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Ramos KN, Leino D, Luebbering N, Grimley MS, Badia P, Davies SM, Khandelwal P. Use of Teduglutide in the Management of Gastrointestinal Graft-versus-Host Disease in Children and Young Adults. Transplant Cell Ther 2024; 30:454.e1-454.e6. [PMID: 38311212 DOI: 10.1016/j.jtct.2024.01.080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 01/14/2024] [Accepted: 01/25/2024] [Indexed: 02/10/2024]
Abstract
Loss of intestinal L cells and reduced levels of glucagon-like peptide-2 (GLP-2) have been implicated in acute graft-versus-host disease (GVHD) in murine models. Teduglutide, a human recombinant GLP-2 analog, may be beneficial in acute gastrointestinal (GI) GVHD owing to its known tissue protective and regenerative functions. We retrospectively reviewed patients who received teduglutide for treatment of GI GVHD. Endoscopy was performed at diagnosis and at completion of the teduglutide course. GLP-1 immunohistochemistry (IHC) was performed at diagnosis and the end of teduglutide therapy in 2 patients to evaluate L cells. We initiated daily teduglutide 0.05 mg/kg subcutaneously as adjunctive therapy in 3 pediatric patients with refractory GI GVHD. All 3 patients had resolution of GI GVHD following completion of the teduglutide course, as evidenced by reduced apoptosis and regenerative changes on post-treatment endoscopy. Reportable GLP-1 IHC in 2 patients demonstrated increased L cells at the end of teduglutide treatment compared to at diagnosis. No adverse effects to teduglutide were observed. Teduglutide is a promising adjunctive and non-immune suppressive agent for managing acute GI GVHD.
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Affiliation(s)
- Kristie N Ramos
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics University of Cincinnati, Cincinnati, Ohio
| | - Daniel Leino
- Department of Pediatrics University of Cincinnati, Cincinnati, Ohio; Division of Pathology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Nathan Luebbering
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics University of Cincinnati, Cincinnati, Ohio
| | - Michael S Grimley
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics University of Cincinnati, Cincinnati, Ohio
| | - Priscila Badia
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics University of Cincinnati, Cincinnati, Ohio
| | - Stella M Davies
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics University of Cincinnati, Cincinnati, Ohio
| | - Pooja Khandelwal
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics University of Cincinnati, Cincinnati, Ohio.
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Takahashi T, Maejima T, Miyazaki D, Fukahori S, Hagiwara M. Teduglutide-induced acute gastric mucosal necrosis in short bowel syndrome with hepatorenal failure: Case report. Int J Surg Case Rep 2024; 117:109524. [PMID: 38493615 PMCID: PMC10958469 DOI: 10.1016/j.ijscr.2024.109524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 03/06/2024] [Accepted: 03/08/2024] [Indexed: 03/19/2024] Open
Abstract
INTRODUCTION Short bowel syndrome (SBS) resulting from acute aortic dissection (AAD)-induced visceral malperfusions leads to chronic intestinal failure (CIF), necessitating patients to adopt home parenteral nutrition to prevent malabsorption. Teduglutide (TED), a glucagon-like peptide-2 analog, is a promising pharmacotherapy for intestinal rehabilitation that reduces parenteral support and improves the quality of life. Gastric mucosal necrosis, a rare gastrointestinal disorder, had never been observed as an adverse event relevant to this drug. We report a case of mucosal necrosis in the stomach after TED treatment for SBS-CIF with hepatorenal failure. PRESENTATION OF CASE A 68-year-old Japanese man who underwent massive intestinal resection for AAD experienced malnutrition and diarrhea caused by SBS-CIF. The patient received TED to improve intestinal absorption and entero-hepatic circulation besides controlling infectious diseases. Endoscopy showed mucosal hyperplasia in the stomach and duodenum 1.5 months after TED administration. The patient consented to enteral nutrition via a nasogastric tube because of anorexia. The nutritional status gradually improved after initiating enteral feeding. However, the patient experienced hematemesis 13 days after enteral feeding, and endoscopy revealed acute gastric mucosal necrosis, followed by fatal septic shock. DISCUSSION For patients with SBS, TED is expected to increase intestinal absorption through epithelial proliferation. When SBS is accompanied by multiple ischemic organ failure, TED therapeutic effects remain unclear as malnutrition-associated infectious diseases are refractory, and many underlying mechanisms can be involved. CONCLUSION TED administration should be deliberately considered for patients with SBS-CIF and multiple organ failure experiencing uncontrolled systemic infection.
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Affiliation(s)
- Tohru Takahashi
- Department of General Surgery, Sapporo Higashi Tokushukai Hospital, 3-1, North 33 East 14, East district, Sapporo, Hokkaido prefecture 065-0033, Japan.
| | - Taku Maejima
- Department of General Surgery, Sapporo Higashi Tokushukai Hospital, 3-1, North 33 East 14, East district, Sapporo, Hokkaido prefecture 065-0033, Japan
| | - Dai Miyazaki
- Department of General Surgery, Sapporo Higashi Tokushukai Hospital, 3-1, North 33 East 14, East district, Sapporo, Hokkaido prefecture 065-0033, Japan
| | - Susumu Fukahori
- Department of General Surgery, Sapporo Higashi Tokushukai Hospital, 3-1, North 33 East 14, East district, Sapporo, Hokkaido prefecture 065-0033, Japan
| | - Masahiro Hagiwara
- Department of General Surgery, Sapporo Higashi Tokushukai Hospital, 3-1, North 33 East 14, East district, Sapporo, Hokkaido prefecture 065-0033, Japan
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Marotti V, Xu Y, Bohns Michalowski C, Zhang W, Domingues I, Ameraoui H, Moreels TG, Baatsen P, Van Hul M, Muccioli GG, Cani PD, Alhouayek M, Malfanti A, Beloqui A. A nanoparticle platform for combined mucosal healing and immunomodulation in inflammatory bowel disease treatment. Bioact Mater 2024; 32:206-221. [PMID: 37859689 PMCID: PMC10582360 DOI: 10.1016/j.bioactmat.2023.09.014] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 09/19/2023] [Accepted: 09/22/2023] [Indexed: 10/21/2023] Open
Abstract
Current treatments for inflammatory bowel disease (IBD) treatment consist of anti-inflammatory products. In this study, we sought to induce the physiological secretion of glucagon-like peptide 2, a peptide with intestinal growth-promoting activity, via nanoparticles while simultaneously providing with immunomodulation by tailoring the nanoparticle surface. To this end, we developed hybrid lipid hyaluronate-KPV conjugated nanoparticles loaded with teduglutide for combination therapy in IBD. The nanocarriers induced (or did not induce) immunosuppression depending on the presence (or absence) of a hyaluronan-KPV functionalization. This strategy holds promise as a nanoparticle platform for combined mucosal healing and immunomodulation in IBD treatment.
