle weakness was quite unexpected as the Na+ current density in the sarcolemma is large, securing the ability to generate and propagate muscle action potentials. The properties of SCN4A LoF mutations are well documented at the channel level in cellular electrophysiological studies However, much less is known about the functional consequences of Nav1.4 LoF in skeletal myofibers with no available pertinent cell or animal models. Regarding the therapeutic issues for Nav1.4 channelopathies, former efforts were aimed at developing subtype-selective Nav channel antagonists to block myofiber hyperexcitability. Non-selective, Nav channel blockers are clinically efficient in SCM and paramyotonia congenita, whereas patient education and carbonic anhydrase inhibitors are helpful to prevent attacks in periodic paralyses. Developing therapeutic tools able to counteract Nav1.4 LoF in skeletal muscles is then a new challenge in the field of Nav channelopathies. Here, we review the current knowledge regarding Nav1.4 LoF and discuss the possible therapeutic strategies to be developed in order to improve muscle force in SCW.
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Affiliation(s)
- Sophie Nicole
- Institut de Génomique Fonctionnelle (IGF), Université de Montpellier, CNRS, INSERM, Montpellier, France.,LabEx 'Ion Channel Science and Therapeutics (ICST), Montpellier, France
| | - Philippe Lory
- Institut de Génomique Fonctionnelle (IGF), Université de Montpellier, CNRS, INSERM, Montpellier, France.,LabEx 'Ion Channel Science and Therapeutics (ICST), Montpellier, France
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33
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Stunnenberg BC, Berends J, Griggs RC, Statland J, Drost G, Nikles J, Groenewoud H, van Engelen BGM, Jan van der Wilt G, Raaphorst J. N-of-1 Trials in Neurology: A Systematic Review. Neurology 2021; 98:e174-e185. [PMID: 34675101 DOI: 10.1212/wnl.0000000000012998] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 10/14/2021] [Indexed: 11/15/2022] Open
Abstract
ObjectiveTo perform a systematic review of published N-of-1 trials (e.g. single patient cross-over trials) in neurological disorders, including an assessment of methodological quality and reporting.MethodsWe searched PubMed, MEDLINE and Embase, from inception date - the first of December 2019, for reports on N-of-1 trials in neurological disorders. Basic trial information on design, disease, intervention, analysis and treatment success was extracted. Strengths and weaknesses of the N-of-1 trials were assessed using the CONSORT extension for N-of-1 trials (CENT) 2015 criteria checklist and the Jadad score as measures of quality and reporting.ResultsWe retrieved 40 reports of N-of-1 trials in neurological disorders (19 individual N-of-1 trials, 21 series of N-of-1 trials). Most N-of-1 trials were performed in neuromuscular and neurodegenerative / movement disorders. Unlike the majority of trials that studied the main symptom(s) of a chronic stable condition, nine N-of-1 trials studied a stable chronic symptom of a progressive or acute neurological disorder. Besides pharmacological interventions, electrical stimulation protocols and nutritional products were studied. A mean total CENT score of 20.88 (SD, 9.10; range 0-43) and mean total Jadad score of 2.90 (SD, 2.15; range 0-5) were found as methodological measures of quality and reporting across all N-of-1 trialsConclusionsN-of-1 trials have been reported in numerous neurological disorders, not only in chronic stable disorders, but also in progressive or acute disorders with a stable symptom. This indicates the emerging therapeutic area of N-of-1 trials in Neurology.Methodological quality and reporting of N-of-1 trials were found suboptimal and can easily be improved in future trials by appropriately describing the methods of blinding and randomization and follow CENT guidelines. As most N-of-1 trials remain unreported in medical literature, this systematic review probably only represent the tip of the iceberg of conducted N-of-1 trials in neurological disorders. In addition to conventional trial designs, N-of-1 trials can help to bridge the gap between research and clinical care by providing an alternative, personalized level 1 evidence-base for suitable treatments.
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Affiliation(s)
- Bas C Stunnenberg
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Donders Center for Medical Neuroscience, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Joost Berends
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Donders Center for Medical Neuroscience, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Robert C Griggs
- Department of Neurology, University of Rochester Medical Center, Rochester, USA
| | - Jeffrey Statland
- Department of Neurology, University of Kansas Medical Center, Kansas City, USA
| | - Gea Drost
- University of Groningen, Department of Neurology and Neurosurgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Jane Nikles
- The University of Queensland Centre for Clinical Research, The University of Queensland, Herston, Brisbane, Queensland, Australia
| | - Hans Groenewoud
- Department of Health Evidence, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Baziel G M van Engelen
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Donders Center for Medical Neuroscience, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Gert Jan van der Wilt
- Department of Health Evidence, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Joost Raaphorst
- Amsterdam UMC, University of Amsterdam, Department of Neurology, Amsterdam Neuroscience, Amsterdam, Netherlands
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Ma Y, Fu Y, Tian Y, Gou W, Miao Z, Yang M, Ordovás JM, Zheng JS. Individual Postprandial Glycemic Responses to Diet in n-of-1 Trials: Westlake N-of-1 Trials for Macronutrient Intake (WE-MACNUTR). J Nutr 2021; 151:3158-3167. [PMID: 34255080 PMCID: PMC8485912 DOI: 10.1093/jn/nxab227] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 03/17/2021] [Accepted: 06/18/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND The role of different types and quantities of macronutrients on human health has been controversial, and the individual response to dietary macronutrient intake needs more investigation. OBJECTIVES We aimed to use an 'n-of-1' study design to investigate the individual variability in postprandial glycemic response when eating diets with different macronutrient distributions among apparently healthy adults. METHODS Thirty apparently healthy young Chinese adults (women, 68%) aged between 22 and 34 y, with BMI between 17.2 and 31.9 kg/m2, were provided with high-fat, low-carbohydrate (HF-LC, 60-70% fat, 15-25% carbohydrate, 15% protein, of total energy) and low-fat, high-carbohydrate (LF-HC, 10-20% fat, 65-75% carbohydrate, 15% protein) diets, for 6 d wearing continuous glucose monitoring systems, respectively, in a randomized sequence, interspersed by a 6-d wash-out period. Three cycles were conducted. The primary outcomes were the differences of maximum postprandial glucose (MPG), mean amplitude of glycemic excursions (MAGE), and AUC24 between intervention periods of LF-HC and HF-LC diets. A Bayesian model was used to predict responders with the posterior probability of any 1 of the 3 outcomes reaching a clinically meaningful difference. RESULTS Twenty-eight participants were included in the analysis. Posterior probability of reaching a clinically meaningful difference of MPG (0.167 mmol/L), MAGE (0.072 mmol/L), and AUC24 (13.889 mmol/L·h) between LF-HC and HF-LC diets varied among participants, and those with posterior probability >80% were identified as high-carbohydrate responders (n = 9) or high-fat responders (n = 6). Analyses of the Bayesian-aggregated n-of-1 trials among all participants showed a relatively low posterior probability of reaching a clinically meaningful difference of the 3 outcomes between LF-HC and HF-LC diets. CONCLUSIONS N-of-1 trials are feasible to characterize personal response to dietary intervention in young Chinese adults.
