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Stoffella S, Ly N, McGarry M, Neemuchwala F, Church G, Chan M, Cuneo A, Omori M, Gibb E. Cystic fibrosis transmembrane conductance regulator modulator administration to a F508del heterozygous infant with meconium pseudocyst and short bowel syndrome: A case report. Pediatr Pulmonol 2024; 59:791-793. [PMID: 38088240 DOI: 10.1002/ppul.26809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 11/27/2023] [Accepted: 11/29/2023] [Indexed: 02/16/2024]
Affiliation(s)
- Sylvia Stoffella
- Department of Pharmacy, University of California San Francisco, San Francisco, California, USA
| | - Ngoc Ly
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - Meghan McGarry
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - Fatima Neemuchwala
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - Gwynne Church
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - Marilynn Chan
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - Addison Cuneo
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - Makiko Omori
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - Elizabeth Gibb
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
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Lonabaugh K, Li G, List R, Huang R, James A, Barros A, Somerville L, Albon D. Real world study on elexacaftor- tezacaftor-ivacaftor impact on cholesterol levels in adults with cystic fibrosis. Pharmacotherapy 2024; 44:231-240. [PMID: 38143243 DOI: 10.1002/phar.2903] [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: 06/20/2023] [Revised: 11/20/2023] [Accepted: 11/21/2023] [Indexed: 12/26/2023]
Abstract
INTRODUCTION The introduction of the highly effective modulator therapy elexacaftor-tezacaftor-ivacaftor (ETI) has revolutionized the care of persons with cystic fibrosis (PwCF) with major improvements seen in lung function and body mass index. The effects of ETI therapy in real-world cohorts on other parameters such as cholesterol levels are largely unknown. METHODS A single-center, retrospective chart review study was conducted to assess the change in lipid panels before and after ETI initiation. The study investigated total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), and triglyceride levels using both a univariate and multivariate mixed-effects model to evaluate the change after initiation of ETI in a cohort of PwCF. RESULTS There were 128 adult PwCF included in the analysis. Statistically significant changes were seen in both univariate and multivariate analyses for TC, LDL-C, and HDL-C. On multivariate analysis, TC increased by an average of 15.0 mg/dL after ETI initiation (p < 0.0001), LDL-C increased by an average of 9.3 mg/dL (p < 0.001), and HDL-C increased by an average of 3.8 mg/dL (p < 0.001) after ETI initiation. CONCLUSION In this real-world cohort of PwCF, cholesterol parameters increased after initiation with ETI therapy. Further consideration may need to be given for PwCF in regards to screening for cardiometabolic risk factors as PwCF age as well as the potential need for cholesterol-lowering therapies.
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Affiliation(s)
- Kevin Lonabaugh
- University of Virginia Health, Charlottesville, Virginia, USA
| | - Galvin Li
- University of Virginia Health, Charlottesville, Virginia, USA
| | - Rhonda List
- University of Virginia Health, Charlottesville, Virginia, USA
| | - Reyna Huang
- University of Virginia Health, Charlottesville, Virginia, USA
| | - Amber James
- University of Virginia Health, Charlottesville, Virginia, USA
| | - Andrew Barros
- University of Virginia Health, Charlottesville, Virginia, USA
| | | | - Dana Albon
- University of Virginia Health, Charlottesville, Virginia, USA
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Reasoner SA, Bernard R, Waalkes A, Penewit K, Lewis J, Sokolow AG, Brown RF, Edwards KM, Salipante SJ, Hadjifrangiskou M, Nicholson MR. Longitudinal profiling of the intestinal microbiome in children with cystic fibrosis treated with elexacaftor- tezacaftor-ivacaftor. mBio 2024; 15:e0193523. [PMID: 38275294 PMCID: PMC10865789 DOI: 10.1128/mbio.01935-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 12/18/2023] [Indexed: 01/27/2024] Open
Abstract
The intestinal microbiome influences growth and disease progression in children with cystic fibrosis (CF). Elexacaftor-tezacaftor-ivacaftor (ELX/TEZ/IVA), the newest pharmaceutical modulator for CF, restores the function of the pathogenic mutated CF transmembrane conductance regulator (CFTR) channel. We performed a single-center longitudinal analysis of the effect of ELX/TEZ/IVA on the intestinal microbiome, intestinal inflammation, and clinical parameters in children with CF. Following ELX/TEZ/IVA, children with CF had significant improvements in body mass index and percent predicted forced expiratory volume in one second, and required fewer antibiotics for respiratory infections. Intestinal microbiome diversity increased following ELX/TEZ/IVA coupled with a decrease in the intestinal carriage of Staphylococcus aureus, the