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Affiliation(s)
- Valentina Marotti
- UCLouvain, Université catholique de Louvain, Louvain Drug Research Institute, Advanced Drug Delivery and Biomaterials, 1200 Brussels, Belgium
| | - Yining Xu
- UCLouvain, Université catholique de Louvain, Louvain Drug Research Institute, Advanced Drug Delivery and Biomaterials, 1200 Brussels, Belgium
| | - Cécilia Bohns Michalowski
- UCLouvain, Université catholique de Louvain, Louvain Drug Research Institute, Advanced Drug Delivery and Biomaterials, 1200 Brussels, Belgium
| | - Wunan Zhang
- UCLouvain, Université catholique de Louvain, Louvain Drug Research Institute, Advanced Drug Delivery and Biomaterials, 1200 Brussels, Belgium
| | - Inês Domingues
- UCLouvain, Université catholique de Louvain, Louvain Drug Research Institute, Advanced Drug Delivery and Biomaterials, 1200 Brussels, Belgium
| | - Hafsa Ameraoui
- UCLouvain, Université catholique de Louvain, Louvain Drug Research Institute, Bioanalysis and Pharmacology of Bioactive Lipids, 1200 Brussels, Belgium
| | - Tom G. Moreels
- UCLouvain, Université catholique de Louvain, Institute of Experimental and Clinical Research, Laboratory of Hepato-Gastroenterology, 1200 Brussels, Belgium
- Cliniques universitaires Saint-Luc, Department of Hepato-Gastroenterology, Brussels, Belgium
| | - Pieter Baatsen
- EM-platform, VIB Bio Imaging Core, KU Leuven, Campus Gasthuisberg, Herestraat 49, 3000 Leuven, Belgium
| | - Matthias Van Hul
- UCLouvain, Université catholique de Louvain, Louvain Drug Research Institute, Metabolism and Nutrition Group, 1200 Brussels, Belgium
| | - Giulio G. Muccioli
- UCLouvain, Université catholique de Louvain, Louvain Drug Research Institute, Bioanalysis and Pharmacology of Bioactive Lipids, 1200 Brussels, Belgium
| | - Patrice D. Cani
- UCLouvain, Université catholique de Louvain, Louvain Drug Research Institute, Metabolism and Nutrition Group, 1200 Brussels, Belgium
- UCLouvain, Institute of Experimental and Clinical Research, 1200 Brussels, Belgium
- WEL Research Institute, Avenue Pasteur, 6, 1300 Wavre, Belgium
| | - Mireille Alhouayek
- UCLouvain, Université catholique de Louvain, Louvain Drug Research Institute, Bioanalysis and Pharmacology of Bioactive Lipids, 1200 Brussels, Belgium
| | - Alessio Malfanti
- UCLouvain, Université catholique de Louvain, Louvain Drug Research Institute, Advanced Drug Delivery and Biomaterials, 1200 Brussels, Belgium
| | - Ana Beloqui
- UCLouvain, Université catholique de Louvain, Louvain Drug Research Institute, Advanced Drug Delivery and Biomaterials, 1200 Brussels, Belgium
- WEL Research Institute, Avenue Pasteur, 6, 1300 Wavre, Belgium
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Gattini D, Belza C, Kraus R, Avitzur Y, Ungar WJ, Wales PW. Cost-utility analysis of teduglutide compared to standard care in weaning parenteral nutrition support in children with short bowel syndrome. Clin Nutr 2023; 42:2363-2371. [PMID: 37862822 DOI: 10.1016/j.clnu.2023.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 09/29/2023] [Accepted: 10/02/2023] [Indexed: 10/22/2023]
Abstract
BACKGROUND & AIMS A growing proportion of children with short bowel syndrome (SBS) remain dependent on long-term parenteral nutrition (PN). Teduglutide offers the potential for more children to decrease PN support and achieve enteral autonomy (EA), but at a significant expense. This study aims to assess the incremental costs of teduglutide plus standard of care compared to standard of care alone in weaning PN support per quality-adjusted life year (QALY) gained in children with SBS. METHODS This is a cost-utility analysis comparing teduglutide with standard of care alone in children with SBS. A microsimulation model of children with SBS on PN aged 1-17 years was constructed over a time horizon of six years, with a cycle length of one month. The study adopted the healthcare system and societal payer perspectives in Ontario, Canada. The health outcome measure was QALYs, with results expressed in terms of incremental costs and QALYs. Scenario analyses were performed to examine the effects of different time horizons, timing of teduglutide initiation, and modeling cost of teduglutide based on pediatric weight-dosing. RESULTS Incremental healthcare system costs for teduglutide compared to standard of care were CAD$441,314 (95% CI, 414,006 to 441,314) and incremental QALYs were 1.80 (95% CI, 1.70 to 1.89) resulting in an incremental cost-effectiveness ratio (ICER) of CAD$285,334 (95% CI, 178,209 to 392,459) per QALY gained. Incremental societal costs were CAD$418,504 (95% CI, 409,487 to 427,522) and incremental societal QALYs were 1.91 (95% CI, 1.85 to 1.98) resulting in an ICER of CAD$261,880 (95% CI, 136,887 to 386,874) per QALY gained. Scenario analysis showed that teduglutide was cost-effective when it was started two years after intestinal resection (ICER CAD$48,741, 95% CI, 17,317 to 80,165) and when its monthly cost was adjusted using weight-based dosing, avoiding wastage of the remaining 5 mg dose vial (Teduglutide dominated over SOC as the less costly and most effective strategy). CONCLUSIONS Although teduglutide was not cost-effective in weaning PN support in children with SBS, starting teduglutide once natural intestinal adaptation is reduced and adjusting its monthly cost to reflect cost by volume as dictated by weight-based dosing rendered the intervention cost-effective relative to standard of care. These results indicate the potential for clinicians to re-assess optimal time for initiation of teduglutide after intestinal resection, drug manufacturers to consider the use of multi-dose or paediatric-dose vials, and the opportunity for decision-makers to re-evaluate teduglutide funding.
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Affiliation(s)
- Daniela Gattini
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Division of Gastroenterology, Hepatology & Nutrition, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada; Group for Improvement of Intestinal Function and Treatment (GIFT), Transplant and Regenerative Medicine Centre, Toronto, Ontario, Canada
| | - Christina Belza
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Group for Improvement of Intestinal Function and Treatment (GIFT), Transplant and Regenerative Medicine Centre, Toronto, Ontario, Canada
| | - Raphael Kraus
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Pediatric Rheumatologist, Centre Hospitalier Sainte-Justine (CHUSJ), Montreal, Quebec, Canada
| | - Yaron Avitzur
- Division of Gastroenterology, Hepatology & Nutrition, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada; Group for Improvement of Intestinal Function and Treatment (GIFT), Transplant and Regenerative Medicine Centre, Toronto, Ontario, Canada
| | - Wendy J Ungar
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Child Health Evaluative Sciences Program, Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
| | - Paul W Wales
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Division of General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, United States; Cincinnati Center of Excellence for Intestinal Rehabilitation (CinCEIR), Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States.
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Florencio Ojeda L, Domínguez Rabadán R, Laínez López M, Jaldón Hidalgo G, Rodríguez Andrés N, Penco Ramírez C, Rebollo Pérez MI. Nutritional management of a patient with chronic intestinal failure and hemodialysis receiving teduglutide: A case report. Nutrition 2023; 113:112137. [PMID: 37481817 DOI: 10.1016/j.nut.2023.112137] [Citation(s) in RCA: 1] [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] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 06/12/2023] [Accepted: 06/14/2023] [Indexed: 07/25/2023]
Abstract
We present the case of a 35-y-old woman with short bowel syndrome secondary to extensive intestinal resection with associated chronic kidney disease who was undergoing hemodialysis. This patient required permanent supplementation with intradialytic parenteral nutrition because of a high-output end-jejunostomy. The patient was a candidate for treatment with teduglutide, a glucagon-like peptide 2 analog, intending to increase intestinal absorption. A complete nutritional assessment was performed using bioelectrical impedance vector analysis. Teduglutide treatment was successful, and after a 1-y follow-up, the patient had considerably reduced end-jejunostomy output (reduction of 6 L/d) and an improved nutritional status (9.1 kg weight gain, 1.4 kg fat-free mass gain, and a 2.2-degree increase in bioimpedance phase angle). However, we have been unable to reduce intradialytic parenteral nutrition, which the patient requires thrice weekly. No significant secondary effects have occurred because of teduglutide administration. This may be the first reported use of teduglutide in a patient with short bowel syndrome undergoing hemodialysis who was monitored using bioelectrical impedance data during follow-up.
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Affiliation(s)
| | | | - María Laínez López
- Endocrinology and Nutrition Unit, Juan Ramón Jiménez Hospital, Huelva, Spain
| | | | | | - Cinta Penco Ramírez
- Endocrinology and Nutrition Unit, Juan Ramón Jiménez Hospital, Huelva, Spain
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Alizadeh AA, Rasouli S, Jamshidi Kandjani O, Hemmati S, Dastmalchi S. Expression, Purification and Characterization of Functional Teduglutide Using GST Fusion System in Prokaryotic Cells. Adv Pharm Bull 2023; 13:592-600. [PMID: 37646058 PMCID: PMC10460804 DOI: 10.34172/apb.2023.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Revised: 11/15/2022] [Accepted: 12/04/2022] [Indexed: 09/01/2023] Open
Abstract
Purpose Teduglutide is the first and only FDA-approved drug for long-term treatment of short bowel syndrome (SBS). The current study aimed to present an approach for production of teduglutide using recombinant DNA technology. Methods The coding gene for teduglutide was cloned into pGEX-2T vector, where coding sequence for factor Xa cleavage site was added between GST and teduglutide coding genes. The GST-teduglutide protein was overexpressed in E. coli BL21 (DE3) strain and affinity purified using glutathione sepharose affinity column. Results On-column proteolytic activity of factor Xa followed by size exclusion chromatography resulted in the pure teduglutide. Circular dichroism (CD) spectropolarimetry showed that the produced teduglutide folds into mainly α-helical structure (>50%), as expected. In mass spectroscopy analysis, the fragments of teduglutide resulted by cyanogen bromide cleavage as well as those expected theoretically due to mass fragmentation were identified. The functionality of the produced peptide was evaluated by measuring its proliferative effect on Caco2 intestinal epithelial cells, and the results indicated that produced teduglutide induces cell proliferation by 19±0.30 and 33±7.82 % at 1.21 and 3.64 µM concentrations, respectively, compared to untreated cells. Conclusion Teduglutide was successfully expressed and purified and its functionality and structural integrity were confirmed by in vitro experiments. We believe that the experimental-scale method presented in the current study can be useful for pilot-scale and also industrial-scale production of teduglutide.
