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Balwani M, Keel S, Meissner P, Sonderup M, Stein P, Yasuda M. Case-based discussion of the acute hepatic porphyrias: Updates on pathogenesis, diagnosis and management. Liver Int 2024. [PMID: 38618923 DOI: 10.1111/liv.15924] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Revised: 03/21/2024] [Accepted: 03/22/2024] [Indexed: 04/16/2024]
Abstract
The acute hepatic porphyrias (AHPs) include three autosomal dominant disorders, acute intermittent porphyria, variegate porphyria and hereditary coproporphyria, and the ultra-rare autosomal recessive 5-aminolevulinic acid dehydratase-deficient porphyria. All four are characterized by episodic acute neurovisceral attacks that can be life-threatening if left untreated. The attacks are precipitated by factors that induce hepatic 5-aminolevulinic acid synthase 1 (ALAS1), resulting in accumulation of the porphyrin precursors, 5-aminolevulinic acid and porphobilinogen, which are believed to cause neurotoxicity. Diagnosis of these rare disorders is often delayed because the symptoms are non-specific with many common aetiologies. However, once clinical suspicion of an AHP is raised, diagnosis can be made by specialized biochemical testing, particularly during attacks. Moderate or severe attacks are treated with intravenous hemin infusions, together with supportive care to relieve pain and other symptoms. Prophylactic treatments are recommended in patients with confirmed recurrent attacks (≥4 attacks in a maximum period of 12 months), the most effective being givosiran, an RNAi therapeutic targeting hepatocyte ALAS1 mRNA. AHP patients with clinically and/or biochemically active disease are at elevated risk for developing long-term complications, including chronic kidney disease, chronic hypertension and hepatocellular carcinoma, thus, surveillance is recommended. Here, using a case-based format, we provide an update on the pathogenesis, diagnosis and treatment of the AHPs based on literature review and clinical experiences.
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Affiliation(s)
- Manisha Balwani
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Siobán Keel
- Department of Medicine, Division of Hematology and Oncology, University of Washington, Seattle, Washington, USA
| | - Peter Meissner
- Department of Integrative Biomedical Sciences, Division of Medical Biochemistry and Structural Biology, University of Cape Town, Cape Town, South Africa
| | - Mark Sonderup
- Division of Hepatology, Department of Medicine, Faculty of Health Sciences, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - Penelope Stein
- Department of Haematological Medicine, King's College Hospital, London, UK
| | - Makiko Yasuda
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Kubicka-Trząska A, Bugara D, Żuber-Łaskawiec K, Pociej-Marciak W, Markiewicz A, Romanowska-Dixon B, Karska-Basta I. Use of Optical Coherence Tomography and Optical Coherence Tomography Angiography in the Diagnosis and Follow-Up of Endogenous Candida Endophthalmitis: A Case Report. Medicina (Kaunas) 2024; 60:207. [PMID: 38399495 PMCID: PMC10890289 DOI: 10.3390/medicina60020207] [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] [Received: 12/03/2023] [Revised: 01/18/2024] [Accepted: 01/23/2024] [Indexed: 02/25/2024]
Abstract
Background: Endogenous Candida endophthalmitis (ECE) is a rare but sight-threatening disease. Patients with ECE present with various clinical signs and symptoms, which can complicate the diagnosis. The aim of this report was to demonstrate the outcomes of treatment and to diagnose macular complications caused by intraocular inflammation. Case presentation: A 41-year-old woman with a history of acute intermittent porphyria presented with a progressive vision loss in her left eye. Left-eye OCT revealed findings consistent with a fungal etiology, which was confirmed by the culture of swabs collected from a central vein catheter. The outcomes of intravenous fluconazole treatment were not satisfactory, and the patient developed recurrent attacks of porphyria, suggesting a porphyrogenic effect of systemic antifungal therapy. Repeated intravitreal injections with amphotericin B led to a gradual regression of inflammatory lesions. However, follow-up examinations revealed active macular neovascularization (MNV) on both OCT and OCTA scans. The patient was administered intravitreal bevacizumab. At the 11th month of follow-up, OCT and OCTA scans showed significant inflammatory lesions regression with macula scarring, and no MNV activity was detected. Conclusions: This case highlights the importance of OCT and OCTA as valuable noninvasive imaging techniques for the identification of ECE, the monitoring of its clinical course, and the diagnosis of macular complications.
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Affiliation(s)
- Agnieszka Kubicka-Trząska
- Department of Ophthalmology, Faculty of Medicine, Medical College, Jagiellonian University, ul. Kopernika 38, 31-501 Krakow, Poland; (D.B.); (K.Ż.-Ł.); (W.P.-M.); (A.M.); (B.R.-D.); (I.K.-B.)
- Clinic of Ophthalmology and Ocular Oncology, University Hospital, ul. Kopernika 38, 31-501 Krakow, Poland
| | - Dawid Bugara
- Department of Ophthalmology, Faculty of Medicine, Medical College, Jagiellonian University, ul. Kopernika 38, 31-501 Krakow, Poland; (D.B.); (K.Ż.-Ł.); (W.P.-M.); (A.M.); (B.R.-D.); (I.K.-B.)
| | - Katarzyna Żuber-Łaskawiec
- Department of Ophthalmology, Faculty of Medicine, Medical College, Jagiellonian University, ul. Kopernika 38, 31-501 Krakow, Poland; (D.B.); (K.Ż.-Ł.); (W.P.-M.); (A.M.); (B.R.-D.); (I.K.-B.)
- Clinic of Ophthalmology and Ocular Oncology, University Hospital, ul. Kopernika 38, 31-501 Krakow, Poland
| | - Weronika Pociej-Marciak
- Department of Ophthalmology, Faculty of Medicine, Medical College, Jagiellonian University, ul. Kopernika 38, 31-501 Krakow, Poland; (D.B.); (K.Ż.-Ł.); (W.P.-M.); (A.M.); (B.R.-D.); (I.K.-B.)
- Clinic of Ophthalmology and Ocular Oncology, University Hospital, ul. Kopernika 38, 31-501 Krakow, Poland
| | - Anna Markiewicz
- Department of Ophthalmology, Faculty of Medicine, Medical College, Jagiellonian University, ul. Kopernika 38, 31-501 Krakow, Poland; (D.B.); (K.Ż.-Ł.); (W.P.-M.); (A.M.); (B.R.-D.); (I.K.-B.)
- Clinic of Ophthalmology and Ocular Oncology, University Hospital, ul. Kopernika 38, 31-501 Krakow, Poland
| | - Bożena Romanowska-Dixon
- Department of Ophthalmology, Faculty of Medicine, Medical College, Jagiellonian University, ul. Kopernika 38, 31-501 Krakow, Poland; (D.B.); (K.Ż.-Ł.); (W.P.-M.); (A.M.); (B.R.-D.); (I.K.-B.)
- Clinic of Ophthalmology and Ocular Oncology, University Hospital, ul. Kopernika 38, 31-501 Krakow, Poland
| | - Izabella Karska-Basta
- Department of Ophthalmology, Faculty of Medicine, Medical College, Jagiellonian University, ul. Kopernika 38, 31-501 Krakow, Poland; (D.B.); (K.Ż.-Ł.); (W.P.-M.); (A.M.); (B.R.-D.); (I.K.-B.)
- Clinic of Ophthalmology and Ocular Oncology, University Hospital, ul. Kopernika 38, 31-501 Krakow, Poland
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Ma CD, Bonkovsky HL. Eslicarbazepine acetate is porphyrogenic and should be used with caution in patients with the acute hepatic porphyrias. Front Pharmacol 2022; 13:953961. [PMID: 36147354 PMCID: PMC9485715 DOI: 10.3389/fphar.2022.953961] [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: 05/28/2022] [Accepted: 08/02/2022] [Indexed: 11/29/2022] Open
Abstract
Eslicarbazepine acetate, a third-generation antiepileptic drug (AED), has shown improved clinical response and safety in comparison to older generation AEDs for patients with partial-onset seizures. It is currently not known whether eslicarbazepine acetate is safe to use in patients with the acute hepatic porphyrias (AHPs) since a few first-generation AEDs, such as phenobarbital and carbamazepine, are known porphyrogenic agents. In this study, we used a recently published in vitro fluorescence-based screening assay to screen for porphyrogenicity in various agents. The assay confirmed that among the tested compounds used, allyl isopropyl acetamide, carbamazepine, eslicarbazepine acetate, and phenobarbital were porphyrogenic. Thus, eslicarbazepine acetate should be avoided if possible in patients with the AHPs, but if initiated, patients should be closely monitored and the drug should be discontinued if a porphyric exacerbation occurs.
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Affiliation(s)
- Christopher D Ma
- Department of Internal Medicine, Section on Gastroenterology and Hepatology, Wake Forest University School of Medicine, Winston-Salem, NC, United States
| | - Herbert L Bonkovsky
- Department of Internal Medicine, Section on Gastroenterology and Hepatology, Wake Forest University School of Medicine, Winston-Salem, NC, United States
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Baumann K, Kauppinen R. Long-term follow-up of acute porphyria in female patients: Update of clinical outcome and life expectancy. Mol Genet Metab Rep 2022; 30:100842. [PMID: 35242573 PMCID: PMC8856918 DOI: 10.1016/j.ymgmr.2022.100842] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 01/22/2022] [Indexed: 12/28/2022] Open
Abstract
Background Acute hepatic porphyria includes four inherited disorders caused by partial deficiencies of enzymes related to the heme biosynthesis. Clinical manifestations include acute attacks, occurring mainly among female patients. This study describes the diversity of acute symptoms, changes in triggering factors and life expectancy among female patients during the past five decades. Methods 107 Finnish female patients were enrolled into a retrospective, longitudinal study during 2015. Clinical, biochemical and genetic data was obtained from the medical reports, registry data and a questionnaire designed for the study. Causes of death were studied in additional 32 female patients. Results Of the 43 patients with hospitalization, 33% had non-complicated, 35% prolonged and 28% severe attacks with no correlation with the disease-causing mutation. Of the deceased patients, 31% died of an acute attack during 1957–1979. Thereafter the incidence and severity of acute attacks have decreased substantially. 55% of the subjects reported acute symptoms (dysautonomia and mental symptoms) without hospitalization, 29% had porphyria symptoms >10 times, and 23% within the last year. Despite 22% of the female patients had died of primary liver cancer, the life expectancy increased more than 10 years during the follow-up, and did not differ from the normal population at present. Conclusions The incidence of acute attacks requiring hospitalization has decreased, but more than half of the female patients reported acute symptoms affecting their well-being. Symptoms are currently triggered by hormonal changes and weight loss emphasizing the importance of early recognition and active management to avoid disease exacerbation. Death due to primary liver cancer is common and should be screened regularly.