predominant respiratory pathogen in children with CF. There was a reduced abundance of microbiome-encoded antibiotic resistance genes. Microbial pathways for aerobic respiration were reduced after ELX/TEZ/IVA. The abundance of microbial acid tolerance genes was reduced, indicating microbial adaptation to increased CFTR function. In all, this study represents the first comprehensive analysis of the intestinal microbiome in children with CF receiving ELX/TEZ/IVA.IMPORTANCECystic fibrosis (CF) is an autosomal recessive disease with significant gastrointestinal symptoms in addition to pulmonary complications. Recently approved treatments for CF, CF transmembrane conductance regulator (CFTR) modulators, are anticipated to substantially improve the care of people with CF and extend their lifespans. Prior work has shown that the intestinal microbiome correlates with health outcomes in CF, particularly in children. Here, we study the intestinal microbiome of children with CF before and after the CFTR modulator, ELX/TEZ/IVA. We identify promising improvements in microbiome diversity, reduced measures of intestinal inflammation, and reduced antibiotic resistance genes. We present specific bacterial taxa and protein groups which change following ELX/TEZ/IVA. These results will inform future mechanistic studies to understand the microbial improvements associated with CFTR modulator treatment. This study demonstrates how the microbiome can change in response to a targeted medication that corrects a genetic disease.
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Affiliation(s)
- Seth A. Reasoner
- Department of Pathology, Microbiology, and Immunology, Division of Molecular Pathogenesis, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Rachel Bernard
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Monroe Carrell Junior Children’s Hospital at Vanderbilt, Nashville, Tennessee, USA
| | - Adam Waalkes
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA
| | - Kelsi Penewit
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA
| | - Janessa Lewis
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA
| | - Andrew G. Sokolow
- Department of Pediatrics, Division of Allergy, Immunology, and Pulmonary Medicine, Monroe Carrell Junior Children’s Hospital at Vanderbilt, Nashville, Tennessee, USA
| | - Rebekah F. Brown
- Department of Pediatrics, Division of Allergy, Immunology, and Pulmonary Medicine, Monroe Carrell Junior Children’s Hospital at Vanderbilt, Nashville, Tennessee, USA
| | - Kathryn M. Edwards
- Department of Pediatrics, Division of Infectious Diseases, Monroe Carrell Junior Children’s Hospital at Vanderbilt, Nashville, Tennessee, USA
| | - Stephen J. Salipante
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA
| | - Maria Hadjifrangiskou
- Department of Pathology, Microbiology, and Immunology, Division of Molecular Pathogenesis, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Center for Personalized Microbiology (CPMi), Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Vanderbilt Institute for Infection, Immunology and Inflammation, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Maribeth R. Nicholson
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Monroe Carrell Junior Children’s Hospital at Vanderbilt, Nashville, Tennessee, USA
- Vanderbilt Institute for Infection, Immunology and Inflammation, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Reasoner SA, Bernard R, Waalkes A, Penewit K, Lewis J, Sokolow AG, Brown RF, Edwards KM, Salipante SJ, Hadjifrangiskou M, Nicholson MR. Longitudinal Profiling of the Intestinal Microbiome in Children with Cystic Fibrosis Treated with Elexacaftor- Tezacaftor-Ivacaftor. medRxiv 2023:2023.08.11.23293949. [PMID: 37645804 PMCID: PMC10462202 DOI: 10.1101/2023.08.11.23293949] [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] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
The intestinal microbiome influences growth and disease progression in children with cystic fibrosis (CF). Elexacaftor-tezacaftor-ivacaftor (ELX/TEZ/IVA), the newest pharmaceutical modulator for CF, restores function of the pathogenic mutated CFTR channel. We performed a single-center longitudinal analysis of the effect of ELX/TEZ/IVA on the intestinal microbiome, intestinal inflammation, and clinical parameters in children with CF. Following ELX/TEZ/IVA, children with CF had significant improvements in BMI, ppFEV1 and required fewer antibiotics for respiratory infections. Intestinal microbiome diversity increased following ELX/TEZ/IVA coupled with a decrease in the intestinal carriage of Staphylococcus aureus, the predominant respiratory pathogen in children with CF. There was a reduced abundance of microbiome-encoded antibiotic-resistance genes. Microbial pathways for aerobic respiration were reduced after ELX/TEZ/IVA. The abundance of microbial acid tolerance genes was reduced, indicating microbial adaptation to increased CFTR function. In all, this study represents the first comprehensive analysis of the intestinal microbiome in children with CF receiving ELX/TEZ/IVA.