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Affiliation(s)
- Yue Ma
- Key Laboratory of Growth Regulation and Translational Research of Zhejiang Province, School of Life Sciences, Westlake University, Hangzhou, China
- Westlake Intelligent Biomarker Discovery Lab, Westlake Laboratory of Life Sciences and Biomedicine, Hangzhou, China
- Institute of Basic Medical Sciences, Westlake Institute for Advanced Study, Hangzhou, China
| | - Yuanqing Fu
- Key Laboratory of Growth Regulation and Translational Research of Zhejiang Province, School of Life Sciences, Westlake University, Hangzhou, China
- Westlake Intelligent Biomarker Discovery Lab, Westlake Laboratory of Life Sciences and Biomedicine, Hangzhou, China
- Institute of Basic Medical Sciences, Westlake Institute for Advanced Study, Hangzhou, China
| | - Yunyi Tian
- Key Laboratory of Growth Regulation and Translational Research of Zhejiang Province, School of Life Sciences, Westlake University, Hangzhou, China
- Westlake Intelligent Biomarker Discovery Lab, Westlake Laboratory of Life Sciences and Biomedicine, Hangzhou, China
| | - Wanglong Gou
- Key Laboratory of Growth Regulation and Translational Research of Zhejiang Province, School of Life Sciences, Westlake University, Hangzhou, China
- Westlake Intelligent Biomarker Discovery Lab, Westlake Laboratory of Life Sciences and Biomedicine, Hangzhou, China
| | - Zelei Miao
- Key Laboratory of Growth Regulation and Translational Research of Zhejiang Province, School of Life Sciences, Westlake University, Hangzhou, China
- Westlake Intelligent Biomarker Discovery Lab, Westlake Laboratory of Life Sciences and Biomedicine, Hangzhou, China
| | - Min Yang
- Chronic Disease Research Institute, Department of Nutrition and Food Hygiene, Zhejiang University School of Public Health, Hangzhou, China
| | - José M Ordovás
- Jean Mayer USDA Human Nutrition Research Center on Aging at Tufts University, Boston, MA, USA
- IMDEA Food Institute, Madrid, Spain
| | - Ju-Sheng Zheng
- Key Laboratory of Growth Regulation and Translational Research of Zhejiang Province, School of Life Sciences, Westlake University, Hangzhou, China
- Westlake Intelligent Biomarker Discovery Lab, Westlake Laboratory of Life Sciences and Biomedicine, Hangzhou, China
- Institute of Basic Medical Sciences, Westlake Institute for Advanced Study, Hangzhou, China
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35
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Mousele C, Matthews E, Pitceathly RDS, Hanna MG, MacDonald S, Savvatis K, Carr A, Turner C. Long-term Safety and Efficacy of Mexiletine in Myotonic Dystrophy Types 1 and 2. Neurol Clin Pract 2021; 11:e682-e685. [PMID: 34840883 PMCID: PMC8610501 DOI: 10.1212/cpj.0000000000001073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 02/10/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND AND OBJECTIVE Myotonic dystrophy types 1 and 2 are progressive multisystem genetic disorders whose core clinical feature is myotonia. Mexiletine, an antagonist of voltage-gated sodium channels, is a recommended antimyotonic agent in the nondystrophic myotonias, but its use in myotonic dystrophy is limited because of lack of data regarding its long-term efficacy and safety profile. METHODS To address this issue, this study retrospectively evaluated patients with myotonic dystrophy receiving mexiletine over a mean time period of 32.9 months (range 0.1-216 months). RESULTS This study demonstrated that 96% of patients reported some improvement in myotonia symptoms with mexiletine treatment. No clinically relevant cardiac adverse events were associated with the long-term use of mexiletine. CONCLUSIONS These findings support that mexiletine is both safe and effective when used long-term in myotonic dystrophy. CLASSIFICATION OF EVIDENCE This study provides Class IV evidence that mexiletine is a well-tolerated and effective treatment for myotonic dystrophy types 1 and 2.
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Affiliation(s)
- Christina Mousele
- UCL Queen Square Institute of Neurology and The National Hospital for Neurology and Neurosurgery (CM); Department of Neuromuscular Diseases, UCL Queen Square Institute of Neurology and The National Hospital for Neurology and Neurosurgery (EM, RDSP, MGH, AC, CT); The National Hospital for Neurology and Neurosurgery (SM), Atkinson-Morley Neuromuscular Centre (EM); and Inherited Cardiovascular Diseases Unit, Barts Health Centre, Barts Healthcare NHS Trust (KS), London, United Kingdom
| | - Emma Matthews
- UCL Queen Square Institute of Neurology and The National Hospital for Neurology and Neurosurgery (CM); Department of Neuromuscular Diseases, UCL Queen Square Institute of Neurology and The National Hospital for Neurology and Neurosurgery (EM, RDSP, MGH, AC, CT); The National Hospital for Neurology and Neurosurgery (SM), Atkinson-Morley Neuromuscular Centre (EM); and Inherited Cardiovascular Diseases Unit, Barts Health Centre, Barts Healthcare NHS Trust (KS), London, United Kingdom
| | - Robert D S Pitceathly
- UCL Queen Square Institute of Neurology and The National Hospital for Neurology and Neurosurgery (CM); Department of Neuromuscular Diseases, UCL Queen Square Institute of Neurology and The National Hospital for Neurology and Neurosurgery (EM, RDSP, MGH, AC, CT); The National Hospital for Neurology and Neurosurgery (SM), Atkinson-Morley Neuromuscular Centre (EM); and Inherited Cardiovascular Diseases Unit, Barts Health Centre, Barts Healthcare NHS Trust (KS), London, United Kingdom
| | - Michael G Hanna
- UCL Queen Square Institute of Neurology and The National Hospital for Neurology and Neurosurgery (CM); Department of Neuromuscular Diseases, UCL Queen Square Institute of Neurology and The National Hospital for Neurology and Neurosurgery (EM, RDSP, MGH, AC, CT); The National Hospital for Neurology and Neurosurgery (SM), Atkinson-Morley Neuromuscular Centre (EM); and Inherited Cardiovascular Diseases Unit, Barts Health Centre, Barts Healthcare NHS Trust (KS), London, United Kingdom
| | - Susan MacDonald
- UCL Queen Square Institute of Neurology and The National Hospital for Neurology and Neurosurgery (CM); Department of Neuromuscular Diseases, UCL Queen Square Institute of Neurology and The National Hospital for Neurology and Neurosurgery (EM, RDSP, MGH, AC, CT); The National Hospital for Neurology and Neurosurgery (SM), Atkinson-Morley Neuromuscular Centre (EM); and Inherited Cardiovascular Diseases Unit, Barts Health Centre, Barts Healthcare NHS Trust (KS), London, United Kingdom
| | - Konstantinos Savvatis
- UCL Queen Square Institute of Neurology and The National Hospital for Neurology and Neurosurgery (CM); Department of Neuromuscular Diseases, UCL Queen Square Institute of Neurology and The National Hospital for Neurology and Neurosurgery (EM, RDSP, MGH, AC, CT); The National Hospital for Neurology and Neurosurgery (SM), Atkinson-Morley Neuromuscular Centre (EM); and Inherited Cardiovascular Diseases Unit, Barts Health Centre, Barts Healthcare NHS Trust (KS), London, United Kingdom
| | - Aisling Carr
- UCL Queen Square Institute of Neurology and The National Hospital for Neurology and Neurosurgery (CM); Department of Neuromuscular Diseases, UCL Queen Square Institute of Neurology and The National Hospital for Neurology and Neurosurgery (EM, RDSP, MGH, AC, CT); The National Hospital for Neurology and Neurosurgery (SM), Atkinson-Morley Neuromuscular Centre (EM); and Inherited Cardiovascular Diseases Unit, Barts Health Centre, Barts Healthcare NHS Trust (KS), London, United Kingdom