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Affiliation(s)
- Katrin Baumann
- Helsinki University Hospital, Department of Medicine, Finland
- Helsinki University Hospital, Department of Obstetrics and Gynecology, Finland
- Corresponding author at: Department of Medicine, Helsinki University Hospital, BOX 705, Biomedicum Helsinki 2C, 00029 HUS Helsinki, Finland.
| | - Raili Kauppinen
- Helsinki University Hospital, Department of Medicine, Finland
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Vera-Yunca D, Córdoba KM, Parra-Guillen ZP, Jericó D, Fontanellas A, Trocóniz IF. Mechanistic modelling of enzyme-restoration effects for new recombinant liver-targeted proteins in acute intermittent porphyria. Br J Pharmacol 2022; 179:3815-3830. [PMID: 35170015 PMCID: PMC9310908 DOI: 10.1111/bph.15821] [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: 10/25/2021] [Revised: 01/18/2022] [Accepted: 02/08/2022] [Indexed: 11/28/2022] Open
Abstract
Background and Purpose Acute intermittent porphyria (AIP) is a rare disease caused by a genetic mutation in the hepatic activity of the porphobilinogen‐deaminase. We aimed to develop a mechanistic model of the enzymatic restoration effects of a novel therapy based on the administration of different formulations of recombinant human‐PBGD (rhPBGD) linked to the ApoAI lipoprotein. This fusion protein circulates in blood, incorporating into HDL and penetrating hepatocytes. Experimental Approach Single i.v. dose of different formulations of rhPBGD linked to ApoAI were administered to AIP mice in which a porphyric attack was triggered by i.p. phenobarbital. Data consist on 24 h urine excreted amounts of heme precursors, 5‐aminolevulinic acid (ALA), PBG and total porphyrins that were analysed using non‐linear mixed‐effects analysis. Key Results The mechanistic model successfully characterized over time the amounts excreted in urine of the three heme precursors for different formulations of rhPBGD and unravelled several mechanisms in the heme pathway, such as the regulation in ALA synthesis by heme. Treatment with rhPBGD formulations restored PBGD activity, increasing up to 51 times the value of the rate of tPOR formation estimated from baseline. Model‐based simulations showed that several formulation prototypes provided efficient protective effects when administered up to 1 week prior to the occurrence of the AIP attack. Conclusion and Implications The model developed had excellent performance over a range of doses and formulation type. This mechanistic model warrants use beyond ApoAI‐conjugates and represents a useful tool towards more efficient drug treatments of other enzymopenias as well as for acute intermittent porphyria.
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Affiliation(s)
- Diego Vera-Yunca
- Pharmacometrics & Systems Pharmacology, Department of Pharmaceutical Technology and Chemistry, School of Pharmacy and Nutrition, University of Navarra, Pamplona, Spain.,IdiSNA, Navarra Institute for Health Research, Pamplona, Spain
| | - Karol M Córdoba
- IdiSNA, Navarra Institute for Health Research, Pamplona, Spain.,Hepatology Program, Center for Applied Medical Research (CIMA), University of Navarra, Pamplona, Spain
| | - Zinnia P Parra-Guillen
- Pharmacometrics & Systems Pharmacology, Department of Pharmaceutical Technology and Chemistry, School of Pharmacy and Nutrition, University of Navarra, Pamplona, Spain.,IdiSNA, Navarra Institute for Health Research, Pamplona, Spain
| | - Daniel Jericó
- IdiSNA, Navarra Institute for Health Research, Pamplona, Spain.,Hepatology Program, Center for Applied Medical Research (CIMA), University of Navarra, Pamplona, Spain
| | - Antonio Fontanellas
- IdiSNA, Navarra Institute for Health Research, Pamplona, Spain.,Hepatology Program, Center for Applied Medical Research (CIMA), University of Navarra, Pamplona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
| | - Iñaki F Trocóniz
- Pharmacometrics & Systems Pharmacology, Department of Pharmaceutical Technology and Chemistry, School of Pharmacy and Nutrition, University of Navarra, Pamplona, Spain.,IdiSNA, Navarra Institute for Health Research, Pamplona, Spain
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Wu Y, Li M, Guo Y, Liu T, Zhong L, Huang C, Ye C, Liu Q, Ren Z, Wang Y. The Effects of AT-533 and AT-533 gel on Liver Cytochrome P450 Enzymes in Rats. Eur J Drug Metab Pharmacokinet 2022; 47:345-352. [PMID: 35137361 DOI: 10.1007/s13318-022-00757-w] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND AND OBJECTIVES AT-533 is a novel heat shock protein 90 inhibitor, which exhibits various biological activities in vitro and in vivo. Cytochrome P450 (CYP) enzymes in the liver are involved in the biotransformation of drugs and considered to be essential indicators of liver toxicity. The aim of this study was to assess the effect of AT-533, either as active pharmaceutical ingredient or in gel form, on liver CYP enzymes. METHODS The effect of AT-533 or AT-533 gel on rat liver cytochrome P450 enzymes, including CYP1A2, CYP2C9, CYP2C19, CYP2D6, and CYP3A4, was analyzed using LC-MS/MS. RESULTS AT-533 and AT-533 gel did not significantly increase or reduce the enzymatic activity of CYP1A2, CYP2C9, CYP2C19, CYP2D6, and CYP3A4 at any treatment dose. CONCLUSIONS AT-533 and AT-533 gel did not have any effect on CYP activity and may be considered safe for external use in gel form, as an alternative to conventional treatment.
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Affiliation(s)
- Yanting Wu
- Department of Cell Biology, College of Life Science and Technology, Jinan University, No. 601, Whampoa Road West, Guangzhou, 510632, People's Republic of China.,Department of Cell Biology, Guangdong Province Key Laboratory of Bioengineering Medicine, Guangdong Provincial Biotechnology Drug & Engineering Technology Research Center, National Engineering Research Center of Genetic Medicine, Guangzhou, People's Republic of China
| | - Menghe Li
- Department of Cell Biology, College of Life Science and Technology, Jinan University, No. 601, Whampoa Road West, Guangzhou, 510632, People's Republic of China.,Department of Cell Biology, Guangdong Province Key Laboratory of Bioengineering Medicine, Guangdong Provincial Biotechnology Drug & Engineering Technology Research Center, National Engineering Research Center of Genetic Medicine, Guangzhou, People's Republic of China
| | - Yuying Guo
- Department of Cell Biology, Guangzhou Jinan Biomedicine Research and Development Center Co. Ltd, Guangzhou, People's Republic of China
| | - Tao Liu
- Department of Cell Biology, College of Life Science and Technology, Jinan University, No. 601, Whampoa Road West, Guangzhou, 510632, People's Republic of China.,Department of Cell Biology, Guangdong Province Key Laboratory of Bioengineering Medicine, Guangdong Provincial Biotechnology Drug & Engineering Technology Research Center, National Engineering Research Center of Genetic Medicine, Guangzhou, People's Republic of China
| | - Lishan Zhong
- Department of Cell Biology, College of Life Science and Technology, Jinan University, No. 601, Whampoa Road West, Guangzhou, 510632, People's Republic of China.,Department of Cell Biology, Guangdong Province Key Laboratory of Bioengineering Medicine, Guangdong Provincial Biotechnology Drug & Engineering Technology Research Center, National Engineering Research Center of Genetic Medicine, Guangzhou, People's Republic of China
| | - Chen Huang
- Department of Cell Biology, College of Life Science and Technology, Jinan University, No. 601, Whampoa Road West, Guangzhou, 510632, People's Republic of China.,Department of Cell Biology, Guangdong Province Key Laboratory of Bioengineering Medicine, Guangdong Provincial Biotechnology Drug & Engineering Technology Research Center, National Engineering Research Center of Genetic Medicine, Guangzhou, People's Republic of China
| | - Cuifang Ye
- Department of Cell Biology, College of Life Science and Technology, Jinan University, No. 601, Whampoa Road West, Guangzhou, 510632, People's Republic of China.,Department of Cell Biology, Guangdong Province Key Laboratory of Bioengineering Medicine, Guangdong Provincial Biotechnology Drug & Engineering Technology Research Center, National Engineering Research Center of Genetic Medicine, Guangzhou, People's Republic of China
| | - Qiuying Liu
- Department of Cell Biology, College of Life Science and Technology, Jinan University, No. 601, Whampoa Road West, Guangzhou, 510632, People's Republic of China.,Department of Cell Biology, Guangdong Province Key Laboratory of Bioengineering Medicine, Guangdong Provincial Biotechnology Drug & Engineering Technology Research Center, National Engineering Research Center of Genetic Medicine, Guangzhou, People's Republic of China.,Department of pharmacy, School of Pharmaceutical Sciences, Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Zhe Ren
- Department of Cell Biology, College of Life Science and Technology, Jinan University, No. 601, Whampoa Road West, Guangzhou, 510632, People's Republic of China.,Department of Cell Biology, Guangdong Province Key Laboratory of Bioengineering Medicine, Guangdong Provincial Biotechnology Drug & Engineering Technology Research Center, National Engineering Research Center of Genetic Medicine, Guangzhou, People's Republic of China
| | - Yifei Wang
- Department of Cell Biology, College of Life Science and Technology, Jinan University, No. 601, Whampoa Road West, Guangzhou, 510632, People's Republic of China. .,Department of Cell Biology, Guangdong Province Key Laboratory of Bioengineering Medicine, Guangdong Provincial Biotechnology Drug & Engineering Technology Research Center, National Engineering Research Center of Genetic Medicine, Guangzhou, People's Republic of China. .,Department of Cell Biology, Guangzhou Jinan Biomedicine Research and Development Center Co. Ltd, Guangzhou, People's Republic of China.
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Vassiliou D, Lindén Hirschberg A, Sardh E. Treatment with assisted reproduction technologies in women with acute hepatic porphyria. Acta Obstet Gynecol Scand 2021; 100:1712-1721. [PMID: 34060066 DOI: 10.1111/aogs.14200] [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: 03/04/2021] [Revised: 05/24/2021] [Accepted: 05/25/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Acute porphyrias are rare disorders of the heme biosynthetic pathway and present with acute neurovisceral symptoms that can be induced by hormonal changes and medications. Women are far more likely to present with clinical symptoms than men, particularly during parts of their lifetime with changes in the level of female sex hormones such as ovulation, menstruation, and pregnancy. Treatment of ovulatory dysfunction and controlled ovarian hyperstimulation require the administration of hormones, which are considered porphyrinogenic. Women with acute hepatic porphyria have therefore been considered unsuitable for such treatments in the past. MATERIAL AND METHODS We report on nine women with acute hepatic porphyria who underwent in vitro fertilization (IVF), preceded by ovarian stimulation. Their mean age at the start of IVF was 33.2 years (range 27-38 years). Two women had been diagnosed with polycystic ovarian syndrome, two were treated for hyperprolactinemia, two had hypothyroidism, of which one also had type 1 diabetes, one had a uterus malformation, one had anovulatory cycles, and one used a sperm donor. RESULTS All patients were able to undergo fertility treatment without experiencing severe porphyria attacks. CONCLUSIONS Women with acute hepatic porphyria considering fertility treatments should be assessed individually for potential risks, treatment should be planned in close collaboration with a porphyria specialist, and biochemical activity should be monitored regularly during ovarian stimulation. As we gather more knowledge, we hope that the porphyrinogenicity of the stimulation agents is re-assessed and that more studies will shed light on the reproductive health of women living with acute hepatic porphyria.