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Affiliation(s)
- Seth A. Reasoner
- Division of Molecular Pathogenesis, Department of Pathology, Microbiology & Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Rachel Bernard
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Monroe Carrell Junior Children’s Hospital at Vanderbilt, Nashville, TN, USA
| | - Adam Waalkes
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA, USA
| | - Kelsi Penewit
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA, USA
| | - Janessa Lewis
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA, USA
| | - Andrew G. Sokolow
- Division of Allergy, and Immunology, and Pulmonary Medicine, Department of Pediatrics, Monroe Carrell Junior Children’s Hospital at Vanderbilt, Nashville, TN, USA
| | - Rebekah F. Brown
- Division of Allergy, and Immunology, and Pulmonary Medicine, Department of Pediatrics, Monroe Carrell Junior Children’s Hospital at Vanderbilt, Nashville, TN, USA
| | - Kathryn M. Edwards
- Division of Infectious Diseases, Department of Pediatrics, Monroe Carrell Junior Children’s Hospital at Vanderbilt, Nashville, Tennessee, USA
| | - Stephen J. Salipante
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA, USA
| | - Maria Hadjifrangiskou
- Division of Molecular Pathogenesis, Department of Pathology, Microbiology & Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
- Center for Personalized Microbiology (CPMi), Vanderbilt University Medical Center, Nashville, TN, USA
- Vanderbilt Institute for Infection, Immunology and Inflammation, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Maribeth R. Nicholson
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Monroe Carrell Junior Children’s Hospital at Vanderbilt, Nashville, TN, USA
- Vanderbilt Institute for Infection, Immunology and Inflammation, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Tümmler B, Burgel PR. Editorial: Real-world experience with CFTR modulator therapy. Front Pharmacol 2023; 14:1331829. [PMID: 38035017 PMCID: PMC10682817 DOI: 10.3389/fphar.2023.1331829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 11/10/2023] [Indexed: 12/02/2023] Open
Affiliation(s)
- Burkhard Tümmler
- Department for Pediatric Pneumology, Allergology and Neonatology, Hannover Medical School, Hannover, Germany
- Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Member of the German Center for Lung Research (DZL), Hannover, Germany
| | - Pierre-Régis Burgel
- Université Paris Cité, Institut Cochin, Inserm U1016, Paris, France
- Cochin Hospital, Assistance Publique Hôpitaux de Paris, Paris, France
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Middleton PG, Simmonds NJ. Cystic fibrosis modulator therapy can reverse cystic bronchiectasis. Respirol Case Rep 2023; 11:e01172. [PMID: 37323158 PMCID: PMC10261305 DOI: 10.1002/rcr2.1172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 05/23/2023] [Indexed: 06/17/2023] Open
Abstract
Bronchiectasis is often considered progressive and irreversible, so cases of regression or reversal are an important step in understanding the underlying pathophysiological mechanisms. Cystic fibrosis, (CF) caused by pathogenic variants in the cystic fibrosis transmembrane conductance regulator (CFTR) gene has been a success story in personalized medicine. The recent development of CFTR modulator therapies has revolutionized care. Dramatic improvements in lung function, sputum production, daytime functioning, and quality of life are seen within weeks. However, the effect of long-term exposure to elexacaftor + tezacaftor + ivacaftor (ETI) on the structural abnormalities is at present unknown. This case series outlines three adults with CF who have demonstrated progressive improvement in the cylindrical, varicose and importantly cystic changes of bronchiectasis with prolonged ETI treatment. This raises the exciting question of reversibility of bronchiectasis as well as the mechanisms involved in the maintenance and progression of bronchiectasis as it relates to CF.