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Affiliation(s)
- Ali Akbar Alizadeh
- Biotechnology Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Saba Rasouli
- Pharmaceutical Analysis Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
- School of Pharmacy, Tabriz University of Medical Sciences, Tabriz, Iran
| | | | - Salar Hemmati
- Drug Applied Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Siavoush Dastmalchi
- Biotechnology Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
- School of Pharmacy, Tabriz University of Medical Sciences, Tabriz, Iran
- Faculty of Pharmacy, Near East University, Po.Box: 99138, Nicosia, North Cyprus, Mersin 10, Turkey
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Pérez-Robles R, Salmerón-García A, Hermosilla J, Torrente-López A, Clemente-Bautista S, Jiménez-Lozano I, Cabañas-Poy MJ, Cabeza J, Navas N. Comprehensive physicochemical characterization of a peptide-based medicine: Teduglutide (Revestive®) structural description and stress testing. Eur J Pharm Biopharm 2023; 184:103-115. [PMID: 36669672 DOI: 10.1016/j.ejpb.2023.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 12/29/2022] [Accepted: 01/02/2023] [Indexed: 01/19/2023]
Abstract
Teduglutide (Revestive®) is a glucagon-like peptide-2 analogue used for the treatment of short bowel syndrome, a rare life-threatening condition in which the amount of functional gut is too short to enable proper absorption of nutrients and fluids. During handling prior to administration to the patient in hospital, it is possible that peptide-based medicines may be exposed to environmental stress conditions that could affect their quality. It is therefore essential to carry out stress testing studies to evaluate how such medicines respond to these stresses. For this reason, in this paper we present a strategy for a comprehensive analytical characterization of a peptide and a stress testing study in which it was subjected to various stress conditions: heating at 40 °C and 60 °C, light exposure and shaking. Several complementary analytical techniques were used throughout this study: Far UV circular dichroism, intrinsic protein fluorescence spectroscopy, dynamic light scattering, size-exclusion chromatography and intact and peptide mapping reverse-phase chromatography coupled to mass spectrometry. To the best of our knowledge, this is the first study to offer an in-depth description of the chemical structure of teduglutide peptide and its physicochemical characteristics after stress stimuli were applied to the reconstituted medicine Revestive®.
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Affiliation(s)
- Raquel Pérez-Robles
- Instituto de Investigación Biosanitaria de Granada (ibs.GRANADA), Granada, Spain; Department of Analytical Chemistry, Science Faculty, University of Granada, Granada, Spain; Fundación para la Investigación Biosanitaria de Andalucía Oriental-Alejandro Otero, Granada, Spain
| | - Antonio Salmerón-García
- Instituto de Investigación Biosanitaria de Granada (ibs.GRANADA), Granada, Spain; Department of Clinical Pharmacy, San Cecilio University Hospital, Granada, Spain
| | - Jesus Hermosilla
- Instituto de Investigación Biosanitaria de Granada (ibs.GRANADA), Granada, Spain; Department of Analytical Chemistry, Science Faculty, University of Granada, Granada, Spain
| | - Anabel Torrente-López
- Instituto de Investigación Biosanitaria de Granada (ibs.GRANADA), Granada, Spain; Department of Analytical Chemistry, Science Faculty, University of Granada, Granada, Spain
| | | | - Inés Jiménez-Lozano
- Maternal and Child Pharmacy Service, Vall d'Hebron Hospital, Pharmacy, Barcelona, Spain
| | | | - Jose Cabeza
- Instituto de Investigación Biosanitaria de Granada (ibs.GRANADA), Granada, Spain; Department of Clinical Pharmacy, San Cecilio University Hospital, Granada, Spain
| | - Natalia Navas
- Instituto de Investigación Biosanitaria de Granada (ibs.GRANADA), Granada, Spain; Department of Analytical Chemistry, Science Faculty, University of Granada, Granada, Spain.
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Nakamura S, Wada M, Mizushima T, Sugita A, Tazuke Y, Ohge H, Udagawa E, Suzuki RK, Yoon M, Grimm A, Chen ST, Ikeuchi H. Efficacy, safety, and pharmacokinetics of teduglutide in adult Japanese patients with short bowel syndrome and intestinal failure: two phase III studies with an extension. Surg Today 2023; 53:347-59. [PMID: 36201060 DOI: 10.1007/s00595-022-02587-4] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 07/08/2022] [Indexed: 10/10/2022]
Abstract
PURPOSE The short- and long-term efficacy, safety, and pharmacokinetics of teduglutide were analyzed in adult Japanese patients with short bowel syndrome and intestinal failure (SBS-IF). METHODS Patients received teduglutide 0.05 mg/kg/day in clinical trials (TED-C14-004, SHP633-306, and extension SHP633-307). Data were analyzed at 24 weeks and an interim data cut-off of 4.5 years. RESULTS The parenteral support (PS) volume decreased by ≥ 20% for 9/18 patients at 24 weeks and in all 11 patients by data cut-off in SHP633-307. The mean (standard deviation) PS volume decreased from baseline at 24 weeks in TED-C14-004 (-30.1 ± 25.9%) and SHP633-306 (-25.6 ± 25.5%), and at data cut-off in SHP633-307 (-57.08 ± 28.49%). Teduglutide was absorbed quickly. The adverse events were consistent with the underlying disease and known adverse drug reactions. Anti-teduglutide antibody titers declined with long-term treatment. CONCLUSIONS In Japanese adults with SBS-IF, teduglutide treatment was associated with clinically meaningful reductions in PS requirements, similar to findings in prior international studies. No new safety concerns specific to the Japanese SBS-IF patient population were identified with short- or long-term teduglutide treatment. Anti-teduglutide antibody titers disappeared in most Japanese adults with long-term treatment. These results constitute the longest evaluation of teduglutide treatment within clinical trials reported to date.
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Radetic M, Kamel A, Lahey M, Brown M, Sharma A. Management of Short Bowel Syndrome (SBS) and Intestinal Failure. Dig Dis Sci 2023; 68:29-37. [PMID: 36434372 DOI: 10.1007/s10620-022-07760-w] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Accepted: 11/02/2022] [Indexed: 11/26/2022]
Abstract
Short bowel syndrome (SBS) is a chronic disease whose natural history requires a changing array of management strategies over time. Chief amongst these is the chronic use of parenteral nutrition (PN) to ensure adequate nutritional intake. With time and appropriate management, approximately half of all SBS patients will successfully regain a functional, baseline level of intrinsic bowel function that will allow for them to achieve PN independence. However, the other half of SBS patients will progress into chronic intestinal failure which warrants a change in therapy to include more aggressive medical and potentially surgical measures. This review examines the evolving treatment strategies involved in the management of SBS as well as intestinal failure.
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Kounatidis D, Vallianou NG, Tsilingiris D, Christodoulatos GS, Geladari E, Stratigou T, Karampela I, Dalamaga M. Therapeutic Potential of GLP-2 Analogs in Gastrointestinal Disorders: Current Knowledge, Nutritional Aspects, and Future Perspectives. Curr Nutr Rep 2022; 11:618-642. [PMID: 35933503 DOI: 10.1007/s13668-022-00433-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/25/2022] [Indexed: 01/31/2023]
Abstract
PURPOSE OF REVIEW Although Glucagon-like peptide (GLP)-1 receptor agonists have been used for almost two decades in the treatment of diabetes mellitus type 2 and, lately, in obesity, recent years have seen an increasing interest in the pharmacological agonism of other proglucagon-derived peptides, including GLP-2. Herein, we aimed to review the available evidence on the effects of GLP-2 agonism from animal and clinical studies. Furthermore, we summarize the current clinical applications of GLP-2 agonists among patients with intestinal failure associated with short bowel syndrome (SBS-IF) as well as potential future expansion of their indications to other intestinal disorders. RECENT FINDINGS Evidence from preclinical studies has highlighted the cellular trophic and functional beneficial actions of GLP-2 on small intestinal and colonic mucosa. Subsequently, pharmacologic agonism of GLP-2 has gathered interest for the treatment of patients with conditions pertaining to the loss of intestinal anatomical and/or functional integrity to a degree requiring parenteral support, collectively referred to as intestinal failure. GLP-2 analogs positively influence nutrient absorption in animal models and humans, although continued therapy is likely needed for sustained effects. The degradation-resistant GLP-2-analog teduglutide has received approval for the treatment of SBS-IF, in which it may decisively reduce patient dependency on parenteral support and improve quality of life. Another two longer-acting analogs, glepaglutide and apraglutide, are currently undergoing phase III clinical trials. The use of GLP-2 analogs is effective in the management of SBS-IF and may show promise in the treatment of other severe gastrointestinal disorders associated with loss of effective intestinal resorptive surface area.