| | - Christopher Turner
- UCL Queen Square Institute of Neurology and The National Hospital for Neurology and Neurosurgery (CM); Department of Neuromuscular Diseases, UCL Queen Square Institute of Neurology and The National Hospital for Neurology and Neurosurgery (EM, RDSP, MGH, AC, CT); The National Hospital for Neurology and Neurosurgery (SM), Atkinson-Morley Neuromuscular Centre (EM); and Inherited Cardiovascular Diseases Unit, Barts Health Centre, Barts Healthcare NHS Trust (KS), London, United Kingdom
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36
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Selker HP, Cohen T, D'Agostino RB, Dere WH, Ghaemi SN, Honig PK, Kaitin KI, Kaplan HC, Kravitz RL, Larholt K, McElwee NE, Oye KA, Palm ME, Perfetto E, Ramanathan C, Schmid CH, Seyfert-Margolis V, Trusheim M, Eichler HG. A Useful and Sustainable Role for N-of-1 Trials in the Healthcare Ecosystem. Clin Pharmacol Ther 2021; 112:224-232. [PMID: 34551122 PMCID: PMC9022728 DOI: 10.1002/cpt.2425] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 09/05/2021] [Indexed: 11/29/2022]
Abstract
Clinicians and patients often try a treatment for an initial period to inform longer‐term therapeutic decisions. A more rigorous approach involves N‐of‐1 trials. In these single‐patient crossover trials, typically conducted in patients with chronic conditions, individual patients are given candidate treatments in a double‐blinded, random sequence of alternating periods to determine the most effective treatment for that patient. However, to date, these trials are rarely done outside of research settings and have not been integrated into general care where they could offer substantial benefit. Designating this classical, N‐of‐1 trial design as type 1, there also are new and evolving uses of N‐of‐1 trials that we designate as type 2. In these, rather than focusing on optimizing treatment for chronic diseases when multiple approved choices are available, as is typical of type 1, a type 2 N‐of‐1 trial tests treatments designed specifically for a patient with a rare disease, to facilitate personalized medicine. While the aims differ, both types face the challenge of collecting individual‐patient evidence using standard, trusted, widely accepted methods. To fulfill their potential for producing both clinical and research benefits, and to be available for wide use, N‐of‐1 trials will have to fit into the current healthcare ecosystem. This will require generalizable and accepted processes, platforms, methods, and standards. This also will require sustainable value‐based arrangements among key stakeholders. In this article, we review opportunities, stakeholders, issues, and possible approaches that could support general use of N‐of‐1 trials and deliver benefit to patients and the healthcare enterprise. To assess and expand the benefits of N‐of‐1 trials, we propose multistakeholder meetings, workshops, and the generation of methods, standards, and platforms that would support wider availability and the value of N‐of‐1 trials.
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Affiliation(s)
- Harry P Selker
- Tufts Medical Center, Tufts Clinical and Translational Science Institute, Boston, Massachusetts, USA.,Tufts Medical Center, Institute for Clinical Research and Health Policy Studies, Boston, Massachusetts, USA
| | - Theodora Cohen
- Tufts Medical Center, Tufts Clinical and Translational Science Institute, Boston, Massachusetts, USA.,Tufts Medical Center, Institute for Clinical Research and Health Policy Studies, Boston, Massachusetts, USA
| | - Ralph B D'Agostino
- Department of Mathematics and Statistics, Boston University, Boston, Massachusetts, USA.,Baim Institute for Clinical Research, Boston, Massachusetts, USA
| | - Willard H Dere
- Department of Internal Medicine, Utah Center for Clinical and Translational Science, University of Utah, Salt Lake City, Utah, USA.,University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - S Nassir Ghaemi
- Psychiatry, Tufts University School of Medicine, Boston, Massachusetts, USA.,Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Kenneth I Kaitin
- Tufts Center for the Study of Drug Development, Tufts University, Boston, Massachusetts, USA
| | - Heather C Kaplan
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Perinatal Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Richard L Kravitz
- Department of Internal Medicine, University of California, Davis, Davis, California, USA
| | - Kay Larholt
- Center for Biomedical Innovation, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
| | - Newell E McElwee
- Health Economics and Outcomes Research, Boehringer Ingelheim Pharmaceuticals, Inc, Ridgefield, Connecticut, USA
| | - Kenneth A Oye
- Department of Political Science, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA.,Center for Biomedical Innovation, Cambridge, Massachusetts, USA
| | - Marisha E Palm
- Tufts Medical Center, Tufts Clinical and Translational Science Institute, Boston, Massachusetts, USA.,Tufts Medical Center, Institute for Clinical Research and Health Policy Studies, Boston, Massachusetts, USA
| | - Eleanor Perfetto
- Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, Baltimore, Maryland, USA.,National Health Council, Washington, District of Columbia, USA
| | | | | | | | - Mark Trusheim
- Sloan School of Management, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
| | - Hans-Georg Eichler
- Regulatory Science and Innovation Task Force, European Medicines Agency, Amsterdam, The Netherlands.,Medical University of Vienna, Vienna, Austria
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Diaz FJ. Using population crossover trials to improve the decision process regarding treatment individualization in N-of-1 trials. Stat Med 2021; 40:4345-4361. [PMID: 34213011 PMCID: PMC10773237 DOI: 10.1002/sim.9030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 03/26/2021] [Accepted: 04/25/2021] [Indexed: 11/08/2022]
Abstract
Healthcare researchers are showing renewed interest in the utilization of N-of-1 clinical trials for the individualization of pharmacological treatments. Here, we propose a frequentist approach to conducting treatment individualization in N-of-1 trials that we call "partial empirical Bayes." We infer the most beneficial treatment for the patient from combining the information provided by a previously conducted population crossover trial with individual patient data. We propose a method for estimating an optimal number of treatment cycles and investigate the statistical conditions under which N-of-1 trials are more beneficial than traditional clinical approaches. We represent the patient population with a random-coefficients linear model and calculate estimators of posttreatment individual disease severities. We show the estimators' consistency under the most common N-of-1 designs and examine their prediction errors and performance with small numbers of patient's responses. We demonstrate by simulating new patients that our approach is equivalent or superior to both the common clinical practice of recommending the on-average best treatment for all patients and the common individualization method that simply compares average responses to the tested treatments. We conclude that some situations exist in which individualization with N-of-1 trials is highly beneficial while other situations exist in which individualization may be unfruitful.