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Affiliation(s)
- Daphne Vassiliou
- Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden.,Porphyria Center Sweden, Center for Inherited Metabolic Diseases (CMMS), Karolinska University Hospital, Stockholm, Sweden.,Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Angelica Lindén Hirschberg
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.,Department of Gynecology and Reproductive Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Eliane Sardh
- Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden.,Porphyria Center Sweden, Center for Inherited Metabolic Diseases (CMMS), Karolinska University Hospital, Stockholm, Sweden.,Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
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Lazareth H, Talbi N, Kamar N, Levi C, Moulin B, Caillard S, Frimat L, Chemouny J, Chatelet V, Vachey C, Snanoudj R, Lefebvre T, Karras A, Gouya L, Schmitt C, Puy H, Pallet N. Kidney transplantation improves the clinical outcomes of Acute Intermittent Porphyria. Mol Genet Metab 2020; 131:259-266. [PMID: 32893121 DOI: 10.1016/j.ymgme.2020.08.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 08/17/2020] [Accepted: 08/18/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Acute Intermittent Porphyria (AIP) is a rare inherited autosomal dominant disorder of heme biosynthesis. Porphyria-associated kidney disease occurs in more than 50% of the patients with AIP, and end stage renal disease (ESRD) can be a devastating complication for AIP patients. The outcomes of AIP patients after kidney transplantation are poorly known. METHODS We examined the outcomes of 11 individuals with AIP, identified as kidney transplant recipients in the French Porphyria Center Registry. RESULTS AIP had been diagnosed on average 19 years before the diagnosis of ESRD except for one patient in whom the diagnosis of AIP had been made 5 years after the initiation of dialysis. Median follow-up after transplantation was 9 years. A patient died 2 months after transplantation from a cardiac arrest and a patient who received a donation after cardiac death experienced a primary non-function. No rejection episode and no noticeable adverse event occurred after transplantation. Serum creatinine was on average 117 μmol/l, and proteinuria <0.5 g/l in all patients at last follow up. All usually prescribed drugs after transplantation are authorized except for trimethoprim/sulfamethoxazole. Critically, acute porphyria attacks almost disappeared after kidney transplantation, and skin lesions resolved in all patients. CONCLUSION Kidney transplantation is the treatment of choice for AIP patients with ESRD and dramatically reduces the disease activity.
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Affiliation(s)
- Helene Lazareth
- Nephrology Department, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris University, France
| | - Neila Talbi
- French Porphyria Center, Hôpital Louis Mourier, Assistance Publique-Hôpitaux de Paris, Colombes and Research Center on Inflammation, INSERM U1149, Paris University, France
| | - Nassim Kamar
- Department of Nephrology, Dialysis and Organ Transplantation, CHU Rangueil, INSERM U1043, IFR-BMT, University Paul Sabatier, Toulouse, France
| | - Charlène Levi
- Department of Transplantation, Nephrology and Clinical Immunology, Edouard Herriot University Hospital, Lyon, France
| | - Bruno Moulin
- Nephrology and Transplantation Department, University Hospital, Strasbourg, France
| | - Sophie Caillard
- Nephrology and Transplantation Department, University Hospital, Strasbourg, France
| | - Luc Frimat
- Nephrology, Dialysis and Transplantation Department, CHU Nancy, Nancy, France
| | - Jonathan Chemouny
- Nephrology, Dialysis and Transplantation Department, Univ Rennes, CHU Rennes, Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail) - UMR_S 1085, CIC-P 1414 (Centre d'investigation clinique), F-35000 Rennes, France
| | - Valérie Chatelet
- Nephrology, Dialysis, Transplantation Department, CHU Cote de Nacre, Caen University, Caen, France
| | - Clément Vachey
- Nephrology, Dialysis and Transplantation Department, CHU Besançon, Besançon, France
| | - Renaud Snanoudj
- Nephrology, Dialysis and Renal Transplantation Department, Hospital Foch, Suresnes, France
| | - Thibaud Lefebvre
- French Porphyria Center, Hôpital Louis Mourier, Assistance Publique-Hôpitaux de Paris, Colombes and Research Center on Inflammation, INSERM U1149, Paris University, France
| | - Alexandre Karras
- Nephrology Department, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris University, France
| | - Laurent Gouya
- French Porphyria Center, Hôpital Louis Mourier, Assistance Publique-Hôpitaux de Paris, Colombes and Research Center on Inflammation, INSERM U1149, Paris University, France
| | - Caroline Schmitt
- French Porphyria Center, Hôpital Louis Mourier, Assistance Publique-Hôpitaux de Paris, Colombes and Research Center on Inflammation, INSERM U1149, Paris University, France
| | - Hervé Puy
- French Porphyria Center, Hôpital Louis Mourier, Assistance Publique-Hôpitaux de Paris, Colombes and Research Center on Inflammation, INSERM U1149, Paris University, France
| | - Nicolas Pallet
- Nephrology Department, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris University, France; Clinical Chemistry Department, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris University, Paris, France.
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van Tongeren JMZ, Harkes-Idzinga SF, van der Sijs H, Atiqi R, van den Bemt BJF, Draijer LW, Hiel D, Kerremans A, Kremers B, de Leeuw M, Olthoff MV, Pham TKL, Valentijn-Robertz R, Tsoi K, Wichers I, de Wit M, Borgsteede SD. The Development of Practice Recommendations for Drug-Disease Interactions by Literature Review and Expert Opinion. Front Pharmacol 2020; 11:707. [PMID: 32499701 PMCID: PMC7243438 DOI: 10.3389/fphar.2020.00707] [Citation(s) in RCA: 4] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 04/29/2020] [Indexed: 12/12/2022] Open
Abstract
Background Drug-disease interactions negatively affect the benefit/risk ratio of drugs for specific populations. In these conditions drugs should be avoided, adjusted, or accompanied by extra monitoring. The motivation for many drug-disease interactions in the Summary of Product Characteristics (SmPC) is sometimes insufficiently supported by (accessible) evidence. As a consequence the translation of SmPC to clinical practice may lead to non-specific recommendations. For the translation of this information to the real world, it is necessary to evaluate the available knowledge about drug-disease interactions, and to formulate specific recommendations for prescribers and pharmacists. The aim of this paper is to describe a standardized method how to develop practice recommendations for drug-disease interactions by literature review and expert opinion. Methods The development of recommendations for drug-disease interactions will follow a six-step plan involving a multidisciplinary expert panel (1). The scope of the drug-disease interaction will be specified by defining the disease and by describing relevant effects of this drug-disease interaction. Drugs possibly involved in this drug-disease interaction are selected by checking the official product information, literature, and expert opinion (2). Evidence will be collected from the official product information, guidelines, handbooks, and primary literature (3). Study characteristics and outcomes will be evaluated and presented in standardized reports, including preliminary conclusions on the clinical relevance and practice recommendations (4). The multidisciplinary expert panel will discuss the reports and will either adopt or adjust the conclusions (5). Practice recommendations will be integrated in clinical decision support systems and published (6). The results of the evaluated drug-disease interactions will remain up-to-date by screening new risk information, periodic literature review, and (re)assessments initiated by health care providers. Actionable Recommendations The practice recommendations will result in advices for specific DDSI. The content and considerations of these DDSIs will be published and implemented in all Clinical Decision Support Systems in the Netherlands. Discussion The recommendations result in professional guidance in the context of individual patient care. The professional will be supported in the decision making in concerning pharmacotherapy for the treatment of a medical problem, and the clinical risks of the proposed medication in combination with specific diseases.
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Affiliation(s)
| | - S Froukje Harkes-Idzinga
- Medicines Information Centre, Royal Dutch Pharmacists Association (KNMP), The Hague, Netherlands
| | - Heleen van der Sijs
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Roya Atiqi
- Department of Internal Medicine, University Medical Center Groningen, Groningen, Netherlands
| | - Bart J F van den Bemt
- Department of Pharmacy, Sint Maartenskliniek, Nijmegen, Netherlands.,Department of Pharmacy, Radboud University Medical Center, Nijmegen, Netherlands
| | | | - Deline Hiel
- Department of Hospital Pharmacy, Alrijne Zorggroep, Leiden, Netherlands
| | | | | | - Marc de Leeuw
- Medicines Information Centre, Royal Dutch Pharmacists Association (KNMP), The Hague, Netherlands
| | - Marleen V Olthoff
- Department of Clinical Decision Support, Health Base Foundation, Houten, Netherlands
| | - T Kim-Loan Pham
- Department of Clinical Decision Support, Health Base Foundation, Houten, Netherlands
| | | | - Kayan Tsoi
- Department of Clinical Decision Support, Health Base Foundation, Houten, Netherlands
| | - Iris Wichers
- Department of Guideline Development and Research, Dutch College of General Practitioners, Utrecht, Netherlands
| | - Maaike de Wit
- Medicines Information Centre, Royal Dutch Pharmacists Association (KNMP), The Hague, Netherlands
| | - Sander D Borgsteede
- Department of Clinical Decision Support, Health Base Foundation, Houten, Netherlands.,Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, Netherlands
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10
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Spiritos Z, Salvador S, Mosquera D, Wilder J. Acute Intermittent Porphyria: Current Perspectives And Case Presentation. Ther Clin Risk Manag 2019; 15:1443-1451. [PMID: 31908464 PMCID: PMC6930514 DOI: 10.2147/tcrm.s180161] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [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: 04/04/2019] [Accepted: 09/14/2019] [Indexed: 11/23/2022] Open
Abstract
Acute intermittent porphyria (AIP) is an autosomal dominant metabolic disorder characterized by a deficiency in heme biosynthesis. Heme biosynthesis occurs throughout the body, but it is most prominent in the erythroblastic system and liver. AIP is a hepatic porphyria whereby the liver is the source of toxic heme metabolites. Clinical manifestations of AIP result from a genetic mutation that leads to partial function of porphobiliogen deaminase (PBGD). This causes an accumulation of upstream, neurotoxic metabolites. Symptoms include but are not limited to peripheral neuropathies, autonomic neuropathies and psychiatric manifestations. AIP can be life threatening and clinical signs and symptoms are often heterogeneous and non-specific. Therefore, it is important to be able to recognize these patients to make a prudent diagnosis and offer appropriate therapy. Here, we review the epidemiology, pathophysiology, clinical presentation, diagnosis, and management of AIP including the role of liver transplantation.
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Affiliation(s)
- Zachary Spiritos
- Department of Medicine, Division of Gastroenterology, Duke University School of Medicine, Durham, NC, USA
| | - Shakirat Salvador
- Department of Medicine, Division of Gastroenterology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Diana Mosquera
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Julius Wilder
- Department of Medicine, Division of Gastroenterology, Duke University School of Medicine, Durham, NC, USA
- Department of Medicine, Duke Clinical Research Institute, Durham, NC, USA
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11
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Storjord E, Dahl JA, Landsem A, Ludviksen JK, Karlsen MB, Karlsen BO, Brekke OL. Lifestyle factors including diet and biochemical biomarkers in acute intermittent porphyria: Results from a case-control study in northern Norway. Mol Genet Metab 2019; 128:254-270. [PMID: 30583995 DOI: 10.1016/j.ymgme.2018.12.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 11/28/2018] [Accepted: 12/09/2018] [Indexed: 12/24/2022]
Abstract
BACKGROUND Lifestyle factors, including a low intake of carbohydrates, dieting, alcohol consumption, cigarette smoking and stress are some of the possible triggers of attacks in acute intermittent porphyria (AIP). The influence of lifestyle factors, including energy intake, diet and alcohol consumption on the biochemical disease activity in AIP and biochemical nutritional markers were examined. METHODS A case-control study with 50 AIP cases and 50 controls matched for age, sex and place of residence was performed. Dietary intake was registered using a food diary in 46 matched pairs. Symptoms, alcohol intake, stress and other triggering factors of the last AIP attack were recorded on questionnaires. Porphyrin precursors, liver and kidney function markers, vitamins, diabetogenic hormones and other nutritional biomarkers were analyzed by routine methods. The Wilcoxon matched-pairs signed rank test was used to compare the cases vs. controls. The Spearman's rank correlation coefficient was used on the cases. RESULTS Increasing total energy intake was negatively correlated with the biochemical disease activity. The intake of carbohydrates was lower than recommended, i.e., 40 and 39% of total energy intake in the AIP cases and controls, respectively. The plasma resistin level was significantly higher (p = .03) in the symptomatic than asymptomatic cases. Plasma insulin was lower in those with high porphobilinogen levels. The intake of sugar and candies were higher in the AIP cases with low U-delta aminolevulinic acid (ALA) levels (p = .04). Attacks were triggered by psychological stress (62%), physical strain (38%), food items (24%) and alcohol (32%) in the 34 symptomatic cases. Alcohol was used regularly by 88% of the cases (3.2 g ethanol/day) and 90% of the controls (6.3 g/day), but the intake was significantly lower in symptomatic than in asymptomatic cases (p = .045). CONCLUSION A high intake of energy, sugar and candies and a higher insulin level were associated with a lower biochemical disease activity. The resistin level was higher in the symptomatic than the asymptomatic cases. AIP patients drink alcohol regularly, but the intake was significantly lower in the symptomatic cases. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01617642.