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Affiliation(s)
- Dimitris Kounatidis
- Departments of Internal Medicine and Endocrinology, Evangelismos General Hospital, 45-47 Ypsilantou Street, 10676, Athens, Greece
| | - Natalia G Vallianou
- Departments of Internal Medicine and Endocrinology, Evangelismos General Hospital, 45-47 Ypsilantou Street, 10676, Athens, Greece.
| | - Dimitrios Tsilingiris
- First Department of Propaedeutic Internal Medicine, School of Medicine, National and Kapodistrian University of Athens, Laiko General Hospital, 17 St Thomas Street, 11527, Athens, Greece
| | - Gerasimos Socrates Christodoulatos
- Department of Biological Chemistry, Medical School, National and Kapodistrian University of Athens, 75 Mikras Asias, Goudi, 11527, Athens, Greece
| | - Eleni Geladari
- Departments of Internal Medicine and Endocrinology, Evangelismos General Hospital, 45-47 Ypsilantou Street, 10676, Athens, Greece
| | - Theodora Stratigou
- Departments of Internal Medicine and Endocrinology, Evangelismos General Hospital, 45-47 Ypsilantou Street, 10676, Athens, Greece
| | - Irene Karampela
- 2nd Department of Critical Care, Medical School, University of Athens, Attikon General University Hospital, 1 Rimini Street, Chaidari, 12462, Athens, Greece
| | - Maria Dalamaga
- Department of Biological Chemistry, Medical School, National and Kapodistrian University of Athens, 75 Mikras Asias, Goudi, 11527, Athens, Greece.
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Pizzoferrato M, Puca P, Ennas S, Cammarota G, Guidi L. Glucagon-like peptide-2 analogues for Crohn’s disease patients with short bowel syndrome and intestinal failure. World J Gastroenterol 2022; 28:6258-6270. [PMID: 36504557 PMCID: PMC9730438 DOI: 10.3748/wjg.v28.i44.6258] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Revised: 11/01/2022] [Accepted: 11/17/2022] [Indexed: 02/06/2023] Open
Abstract
Short bowel syndrome (SBS) with intestinal failure (IF) is a rare but severe complication of Crohn’s disease (CD), which is the most frequent benign condition that leads to SBS after repeated surgical resections, even in the era of biologics and small molecules. Glucagon-like peptide-2 analogues have been deeply studied recently for the treatment of SBS-IF. These drugs have a significant intestinotrophic effect and the potential to reduce the chronic dependence of SBS-IF patients on parenteral support or nutrition. Teduglutide has been approved for the treatment of SBS-IF, and apraglutide is currently in clinical development. The use of these drugs was examined with a focus on their use in CD patients.
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Affiliation(s)
- Marco Pizzoferrato
- UOC Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
| | - Pierluigi Puca
- UOC Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome 00168, Italy
| | - Sara Ennas
- UOC Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
| | - Giovanni Cammarota
- UOC Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome 00168, Italy
| | - Luisa Guidi
- UOC Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
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Pérez-Robles R, Hermosilla J, Navas N, Clemente-Bautista S, Jiménez-Lozano I, Cabañas-Poy MJ, Ruiz-Travé J, Hernández-García MA, Cabeza J, Salmerón-García A. Tracking the physicochemical stability of teduglutide (Revestive®) clinical solutions over time in different storage containers. J Pharm Biomed Anal 2022; 221:115064. [PMID: 36152491 DOI: 10.1016/j.jpba.2022.115064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 09/12/2022] [Accepted: 09/15/2022] [Indexed: 11/20/2022]
Abstract
Teduglutide, the active ingredient of the medicine Revestive® (5 mg), is a recombinant therapeutic peptide that mimics the effects of the endogenous glucagon-like peptide 2 (GLP-2). It stimulates intestinal growth, adaptation and function in patients with Short Bowel Syndrome who are dependent on parenteral nutrition. The Summary of Product Characteristics recommends immediate use of the reconstituted solutions and the discarding of any subsequent surplus. This study aims to carry out a long-term stability study that reproduces hospital conditions of use which provide sound evidence regarding the use of teduglutide surplus beyond the Summary Product Characteristics recommendations. We conducted a stability study of teduglutide solutions prepared from a 5 mg vial of Revestive®. Some of the solutions were stored in their original vial after reconstitution, while others were repackaged in plastic syringes to evaluate their physicochemical stability over time. For this purpose, we applied a set of previously validated analytical methodologies to evaluate the main critical quality attributes of teduglutide, i.e., primary (including post-tralational modifications), secondary and tertiary structures, aggregates, particulate, concentration and pH. The results indicate that the solutions maintain high physicochemical stability over time, regardless of the storage temperature (4ºC or -20ºC) or the storage container (vials or syringes). This research provides new data on the stability of Revestive® that will be of great value to hospital pharmacists. This comprehensive assessment of the physicochemical long-term stability of TGT has demonstrated that under the storage conditions and over the period studied here, the medicine maintains its quality, efficacy and safety profiles.
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Affiliation(s)
- Raquel Pérez-Robles
- Instituto de Investigación Biosanitaria de Granada (ibs.GRANADA), Granada, Spain; Department of Analytical Chemistry, Science Faculty, University of Granada, Granada, Spain; Fundación para la Investigación Biosanitaria de Andalucía Oriental-Alejandro Otero, Granada, Spain
| | - Jesús Hermosilla
- Instituto de Investigación Biosanitaria de Granada (ibs.GRANADA), Granada, Spain; Department of Analytical Chemistry, Science Faculty, University of Granada, Granada, Spain
| | - Natalia Navas
- Instituto de Investigación Biosanitaria de Granada (ibs.GRANADA), Granada, Spain; Department of Analytical Chemistry, Science Faculty, University of Granada, Granada, Spain.
| | | | - Inés Jiménez-Lozano
- Maternal and Child Pharmacy Service, Vall d'Hebron Hospital, Pharmacy, Barcelona, Spain
| | | | - Julio Ruiz-Travé
- Department of Analytical Chemistry, Science Faculty, University of Granada, Granada, Spain
| | | | - Jose Cabeza
- Instituto de Investigación Biosanitaria de Granada (ibs.GRANADA), Granada, Spain; Department of Clinical Pharmacy, San Cecilio University Hospital, Granada, Spain
| | - Antonio Salmerón-García
- Instituto de Investigación Biosanitaria de Granada (ibs.GRANADA), Granada, Spain; Department of Clinical Pharmacy, San Cecilio University Hospital, Granada, Spain
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Schlager L, Stift A, Gartner J, Hütterer E, Harpain F. Bridging intestinal failure with Teduglutide - A case report. Int J Surg Case Rep 2021; 86:106270. [PMID: 34418803 PMCID: PMC8384933 DOI: 10.1016/j.ijscr.2021.106270] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 07/29/2021] [Accepted: 08/01/2021] [Indexed: 11/30/2022] Open
Abstract
Introduction and importance Intestinal failure (IF) describes the state of a person's gastrointestinal absorption capabilities becoming unable to absorb fluids and nutrients needed to sustain normal physiology, leading to severe comorbidities and if left untreated, to death. IF is most commonly seen as a result of short bowel syndrome (SBS). Teduglutide is a glucagon-like peptide 2 (GLP-2) analogue used in the treatment of patients with SBS and intestinal failure (IF) as a way to reduce the need for parenteral support. Teduglutide leads to the growth of intestinal mucosa by stimulating intestinal crypt cell growth and inhibiting enterocyte apoptosis. It is usually prescribed as a final treatment step after the diagnosis of SBS-IF is made. Case presentation In this case report we present a novel strategy for using teduglutide as a bridging therapy to intestinal reconstruction. The patient achieved enteral autonomy preoperatively, underwent surgery, and remained in enteral autonomy after intestinal reconstruction. Clinical discussion Teduglutide has been previously exclusively used as continuous therapy in SBS-IF, this is the first reported case of using teduglutide as bridging to intestinal reconstruction. The hypothesis of this approach was to achieve an adequate nutritional status for reconstruction without the disadvantages of parenteral support. Conclusion The controlled application of teduglutide can provide the benefits of preoperative nutritional optimization without the disadvantages of parenteral support and at the same time facilitate an earlier and easier intestinal reconstruction. Teduglutide can be used to reduce parenteral support in SBS-IF patients awaiting intestinal reconstruction Teduglutide can be used preoperatively to optimize a patient's nutritional status Using teduglutide as bridging therapy to surgery prevents patients from experiencing parenteral nutrition-associated complications
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Affiliation(s)
- Lukas Schlager
- Department of General Surgery, Division of Visceral Surgery, Medical University of Vienna, Austria
| | - Anton Stift
- Department of General Surgery, Division of Visceral Surgery, Medical University of Vienna, Austria.