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Affiliation(s)
- Francisco J Diaz
- Department of Biostatistics & Data Science, The University of Kansas Medical Center, Kansas City, Kansas, USA
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Nikles J, Onghena P, Vlaeyen JW, Wicksell RK, Simons LE, McGree JM, McDonald S. Establishment of an International Collaborative Network for N-of-1 Trials and Single-Case Designs. Contemp Clin Trials Commun 2021; 23:100826. [PMID: 34401597 PMCID: PMC8350373 DOI: 10.1016/j.conctc.2021.100826] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 06/15/2021] [Accepted: 07/26/2021] [Indexed: 11/24/2022] Open
Abstract
In this article we briefly examine the unique features of Single-Case Designs (SCDs) (studies in a single participant), their history and current trends, and real-world clinical applications. The International Collaborative Network for N-of-1 Trials and Single-Case Designs (ICN) is a formal collaborative network for individuals with an interest in SCDs. The ICN was established in 2017 to support the SCD scientific community and provide opportunities for collaboration, a global communication channel, resource sharing and knowledge exchange. In May 2021, there were more than 420 members in 31 countries. A member survey was undertaken in 2019 to identify priorities for the ICN for the following few years. This article outlines the key priorities identified and the ICN's progress to date in these key areas including network activities (developing a communications strategy to increase awareness, collecting/sharing a comprehensive set of resources, guidelines and tips, and incorporating the consumer perspective) and scientific activities (writing position papers and guest editing special journal issues, exploring key stakeholder perspectives about SCDs, and working to streamline ethical approval processes for SCDs). The ICN provides a practical means to engage with this methodology through membership. We encourage clinicians, researchers, industry, and healthcare consumers to learn more about and conduct SCDs, and to join us in our mission of using SCDs to improve health outcomes for individuals and populations.
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Affiliation(s)
- Jane Nikles
- Centre for Clinical Research, The University of Queensland, Australia
| | | | | | | | | | | | - Suzanne McDonald
- Centre for Clinical Research, The University of Queensland, Australia
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39
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van den Berg S, van der Wel V, de Visser SJ, Stunnenberg BC, Timmers L, van der Ree MH, Postema PG, Hollak CEM. Cost-Based Price Calculation of Mexiletine for Nondystrophic Myotonia. Value Health 2021; 24:925-929. [PMID: 34243835 DOI: 10.1016/j.jval.2021.02.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 12/21/2020] [Accepted: 02/07/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVES Mexiletine is a long-known drug used for the treatment of arrhythmias and repurposed in the 1980s for patients with nondystrophic myotonia (NDM). Recently, the price of mexiletine in Europe increased significantly after registration as an orphan drug for NDM. This led to international discussions on affordability and willingness to reimburse mexiletine in the absence of background information that would justify such a price. Our objective was to calculate a cost-based price for mexiletine for adult patients with NDM based on detailed information on development costs. METHODS We calculated a fair price based on a cost-based pricing model for commercial mexiletine to treat adults with NDM using a recent European drug-pricing model as a framework to include actual costs incurred. Three scenarios were applied: 1 with minimum estimated costs, 1 with maximum estimated costs, and 1 with costs as if mexiletine was innovative. RESULTS The calculated fair price of mexiletine per patient per year (PPPY) is €452 for the minimum scenario and €1996 for the maximum scenario. By using hypothetical R&D costs used for innovative drugs, the price would be €6685 PPPY. In Europe, the list price of mexiletine ranges from €30 707-60 730 PPPY, based on 600 mg daily. CONCLUSIONS The current list price for mexiletine in Europe is manifold higher than any scenario of the cost-based models. Accounting for the reduced costs for clinical development in a repurposing scenario, the cost-based pricing model provides a fair commercial price range, which can be used as benchmark for pricing negotiations and/or reimbursement decisions.
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Affiliation(s)
- Sibren van den Berg
- Medicine for Society, Platform at Amsterdam UMC - University of Amsterdam, The Netherlands; Department of Endocrinology and Metabolism, Amsterdam UMC - University of Amsterdam, The Netherlands.
| | - Vincent van der Wel
- Medicine for Society, Platform at Amsterdam UMC - University of Amsterdam, The Netherlands
| | - Saco J de Visser
- Medicine for Society, Platform at Amsterdam UMC - University of Amsterdam, The Netherlands
| | - Bas C Stunnenberg
- Department of Neurology, Radboud University Medical Center, Nijmegen, The Netherlands; Department of Neurology, Rijnstate Hospital, Arnhem, The Netherlands
| | - Lonneke Timmers
- National Health Care Institute (Zorginstituut Nederland), Diemen, The Netherlands
| | - Martijn H van der Ree
- Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam UMC, University of Amsterdam, Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Pieter G Postema
- Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam UMC, University of Amsterdam, Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Carla E M Hollak
- Medicine for Society, Platform at Amsterdam UMC - University of Amsterdam, The Netherlands; Department of Endocrinology and Metabolism, Amsterdam UMC - University of Amsterdam, The Netherlands
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Vicart S, Franques J, Bouhour F, Magot A, Péréon Y, Sacconi S, Nadaj-Pakleza A, Behin A, Zahr N, Hézode M, Fournier E, Payan C, Lacomblez L, Fontaine B. Efficacy and safety of mexiletine in non-dystrophic myotonias: A randomised, double-blind, placebo-controlled, cross-over study. Neuromuscul Disord 2021; 31:1124-1135. [PMID: 34702654 DOI: 10.1016/j.nmd.2021.06.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 06/11/2021] [Accepted: 06/22/2021] [Indexed: 11/30/2022]
Abstract
The MYOMEX study was a multicentre, randomised, double-blind, placebo-controlled, cross-over study aimed to compare the effects of mexiletine vs. placebo in patients with myotonia congenita (MC) and paramyotonia congenita (PC). The primary endpoint was the self-reported score of stiffness severity on a 100 mm visual analogic scale (VAS). Mexiletine treatment started at 200 mg/day and was up-titrated by 200 mg increment each three days to reach a maximum dose of 600 mg/day for total treatment duration of 18 days for each cross-over period. The modified intent-to-treat population included 25 patients (13 with MC and 12 with PC; mean age, 43.0 years; male, 68.0%). The median VAS score for mexiletine was 71.0 at baseline and decreased to 16.0 at the end of the treatment while the score did not change for placebo (81.0 at baseline vs. 78.0 at end of treatment). A mixed effects linear model analysis on ranked absolute changes showed a significant effect of treatment (p < 0.001). The overall score of the Individualized Neuromuscular Quality of Life questionnaire (INQoL) was significantly improved (p < 0.001). No clinically significant adverse events were reported. In conclusion, mexiletine improved stiffness and quality of life in patients with nondystrophic myotonia and was well tolerated.