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Affiliation(s)
- Elin Storjord
- Department of Laboratory Medicine, Nordland Hospital Trust, Bodø, Norway; Institute of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway; Research Laboratory, Nordland Hospital Trust, Bodø, Norway.
| | - Jim A Dahl
- Department of Laboratory Medicine, Nordland Hospital Trust, Bodø, Norway
| | - Anne Landsem
- Institute of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway; Research Laboratory, Nordland Hospital Trust, Bodø, Norway
| | | | - Marlene B Karlsen
- Regional Center for Eating Disorders, Nordland Hospital Trust, Bodø, Norway; Unit for Health Promotion and Prevention, Meløy Municipality, Nordland, Norway
| | - Bård O Karlsen
- Research Laboratory, Nordland Hospital Trust, Bodø, Norway
| | - Ole-L Brekke
- Department of Laboratory Medicine, Nordland Hospital Trust, Bodø, Norway; Institute of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway
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12
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Abstract
Acute intermittent porphyria (AIP) is a rare condition, a metabolic disorder of the haem biosynthesis. An acute crisis of AIP can present as a combination of symptoms, such as abdominal pain, autonomic dysfunction, hyponatremia, muscle weakness and neurological symptoms in the absence of others obvious causes. We report the case of a 53-year-old woman, who was previously diagnosed with AIP 5 weeks after therapeutic suspension has developed an acute disease exacerbation. During hospitalisation, further exacerbation has occurred after analgesia with metamizole. Glucose and hemin infusions resulted in slow improvement. Physical rehabilitation was crucial to peripheral polyneuropathy recovery. Taking into account the porphyrinogenic effect described for metamizole, this drug might have triggered the second attack. Clinical history was sufficient to suspect the diagnosis and to start the treatment immediately, preventing important sequelae.
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Affiliation(s)
- Carlos Dias Silva
- Department of Internal Medicine, Centro Hospitalar e Universitario de Coimbra EPE, Coimbra, Portugal.,Faculdade de Medicina da Universidade de Coimbra, Coimbra, Portugal
| | - José Eduardo Mateus
- Department of Internal Medicine, Centro Hospitalar e Universitario de Coimbra EPE, Coimbra, Portugal.,Faculdade de Medicina da Universidade de Coimbra, Coimbra, Portugal
| | - Carolina Teles
- Department of Internal Medicine, Centro Hospitalar e Universitario de Coimbra EPE, Coimbra, Portugal
| | - Teresa Vaio
- Department of Internal Medicine, Centro Hospitalar e Universitario de Coimbra EPE, Coimbra, Portugal.,Faculdade de Medicina da Universidade de Coimbra, Coimbra, Portugal
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13
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Chapman E, Leal D, Matijasevic E, García E. Desensitization in patients with hypersensitivity to haem arginate: A case report. World Allergy Organ J 2019; 12:100002. [PMID: 30937127 PMCID: PMC6439413 DOI: 10.1016/j.waojou.2018.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 11/14/2018] [Accepted: 11/28/2018] [Indexed: 11/06/2022] Open
Abstract
Background Porphyria comprises a group of metabolic disorders caused by the irregular activities of enzymes within the haem biosynthetic pathway. This disease can provoke a large variety of symptoms. Acute porphyria attacks need to be treated urgently to avoid prolonged illness and fatal complications. Haem arginate, a concentrated haem solution stabilized with arginine, is the only preparation available for treatment in Europe and South America. This report describes a safe desensitization protocol for patients who require such treatment and have haem arginate hypersensitivity. Case presentation A 25-year-old female patient diagnosed with acute intermittent porphyria, who had an anaphylactic reaction while receiving haem arginate. The patient was treated with a desensitization protocol for patients with hypersensitivity to haem arginate. Conclusion Porphyria is a disease that can significantly compromise a patient's quality of life. The desensitization protocol for patients with hypersensitivity to haem arginate is a safe and effective treatment option for patients with a history of haem arginate allergies, to whom it is not possible to administer haematin.
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Affiliation(s)
- Edgardo Chapman
- Fundación Santa Fe de Bogotá, Carrera 7 N 117 - 15, Bogotá, Colombia
| | - Drixie Leal
- Fundación Santa Fe de Bogotá, Carrera 7 N 117 - 15, Bogotá, Colombia.,Facultad de Medicina, Universidad de los Andes, Carrera 7 N 116 - 15, Bogotá, Colombia
| | - Eugenio Matijasevic
- Fundación Santa Fe de Bogotá, Carrera 7 N 117 - 15, Bogotá, Colombia.,Facultad de Medicina, Universidad de los Andes, Carrera 7 N 116 - 15, Bogotá, Colombia
| | - Elizabeth García
- Fundación Santa Fe de Bogotá, Carrera 7 N 117 - 15, Bogotá, Colombia.,Facultad de Medicina, Universidad de los Andes, Carrera 7 N 116 - 15, Bogotá, Colombia
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14
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Indika NLR, Kesavan T, Dilanthi HW, Jayasena KLSPKM, Chandrasiri NDPD, Jayasinghe IN, Piumika UMT, Vidanapathirana DM, Gunarathne KDAV, Dissanayake M, Jasinge E, Arachchi WK, Doheny D, Desnick RJ. Many pitfalls in diagnosis of acute intermittent porphyria: a case report. BMC Res Notes 2018; 11:552. [PMID: 30071891 PMCID: PMC6071335 DOI: 10.1186/s13104-018-3615-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [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: 03/02/2018] [Accepted: 07/19/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Acute intermittent porphyria is a rare autosomal dominant disorder caused by a deficiency of the enzyme, hydroxymethylbilane synthase. Recognition of acute neurovisceral attacks can be difficult due to the nonspecific nature of symptoms. CASE PRESENTATION We report a case of 33-year-old male patient who presented with recurrent episodes of severe abdominal pain, nausea, vomiting, constipation and numbness of bilateral lower limb extremities. These nonspecific neurovisceral attacks were subject to medical and surgical misdiagnoses of acute appendicitis, sinus tachycardia, renal calculi, drug-induced acute interstitial nephritis and two episodes of partial intestinal obstruction. The sixth acute attack raised the suspicion of an acute porphyria. Watson and Schwartz test was positive for porphobilinogen in urine. Mutation analysis by DNA sequencing of the extracted DNA of the proband revealed a previously reported missense mutation, c.517C>T encoding p.R173W in the HMBS gene, confirming the diagnosis of Acute Intermittent Porphyria. Four out of five family members who underwent targeted mutation analyses were mutation-positive. CONCLUSION The most common clinical presentation of Acute Intermittent Porphyria is abdominal pain with neurovisceral manifestations which are common to several medical, psychiatric and surgical pathologies. This leads to underdiagnosis and misdiagnosis of this disorder, incorrect management, and severe complications. Therefore, a high index of suspicion and awareness of front line laboratory investigations are important for diagnosis. Definitive diagnosis enables implementation of strategies to prevent acute attacks, and also triggers genetic testing and genetic counseling of at-risk family members.
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Affiliation(s)
- N L R Indika
- Department of Biochemistry, Faculty of Medical Sciences, University of Sri Jayewardenepura, Nugegoda, 10250, Sri Lanka.
| | - T Kesavan
- Teaching Hospital Karapitiya, Galle, Sri Lanka
| | - H W Dilanthi
- Department of Chemical Pathology, Lady Ridgeway Hospital for Children, Colombo, Sri Lanka
| | - K L S P K M Jayasena
- Department of Chemical Pathology, Lady Ridgeway Hospital for Children, Colombo, Sri Lanka
| | - N D P D Chandrasiri
- Department of Chemical Pathology, Lady Ridgeway Hospital for Children, Colombo, Sri Lanka
| | - I N Jayasinghe
- Department of Chemical Pathology, Lady Ridgeway Hospital for Children, Colombo, Sri Lanka
| | - U M T Piumika
- Department of Chemical Pathology, Lady Ridgeway Hospital for Children, Colombo, Sri Lanka
| | - D M Vidanapathirana
- Department of Chemical Pathology, Lady Ridgeway Hospital for Children, Colombo, Sri Lanka
| | - K D A V Gunarathne
- Department of Chemical Pathology, Lady Ridgeway Hospital for Children, Colombo, Sri Lanka
| | | | - E Jasinge
- Department of Chemical Pathology, Lady Ridgeway Hospital for Children, Colombo, Sri Lanka
| | | | - D Doheny
- Department of Genetics and Genomic Sciences, Mount Sinai School of Medicine, New York, USA
| | - R J Desnick
- Department of Genetics and Genomic Sciences, Mount Sinai School of Medicine, New York, USA
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15
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Sychev DA, Ashraf GM, Svistunov AA, Maksimov ML, Tarasov VV, Chubarev VN, Otdelenov VA, Denisenko NP, Barreto GE, Aliev G. The cytochrome P450 isoenzyme and some new opportunities for the prediction of negative drug interaction in vivo. Drug Des Devel Ther 2018; 12:1147-1156. [PMID: 29780235 PMCID: PMC5951216 DOI: 10.2147/dddt.s149069] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Cytochrome (CYP) 450 isoenzymes are the basic enzymes involved in Phase I biotransformation. The most important role in biotransformation belongs to CYP3A4, CYP2D6, CYP2C9, CYP2C19 and CYP1A2. Inhibition and induction of CYP isoenzymes caused by drugs are important and clinically relevant pharmacokinetic mechanisms of drug interaction. Investigation of the activity of CYP isoenzymes by using phenotyping methods (such as the determination of the concentration of specific substrates and metabolites in biological fluids) during drug administration provides the prediction of negative side effects caused by drug interaction. In clinical practice, the process of phenotyping of CYP isoenzymes and some endogenous substrates in the ratio of cortisol to 6β-hydroxycortisol in urine for the evaluation of CYP3A4 activity has been deemed to be a quite promising, safe and minimally invasive method for patients nowadays.
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Affiliation(s)
- Dmitrij A Sychev
- Russian Medical Academy of Postgraduate Education Studies, Moscow, Russia
| | - Ghulam Md Ashraf
- King Fahd Medical Research Center, King Abdulaziz University, Jeddah, Saudi Arabia
| | | | - Maksim L Maksimov
- Branch Campus of the Federal State Budgetary Educational Institution of Further Professional Education «Russian Medical Academy of Continuous Professional Education» of the Ministry of Healthcare of the Russian Federation, Kazan State Medical Academy, Volga Region, Kazan, Russia
| | - Vadim V Tarasov
- Sechenov First Moscow State Medical University, Moscow, Russia
| | | | | | | | - George E Barreto
- Departamento de Nutrición y Bioquímica, Facultad de Ciencias, Pontificia Universidad Javeriana, Bogotá D.C., Colombia.,Instituto de Ciencias Biomédicas, Universidad Autónoma de Chile, Santiago, Chile
| | - Gjumrakch Aliev
- GALLY International Biomedical Research Consulting LLC, San Antonio, TX, USA.,School of Health Science and Healthcare Administration, University of Atlanta, Johns Creek, GA, USA.,Institute of Physiologically Active Compounds Russian Academy of Sciences, Chernogolovka, Russia
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16
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Abstract
The diagnosis of acute intermittent porphyria (AIP) is often overlooked. We describe a patient with this condition who had all the 'bells and whistles', in whom the diagnosis was only made after considerable delay. Far from an esoteric condition haunting examination candidates, AIP is an important cause of a broad spectrum of neurological symptoms. Its early recognition allows the astute clinician to prevent potentially devastating sequelae. We provide practical guidance on the investigation and management of this complex disorder. With a 'back to basics' approach to the underlying genetics and biochemistry, we hope to dispel some of the confusion that may obstruct a timely diagnosis.