| | - Johanna Gartner
- Department of Gastroenterology and Hepatology, Hanusch Hospital, Vienna, Austria
| | - Elisabeth Hütterer
- Department of Medicine I, Division of Oncology, Medical University of Vienna, Austria
| | - Felix Harpain
- Department of General Surgery, Division of Visceral Surgery, Medical University of Vienna, Austria
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Mazzuoli S, Regano N, Lamacchia S, Silvestri A, Guglielmi FW. Intestinal iatrogenic hyperadaptation in patients with short bowel syndrome and Crohn's disease: Is this an indication for mandatory lifelong injections of teduglutide? Nutrition 2021; 91-92:111396. [PMID: 34399400 DOI: 10.1016/j.nut.2021.111396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 05/20/2021] [Accepted: 06/16/2021] [Indexed: 11/18/2022]
Abstract
Short bowel syndrome with chronic intestinal failure (SBS-CIF) is a rare disease leading to a markedly decreased absorption of fluids and nutrients. Intestinal adaptation in patients with SBS-CIF who are treated with home parenteral nutrition is a natural repair process activated by increased secretions of glucagon-like peptide-2, inducing intestinal trophism, nutrient transport, and lowering gastrointestinal motility. Teduglutide (TED), a glucagon-like peptide-2 analog, offers a new, effective therapeutic alternative to boost intestinal adaptation. There is still no consensus regarding the question of whether intestinal adaptation is permanent or a transient, drug-dependent process requiring lifelong injections of TED. Here we report the clinical cases of two female patients with SBS-CIF secondary to Crohn's disease, who had received TED for 36 and 41 mo. In both patients, TED was discontinued for 5 d but needed to be resumed after an additional 5 d. In patient 1, the discontinuation of TED was accidental (the patient inadvertently injected frozen TED vials); whereas in patient 2, the suspension was at the patient's request. A rapid, significant (P < 0.0001) decline of intestinal function (diarrheal evacuations, fecal volume, food intake) was documented after the suspension of active TED in patient 1. After the resumption of active TED, the symptoms rapidly and significantly (P < 0.0001) improved. The same trend was observed in patient 2. Infective causes of diarrhea were ruled out in both patients. In conclusion, our experience shows that even after long-term treatment, the iatrogenic hyperadaptation process obtained with TED results is a temporary, drug-dependent process and vanishes with the suspension of therapy. These clinical cases suggest that in patients with SBS-CIF receiving TED, this treatment must be administered lifelong.
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Affiliation(s)
- Silvia Mazzuoli
- Gastroenterology Department, Monsignor Raffaele Dimiccoli Hospital, Barletta, Italy
| | - Nunzia Regano
- Gastroenterology Department, Monsignor Raffaele Dimiccoli Hospital, Barletta, Italy
| | - Stefania Lamacchia
- Gastroenterology Department, Monsignor Raffaele Dimiccoli Hospital, Barletta, Italy
| | - Angela Silvestri
- Gastroenterology Department, Monsignor Raffaele Dimiccoli Hospital, Barletta, Italy
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Jamshidi Kandjani O, Alizadeh AA, Moosavi-Movahedi AA, Dastmalchi S. Expression, purification and molecular dynamics simulation of extracellular domain of glucagon-like peptide-2 receptor linked to teduglutide. Int J Biol Macromol 2021; 184:812-820. [PMID: 34174312 DOI: 10.1016/j.ijbiomac.2021.06.141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 06/20/2021] [Accepted: 06/21/2021] [Indexed: 11/26/2022]
Abstract
Teduglutide is the only drug approved for long-term treatment of short bowel syndrome (SBS). This drug exerts its pharmacological effects via binding to the GLP-2 receptors (ECD-GLP2R) located in intestinal tissue. The three dimensional (3D) structure of ECD-GLP2R hasn't been determined yet and hence its mode of interaction with agonists/antagonists is not clear. Therefore, it would be of great importance to develop a structural scaffold for investigation of ECD-GLP2R interactions with its binders. For this, the current study aimed to produce fusion protein of ECD-GLP2R-teduglutide. The ECD-GLP2R-teduglutide protein was expressed in bacterial expression system and purified using affinity and size exclusion chromatography techniques. Using circular dichroism the secondary structure content of purified protein was determined which was comparable to that of theoretical calculations. The low structural stability of purified protein (ΔG = 3.64 kJ.mol-1) was elucidated by monitoring its fluorescence emission at the presence of various concentrations of GdnHCl as a denaturant. Finally, a 3D model for ECD-GLP2R-teduglutide protein was generated and validated using molecular dynamics simulation whose information alongside the experimental studies can be useful for providing new insight into the mode of interaction of ECD-GLP2R with its specific ligands in order to design potent and specific GLP2R agonists.
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Affiliation(s)
- Omid Jamshidi Kandjani
- Biotechnology Research Center, Tabriz University of Medical Sciences, Tabriz, Iran; Parmaceutical Analysis Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Ali Akbar Alizadeh
- Biotechnology Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | | | - Siavoush Dastmalchi
- Biotechnology Research Center, Tabriz University of Medical Sciences, Tabriz, Iran; School of Pharmacy, Tabriz University of Medical Sciences, Tabriz, Iran; Faculty of Pharmacy, Near East University, PO BOX: 99138, Nicosia, North Cyprus, Mersin 10, Turkey.
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16
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Sowerbutts AM, Burden S, Griffiths J, Abraham A, Farrer K, Leahy G, Teubner A, Cloutier A, Twist K, Kelly S, Lal S. Glucagon-like peptide 2 analogues in the treatment of intestinal failure: A qualitative exploration of the views of patients and their families in decision making. Clin Nutr ESPEN 2021; 44:263-9. [PMID: 34330477 DOI: 10.1016/j.clnesp.2021.06.005] [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: 03/22/2021] [Revised: 05/25/2021] [Accepted: 06/03/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND AIMS Patients with short bowel syndrome and type 3 intestinal failure (SBS-IF) are dependent on parenteral nutrition (PN), a lifesaving treatment but inconvenient and with risks. Glucagon-like peptide 2 analogue (teduglutide) can reduce patients' need for PN. However, it comes with the risk of a number of side effects. This qualitative study investigated patients' decision making process to start teduglutide and how family members contributed to the decision. METHODS In-depth semi-structured interviews were conducted with nine participants, six patients with SBS-IF and three family members about the decision to take teduglutide. Interviews were transcribed verbatim and analysed using framework analysis. RESULTS The prominent motivation for taking teduglutide (Revestive® Takeda Pharmaceuticals Limited) was reducing or stopping PN. Other motivations were to help others by assisting in developing the knowledge base around teduglutide, patients felt that they had nothing to lose by trying the drug and the support of relatives. The reasons patients considered not taking the drug were that they had accepted being on PN, the potential side effects of teduglutide and undergoing extra monitoring. However, the monitoring programme also acted as a motivator providing reassurance that patients would be observed and supported with side effects. Family members were happy to support patients' decision to try teduglutide, although they had more reservations, indicating a higher risk threshold. CONCLUSION Patients considered potential benefits of teduglutide outweighed any disadvantages. Relatives, although supportive, had more reservations.
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17
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Alizadeh AA, Dastmalchi S. Designing Novel Teduglutide Analogues with Improved Binding Affinity: An In Silico Peptide Engineering Approach. Curr Comput Aided Drug Des 2021; 17:225-234. [PMID: 32065094 DOI: 10.2174/1573409916666200217091456] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Revised: 12/05/2019] [Accepted: 01/17/2020] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Short bowel syndrome (SBS) is a disabling condition that occurs following the loss of substantial portions of the intestine, leading to inadequate absorption of nutrients and fluids. Teduglutide is the only drug that has been FDA-approved for long-term treatment of SBS. This medicine exerts its biological effects through binding to the GLP-2 receptor. METHODS The current study aimed to use computational mutagenesis approaches to design novel potent analogues of teduglutide. To this end, the constructed teduglutide-GLP2R 3D model was subjected to the alanine scanning mutagenesis where ARG20, PHE22, ILE23, LEU26, ILE27 and LYS30 were identified as the key amino acids involved in ligand-receptor interaction. In order to design potent teduglutide analogues, using MAESTROweb machine learning method, the residues of teduglutide were virtually mutated into all naturally occurring amino acids and the affinity improving mutations were selected for further analysis using PDBePISA methodology which interactively investigates the interactions established at the interfaces of macromolecules. RESULTS The calculations resulted in D15I, D15L, D15M and N24M mutations, which can improve the binding ability of the ligand to the receptor. The final evaluation of identified mutations was performed by molecular dynamics simulations, indicating that D15I and D15M are the most reliable mutations to increase teduglutide affinity towards its receptor. CONCLUSION The findings in the current study may facilitate designing more potent teduglutide analogues leading to the development of novel treatments in short bowel syndrome.
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Affiliation(s)
- Ali A Alizadeh
- Biotechnology Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Siavoush Dastmalchi
- Biotechnology Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
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Abstract
PURPOSE OF REVIEW Pediatric intestinal failure is a complex condition requiring specialized care to prevent potential complications. In this article, we review the available evidence supporting recent advances in care for children with intestinal failure. RECENT FINDINGS Multidisciplinary intestinal rehabilitation teams utilize medical and surgical management techniques to help patients achieve enteral autonomy (EA) while preventing and treating the complications associated with intestinal failure. Recent advances in lipid management strategies, minimization of intestinal failure associated liver disease, prevention of central line-associated blood stream infections, and loss of access, as well as development of promising new hormone analogue therapy have allowed promotion of intestinal adaptation. These advances have decreased the need for intestinal transplant. There have been recent advances in the care of children with intestinal failure decreasing morbidity, mortality, and need for intestinal transplantation. The most promising new therapies involve replacement of enteroendocrine hormones.