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Affiliation(s)
- Savine Vicart
- Assistance Publique-Hôpitaux de Paris, Sorbonne Université, INSERM, Service of Neuro-Myology, Muscle Channelopathies Reference Center and UMR 974, Institute of Myology, University Hospital Pitié-Salpêtrière, Paris, France.
| | - Jérôme Franques
- Assistance Publique-Hôpitaux de Marseille, Department of Neurology and Neuromuscular Diseases, La Timone Hospital, Marseille, France
| | - Françoise Bouhour
- Electroneuromyography and Neuromuscular Disorders Department, Hospices Civils de Lyon, University Hospital of Lyon, France
| | - Armelle Magot
- Reference Centre for Neuromuscular disorders AOC, University Hospital, Hôtel-Dieu, Nantes, France
| | - Yann Péréon
- Reference Centre for Neuromuscular disorders AOC, University Hospital, Hôtel-Dieu, Nantes, France
| | - Sabrina Sacconi
- Université Côte d'Azur, Peripheral Nervous System & Muscle Department, Pasteur 2 Hospital, Centre Hospitalier Universitaire de Nice, Nice, France
| | - Aleksandra Nadaj-Pakleza
- Reference Centre for Neuromuscular disorders AOC, Neurology Department, University Hospital of Angers, Angers, France
| | - Anthony Behin
- Assistance Publique-Hôpitaux de Paris, Service of Neuro-Myology, Reference Centre for Neuromuscular disorders NEIdF, University Hospital Pitié-Salpêtrière, Paris, France
| | - Noël Zahr
- Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Pharmacology Department, University Hospital Pitié-Salpêtrière, Paris, France
| | - Marianne Hézode
- Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Department of Clinical Neurophysiology, University Hospital Pitié-Salpêtrière, Paris, France
| | - Emmanuel Fournier
- Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Department of Clinical Neurophysiology, University Hospital Pitié-Salpêtrière, Paris, France
| | - Christine Payan
- Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Pharmacology Department, University Hospital Pitié-Salpêtrière, Paris, France
| | - Lucette Lacomblez
- Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Pharmacology Department, University Hospital Pitié-Salpêtrière, Paris, France; Assistance Publique-Hôpitaux de Paris, Sorbonne Université, INSERM U 1422, Neurology Department, University Hospital Pitié-Salpêtrière, Paris, France
| | - Bertrand Fontaine
- Assistance Publique-Hôpitaux de Paris, Sorbonne Université, INSERM, Service of Neuro-Myology, Muscle Channelopathies Reference Center and UMR 974, Institute of Myology, University Hospital Pitié-Salpêtrière, Paris, France
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Maggi L, Bonanno S, Altamura C, Desaphy JF. Ion Channel Gene Mutations Causing Skeletal Muscle Disorders: Pathomechanisms and Opportunities for Therapy. Cells 2021; 10:cells10061521. [PMID: 34208776 PMCID: PMC8234207 DOI: 10.3390/cells10061521] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 06/03/2021] [Accepted: 06/10/2021] [Indexed: 02/06/2023] Open
Abstract
Skeletal muscle ion channelopathies (SMICs) are a large heterogeneous group of rare genetic disorders caused by mutations in genes encoding ion channel subunits in the skeletal muscle mainly characterized by myotonia or periodic paralysis, potentially resulting in long-term disabilities. However, with the development of new molecular technologies, new genes and new phenotypes, including progressive myopathies, have been recently discovered, markedly increasing the complexity in the field. In this regard, new advances in SMICs show a less conventional role of ion channels in muscle cell division, proliferation, differentiation, and survival. Hence, SMICs represent an expanding and exciting field. Here, we review current knowledge of SMICs, with a description of their clinical phenotypes, cellular and molecular pathomechanisms, and available treatments.
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Affiliation(s)
- Lorenzo Maggi
- Neuroimmunology and Neuromuscular Disorders Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20133 Milan, Italy;
- Correspondence:
| | - Silvia Bonanno
- Neuroimmunology and Neuromuscular Disorders Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20133 Milan, Italy;
| | - Concetta Altamura
- Department of Biomedical Sciences and Human Oncology, School of Medicine, University of Bari Aldo Moro, 70124 Bari, Italy; (C.A.); (J.-F.D.)
| | - Jean-François Desaphy
- Department of Biomedical Sciences and Human Oncology, School of Medicine, University of Bari Aldo Moro, 70124 Bari, Italy; (C.A.); (J.-F.D.)
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Abstract
A rare disease, or orphan disease, in the United States is a condition with a national prevalence of fewer than 200,000 diagnoses. As therapies for rare diseases are developed and brought to market, pharmacists should understand the challenges of drug development for rare diseases and aid in educating patients about the approval process for rare disease therapies. Developing drugs for treating rare diseases presents unique challenges in proving the drug's safety and efficacy with adequate study design, power, and validity. Results of the clinical trials for rare diseases may be weakened by small patient populations, limited disease information, and difficulty defining end points and biomarkers. In addition to investigational barriers, pharmaceutical companies face financial barriers in justifying the investment of bringing a rare disease therapy to market. Federal programs, such as the Orphan Drug Act of 1983, expedited review, the Rare Pediatric Disease Priority Review Vouchers (RPD PRV) program, and the 21st Century Cures Act, give pharmaceutical companies motivation to develop therapies for rare diseases. The objective of this article is to provide pharmacists with an understanding of the challenges in designing clinical trials for drugs for rare diseases and discuss federal programs that address efforts to develop safe and efficacious drugs for rare diseases.
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Affiliation(s)
- Kanya K Shah
- College of Pharmacy, 4260University of Rhode Island, Kingston, RI, USA
| | - Stephen Kogut
- College of Pharmacy, 4260University of Rhode Island, Kingston, RI, USA
| | - Angela Slitt
- College of Pharmacy, 4260University of Rhode Island, Kingston, RI, USA
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Abstract
Skeletal muscle channelopathies are a group of rare episodic genetic disorders comprising the periodic paralyses and the non-dystrophic myotonias. They may cause significant morbidity, limit vocational opportunities, be socially embarrassing, and sometimes are associated with sudden cardiac death. The diagnosis is often hampered by symptoms that patients may find difficult to describe, a normal examination in the absence of symptoms, and the need to interpret numerous tests that may be normal or abnormal. However, the symptoms respond very well to holistic management and pharmacological treatment, with great benefit to quality of life. Here, we review when to suspect a muscle channelopathy, how to investigate a possible case and the options for therapy once a diagnosis is made.
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Affiliation(s)
- Emma Matthews
- Atkinson-Morley Neuromuscular Centre, St George's University Hospitals NHS Foundation Trust, London, UK
- Department of Neuromuscular Diseases, UCL, Institute of Neurology, London, UK
| | - Sarah Holmes
- Queen Square Centre for Neuromuscular Diseases, National Hospital for Neurology and Neurosurgery, London, UK
| | - Doreen Fialho
- Department of Neuromuscular Diseases, UCL, Institute of Neurology, London, UK
- Queen Square Centre for Neuromuscular Diseases, National Hospital for Neurology and Neurosurgery, London, UK
- Department of Clinical Neurophysiology, King's College Hospital NHS Foundation Trust, London, UK
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Ravaglia S, Maggi L, Zito A, Arceri S, Gallotti P, Altamura C, Desaphy JF, Bernasconi P, Alfonsi E. Buprenorphine may be effective for treatment of paramyotonia congenita. Muscle Nerve 2021; 64:95-99. [PMID: 33835497 DOI: 10.1002/mus.27249] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 04/03/2021] [Accepted: 04/05/2021] [Indexed: 11/10/2022]
Abstract
INTRODUCTION/AIMS Paramyotonia congenita (PMC) is a skeletal muscle sodium channelopathy characterized by paradoxical myotonia, cold sensitivity, and exercise/cold-induced paralysis. Treatment with sodium-channel-blocking antiarrhythmic agents may expose patients to a risk of arrhythmia or may be poorly tolerated or ineffective. In this study we explored the effectiveness of non-antiarrhythmic sodium-channel blockers in two patients with PMC. METHODS Earlier treatment with mexiletine was discontinued for gastrointestinal side effects in one of the patients and lack of clinical benefit in the other. One patient received lacosamide, ranolazine, and buprenorphine, and the other was given buprenorphine only. Drug efficacy was assessed by clinical scores, timed tests, and by long and short exercise tests. RESULTS In both patients, buprenorphine improved pain scores by at least 50%, stiffness and weakness levels, and handgrip/eyelid-opening times. The fall in compound muscle action potential (CMAP) during short exercise normalized in both patients at baseline, and improved after cooling. During long exercise, one patient showed an earlier recovery of CMAP, and the other patient had a less severe decrease (<60%). With buprenorphine, the fall in CMAP induced by cooling normalized in one patient (from -72% to -4%) and improved (from -49% to -37%) in the other patient. DISCUSSION Buprenorphine showed promising results for the treatment of exercise-induced paralysis and cold intolerance in the two patients assessed. The exercise test may be useful for quantitative assessment of treatment response. Further studies on a larger number of patients, under carefully controlled conditions, should be considered to address the effectiveness and long-term tolerability of this therapeutic option.