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Affiliation(s)
- Ronan O'Malley
- Department of Neurology, Sheffield Teaching Hospitals (STH), Sheffield, UK.,Department of Neuroscience, University of Sheffield, Sheffield, UK
| | - Ganesh Rao
- Department of Neuroscience, University of Sheffield, Sheffield, UK.,Department of Neurophysiology, Sheffield Teaching Hospitals (STH), Sheffield, UK
| | - Penelope Stein
- Department of Haematological Medicine, Kings College Hospital NHS Foundation Trust, London, UK
| | - Oliver Bandmann
- Department of Neurology, Sheffield Teaching Hospitals (STH), Sheffield, UK.,Department of Neuroscience, University of Sheffield, Sheffield, UK
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17
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Ruspini SF, Zuccoli JR, Lavandera JV, Martínez MDC, Oliveri LM, Gerez EN, Batlle AMDC, Buzaleh AM. Effects of volatile anaesthetics on heme metabolism in a murine genetic model of Acute Intermittent Porphyria. A comparative study with other porphyrinogenic drugs. Biochim Biophys Acta Gen Subj 2018; 1862:1296-1305. [PMID: 29476795 DOI: 10.1016/j.bbagen.2018.02.013] [Citation(s) in RCA: 2] [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: 07/18/2017] [Revised: 02/13/2018] [Accepted: 02/19/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND Acute Intermittent Porphyria (AIP) is an inherited disease produced by a deficiency of Porphobilinogen deaminase (PBG-D). The aim of this work was to evaluate the effects of Isoflurane and Sevoflurane on heme metabolism in a mouse genetic model of AIP to further support our previous proposal for avoiding their use in porphyric patients. A comparative study was performed administering the porphyrinogenic drugs allylisopropylacetamide (AIA), barbital and ethanol, and also between sex and mutation using AIP (PBG-D activity 70% reduced) and T1 (PBG-D activity 50% diminished) mice. METHODS The activities of 5-Aminolevulinic synthetase (ALA-S), PBG-D, Heme oxygenase (HO) and CYP2E1; the expression of ALA-S and the levels of 5-aminolevulinic acid (ALA) were measured in different tissues of mice treated with the drugs mentioned. RESULTS Isoflurane increased liver, kidney and brain ALA-S activity of AIP females but only affected kidney AIP males. Sevoflurane induced ALA-S activity in kidney and brain of female AIP group. PBG-D activity was further reduced by Isoflurane in liver male T1; in AIP male mice activity remained in its low basal levels. Ethanol and barbital also caused biochemical alterations. Only AIA triggered neurological signs similar to those observed during human acute attacks in male AIP being the symptoms less pronounced in females although ALA-S induction was greater. Heme degradation was affected. DISCUSSION Biochemical alterations caused by the porphyrinogenic drugs assayed were different in male and female mice and also between T1 and AIP being more affected the females of AIP group. GENERAL SIGNIFICANCE This is the first study using volatile anaesthetics in an AIP genetic model confirming Isoflurane and Sevoflurane porphyrinogenicity.
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Affiliation(s)
- Silvina Fernanda Ruspini
- Centro de Investigaciones sobre Porfirinas y Porfirias (CIPYP), CONICET, Hospital de Clínicas José de San Martín, Universidad de Buenos Aires, Argentina
| | - Johanna Romina Zuccoli
- Centro de Investigaciones sobre Porfirinas y Porfirias (CIPYP), CONICET, Hospital de Clínicas José de San Martín, Universidad de Buenos Aires, Argentina
| | - Jimena Verónica Lavandera
- Cátedra de Bromatología y Nutrición, Facultad de Bioquímica y Ciencias Biológicas, Universidad Nacional del Litoral, Santa Fe, Argentina
| | - Marìa Del Carmen Martínez
- Centro de Investigaciones sobre Porfirinas y Porfirias (CIPYP), CONICET, Hospital de Clínicas José de San Martín, Universidad de Buenos Aires, Argentina; Departamento de Química Biológica, Facultad de Ciencias Exactas y Naturales, Universidad de Buenos Aires, Argentina.
| | - Leda María Oliveri
- Centro de Investigaciones sobre Porfirinas y Porfirias (CIPYP), CONICET, Hospital de Clínicas José de San Martín, Universidad de Buenos Aires, Argentina
| | - Esther Noemí Gerez
- Centro de Investigaciones sobre Porfirinas y Porfirias (CIPYP), CONICET, Hospital de Clínicas José de San Martín, Universidad de Buenos Aires, Argentina
| | - Alcira María Del Carmen Batlle
- Centro de Investigaciones sobre Porfirinas y Porfirias (CIPYP), CONICET, Hospital de Clínicas José de San Martín, Universidad de Buenos Aires, Argentina
| | - Ana María Buzaleh
- Centro de Investigaciones sobre Porfirinas y Porfirias (CIPYP), CONICET, Hospital de Clínicas José de San Martín, Universidad de Buenos Aires, Argentina; Departamento de Química Biológica, Facultad de Ciencias Exactas y Naturales, Universidad de Buenos Aires, Argentina.
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18
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Abstract
PURPOSE OF REVIEW The aim of this paper is to review psychiatric manifestations, comorbidities, and psychopharmacological management in individuals with acute porphyria (AP). RECENT FINDINGS Recent literature begins to clarify associations between AP, schizophrenia, bipolar disorder, and other psychopathology. Broad psychiatric symptoms have been associated to acute porphyria (AP) and correspond to a spectrum of heterogeneous manifestations such as anxiety, affective alterations, behavioral changes, personality, and psychotic symptoms. These symptoms may be difficult to identify as being related to porphyria since symptoms may arise at any time during the disease process. In addition, these patients may present psychiatric conditions secondary to the disease, such as adjustment disorder and substance use disorders. Timely diagnosis and appropriate treatment of psychiatric manifestations positively impact the course of the disease.
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19
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20
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Balwani M, Wang B, Anderson KE, Bloomer JR, Bissell DM, Bonkovsky HL, Phillips JD, Desnick RJ. Acute hepatic porphyrias: Recommendations for evaluation and long-term management. Hepatology 2017; 66:1314-1322. [PMID: 28605040 PMCID: PMC5605422 DOI: 10.1002/hep.29313] [Citation(s) in RCA: 98] [Impact Index Per Article: 14.0] [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: 01/24/2017] [Revised: 05/10/2017] [Accepted: 06/08/2017] [Indexed: 12/12/2022]
Abstract
The acute hepatic porphyrias are a group of four inherited disorders, each resulting from a deficiency in the activity of a specific enzyme in the heme biosynthetic pathway. These disorders present clinically with acute neurovisceral symptoms which may be sporadic or recurrent and, when severe, can be life-threatening. The diagnosis is often missed or delayed as the clinical features resemble other more common medical conditions. There are four major subgroups: symptomatic patients with sporadic attacks (<4 attacks/year) or recurrent acute attacks (≥4 attacks/year), asymptomatic high porphyrin precursor excretors, and asymptomatic latent patients without symptoms or porphyrin precursor elevations. Given their clinical heterogeneity and potential for significant morbidity with suboptimal management, comprehensive clinical guidelines for initial evaluation, follow-up, and long-term management are needed, particularly because no guidelines exist for monitoring disease progression or response to treatment. The Porphyrias Consortium of the National Institutes of Health's Rare Diseases Clinical Research Network, which consists of expert centers in the clinical management of these disorders, has formulated these recommendations. These recommendations are based on the literature, ongoing natural history studies, and extensive clinical experience. Initial assessments should include diagnostic confirmation by biochemical testing, subsequent genetic testing to determine the specific acute hepatic porphyria, and a complete medical history and physical examination. Newly diagnosed patients should be counseled about avoiding known precipitating factors. The frequency of follow-up depends on the clinical subgroup, with close monitoring of patients with recurrent attacks who may require treatment modifications as well as those with clinical complications. Comprehensive care should include subspecialist referrals when needed. Annual assessments include biochemical testing and monitoring for long-term complications. These guidelines provide a framework for monitoring patients with acute hepatic porphyrias to ensure optimal outcomes. (Hepatology 2017;66:1314-1322).
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Affiliation(s)
- Manisha Balwani
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, NY, NY
| | - Bruce Wang
- Department of Medicine, University of California, San Francisco, CA
| | - Karl E. Anderson
- Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, TX
| | | | | | - Herbert L. Bonkovsky
- Department of Medicine, Wake Forest NC Baptist Medical Center, Winston-Salem, NC
| | - John D. Phillips
- Department of Internal Medicine, University of Utah, Salt Lake City, UT
| | - Robert J. Desnick
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, NY, NY
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Ajayi T, Ward R, Summers B, Byrns J, Kappus M, Choi S, Wilder J. Pathophysiology, Pharmacology and Treatment of Acute Intermittent Porphyria: A Patient Case Description and Recommendations from the Current Literature. Journal of Exploratory Research in Pharmacology 2017; 2:49-53. [DOI: 10.14218/jerp.2016.00022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Abstract
Acute porphyrias are rare inherited disorders due to deficiencies of haem synthesis enzymes. To date, all UK cases have been one of the three autosomal dominant forms, although penetrance is low and most gene carriers remain asymptomatic. Clinical presentation is typically with acute neurovisceral attacks characterised by severe abdominal pain, vomiting, tachycardia and hypertension. Severe attacks may be complicated by hyponatraemia, peripheral neuropathy sometimes causing paralysis, seizures and psychiatric features. Attacks are triggered by prescribed drugs, alcohol, hormonal changes, fasting or stress. The diagnosis is made by finding increased porphobilinogen excretion in a light-protected random urine sample. Management includes administration of intravenous human haemin and supportive treatment with non-porphyrinogenic drugs. A few patients develop recurrent attacks, a chronic illness requiring specialist management. Late complications include chronic pain, hepatocellular carcinoma, chronic renal failure and hypertension. In the UK, the National Acute Porphyria Service provides clinical advice and supplies haemin when indicated.