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Affiliation(s)
- Danielle Wendel
- Division of Gastroenterology and Hepatology, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA, USA.
| | - Conrad R Cole
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati School of Medicine, Cincinnati, OH, USA
| | - Valeria C Cohran
- Division of Gastroenterology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Chen K, Joly F, Mu F, Kelkar SS, Olivier C, Xie J, Seidner DL. Predictors and timing of response to teduglutide in patients with short bowel syndrome dependent on parenteral support. Clin Nutr ESPEN 2021; 43:420-427. [PMID: 34024550 DOI: 10.1016/j.clnesp.2021.03.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 03/05/2021] [Accepted: 03/09/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND AIMS This study aimed to identify predictors and estimate time to teduglutide response among adult patients with short bowel syndrome with intestinal failure (SBS-IF) dependent on parenteral support (PS). METHODS Post-hoc analysis was performed on individual patient data from teduglutide-treated patients in the phase III teduglutide trial STEPS and the STEPS-2 extension. Response was defined as ≥20% PS volume reduction from baseline for two consecutive visits. Early responders experienced the reduction at 20 and 24 weeks during STEPS while late responders experienced the reduction during STEPS-2. Timing and predictors for response were assessed among the treated population using Cox proportional hazard model. Time to response was compared in aetiological subgroups using Kaplan-Meier analysis. Patient characteristics and time to response were compared between early vs. late responders. RESULTS A total of 34 patients were included in this analysis; overall median time to response was 4.3 months. The presence of stoma predicted a positive response to teduglutide (hazard ratio [HR]: 5.6; 95% confidence interval [CI]: 1.4-21.9; p = 0.013). Vascular disease (vs. inflammatory bowel disease [IBD]) as cause of major intestinal resection (HR: 0.2; 95% CI: 0.0-0.8; p = 0.015), presence of ileocecal valve (HR: 0.1; 95% CI: 0.0-0.8; p = 0.047), and female sex (HR: 0.3; 95% CI: 0.1-1.0; p = 0.026) are negatively associated with response. In subgroup analyses, patients with IBD (vs. vascular disease), with (vs. without) a stoma, and without (vs. with) colon-in-continuity had a shorter time to response (all p < 0.05). The mean times to response were 3.6 (standard deviation (SD): 1.1) months for early responders (n = 27) and 10.0 (SD: 6.1) months for late responders (n = 7). Fewer early responders had colon-in-continuity (51.9%) and ileocecal valve (0.0%) compared to late responders (100% and 28.6%, respectively; both p < 0.05). Early responders had a lower mean percentage of colon remaining compared to late responders (24.6% vs. 57.1%, respectively; p = 0.016). CONCLUSIONS Time to response to teduglutide depends on bowel anatomy and SBS-IF aetiology. IBD, presence of a stoma, and absence of ileocecal valve were associated with earlier response to teduglutide. These findings may enhance management of patients with SBS-IF; however, due to sample size limitations, additional studies are needed to confirm these findings.
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Affiliation(s)
- Kristina Chen
- Shire Human Genetic Therapies, Inc. (a Takeda company), Takeda Pharmaceutical Company Limited, 650 E Kendall Street, Cambridge, MA 02142, USA.
| | - Francisca Joly
- Beaujon Hospital, Clichy and Research Center for Inflammation, University of Paris, 100 Boulevard du Général Leclerc, 92110, Paris, France.
| | - Fan Mu
- Analysis Group, 111 Huntington Ave., Floor 14, Boston, MA 02199, USA.
| | - Sneha S Kelkar
- Analysis Group, 151 West 42nd St., Floor 23, New York, NY 10036, USA.
| | - Clement Olivier
- Shire International GmbH (a Takeda company), Zug, Switzerland.
| | - Jipan Xie
- Analysis Group, 333 South Hope St., 27th Floor, Los Angeles, CA 90071, USA.
| | - Douglas L Seidner
- Digestive Disease and Surgical Institute, Department of Gastroenterology, Hepatology and Nutrition, Cleveland Clinic, 9500 Euclid Ave./A51, Cleveland, OH 44195, USA.
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Maruta K, Takajo T, Akiba Y, Said H, Irie E, Kato I, Kuwahara A, Kaunitz JD. GLP-2 Acutely Prevents Endotoxin-Related Increased Intestinal Paracellular Permeability in Rats. Dig Dis Sci 2020; 65:2605-2618. [PMID: 32006214 PMCID: PMC7392813 DOI: 10.1007/s10620-020-06097-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Accepted: 01/20/2020] [Indexed: 01/15/2023]
Abstract
BACKGROUND Circulating endotoxin (lipopolysaccharide, LPS) increases the gut paracellular permeability. We hypothesized that glucagon-like peptide-2 (GLP-2) acutely reduces LPS-related increased intestinal paracellular permeability by a mechanism unrelated to its intestinotrophic effect. METHODS We assessed small intestinal paracellular permeability in vivo by measuring the appearance of intraduodenally perfused FITC-dextran 4000 (FD4) into the portal vein (PV) in rats 1-24 h after LPS treatment (5 mg/kg, ip). We also examined the effect of a stable GLP-2 analog teduglutide (TDG) on FD4 permeability. RESULTS FD4 movement into the PV was increased 6 h, but not 1 or 3 h after LPS treatment, with increased PV GLP-2 levels and increased mRNA expressions of proinflammatory cytokines and proglucagon in the ileal mucosa. Co-treatment with a GLP-2 receptor antagonist enhanced PV FD4 concentrations. PV FD4 concentrations 24 h after LPS were higher than FD4 concentrations 6 h after LPS, reduced by exogenous GLP-2 treatment given 6 or 12 h after LPS treatment. FD4 uptake measured 6 h after LPS was reduced by TDG 3 or 6 h after LPS treatment. TDG-associated reduced FD4 uptake was reversed by the VPAC1 antagonist PG97-269 or L-NAME, not by EGF or IGF1 receptor inhibitors. CONCLUSIONS Systemic LPS releases endogenous GLP-2, reducing LPS-related increased permeability. The therapeutic window of exogenous GLP-2 administration is at minimum within 6-12 h after LPS treatment. Exogenous GLP-2 treatment is of value in the prevention of increased paracellular permeability associated with endotoxemia.
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Affiliation(s)
- Koji Maruta
- Department of Medicine, School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Takeshi Takajo
- Department of Medicine, School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Yasutada Akiba
- Greater Los Angeles Veterans Affairs Healthcare System, West Los Angeles VA Medical Center, Bldg. 114, Suite 217, 11301 Wilshire Blvd., Los Angeles, CA 90073, USA,Department of Medicine, School of Medicine, University of California Los Angeles, Los Angeles, CA, USA,Brentwood Biomedical Research Institute, Los Angeles, CA, USA
| | - Hyder Said
- Department of Medicine, School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Emi Irie
- Greater Los Angeles Veterans Affairs Healthcare System, West Los Angeles VA Medical Center, Bldg. 114, Suite 217, 11301 Wilshire Blvd., Los Angeles, CA 90073, USA
| | - Ikuo Kato
- Department of Medical Biochemistry, Kobe Pharmaceutical University, Kobe, Japan
| | - Atsukazu Kuwahara
- Research Unit for Epithelial Physiology, Research Organization of Science and Technology, Ritsumeikan University, Kusatsu, Japan
| | - Jonathan D. Kaunitz
- Greater Los Angeles Veterans Affairs Healthcare System, West Los Angeles VA Medical Center, Bldg. 114, Suite 217, 11301 Wilshire Blvd., Los Angeles, CA 90073, USA,Department of Medicine, School of Medicine, University of California Los Angeles, Los Angeles, CA, USA,Department of Surgery, School of Medicine, University of California Los Angeles, Los Angeles, CA, USA,Brentwood Biomedical Research Institute, Los Angeles, CA, USA
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Borghini R, Caronna R, Donato G, Picarelli A. GLP-2 analog Teduglutide in active Crohn's disease and short bowel syndrome: Confirmation of anti-inflammatory role and future perspectives. Dig Liver Dis 2020; 52:686-687. [PMID: 32340888 DOI: 10.1016/j.dld.2020.03.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 03/20/2020] [Accepted: 03/24/2020] [Indexed: 12/11/2022]
Affiliation(s)
- Raffaele Borghini
- Department of Translational and Precision Medicine, Sapienza University, Viale del Policlinico, 155, 00161 Rome, Italy.
| | - Roberto Caronna
- Department of Surgical Sciences, Sapienza University, Rome, Italy.
| | - Giuseppe Donato
- Department of Translational and Precision Medicine, Sapienza University, Viale del Policlinico, 155, 00161 Rome, Italy.
| | - Antonio Picarelli
- Department of Translational and Precision Medicine, Sapienza University, Viale del Policlinico, 155, 00161 Rome, Italy.