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Affiliation(s)
| | - Lorenzo Maggi
- Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | | | | | - Pietro Gallotti
- Istituto Clinico "Beato Matteo," Hospital Group San Donato, Vigevano, Italy
| | - Concetta Altamura
- Sezione di Farmacologia, Dipartimento di Scienze Biomediche e Oncologia Umana, Scuola di Medicina, Università degli Studi di Bari Aldo Moro, Bari, Italy
| | - Jean Francois Desaphy
- Sezione di Farmacologia, Dipartimento di Scienze Biomediche e Oncologia Umana, Scuola di Medicina, Università degli Studi di Bari Aldo Moro, Bari, Italy
| | - Pia Bernasconi
- Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
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Shrestha S, Jain S. A Bayesian-bandit adaptive design for N-of-1 clinical trials. Stat Med 2021; 40:1825-1844. [PMID: 33462851 DOI: 10.1002/sim.8873] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 11/29/2020] [Accepted: 12/19/2020] [Indexed: 11/10/2022]
Abstract
N-of-1 trials, which are randomized, double-blinded, controlled, multiperiod, crossover trials on a single subject, have been applied to determine the heterogeneity of the individual's treatment effect in precision medicine settings. An aggregated N-of-1 design, which can estimate the population effect from these individual trials, is a pragmatic alternative when a randomized controlled trial (RCT) is infeasible. We propose a Bayesian adaptive design for both the individual and aggregated N-of-1 trials using a multiarmed bandit framework that is estimated via efficient Markov chain Monte Carlo. A Bayesian hierarchical structure is used to jointly model the individual and population treatment effects. Our proposed adaptive trial design is based on Thompson sampling, which randomly allocates individuals to treatments based on the Bayesian posterior probability of each treatment being optimal. While we use a subject-specific treatment effect and Bayesian posterior probability estimates to determine an individual's treatment allocation, our hierarchical model facilitates these individual estimates to borrow strength from the population estimates via shrinkage to the population mean. We present the design's operating characteristics and performance via a simulation study motivated by a recently completed N-of-1 clinical trial. We demonstrate that from a patient-centered perspective, subjects are likely to benefit from our adaptive design, in particular, for those individuals that deviate from the overall population effect.
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Affiliation(s)
- Sama Shrestha
- Biostatistics Research Center, Herbert Wertheim School of Public Health, University of California, San Diego, California, USA
| | - Sonia Jain
- Biostatistics Research Center, Herbert Wertheim School of Public Health, University of California, San Diego, California, USA
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Heatwole C, Luebbe E, Rosero S, Eichinger K, Martens W, Hilbert J, Dekdebrun J, Dilek N, Zizzi C, Johnson N, Puwanant A, Tawil R, Schifitto G, Beck CA, Richeson JF, Zareba W, Thornton C, McDermott MP, Moxley R. Mexiletine in Myotonic Dystrophy Type 1: A Randomized, Double-Blind, Placebo-Controlled Trial. Neurology 2021; 96:e228-e240. [PMID: 33046619 PMCID: PMC7905778 DOI: 10.1212/wnl.0000000000011002] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 08/24/2020] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE To assess mexiletine's long-term safety and effect on 6-minute walk distance in a well-defined cohort of patients with myotonic dystrophy type 1 (DM1). METHODS We performed a randomized, double-blind, placebo-controlled trial of mexiletine (150 mg 3 times daily) to evaluate its efficacy and safety in a homogenous cohort of adult ambulatory patients with DM1. The primary outcome was change in 6-minute walk distance at 6 months. Secondary outcomes included changes in hand grip myotonia, strength, swallowing, forced vital capacity, lean muscle mass, Myotonic Dystrophy Health Index scores, and 24-hour Holter and ECG results at 3 and 6 months. RESULTS Forty-two participants were randomized and 40 completed the 6-month follow-up (n = 20 in both groups). No significant effects of mexiletine were observed on 6-minute walk distance, but hand grip myotonia was improved with mexiletine treatment. There were no differences between the mexiletine and placebo groups with respect to the frequency or type of adverse events. Changes in PR, QRS, and QTc intervals were similar in mexiletine- and placebo-treated participants. CONCLUSIONS There was no benefit of mexiletine on 6-minute walk distance at 6 months. Although mexiletine had a sustained positive effect on objectively measured hand grip myotonia, this was not seen in measures reflecting participants' perceptions of their myotonia. No effects of mexiletine on cardiac conduction measures were seen over the 6-month follow-up period. CLASSIFICATION OF EVIDENCE This study provides Class I evidence that for ambulatory patients with DM1, mexiletine does not significantly change 6-minute walk distance at 6 months.
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Affiliation(s)
- Chad Heatwole
- From the Department of Neurology (C.H., E.L., S.R., K.E., W.M., J.H., J.D., N.D., C.Z., R.T., G.S., C.A.B., J.F.R., W.Z., C.T., M.P.M., R.M.), University of Rochester, MN; Virginia Commonwealth University (N.J.), Richmond; and Wake Forest Baptist Health (A.P.), Winston-Salem, NC.