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Affiliation(s)
- Penelope E Stein
- Department of Haematological Medicine, King's College Hospital, London, UK
| | - Michael N Badminton
- Department of Medical Biochemistry and Immunology, University Hospital of Wales, Cardiff, UK
| | - David C Rees
- Department of Haematological Medicine, King's College Hospital, London, UK
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Weersink RA, Bouma M, Burger DM, Drenth JPH, Hunfeld NGM, Kranenborg M, Monster-Simons MH, van Putten SAW, Metselaar HJ, Taxis K, Borgsteede SD. Evaluating the safety and dosing of drugs in patients with liver cirrhosis by literature review and expert opinion. BMJ Open 2016; 6:e012991. [PMID: 27733414 PMCID: PMC5073492 DOI: 10.1136/bmjopen-2016-012991] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Liver cirrhosis can have a major impact on drug pharmacokinetics and pharmacodynamics. Patients with cirrhosis often suffer from potentially preventable adverse drug reactions. Guidelines on safe prescribing for these patients are lacking. The aim of this study is to develop a systematic method for evaluating the safety and optimal dosage of drugs in patients with liver cirrhosis. METHODS AND ANALYSIS For each drug, a six-step evaluation process will be followed. (1) Available evidence on the pharmacokinetics and safety of a drug in patients with liver cirrhosis will be collected from the Summary of Product Characteristics (SmPC) and a systematic literature review will be performed. (2) Data regarding two outcomes, namely pharmacokinetics and safety, will be extracted and presented in a standardised assessment report. (3) A safety classification and dosage suggestion will be proposed for each drug. (4) An expert panel will discuss the validity and clinical relevance of this suggested advice. (5) Advices will be implemented in all relevant Clinical Decision Support Systems in the Netherlands and published on a website for patients and healthcare professionals. (6) The continuity of the advices will be guaranteed by a yearly check of new literature and comments on the advices. This protocol will be applied in the evaluation of a selection of drugs: (A) drugs used to treat (complications of) liver cirrhosis, and (B) drugs frequently prescribed to the general population. ETHICS AND DISSEMINATION Since this study does not directly involve human participants, it does not require ethical clearance. Besides implementation on a website and in clinical decision support systems, we aim to publish the generated advices of one or two drug classes in a peer-reviewed journal and at conference meetings.
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Affiliation(s)
- Rianne A Weersink
- Health Base Foundation, Houten, The Netherlands Department of Pharmacy, Unit of Pharmacotherapy, -Epidemiology & -Economics, University of Groningen, Groningen, The Netherlands
| | - Margriet Bouma
- Department of Guideline Development, Dutch College of General Practice, Utrecht, The Netherlands
| | - David M Burger
- Department of Pharmacy, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Joost P H Drenth
- Department of Gastroenterology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Nicole G M Hunfeld
- Department of Pharmacy and Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Minke Kranenborg
- Centre for Information on Medicines, Royal Dutch Pharmacists Association (KNMP), The Hague, The Netherlands
| | | | | | - Herold J Metselaar
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Katja Taxis
- Department of Pharmacy, Unit of Pharmacotherapy, -Epidemiology & -Economics, University of Groningen, Groningen, The Netherlands
| | - Sander D Borgsteede
- Health Base Foundation, Houten, The Netherlands SIR Institute for Pharmacy Practice and Policy, Leiden, The Netherlands
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Schreuder N, Mamedova I, Jansman FG. Radiopharmaceuticals in Acute Porphyria. Clin Ther 2016; 38:2239-47. [PMID: 27568214 DOI: 10.1016/j.clinthera.2016.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Revised: 07/11/2016] [Accepted: 07/12/2016] [Indexed: 11/23/2022]
Abstract
PURPOSE The acute porphyrias are a group of rare metabolic disorders of the heme biosynthetic pathway. Carriers of the acute porphyria gene are prone to potentially fatal acute attacks, which can be precipitated by drug exposure. It is therefore important to know whether a drug is safe for carriers of the acute porphyria gene. In this study, radiopharmaceuticals were assessed on their porphyrogenicity (ie, the potential of a drug to induce an attack). METHODS The assessment was conducted by classifying the drugs according to the Thunell model. FINDINGS From 41 radiopharmaceuticals assessed, I-131 norcholesterol, Tc-99m mebrofenin, Tc-99m phytate, Tc-99m sestamibi, and Tl-201 chloride were classified as possibly porphyrogenic. IMPLICATIONS I-131 norcholesterol, Tc-99m mebrofenin, Tc-99m phytate, Tc-99m sestamibi, and Tl-201 chloride should not be prescribed for patients experiencing acute porphyria unless an urgent indication is present and no safer alternative is available. In such cases, potential users should seek advice from a porphyria expert. Preventive measures may also be required.
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Grimes R, Gilleece Y, Appleby T, Stockwell S, Pinto-Sander N, Sahabandu T, Stein P, Bradshaw D. A case of hereditary coproporphyria precipitated by efavirenz. AIDS 2016; 30:2142-3. [PMID: 27465283 DOI: 10.1097/QAD.0000000000001173] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Bharti S, Malhotra P, Hirsch B. Acute intermittent porphyria precipitated by atazanavir/ritonavir. Int J STD AIDS 2016; 27:1234-1235. [PMID: 26872826 DOI: 10.1177/0956462416633981] [Citation(s) in RCA: 2] [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: 10/12/2015] [Accepted: 01/28/2016] [Indexed: 11/15/2022]
Abstract
Porphyrias are a group of metabolic disorders that are relatively uncommon and underdiagnosed. Although the association between HIV infection and antiretrovirals with porphyria cutanea tarda is well established, there are fewer data linking HIV and the acute hepatic porphyrias. We report the first case of acute intermittent porphyria precipitated by the drugs atazanavir and ritonavir, presenting with unexplained abdominal pain.
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Affiliation(s)
- Sheena Bharti
- Division of Infectious Diseases, Department of Medicine, Hofstra North Shore-LIJ School of Medicine, Manhasset, NY, USA
| | - Prashant Malhotra
- Division of Infectious Diseases, Department of Medicine, Hofstra North Shore-LIJ School of Medicine, Manhasset, NY, USA
| | - Bruce Hirsch
- Division of Infectious Diseases, Department of Medicine, Hofstra North Shore-LIJ School of Medicine, Manhasset, NY, USA
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Yoshida T, Ashino T, Kobayashi Y. Chemical-induced coordinated and reciprocal changes in heme metabolism, cytochrome P450 synthesis and others in the liver of humans and rodents. J Toxicol Sci 2016; 41:SP89-SP103. [PMID: 28320986 DOI: 10.2131/jts.41.sp89] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
A wide variety of drugs and chemicals have been shown to produce induction and inhibition of heme-metabolizing enzymes, and of drug-metabolizing enzymes, including cytochrome P450s (P450s, CYPs), which consist of many molecular species with lower substrate specificity. Such chemically induced enzyme alterations are coordinately or reciprocally regulated through the same and/or different signal transductions. From the toxicological point of view, these enzymatic changes sometimes exacerbate inherited diseases, such as precipitation of porphyrogenic attacks, although the induction of these enzymes is dependent on the animal species in response to the differences in the stimuli of the liver, where they are also metabolized by P450s. Since P450s are hemoproteins, their induction and/or inhibition by chemical compounds could be coordinately accompanied by heme synthesis and/or inhibition. This review will take a retrospective view of research works carried out in our department and current findings on chemical-induced changes in hepatic heme metabolism in many places, together with current knowledge. Specifically, current beneficial aspects of induction of heme oxygenase-1, a rate-limiting heme degradation enzyme, and its relation to reciprocal and coordinated changes in P450s, with special reference to CYP2A5, in the liver are discussed. Mechanistic studies are also summarized in relation to current understanding on these aspects. Emphasis is also paid to an example of a single chemical compound that could cause various changes by mediating multiple signal transduction systems. Current toxicological studies have been developing by utilizing a sophisticated "omics" technology and survey integrated changes in the tissues produced by the administration of a chemical, even in time- and dose-dependent manners. Toxicological studies are generally carried out step by step to determine and elucidate mechanisms produced by drugs and chemicals. Such approaches are correct; however, current "omics" technology can clarify overall changes occurring in the cells and tissues after treating animals with drugs and chemicals, integrate them and discuss the results. In the present review, we will discuss chemical-induced similar changes of heme synthesis and degradation, and of P450s and finally convergence to similar or different directions.
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Abstract
Porphyria diseases are a group of metabolic disorders caused by abnormal functioning of heme biosynthesis enzymes and characterized by excessive accumulation and excretion of porphyrins and their precursors. Precisely which of these chemicals builds up depends on the type of porphyria. Porphyria is not a single disease but a group of nine disorders: acute intermittent porphyria (AIP), hereditary coproporphyria (HCP), variegate porphyria (VP), δ-aminolevulinic acid dehydratase deficiency porphyria (ADP), porphyria cutanea tarda (PCT), hepatoerythropoietic porphyria (HEP), congenital erythropoietic porphyria (CEP), erythropoietic protoporphyria (EPP), and X-linked protoporphyria (XLP). Each porphyria results from overproduction of heme precursors secondary to partial deficiency or, in XLP, increased activity of one of the enzymes of heme biosynthesis. Taken together, all forms of porphyria afflict fewer than 200,000 people in the United States. Based on European studies, the most common porphyria, PCT, has a prevalence of 1 in 10,000, the most common acute porphyria, AlP, has a prevalence of ∼1 in 20,000, and the most common erythropoietic porphyria, EPP, is estimated at 1 in 50,000 to 75,000. CEP is extremely rare, with prevalence estimates of 1 in 1,000,000 or less. Only six cases of ADP are documented. The current porphyria literature is very exhaustive and a brief overview of porphyria diseases is essential in order for the reader to better appreciate the relevance of this area of research prior to undertaking biochemical diagnostics procedures. This unit summarizes the current knowledge on the classification, clinical features, etiology, pathogenesis, and genetics of porphyria diseases.
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Affiliation(s)
| | - Karl Elmo Anderson
- Department of Preventive Medicine and Community Health, The University of Texas Medical Branch, Galveston, Texas 77555-1109
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Abstract
Mechanism-based inactivation (MBI) of CYP450 enzymes is a unique form of inhibition in which the enzymatic machinery of the victim is responsible for generation of the reactive metabolite. This precondition sets up a time-dependency for the inactivation process, a hallmark feature that characterizes all MBI. Yet, MBI itself is a complex biochemical phenomenon that operates in different modes, namely, covalent binding to apoprotein, covalent binding of the porphyrin group and also complexation of the catalytic iron. Using lapatinib as a recent example of toxicological interest, we present an example of a mixed-function MBI that can confound clinical drug-drug interactions manifestation. Lapatinib exhibits both covalent binding to the apoprotein and formation of a metabolite-intermediate complex in an enzyme-selective manner (CYP3A4 versus CYP3A5), each with different reactive metabolites. The clinical implication of this effect is also contingent upon genetic polymorphisms of the enzyme involved as well as the co-administration of other substrates, inhibitors or inducers, culminating in drug-drug interactions. This understanding recapitulates the importance of applying isoform-specific mechanistic investigations to develop customized strategies to manage such outcomes.
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Affiliation(s)
- Han Kiat Ho
- Department of Pharmacy, Faculty of Science, National University of Singapore , Singapore and
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Abstract
The porphyrias are a group of metabolic diseases caused by inherited or acquired enzymatic deficiency in the metabolic pathway of heme biosynthesis. Simplistically, they can be considered as storage diseases, because the partial enzymatic defect gives rise to a metabolic "bottleneck" in the biosynthetic pathway and hence to an accumulation of different metabolic intermediates, potentially toxic and responsible for the various (cutaneous or neurovisceral) clinical manifestations observed in these diseases. In the acute porphyrias (acute intermittent porphyria, hereditary coproporphyria, variegate porphyria, and the very rare delta-aminolevulinic acid dehydratase ALAD-d porphyria), the characteristic severe neurovisceral involvement is mainly ascribed to a tissue accumulation of delta-aminolevulinic acid, a neurotoxic nonporphyrin precursor. Many different factors, both endogenous and exogenous, may favor the accumulation of this precursor in patients who are carriers of an enzymatic defect consistent with an acute porphyria, thus contributing to trigger the serious (and potentially fatal) clinical manifestations of the disease (acute porphyric attacks). To date, many different drugs are known to be able to precipitate an acute porphyric attack, so that the acute porphyrias are also considered as pharmacogenetic or toxygenetic diseases. This article reviews the different biochemical mechanisms underlying the capacity of many drugs to precipitate a porphyric acute attack (drug porphyrogenicity) in carriers of genetic mutations responsible for acute porphyrias, and addresses the issue of prescribing drugs for patients affected by these rare, but extremely complex, diseases.