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Massironi S, Cavalcoli F, Rausa E, Invernizzi P, Braga M, Vecchi M. Understanding short bowel syndrome: Current status and future perspectives. Dig Liver Dis 2020; 52:253-261. [PMID: 31892505 DOI: 10.1016/j.dld.2019.11.013] [Citation(s) in RCA: 71] [Impact Index Per Article: 17.8] [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: 08/13/2019] [Revised: 10/08/2019] [Accepted: 11/18/2019] [Indexed: 02/08/2023]
Abstract
Short bowel syndrome (SBS) is a rare malabsorptive disorder as a result of the loss of bowel mass mostly secondary to surgical resection of the small intestine. Other causes are vascular diseases, neoplasms or inflammatory bowel disease. The spectrum of the disease is widely variable from single micronutrient malabsorption to complete intestinal failure, depending on the remaining length of the small intestine, the anatomical portion of intestine and the function of the remnant bowel. Over the last years, the management of affected patients has remarkably improved with the increase in patients' quality of life and survival, mainly thanks to advances in home-based parenteral nutrition (PN). In the last ten years new treatment strategies have become available together with increasing experience and the encouraging results with new drugs, such as teduglutide, have added a new dimension to the management of SBS. This review aims to summarize the knowledge available in the current literature on SBS epidemiology, pathophysiology, and its surgical (including intestinal lengthening procedures and intestinal transplantation) and medical management with emphasis on the recent advances. Moreover, this review attempts to provide the new understanding and recent approaches to SBS complications such as sepsis, catheter thrombosis, and intestinal failure-associated liver disease.
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Affiliation(s)
- Sara Massironi
- Gastroenterology and Endoscopy Unit, IRCCS Ca' Granda Foundation, Policlinico Hospital, University of the Study of Milan, Italy.
| | | | - Emanuele Rausa
- Division of Surgical Oncology, ASST Bergamo Ovest, Treviglio, Italy
| | - Pietro Invernizzi
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, San Gerardo Hospital, University of Milano, Bicocca School of Medicine, Monza, Italy
| | - Marco Braga
- Division of Surgery, San Gerardo Hospital, University of Milano - Bicocca School of Medicine, Monza, Italy
| | - Maurizio Vecchi
- Gastroenterology and Endoscopy Unit, IRCCS Ca' Granda Foundation, Policlinico Hospital, University of the Study of Milan, Italy
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Borioli V, Cereda E, Lobascio F, Mengoli C, Caraccia M, Pagani A, Aronico N, Pedrazzoli P, Di Sabatino A, Caccialanza R. Comprehensive nutritional assessment in short bowel syndrome with chronic renal failure on teduglutide therapy: A case report. Nutrition 2020; 73:110720. [PMID: 32088500 DOI: 10.1016/j.nut.2020.110720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 10/24/2019] [Accepted: 12/30/2019] [Indexed: 10/25/2022]
Abstract
We report the case of a 62-y-old woman with short bowel syndrome (SBS) and chronic renal failure, successfully treated with teduglutide, who underwent comprehensive systematic nutritional assessment including bioelectrical impedance vectorial analysis (BIVA). The patient did not tolerate the attempt of gradual suspension of parenteral nutrition (PN), bumping into the worsening of nutritional status and renal function. She was declared eligible for teduglutide, a glucagonlike peptide 2 analog that stimulates structural and functional intestinal adaptation and increases nutrient and fluid absorption. To date, there is no standardized nutritional management protocol for PN-dependent SBS patients treated with teduglutide. We here report our first 1-y follow-up data. The patient underwent comprehensive systematic nutritional assessment initially every 2 wk, then monthly. It included handgrip strength (HGS), blood tests (particularly serum creatinine, estimated glomerular filtration rate, urea, electrolytes, micronutrients, serum albumin), fluid intake, urine output, quality-of-life (QoL) evaluation, and BIVA, which estimates fat-free mass (FFM) and measures phase angle (PhA) and hydration status. At treatment initiation, the patient was on PN 3 d/wk. After 3 mo, she was weaned off PN. At 1 y, weight and serum albumin were reduced (-7.5 kg and -0.6 g/dL, respectively); FFM, PhA, and HGS slightly decreased; hydration status and renal function were preserved; and QoL subtly improved. No relevant clinical complications or metabolic imbalances occurred. The inclusion of BIVA in the comprehensive systematic nutritional assessment of SBS patients treated with teduglutide could be proposed for appropriate and safe management, particularly in the presence of renal impairment.
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Affiliation(s)
- Valeria Borioli
- Clinical Nutrition and Dietetics Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Emanuele Cereda
- Clinical Nutrition and Dietetics Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Federica Lobascio
- Clinical Nutrition and Dietetics Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Caterina Mengoli
- First Department of Internal Medicine, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Marilisa Caraccia
- Clinical Nutrition and Dietetics Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Anna Pagani
- Medical Oncology Unit, Fondazione IRCCS Policlinico San Matteo and Department of Internal Medicine, University of Pavia, Pavia, Italy
| | - Nicola Aronico
- First Department of Internal Medicine, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Paolo Pedrazzoli
- Medical Oncology Unit, Fondazione IRCCS Policlinico San Matteo and Department of Internal Medicine, University of Pavia, Pavia, Italy
| | - Antonio Di Sabatino
- First Department of Internal Medicine, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Riccardo Caccialanza
- Clinical Nutrition and Dietetics Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.
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24
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Reiner J, Berlin P, Wobar J, Schäffler H, Bannert K, Bastian M, Vollmar B, Jaster R, Lamprecht G, Witte M. Teduglutide Promotes Epithelial Tight Junction Pore Function in Murine Short Bowel Syndrome to Alleviate Intestinal Insufficiency. Dig Dis Sci 2020; 65:3521-3537. [PMID: 32072437 PMCID: PMC7661426 DOI: 10.1007/s10620-020-06140-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [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] [Received: 12/13/2019] [Accepted: 02/09/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND In short bowel syndrome, epithelial surface loss results in impaired nutrient absorption and may lead to intestinal insufficiency or intestinal failure. Nucleotide oligomerization domain 2 (Nod2) dysfunction predisposes to the development of intestinal failure after intestinal resection and is associated with intestinal barrier defects. Epithelial barrier function is crucial for intestinal absorption and for intestinal adaptation in the short bowel situation. AIMS The aim of the study was to characterize the effects of the GLP-2 analogue Teduglutide in the small intestine in the presence and absence of Nod2 in a mouse model of short bowel syndrome. METHODS Mice underwent 40% ICR and were thereafter treated with Teduglutide versus vehicle injections. Survival, body weight, stool water, and sodium content and plasma aldosterone concentrations were determined. Intestinal and kidney tissue was examined with light and fluorescence microscopy, Ussing chamber studies and quantitative PCR in wild type and transgenic mice. RESULTS Teduglutide reduced intestinal failure incidence in Nod2 k.o. mice. In wt mice, Teduglutide attenuated intestinal insufficiency as indicated by reduced body weight loss and lower plasma aldosterone concentrations, lower stool water content, and lower stool sodium losses. Teduglutide treatment was associated with enhanced epithelial paracellular pore function and enhanced claudin-10 expression in tight junctions in the villus tips, where it colocalized with sodium-glucose cotransporter 1 (SGLT-1), which mediates Na-coupled glucose transport. CONCLUSIONS In the SBS situation, Teduglutide not only maximizes small intestinal mucosal hypertrophy but also partially restores small intestinal epithelial function through an altered distribution of claudin-10, facilitating sodium recirculation for Na-coupled glucose transport and water absorption.
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Affiliation(s)
- Johannes Reiner
- Division of Gastroenterology and Endocrinology, Department of Medicine II, Rostock University Medical Center, Ernst-Heydemann-Str. 6, 18057 Rostock, Germany
| | - Peggy Berlin
- Division of Gastroenterology and Endocrinology, Department of Medicine II, Rostock University Medical Center, Ernst-Heydemann-Str. 6, 18057 Rostock, Germany
| | - Jakob Wobar
- Division of Gastroenterology and Endocrinology, Department of Medicine II, Rostock University Medical Center, Ernst-Heydemann-Str. 6, 18057 Rostock, Germany
| | - Holger Schäffler
- Division of Gastroenterology and Endocrinology, Department of Medicine II, Rostock University Medical Center, Ernst-Heydemann-Str. 6, 18057 Rostock, Germany
| | - Karen Bannert
- Division of Gastroenterology and Endocrinology, Department of Medicine II, Rostock University Medical Center, Ernst-Heydemann-Str. 6, 18057 Rostock, Germany
| | - Manuela Bastian
- Institute for Clinical Chemistry and Laboratory Medicine, Rostock University Medical Center, Ernst-Heydemann-Str. 6, 18057 Rostock, Germany
| | - Brigitte Vollmar
- Rudolf-Zenker-Institute of Experimental Surgery, Rostock University Medical Center, Schillingallee 69a, 18057 Rostock, Germany
| | - Robert Jaster
- Division of Gastroenterology and Endocrinology, Department of Medicine II, Rostock University Medical Center, Ernst-Heydemann-Str. 6, 18057 Rostock, Germany
| | - Georg Lamprecht
- Division of Gastroenterology and Endocrinology, Department of Medicine II, Rostock University Medical Center, Ernst-Heydemann-Str. 6, 18057 Rostock, Germany
| | - Maria Witte
- Department of General, Thoracic, Vascular and Transplantation Surgery, Rostock University Medical Center, Schillingallee 35, 18057 Rostock, Germany
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25
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Abstract
Growth factors and other trophic hormones play an important role in the specific treatment of intestinal failure, with teduglutide being the first approved medication specifically for use in patients with intestinal failure in conjunction with specialized nutritional support. This article focusses on the mode of action, the pivotal study data, treatment response prediction as well as new substances in phase clinical trials.