| | - Elizabeth Luebbe
- From the Department of Neurology (C.H., E.L., S.R., K.E., W.M., J.H., J.D., N.D., C.Z., R.T., G.S., C.A.B., J.F.R., W.Z., C.T., M.P.M., R.M.), University of Rochester, MN; Virginia Commonwealth University (N.J.), Richmond; and Wake Forest Baptist Health (A.P.), Winston-Salem, NC
| | - Spencer Rosero
- From the Department of Neurology (C.H., E.L., S.R., K.E., W.M., J.H., J.D., N.D., C.Z., R.T., G.S., C.A.B., J.F.R., W.Z., C.T., M.P.M., R.M.), University of Rochester, MN; Virginia Commonwealth University (N.J.), Richmond; and Wake Forest Baptist Health (A.P.), Winston-Salem, NC
| | - Katy Eichinger
- From the Department of Neurology (C.H., E.L., S.R., K.E., W.M., J.H., J.D., N.D., C.Z., R.T., G.S., C.A.B., J.F.R., W.Z., C.T., M.P.M., R.M.), University of Rochester, MN; Virginia Commonwealth University (N.J.), Richmond; and Wake Forest Baptist Health (A.P.), Winston-Salem, NC
| | - William Martens
- From the Department of Neurology (C.H., E.L., S.R., K.E., W.M., J.H., J.D., N.D., C.Z., R.T., G.S., C.A.B., J.F.R., W.Z., C.T., M.P.M., R.M.), University of Rochester, MN; Virginia Commonwealth University (N.J.), Richmond; and Wake Forest Baptist Health (A.P.), Winston-Salem, NC
| | - James Hilbert
- From the Department of Neurology (C.H., E.L., S.R., K.E., W.M., J.H., J.D., N.D., C.Z., R.T., G.S., C.A.B., J.F.R., W.Z., C.T., M.P.M., R.M.), University of Rochester, MN; Virginia Commonwealth University (N.J.), Richmond; and Wake Forest Baptist Health (A.P.), Winston-Salem, NC
| | - Jeanne Dekdebrun
- From the Department of Neurology (C.H., E.L., S.R., K.E., W.M., J.H., J.D., N.D., C.Z., R.T., G.S., C.A.B., J.F.R., W.Z., C.T., M.P.M., R.M.), University of Rochester, MN; Virginia Commonwealth University (N.J.), Richmond; and Wake Forest Baptist Health (A.P.), Winston-Salem, NC
| | - Nuran Dilek
- From the Department of Neurology (C.H., E.L., S.R., K.E., W.M., J.H., J.D., N.D., C.Z., R.T., G.S., C.A.B., J.F.R., W.Z., C.T., M.P.M., R.M.), University of Rochester, MN; Virginia Commonwealth University (N.J.), Richmond; and Wake Forest Baptist Health (A.P.), Winston-Salem, NC
| | - Christine Zizzi
- From the Department of Neurology (C.H., E.L., S.R., K.E., W.M., J.H., J.D., N.D., C.Z., R.T., G.S., C.A.B., J.F.R., W.Z., C.T., M.P.M., R.M.), University of Rochester, MN; Virginia Commonwealth University (N.J.), Richmond; and Wake Forest Baptist Health (A.P.), Winston-Salem, NC
| | - Nicholas Johnson
- From the Department of Neurology (C.H., E.L., S.R., K.E., W.M., J.H., J.D., N.D., C.Z., R.T., G.S., C.A.B., J.F.R., W.Z., C.T., M.P.M., R.M.), University of Rochester, MN; Virginia Commonwealth University (N.J.), Richmond; and Wake Forest Baptist Health (A.P.), Winston-Salem, NC
| | - Araya Puwanant
- From the Department of Neurology (C.H., E.L., S.R., K.E., W.M., J.H., J.D., N.D., C.Z., R.T., G.S., C.A.B., J.F.R., W.Z., C.T., M.P.M., R.M.), University of Rochester, MN; Virginia Commonwealth University (N.J.), Richmond; and Wake Forest Baptist Health (A.P.), Winston-Salem, NC
| | - Rabi Tawil
- From the Department of Neurology (C.H., E.L., S.R., K.E., W.M., J.H., J.D., N.D., C.Z., R.T., G.S., C.A.B., J.F.R., W.Z., C.T., M.P.M., R.M.), University of Rochester, MN; Virginia Commonwealth University (N.J.), Richmond; and Wake Forest Baptist Health (A.P.), Winston-Salem, NC
| | - Giovanni Schifitto
- From the Department of Neurology (C.H., E.L., S.R., K.E., W.M., J.H., J.D., N.D., C.Z., R.T., G.S., C.A.B., J.F.R., W.Z., C.T., M.P.M., R.M.), University of Rochester, MN; Virginia Commonwealth University (N.J.), Richmond; and Wake Forest Baptist Health (A.P.), Winston-Salem, NC
| | - Christopher A Beck
- From the Department of Neurology (C.H., E.L., S.R., K.E., W.M., J.H., J.D., N.D., C.Z., R.T., G.S., C.A.B., J.F.R., W.Z., C.T., M.P.M., R.M.), University of Rochester, MN; Virginia Commonwealth University (N.J.), Richmond; and Wake Forest Baptist Health (A.P.), Winston-Salem, NC
| | - J Franklin Richeson
- From the Department of Neurology (C.H., E.L., S.R., K.E., W.M., J.H., J.D., N.D., C.Z., R.T., G.S., C.A.B., J.F.R., W.Z., C.T., M.P.M., R.M.), University of Rochester, MN; Virginia Commonwealth University (N.J.), Richmond; and Wake Forest Baptist Health (A.P.), Winston-Salem, NC
| | - Wojciech Zareba
- From the Department of Neurology (C.H., E.L., S.R., K.E., W.M., J.H., J.D., N.D., C.Z., R.T., G.S., C.A.B., J.F.R., W.Z., C.T., M.P.M., R.M.), University of Rochester, MN; Virginia Commonwealth University (N.J.), Richmond; and Wake Forest Baptist Health (A.P.), Winston-Salem, NC
| | - Charles Thornton
- From the Department of Neurology (C.H., E.L., S.R., K.E., W.M., J.H., J.D., N.D., C.Z., R.T., G.S., C.A.B., J.F.R., W.Z., C.T., M.P.M., R.M.), University of Rochester, MN; Virginia Commonwealth University (N.J.), Richmond; and Wake Forest Baptist Health (A.P.), Winston-Salem, NC
| | - Michael P McDermott
- From the Department of Neurology (C.H., E.L., S.R., K.E., W.M., J.H., J.D., N.D., C.Z., R.T., G.S., C.A.B., J.F.R., W.Z., C.T., M.P.M., R.M.), University of Rochester, MN; Virginia Commonwealth University (N.J.), Richmond; and Wake Forest Baptist Health (A.P.), Winston-Salem, NC
| | - Richard Moxley
- From the Department of Neurology (C.H., E.L., S.R., K.E., W.M., J.H., J.D., N.D., C.Z., R.T., G.S., C.A.B., J.F.R., W.Z., C.T., M.P.M., R.M.), University of Rochester, MN; Virginia Commonwealth University (N.J.), Richmond; and Wake Forest Baptist Health (A.P.), Winston-Salem, NC
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Desaphy JF, Altamura C, Vicart S, Fontaine B. Targeted Therapies for Skeletal Muscle Ion Channelopathies: Systematic Review and Steps Towards Precision Medicine. J Neuromuscul Dis 2021; 8:357-381. [PMID: 33325393 PMCID: PMC8203248 DOI: 10.3233/jnd-200582] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Skeletal muscle ion channelopathies include non-dystrophic myotonias (NDM), periodic paralyses (PP), congenital myasthenic syndrome, and recently identified congenital myopathies. The treatment of these diseases is mainly symptomatic, aimed at reducing muscle excitability in NDM or modifying triggers of attacks in PP. OBJECTIVE This systematic review collected the evidences regarding effects of pharmacological treatment on muscle ion channelopathies, focusing on the possible link between treatments and genetic background. METHODS We searched databases for randomized clinical trials (RCT) and other human studies reporting pharmacological treatments. Preclinical studies were considered to gain further information regarding mutation-dependent drug effects. All steps were performed by two independent investigators, while two others critically reviewed the entire process. RESULTS For NMD, RCT showed therapeutic benefits of mexiletine and lamotrigine, while other human studies suggest some efficacy of various sodium channel blockers and of the carbonic anhydrase inhibitor (CAI) acetazolamide. Preclinical studies suggest that mutations may alter sensitivity of the channel to sodium channel blockers in vitro, which has been translated to humans in some cases. For hyperkalemic and hypokalemic PP, RCT showed efficacy of the CAI dichlorphenamide in preventing paralysis. However, hypokalemic PP patients carrying sodium channel mutations may have fewer benefits from CAI compared to those carrying calcium channel mutations. Few data are available for treatment of congenital myopathies. CONCLUSIONS These studies provided limited information about the response to treatments of individual mutations or groups of mutations. A major effort is needed to perform human studies for designing a mutation-driven precision medicine in muscle ion channelopathies.