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Affiliation(s)
- Giulia Roveri
- Centre for Porphyrias and Diseases from Disturbances of Amino Acid Metabolism, Division of Internal Medicine II, Department of Medical and Surgical Sciences for Children and Adults, University of Modena and Reggio Emilia, Modena, Italy
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Abstract
Genetic variants in haem metabolism enzymes can be predisposition factors for adverse reactions in some individuals. New areas of haem biology may also be associated with idiosyncratic effects which are yet to be identified.
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Affiliation(s)
- Viktoria Vágány
- MRC Toxicology Unit
- Hodgkin Building
- University of Leicester
- Leicester LE1 9HN
- UK
| | - Andrew G. Smith
- MRC Toxicology Unit
- Hodgkin Building
- University of Leicester
- Leicester LE1 9HN
- UK
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Abstract
That primaquine and other drugs can trigger acute haemolytic anaemia in subjects who have an inherited mutation of the glucose 6-phosphate dehydrogenase (G6PD) gene has been known for over half a century: however, these events still occur, because when giving the drug either the G6PD status of a person is not known, or the risk of this potentially life-threatening complication is under-estimated. Here we review briefly the genetic basis of G6PD deficiency, and then the pathophysiology and the clinical features of drug-induced haemolysis; we also update the list of potentially haemolytic drugs (which includes rasburicase). It is now clear that it is not good practice to give one of these drugs before testing a person for his/her G6PD status, especially in populations in whom G6PD deficiency is common. We discuss therefore how G6PD testing can be done reconciling safety with cost; this is once again becoming of public health importance, as more countries are moving along the pathway of malaria elimination, that might require mass administration of primaquine. Finally, we sketch the triangular relationship between malaria, antimalarials such as primaquine, and G6PD deficiency: which is to some extent protective against malaria, but also a genetically determined hazard when taking primaquine.
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Affiliation(s)
- Lucio Luzzatto
- Istituto Toscano Tumori and Department of Haematology, University of FlorenceFirenze, Italy
| | - Elisa Seneca
- Department of Haematology, University of Naples Federico IINapoli, Italy
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Barbaro M, Kotajärvi M, Harper P, Floderus Y. Partial protoporphyrinogen oxidase (PPOX) gene deletions, due to different Alu-mediated mechanisms, identified by MLPA analysis in patients with variegate porphyria. Orphanet J Rare Dis 2013; 8:13. [PMID: 23324528 PMCID: PMC3554555 DOI: 10.1186/1750-1172-8-13] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2012] [Accepted: 01/09/2013] [Indexed: 11/10/2022] Open
Abstract
Variegate porphyria (VP) is an autosomal dominantly inherited hepatic porphyria. The genetic defect in the PPOX gene leads to a partial defect of protoporphyrinogen oxidase, the penultimate enzyme of heme biosynthesis. Affected individuals can develop cutaneous symptoms in sun-exposed areas of the skin and/or neuropsychiatric acute attacks. The identification of the genetic defect in VP families is of crucial importance to detect the carrier status which allows counseling to prevent potentially life threatening neurovisceral attacks, usually triggered by factors such as certain drugs, alcohol or fasting.In a total of 31 Swedish VP families sequence analysis had identified a genetic defect in 26. In the remaining five families an extended genetic investigation was necessary. After the development of a synthetic probe set, MLPA analysis to screen for single exon deletions/duplications was performed.We describe here, for the first time, two partial deletions within the PPOX gene detected by MLPA analysis. One deletion affects exon 5 and 6 (c.339-197_616+320del1099) and has been identified in four families, most probably after a founder effect. The other extends from exon 5 to exon 9 (c.339-350_987+229del2609) and was found in one family. We show that both deletions are mediated by Alu repeats.Our findings emphasize the usefulness of MLPA analysis as a complement to PPOX gene sequencing analysis for comprehensive genetic diagnostics in patients with VP.
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Affiliation(s)
- Michela Barbaro
- Centre for Inherited Metabolic Diseases, Karolinska University Hospital, Stockholm, Sweden
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Bruchajzer E, Frydrych B, Szymańska JA. Octabromodiphenyl ether - porphyrogenicity after repeated administration to rats. Int J Occup Med Environ Health 2012; 25:392-403. [PMID: 23086635 DOI: 10.2478/S13382-012-0055-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2011] [Accepted: 02/03/2012] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVES Octabromodiphenyl ether (OctaBDE) is a flame retardant which has been withdrawn from common use due to its negative effect on the environment. The literature data regarding its toxicity addresses its effect on liver function, the endocrine and reproductive systems, as well as its developmental toxicology aspects. The aim of this study was to investigate the effect of repeated administration of OctaBDE on heme biosynthesis in rats. MATERIALS AND METHODS The study was performed on female Wistar rats. OctaBDE was administered intragastrically at four different doses (2, 8, 40 or 200 mg/kg/day) for 7, 14, 21 or 28 days. The following measures of heme synthesis disturbance were used: urinary excretion of porphyrins, liver concentration of porphyrins, the activity of delta-aminolevulinate synthase (ALA-S) and delta-aminolevulinate dehydratase (ALA-D) in the liver. RESULTS After 28 days of exposure, lower ALA-S and ALA-D activity was observed in the liver. Additionally, increased concentrations of high carboxylated porphyrins (octa- and heptacarboxyporphyrins) were found in the liver: from 2- to 10-fold after the 2 mg/kg/day doses and from 4- to 14-fold after the 8-200 mg/kg/day doses. The porphyrogenic effect of OctaBDE was also evidenced by augmented, dose-dependent and exposure time-dependent, concentrations of total porphyrins in urine (2-7.5-fold increase) and their urinary excretion (2-9-fold increase). Tetracarboxyporphyrins predominated in the urine; their concentrations increased 2.5-10 fold. CONCLUSIONS The study revealed that repeated exposure to OctaBDE affects heme biosynthesis and the levels of porphyrins. The lowest effective level which induced changes in porphyrin concentration was 2 mg/kg/day.
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Pagano MB, Hobbs W, Linenberger M, Delaney M. Plasma and red cell exchange transfusions for erythropoietic protoporphyria: a case report and review of the literature. J Clin Apher 2012; 27:336-41. [PMID: 22997063 DOI: 10.1002/jca.21249] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2012] [Accepted: 08/23/2012] [Indexed: 01/08/2023]
Abstract
Erythropoietic protoporphyria (EPP) is a rare and usually autosomal dominant disorder characterized by ferrochelatase deficiency and accumulation of protoporphyrin in red blood cells (RBCs), skin, and liver. A small minority of patients develop severe liver dysfunction for which optimum treatment is lacking. Therapeutic plasma exchange (TPE) and RBC exchange (RCE) have been anecdotally reported to benefit patients with EPP and liver failure. A 50-year-old female with EPP developed severe liver dysfunction after knee replacement surgery and high-dose acetaminophen use. Liver biopsy showed cholestatic liver injury without fibrosis. A total of 20 TPE procedures, six RCE procedures, and then 14 more TPE procedures were performed as adjunctive therapy with the purpose of preventing progression to end-stage liver failure. After initial TPE, the plasma and RBC protoporphyrin levels decreased from 834.9 to 180.4 μg/dL (normal, ≤1 μg/dL), and from 3,905 to 2,879 μg/dL (normal, ≤80 μg/dL), respectively, without liver function improvement. RCE decreased RBC protoporphyrin levels from 2,879 to 1,225 μg/dL but plasma protoporphyrin increased from 180.4 to 1,044.1 μg/dL, and liver function failed to improve. Additional TPE again stabilized plasma protoporphyrin and improved RBC protoporphyrin levels but the patient ultimately died owing to end-stage liver disease complications. This case illustrates that TPE and RCE may improve the plasma and RBC biochemical markers of EPP activity but liver function abnormalities may persist and patients may still progress to liver failure either because of irreversible liver injury or independent pathobiological factors unrelated to EPP-induced hepatotoxicity.
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Affiliation(s)
- Monica B Pagano
- Department of Pathology, Transfusion Medicine Division, Johns Hopkins Medical Institutions, Balimore, Maryland, USA.
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Oliveri LM, Davio C, Batlle AM, Gerez EN. ALAS1 gene expression is down-regulated by Akt-mediated phosphorylation and nuclear exclusion of FOXO1 by vanadate in diabetic mice. Biochem J 2012; 442:303-10. [PMID: 22070747 DOI: 10.1042/BJ20111005] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Porphyrias are diseases caused by partial deficiencies of haem biosynthesis enzymes. Acute porphyrias are characterized by a neuropsychiatric syndrome with intermittent induction of hepatic ALAS1 (δ-aminolaevulinate synthase 1), the first and rate-limiting enzyme of the haem pathway. Acute porphyria attacks are usually treated by the administration of glucose; its effect is apparently related to its ability to inhibit ALAS1 by modulating insulin plasma levels. It has been shown that insulin blunts hepatocyte ALAS1 induction, by disrupting the interaction of FOXO1 (forkhead box O1) and PGC-1α (peroxisome-proliferator-activated receptor γ co-activator 1α). We evaluated the expression of ALAS1 in a murine model of diabetes and determined the effects of the insulinomimetic vanadate on the enzyme regulation to evaluate its potential for the treatment of acute porphyria attacks. Both ALAS1 mRNA and protein content were induced in diabetic animals, accompanied by decreased Akt phosphorylation and increased nuclear FOXO1, PGC-1α and FOXO1-PGC-1α complex levels. Vanadate reversed ALAS1 induction, with a concomitant PI3K (phosphoinositide 3-kinase)/Akt pathway activation and subsequent reduction of nuclear FOXO1, PGC-1α and FOXO1-PGC-1α complex levels. These findings support the notion that the FOXO1-PGC-1α complex is involved in the control of ALAS1 expression and suggest further that a vanadate-based therapy could be beneficial for the treatment of acute porphyria attacks.
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Unzu C, Sampedro A, Sardh E, Mauleón I, Enríquez de Salamanca R, Prieto J, Salido E, Harper P, Fontanellas A. Renal failure affects the enzymatic activities of the three first steps in hepatic heme biosynthesis in the acute intermittent porphyria mouse. PLoS One 2012; 7:e32978. [PMID: 22412963 PMCID: PMC3295788 DOI: 10.1371/journal.pone.0032978] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2011] [Accepted: 02/02/2012] [Indexed: 12/15/2022] Open
Abstract
Chronic kidney disease is a long-term complication in acute intermittent porphyria (AIP). The pathophysiological significance of hepatic overproduction of the porphyrin precursors aminolevulinate acid (ALA) and porphobilinogen (PBG) in chronic kidney disease is unclear. We have investigated the effect of repetitive acute attacks on renal function and the effect of total or five-sixth nephrectomy causing renal insufficiency on hepatic heme synthesis in the porphobilinogen deaminase (PBGD)-deficient (AIP) mouse. Phenobarbital challenge in the AIP-mice increased urinary porphyrin precursor excretion. Successive attacks throughout 14 weeks led to minor renal lesions with no impact on renal function. In the liver of wild type and AIP mice, 5/6 nephrectomy enhanced transcription of the first and rate-limiting ALA synthase. As a consequence, urinary PBG excretion increased in AIP mice. The PBG/ALA ratio increased from 1 in sham operated AIP animals to over 5 (males) and over 13 (females) in the 5/6 nephrectomized mice. Total nephrectomy caused a rapid decrease in PBGD activity without changes in enzyme protein level in the AIP mice but not in the wild type animals. In conclusion, high concentration of porphyrin precursors had little impact on renal function. However, progressive renal insufficiency aggravates porphyria attacks and increases the PBG/ALA ratio, which should be considered a warning sign for potentially life-threatening impairment in AIP patients with signs of renal failure.