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Affiliation(s)
- Irina Blumenstein
- Department of Gastroenterology, Hepatology and Clinical Nutrition, University Hospital Frankfurt, Frankfurt am Main, Germany
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26
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Jeppesen PB, Gabe SM, Seidner DL, Lee HM, Olivier C. Citrulline correlations in short bowel syndrome-intestinal failure by patient stratification: Analysis of 24 weeks of teduglutide treatment from a randomized controlled study. Clin Nutr 2019; 39:2479-2486. [PMID: 31784300 DOI: 10.1016/j.clnu.2019.11.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [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: 06/03/2019] [Revised: 10/29/2019] [Accepted: 11/01/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND & AIMS Disease-associated factors influence parenteral support (PS) reduction in response to teduglutide in patients with intestinal failure associated-short bowel syndrome (SBS-IF). We sought to determine correlative relationships between plasma citrulline levels, small bowel length, and PS volume. METHODS A post hoc analysis of plasma citrulline levels from patients in the STEPS 24-week study of teduglutide in patients with SBS-IF. Plasma citrulline was assessed in all patients; patients were stratified 3 times into subgroups based on bowel anatomy, cause of SBS-IF, and baseline PS volumes. Correlation analyses used simple linear regression models. Statistical comparisons between study groups were conducted using 2-sided t tests for 2 independent mean differences. RESULTS Baseline plasma citrulline correlated with remnant small bowel length (r = 0.355, P = 0.002), but not with baseline PS volume (r = -0.167, P = 0.14), in the overall population. There was a robust correlation between the baseline and Week 24 citrulline (r = 0.705, P < 0.0001), and an inverse correlation between change from baseline in citrulline and PS volume from baseline to Week 24 (r = -0.359, P = 0.001). In all subgroups, patients treated with teduglutide showed numerically greater increases in plasma citrulline at Week 24 compared with placebo. CONCLUSION Baseline plasma citrulline showed significant correlations with small bowel length in patients with ≥50% colon remaining/no stoma/colon-in-continuity, and patients with SBS-IF causes other than IBD/vascular disease. Citrulline levels may correlate with PS changes in response to teduglutide and more research may reveal a relationship between citrulline levels within the heterogeneous population of patients with SBS-IF. ClinicalTrials.gov NCT00798967, ClinicalTrialsRegister.eu 2008-006193-15.
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Affiliation(s)
| | - Simon M Gabe
- Lennard Jones Intestinal Failure Unit, St. Mark's Hospital, Northwick Park, London, UK
| | - Douglas L Seidner
- Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Hak-Myung Lee
- Shire Human Genetic Therapies, Inc., Lexington, MA, USA
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27
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Pevny S, Maasberg S, Rieger A, Karber M, Blüthner E, Knappe-Drzikova B, Thurmann D, Büttner J, Weylandt KH, Wiedenmann B, Müller VA, Bläker H, Pascher A, Pape UF. Experience with teduglutide treatment for short bowel syndrome in clinical practice. Clin Nutr 2019; 38:1745-1755. [DOI: 10.1016/j.clnu.2018.07.030] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Revised: 07/10/2018] [Accepted: 07/27/2018] [Indexed: 12/20/2022]
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28
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George AT, Li BH, Carroll RE. Off-Label Teduglutide Therapy in Non-intestinal Failure Patients with Chronic Malabsorption. Dig Dis Sci 2019; 64:1599-1603. [PMID: 30730014 DOI: 10.1007/s10620-019-5473-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [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: 11/22/2018] [Accepted: 01/16/2019] [Indexed: 12/09/2022]
Abstract
BACKGROUND Teduglutide, a glucagon-like peptide 2 analog, has demonstrated efficacy in treating adult patients with short bowel syndrome (SBS) and dependence on parenteral nutrition (PN), but its role in chronic malabsorptive states that do not necessitate PN remains uncertain. AIMS To evaluate teduglutide use beyond its approved indications and to discuss the results of this adjunctive treatment in patients resistant to established therapy. RESULTS This series reports four patients treated with teduglutide off-label. The first case had Crohn's disease (CD) with persistent colocutaneous fistulae that demonstrated complete closure after 8 months of teduglutide therapy. The second case involved a PN-dependent CD patient with persistent fistulae and intra-abdominal abscesses who weaned off PN and had a significant improvement in her nutritional status after 3 months of teduglutide therapy. The third case had CD complicated by severe malnutrition and previous PN-associated line infections, but by 9 months of teduglutide therapy, she gained 5 kg and no longer required re-initiation of PN. The fourth case had a high-output diverting ileostomy with resultant impaired healing of a stage IV decubitus ulcer, and after 2 months of therapy, the patient's pre-albumin increased by 250% and the ulcer had decreased by 40% in size. CONCLUSION The use of teduglutide might be broadened to include patients with functional SBS not meeting strict criteria for intestinal failure. Further studies should evaluate the efficacy of teduglutide in patients who may require short-term small intestine rehabilitation or who have chronically impaired absorptive capacity not yet requiring PN.
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Affiliation(s)
- Alvin T George
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Illinois at Chicago, 840 S Wood St (M/C 716), Chicago, IL, 60612, USA
| | - Betty H Li
- Department of Internal Medicine, University of Chicago Medicine, Chicago, IL, USA
| | - Robert E Carroll
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Illinois at Chicago, 840 S Wood St (M/C 716), Chicago, IL, 60612, USA.
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29
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Jurewitsch B, Jeejeebhoy KN. Effect of teduglutide on restoring oral autonomy for magnesium in two patients with short bowel. Nutrition 2019; 65:13-17. [PMID: 31029916 DOI: 10.1016/j.nut.2019.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 02/05/2019] [Accepted: 02/06/2019] [Indexed: 11/26/2022]
Abstract
It is not known whether Teduglutide can allow patients with Short bowel syndrome, previously dependent on continuous or periodic intravenous (IV) magnesium, to attain oral autonomy with or without supplementation. Here, we report on two patients previously dependent on continuous or intermittently administered IV magnesium to achieve autonomy from IV, one with and one without oral supplementation that was previously ineffective in both patients.
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Affiliation(s)
- Brian Jurewitsch
- Gastroenterology Division, St. Michael's Hospital, Toronto, Ontario, Canada.
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30
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Jami MM, Merritt RJ. Enteral Autonomy with Teduglutide Treatment of Intestinal Failure/Short Bowel Syndrome with Depleted Central Venous Access. Dig Dis Sci 2017; 62:3622-3624. [PMID: 28993968 DOI: 10.1007/s10620-017-4780-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 09/21/2017] [Indexed: 12/26/2022]
Affiliation(s)
- Mohammad M Jami
- Intestinal Rehabilitation Program, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.,, 14777 Los Gatos Boulevard, Suite 200, Los Gatos, CA, 95032, USA
| | - Russell J Merritt
- Intestinal Rehabilitation Program, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA. .,, 4650 Sunset Blvd MS#78, Los Angeles, CA, 90027, USA.
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Abstract
AIM: To assess the therapeutic effect of glucagon-like peptide (GLP-2) analogue teduglutide on non-alcoholic fatty liver disease (NAFLD) in rats.
METHODS: Thirty SD rats were randomized into a normal diet group and a high-fat diet group. After feeding for 12 weeks, six rats were respectively selected from the two groups to determine whether the NAFLD model was successfully established. From the 13th week, the rest rats in the normal diet group served as controls (n = 6), and the rest rats of the high-fat diet group were randomized into a NAFLD group (n = 6) and a GLP-2 group (n = 6). The rats in the GLP-2 group were injected with teduglutide and the other two groups were injected with normal saline for 7 d. Then blood samples were collected from the ocular veniplex and rats were sacrificed. NAFLD related biochemical indicators were determined and pathological results were observed.
RESULTS: The NAFLD model was successfully established. Compared to the normal group, triglyceride (TG) and total cholesterol (TC) levels in liver homogenate and NAFLD activity score (NAS) were significantly higher in the high-fat diet group (P < 0.05). Moreover, duodenal mucosal epithelial cells were loosely arranged, and intercellular space and Claudin-2 protein expression were increased (P < 0.05). After treatment with GLP-2, TG and TC levels in liver homogenate and liver NAS were significantly lower than those of the NAFLD group (P < 0.05). Accordingly, the arrangement of intestinal epithelial cells was improved, and intercellular space and Claudin-2 protein expression were decreased (P < 0.05).
CONCLUSION: NAFLD can cause the loose of intestinal mucosal cells and the increase of Claudin-2 protein expression. Teduglutide might exert its therapeutic effect on NAFLD by decreasing the expression of Claudin-2 protein.
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