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Affiliation(s)
- Jean-François Desaphy
- Department of Biomedical Sciences and Human Oncology, School of Medicine, University of Bari Aldo Moro, Bari, Italy
| | - Concetta Altamura
- Department of Biomedical Sciences and Human Oncology, School of Medicine, University of Bari Aldo Moro, Bari, Italy
| | - Savine Vicart
- Sorbonne Université, INSERM, Assistance Publique Hôpitaux de Paris, Centre de Recherche en Myologie-UMR 974, Reference center in neuro-muscular channelopathies, Institute of Myology, Hôpital Universitaire Pitié-Salpêtrière, Paris, France
| | - Bertrand Fontaine
- Sorbonne Université, INSERM, Assistance Publique Hôpitaux de Paris, Centre de Recherche en Myologie-UMR 974, Reference center in neuro-muscular channelopathies, Institute of Myology, Hôpital Universitaire Pitié-Salpêtrière, Paris, France
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Vereb N, Montagnese F, Gläser D, Schoser B. Non-dystrophic myotonias: clinical and mutation spectrum of 70 German patients. J Neurol 2021; 268:1708-20. [PMID: 33263785 DOI: 10.1007/s00415-020-10328-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 11/09/2020] [Accepted: 11/19/2020] [Indexed: 12/17/2022]
Abstract
Introduction Non-dystrophic myotonias (NDM) are heterogeneous diseases caused by mutations in CLCN1 and SCN4A. The study aimed to describe the clinical and genetic spectrum of NDM in a large German cohort. Methods We retrospectively identified all patients with genetically confirmed NDM diagnosed in our center. The following data were analyzed: demographics, family history, muscular features, cardiac involvement, CK, EMG, genotype, other tested genes, treatment perceived efficacy. Results 70 patients (age 40.2 years ± 14.9; 52.8% males) were included in our study (48 NDM-CLCN1, 22 NDM-SCN4A). The most frequent presenting symptoms were myotonia (NDM-CLCN1 83.3%, NDM-SCN4A 72.2%) and myalgia (NDM-CLCN1 57.4%, NDM-SCN4A 52.6%). Besides a more prominent facial involvement in NDM-SCN4A and cold-sensitivity in NDM-CLCN1, no other significant differences were observed between groups. Cardiac arrhythmia or conduction defects were documented in sixNDM-CLCN1 patients (three of them requiring a pacemaker) and one patient with NDM-SCN4A. CK was normal in 40% of patients. Myotonic runs in EMG were detected in 89.1% of CLCN1 and 78.9% of SCN4A. 50% of NDM-CLCN1 patients had the classic c.2680C>T (p.Arg894*) mutation. 12 new genetic variants are reported. About 50% of patients were not taking any anti-myotonic drug at the last follow-up. The anti-myotonic drugs with the best patient’s perceived efficacy were mexiletine and lamotrigine. Conclusion This study highlights the relevant clinical overlap between NDM-CLCN1 and NDM-SCN4A patients and warrants the use of early and broad genetic investigation for the precise identification of the NDM subtype. Besides the clinical and genetic heterogeneity, the limited response to current anti-myotonic drugs constitutes a continuing challenge. Supplementary Information The online version contains supplementary material available at 10.1007/s00415-020-10328-1.
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Horrigan J, Gomes TB, Snape M, Nikolenko N, McMorn A, Evans S, Yaroshinsky A, Della Pasqua O, Oosterholt S, Lochmüller H. A Phase 2 Study of AMO-02 (Tideglusib) in Congenital and Childhood-Onset Myotonic Dystrophy Type 1 (DM1). Pediatr Neurol 2020; 112:84-93. [PMID: 32942085 DOI: 10.1016/j.pediatrneurol.2020.08.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 07/31/2020] [Accepted: 08/02/2020] [Indexed: 11/15/2022]
Abstract
BACKGROUND GSK3β is an intracellular regulatory kinase that is dysregulated in multiple tissues in type 1 myotonic dystrophy, a rare neuromuscular disorder that manifests at any age. AMO-02 (tideglusib) inhibits GSK3β activity in preclinical models of type 1 myotonic dystrophy and promotes cellular maturation as well as normalizes aberrant molecular and behavioral phenotypes. This phase 2 study assessed the pharmacokinetics, safety and tolerability, and preliminary efficacy of AMO-02 in adolescents and adults with congenital and childhood-onset type 1 myotonic dystrophy. METHODS Sixteen subjects (aged 13 to 34 years) with congenital and childhood-onset type 1 myotonic dystrophy received 12 weeks of single-blind fixed-dose oral treatment with either 400 mg (n = 8) or 1000 mg (n = 8) AMO-02 (NCT02858908). Blood samples were obtained for pharmacokinetic assessment. Safety assessments, such as laboratory tests and electrocardiograms, as well as efficacy assessments of syndromal, cognitive, and muscular functioning, were obtained. RESULTS AMO-02 plasma concentrations conformed to a two-compartment model with first-order absorption and elimination, and dose-dependent increases in exposure (area under the curve) were observed. AMO-02 was generally safe and well-tolerated. No early discontinuations due to adverse events or dose adjustments of AMO-02 occurred. The majority of subjects manifested clinical improvement in their central nervous system and neuromuscular symptoms after 12 weeks of treatment compared with the placebo baseline, with a larger response noted at the 1000 mg/day dose level. AMO-02 exposure (cumulative area under the curve) was significantly correlated (P < 0.01) with change from baseline on several key efficacy assessments. CONCLUSION AMO-02 has favorable pharmacokinetic and clinical risk/benefit profiles meriting further study as a potential treatment for congenital and childhood-onset type 1 myotonic dystrophy.
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Affiliation(s)
| | - Tiago Bernardino Gomes
- John Walton Muscular Dystrophy Research Centre, Institute of Genetic Medicine, Newcastle University, UK
| | | | - Nikoletta Nikolenko
- National Hospital for Neurology and Neurosurgery, Queen Square, University College London Hospitals NHS Foundation Trust, London, UK
| | | | | | | | - Oscar Della Pasqua
- Clinical Pharmacology and Therapeutics, University College London, London, UK
| | - Sean Oosterholt
- Clinical Pharmacology and Therapeutics, University College London, London, UK
| | - Hanns Lochmüller
- Children's Hospital of Eastern Ontario Research Institute; Division of Neurology, Department of Medicine, The Ottawa Hospital; and Brain and Mind Research Institute, University of Ottawa, Ottawa, Canada
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