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Affiliation(s)
- Carmen Unzu
- Gene Therapy and Hepatology Area, Centre for Applied Medical Research (CIMA), University of Navarra, Pamplona, Spain
| | - Ana Sampedro
- Gene Therapy and Hepatology Area, Centre for Applied Medical Research (CIMA), University of Navarra, Pamplona, Spain
| | - Eliane Sardh
- Department of Internal Medicine, Karolinska Institutet, Stockholm Söder Hospital, Stockholm, Sweden
- Porphyria Centre Sweden, Department of Laboratory Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Itsaso Mauleón
- Gene Therapy and Hepatology Area, Centre for Applied Medical Research (CIMA), University of Navarra, Pamplona, Spain
| | | | - Jesús Prieto
- Gene Therapy and Hepatology Area, Centre for Applied Medical Research (CIMA), University of Navarra, Pamplona, Spain
| | - Eduardo Salido
- Centre for Biomedical Research on Rare Diseases (CIBERER), University Hospital of Canarias, University of La Laguna, La Laguna, Spain
| | - Pauline Harper
- Porphyria Centre Sweden, Department of Laboratory Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Antonio Fontanellas
- Gene Therapy and Hepatology Area, Centre for Applied Medical Research (CIMA), University of Navarra, Pamplona, Spain
- * E-mail:
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Hift RJ, Thunell S, Brun A. Drugs in porphyria: From observation to a modern algorithm-based system for the prediction of porphyrogenicity. Pharmacol Ther 2011; 132:158-69. [DOI: 10.1016/j.pharmthera.2011.06.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2011] [Accepted: 06/01/2011] [Indexed: 02/06/2023]
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Lin CSY, Lee MJ, Park SB, Kiernan MC. Purple pigments: the pathophysiology of acute porphyric neuropathy. Clin Neurophysiol 2011; 122:2336-44. [PMID: 21855406 DOI: 10.1016/j.clinph.2011.07.036] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2011] [Revised: 07/07/2011] [Accepted: 07/08/2011] [Indexed: 10/15/2022]
Abstract
The porphyrias are inherited metabolic disorders arising from disturbance in the haem biosynthesis pathway. The neuropathy associated with acute intermittent porphyria (AIP) occurs due to mutation involving the enzyme porphobilinogen deaminase (PBGD) and is characterised by motor-predominant features. Definitive diagnosis often encompasses a combination of biochemical, enzyme analysis and genetic testing, with clinical neurophysiological findings of a predominantly motor axonal neuropathy. Symptomatic and supportive treatment are the mainstays during an acute attack. If administered early, intravenous haemin may prevent progression of neuropathy. While the pathophysiology of AIP neuropathy remains unclear, axonal dysfunction appears intrinsically linked to the effects of neural energy deficits acquired through haem deficiency coupled to the neurotoxic effects of porphyrin precursors. The present review will provide an overview of AIP neuropathy, including discussion of recent advances in understanding developed through neurophysiological approaches that have further delineated the pathophysiology of axonal degeneration.
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Affiliation(s)
- Cindy S-Y Lin
- School of Medical Sciences, Faculty of Medicine, University of New South Wales, Sydney, Australia.
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Dulioust A, Fonquernie L, Maisonobe T, Puy H, Gasnault J, Deybach JC. Acute porphyric attack mimicking HIV-associated progressive polyradiculoneuropathy. Med Mal Infect 2011; 41:441-3. [DOI: 10.1016/j.medmal.2011.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2010] [Revised: 02/10/2011] [Accepted: 03/16/2011] [Indexed: 11/30/2022]
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Abstract
The porphyrias are a group of uncommon metabolic diseases caused by enzyme deficiencies within heme biosynthesis that lead to neurotoxic or phototoxic heme precursor accumulation. There are four acute porphyrias characterized by neuropsychiatric symptoms: acute intermittent porphyria, variegate porphyria, hereditary coproporphyria, and 5-aminolevulinic acid dehydratase deficiency porphyria. Treatment includes elimination of any porphyrogenic factor and symptomatic treatment. Carbohydrate and intravenous heme administration constitute specific therapies in the disorders' acute phase. The mainstay treatment in the cutaneous porphyrias is avoidance of sunlight exposure. In porphyria cutanea tarda and the two acute porphyrias with skin manifestations, variegate porphyria and hereditary coproporphyria, care of the vulnerable skin is important. In porphyria cutanea tarda, specific treatment is accomplished by a series of phlebotomies and/or by low-dose chloroquine administration. In erythropoietic protoporphyria, light-protective beta-carotene is prescribed.
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Barbaro M, Kotajärvi M, Harper P, Floderus Y. Identification of an AluY-mediated deletion of exon 5 in the CPOX gene by MLPA analysis in patients with hereditary coproporphyria. Clin Genet 2011; 81:249-56. [PMID: 21231929 DOI: 10.1111/j.1399-0004.2011.01628.x] [Citation(s) in RCA: 9] [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] [Indexed: 11/28/2022]
Abstract
Hereditary coproporphyria (HCP) is an autosomal dominantly inherited hepatic porphyria, caused by a mutation in the coproporphyrinogen oxidase (CPOX) gene. The genetic defect leads to a partial defect of CPOX, the sixth enzyme involved in haem biosynthesis. Affected individuals can develop acute life-threatening attacks of neurovisceral symptoms and/or more rarely cutaneous symptoms such as skin fragility and blistering. The identification of the genetic defect in HCP families is of crucial importance to detect the carrier status which allows counselling to prevent possible triggering factors, e.g. certain drugs, alcohol, or fasting. In a total of nine Swedish HCP families, routine gene sequence analysis had identified a causative mutation in only five. In the present study, using an in-house developed synthetic probe set for multiplex ligation-dependent probe amplification (MLPA) analysis, we detected a deletion of the fifth exon in the CPOX gene in the remaining four families. The deletion is 3381 bp in size and has originated by an Alu-mediated mechanism. This finding emphasizes the usefulness of MLPA analysis as a complement to gene sequencing for comprehensive genetic diagnostics in HCP patients.
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Affiliation(s)
- M Barbaro
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
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Bruchajzer E. Porphyrogenic effect of pentabromodiphenyl ether after repeated administration to rats. Arch Toxicol 2011; 85:965-74. [PMID: 21113805 DOI: 10.1007/s00204-010-0621-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2010] [Accepted: 11/09/2010] [Indexed: 10/18/2022]
Abstract
Until recently, pentabromodiphenyl ether (PentaBDE) was most commonly used as a flame retardant. On account of the hazardous effect of PentaBDE on the environment, its use was discontinued some years ago. The toxicity of this compound has been well documented in the literature, especially with regard to the endocrine system, induction of liver microsomal enzymes, and disturbance of redox homeostasis. The aim of this study was to investigate the porphyrogenic effect of PentaBDE after its repeated administration to rats at doses of 2, 8, 40, or 200 mg/kg/day. After a 28-day exposure, a dose-dependent increase (maximum 2.5-fold) in ALA-S activity in the liver was observed. The enhanced concentration of total porphyrins in the liver (3- to 19-fold after doses of 8-200 mg/kg/day) was also found. The most pronounced changes in liver concentrations of porphyrins were shown by high carboxylated porphyrins (a 19-fold increase for octacarboxyporphyrins and a 36-fold increase for heptacarboxyporphyrins). They made over 95% of total porphyrins accumulated in the liver. The porphyrogenic effect of PentaBDE was also evidenced by the augmented urinary excretion of total porphyrins. After 28 days of exposure, the observed changes (2- to 7-fold increase) were found to be dose-dependent. Tetracarboxyporphyrins predominated in urine; their urinary concentrations were 4-12 times higher, and their daily urinary excretion is 2-9 times higher. A dose of 2 mg/kg/day was the lowest dose that caused changes in the levels of porphyrins (LOAEL). The experiment revealed the effect of PentaBDE on the heme biosynthesis and porphyrin concentrations, which indicates its porphyrogenic effect.
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Abstract
Porphyrias are a group of eight rare inherited metabolic disorders of heme biosynthesis pathway. Porphyrias are still underdiagnosed, although examinations of urine and plasma are first-line tests for detecting excess of porphyrins or heme precursors in suspected patients. Diagnosis, particularly for the acute forms, is essential to avoid precipitating factors and the use of triggering drugs. Mutation screening of family members is recommended to identify presymptomatic carriers and to prevent acute attacks. The therapeutic approach should be appropriate regarding specific forms of porphyria and treatment should be started promptly.
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Affiliation(s)
- Maria Domenica Cappellini
- Dipartimento di Medicina Interna, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico, Università degli Studi di Milano, Via F. Sforza 35, 20122, Milan, Italy.
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Abstract
Hereditary porphyrias are a group of eight metabolic disorders of the haem biosynthesis pathway that are characterised by acute neurovisceral symptoms, skin lesions, or both. Every porphyria is caused by abnormal function of a separate enzymatic step, resulting in a specific accumulation of haem precursors. Seven porphyrias are the result of a partial enzyme deficiency, and a gain of function mechanism has been characterised in a new porphyria. Acute porphyrias present with acute attacks, typically consisting of severe abdominal pain, nausea, constipation, confusion, and seizure, and can be life-threatening. Cutaneous porphyrias present with either acute painful photosensitivity or skin fragility and blisters. Rare recessive porphyrias usually manifest in early childhood with either severe cutaneous photosensitivity and chronic haemolysis or chronic neurological symptoms with or without photosensitivity. Porphyrias are still underdiagnosed, but when they are suspected, and dependent on clinical presentation, simple first-line tests can be used to establish the diagnosis in all symptomatic patients. Diagnosis is essential to enable specific treatments to be started as soon as possible. Screening of families to identify presymptomatic carriers is crucial to decrease risk of overt disease of acute porphyrias through counselling about avoidance of potential precipitants.
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Affiliation(s)
- Hervé Puy
- Assistance Publique Hôpitaux de Paris, Centre Français des Porphyries, Hôpital Louis Mourier, Colombes, France
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Abstract
A 47-year-old man presented with abdominal pain, neck stiffness, severe transient hypertension and unusually dark urine. Cerebrospinal fluid investigations and angiography confirmed the diagnosis of a subarachnoid haemorrhage. Porphyrin studies on the patient and his family demonstrated that the family has acute intermittent porphyria. This is the second case report of an acute hepatic porphyria presenting with a subarachnoid haemorrhage. Acute transient hypertension during the attack of porphyria caused the rupture of an intracranial arterial aneurysm.
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Affiliation(s)
| | - David M Simms
- Chemical Pathology Department, Kingston Hospital, Kingston upon Thames KT2 7QB, UK
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Thiery-Vuillemin A, Chaigneau L, Meaux-Ruault N, Villanueva C, N'guyen T, Maurina T, Stein U, Lorgis V, Demarchi M, Pivot X. Anticancer therapy in patients with porphyrias: evidence today. Expert Opin Drug Saf 2008; 7:159-65. [DOI: 10.1517/14740338.7.2.159] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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