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Affiliation(s)
- Peter G. Middleton
- CF Service, Department Respiratory & Sleep MedicineWestmead HospitalSydneyNew South WalesAustralia
- Westmead Clinical SchoolUniversity of SydneySydneyNew South WalesAustralia
| | - Nicholas J. Simmonds
- Adult Cystic Fibrosis CentreRoyal Brompton HospitalLondonUK
- Respiratory MedicineImperial College London, Royal Brompton HospitalLondonUK
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Olivier M, Kavvalou A, Welsner M, Hirtz R, Straßburg S, Sutharsan S, Stehling F, Steindor M. Real-life impact of highly effective CFTR modulator therapy in children with cystic fibrosis. Front Pharmacol 2023; 14:1176815. [PMID: 37229253 PMCID: PMC10203630 DOI: 10.3389/fphar.2023.1176815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 04/17/2023] [Indexed: 05/27/2023] Open
Abstract
Introduction: Recently, cystic fibrosis transmembrane regulator modulator therapy with elexacaftor/tezacaftor/ivacaftor has become available for children with cystic fibrosis (CF) carrying at least one F508del mutation. Objective: To assess the intermediate term effects of elexacaftor/tezacaftor/ivacaftor in children with cystic fibrosis in a real-world setting. Methods: We performed a retrospective analysis of records of children with cystic fibrosis, who started elexacaftor/tezacaftor/ivacaftor between 8/2020 and 10/2022. Pulmonary function tests, nutritional status, sweat chloride and laboratory data were assessed before, 3 and 6 months after the start of elexacaftor/tezacaftor/ivacaftor respectively. Results: Elexacaftor/tezacaftor/ivacaftor was started in 22 children 6-11 years and in 24 children 12-17 years. Twenty-seven (59%) patients were homozygous for F508del (F/F) and 23 (50%) patients were transitioned from ivacaftor/lumacaftor (IVA/LUM) or tezacaftor/ivacaftor (TEZ/IVA) to elexacaftor/tezacaftor/ivacaftor. Overall, mean sweat chloride concentration decreased by 59.3 mmol/L (95% confidence interval: -65.0 to -53.7 mmol/L, p < 0.0001) under elexacaftor/tezacaftor/ivacaftor. Sweat chloride concentration also decreased significantly after transition from IVA/LUM or TEZ/IVA to elexacaftor/tezacaftor/ivacaftor (-47.8 mmol/l; 95% confidence interval: -57.6 to -37.8 mmol/l, n = 14, p < 0.0001). Sweat chloride reduction was more marked in children with the F/F than in those with the F/MF genotype (69.4 vs 45.9 mmol/L, p < 0.0001). At 3 months follow-up, body-mass-index-z-score increased by 0.31 (95% CI, 0.2-0.42, p < 0.0001) with no further increase at 6 months. BMI-for-age-z-score was more markedly improved in the older group. Overall pulmonary function (percent predicted FEV1) at 3 months follow-up increased by 11.4% (95% CI: 8.0-14.9, p < 0.0001) with no further significant change after 6 months. No significant differences were noted between the age groups. Children with the F/MF genotype had a greater benefit regarding nutritional status and pulmonary function tests than those with the F/F genotype. Adverse events led to elexacaftor/tezacaftor/ivacaftor dose reduction in three cases and a temporary interruption of therapy in four cases. Conclusion: In a real-world setting, elexacaftor/tezacaftor/ivacaftor therapy had beneficial clinical effects and a good safety profile in eligible children with cystic fibrosis comparable to previously published data from controlled clinical trials. The positive impact on pulmonary function tests and nutritional status seen after 3 months of elexacaftor/tezacaftor/ivacaftor therapy was sustained at 6 months follow-up.
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Affiliation(s)
- Margarete Olivier
- Pediatric Pulmonology and Sleep Medicine, Cystic Fibrosis Center, Children’s Hospital, University of Duisburg-Essen, Essen, Germany
| | - Alexandra Kavvalou
- Pediatric Pulmonology and Sleep Medicine, Cystic Fibrosis Center, Children’s Hospital, University of Duisburg-Essen, Essen, Germany
| | - Matthias Welsner
- Department of Pulmonary Medicine, Adult Cystic Fibrosis Center, University Hospital Essen—Ruhrlandklinik, University of Duisburg-Essen, Essen, Germany
| | - Raphael Hirtz
- Pediatric Endocrinology, Children’s Hospital, University of Duisburg-Essen, Essen, Germany
| | - Svenja Straßburg
- Department of Pulmonary Medicine, Adult Cystic Fibrosis Center, University Hospital Essen—Ruhrlandklinik, University of Duisburg-Essen, Essen, Germany
| | - Sivagurunathan Sutharsan
- Department of Pulmonary Medicine, Adult Cystic Fibrosis Center, University Hospital Essen—Ruhrlandklinik, University of Duisburg-Essen, Essen, Germany
| | - Florian Stehling
- Pediatric Pulmonology and Sleep Medicine, Cystic Fibrosis Center, Children’s Hospital, University of Duisburg-Essen, Essen, Germany
| | - Mathis Steindor
- Pediatric Pulmonology and Sleep Medicine, Cystic Fibrosis Center, Children’s Hospital, University of Duisburg-Essen, Essen, Germany
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Hong E, Shi A, Beringer P. Drug-drug interactions involving CFTR modulators: a review of the evidence and clinical implications. Expert Opin Drug Metab Toxicol 2023; 19:203-216. [PMID: 37259485 DOI: 10.1080/17425255.2023.2220960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 05/30/2023] [Indexed: 06/02/2023]
Abstract
INTRODUCTION Cystic fibrosis (CF) is characterized by mucus accumulation impairing the lungs, gastrointestinal tract, and other organs. Cystic fibrosis transmembrane conductance regulator (CFTR) modulators (ivacaftor, tezacaftor, elexacaftor, and lumacaftor) significantly improve lung function and nutritional status; however, they are substrates, inhibitors, and/or inducers of certain CYP enzymes and transporters, raising the risk of drug-drug interactions (DDI) with common CF medications. AREAS COVERED A literature search was conducted for DDIs involving CFTR modulators by reviewing new drug applications, drug package inserts, clinical studies, and validated databases of substrates, inhibitors, and inducers. Clinically, CYP3A inducers and inhibitors significantly decrease and increase systemic concentrations of elexacaftor/tezacaftor/ivacaftor, respectively. Additionally, lumacaftor and ivacaftor alter concentrations of CYP3A and P-gp substrates. Potential DDIs without current clinical evidence include ivacaftor and elexacaftor's effect on CYP2C9 and OATP1B1/3 substrates, respectively, and OATP1B1/3 and P-gp inhibitors' effect on tezacaftor. A literature review was conducted using PubMed. EXPERT OPINION Dosing recommendations for CFTR modulators with DDIs are relatively comprehensive; however, recommendations on timing of dosing transition of CFTR modulators when CYP3A inhibitors are initiated or discontinued is incomplete. Certain drug interactions may be managed by choosing an alternative treatment to avoid/minimize DDIs. Next generation CFTR modulator therapies under development are expected to provide increased activity with reduced DDI risk.
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Affiliation(s)
- Eunjin Hong
- Department of Clinical Pharmacy, USC Alfred E. Mann School of Pharmacy and Pharmaceutical Sciences, University of Southern California, Los Angeles, CA, USA
| | - Alan Shi
- Department of Clinical Pharmacy, USC Alfred E. Mann School of Pharmacy and Pharmaceutical Sciences, University of Southern California, Los Angeles, CA, USA
| | - Paul Beringer
- Department of Clinical Pharmacy, USC Alfred E. Mann School of Pharmacy and Pharmaceutical Sciences, University of Southern California, Los Angeles, CA, USA
- USC Anton Yelchin CF Clinic, Los Angeles, CA, USA
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Pigliasco F, Cafaro A, Stella M, Baiardi G, Barco S, Pedemonte N, D'Orsi C, Cresta F, Casciaro R, Castellani C, Calevo MG, Mattioli F, Cangemi G. Simultaneous Quantification of Ivacaftor, Tezacaftor, and Elexacaftor in Cystic Fibrosis Patients' Plasma by a Novel LC-MS/MS Method. Biomedicines 2023; 11. [PMID: 36831163 DOI: 10.3390/biomedicines11020628] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 02/10/2023] [Accepted: 02/16/2023] [Indexed: 02/22/2023] Open
Abstract
The new breakthrough cystic fibrosis (CF) drug combination of ivacaftor (IVA), tezacaftor (TEZ), and elexacaftor (ELX), namely "caftor" drugs, directly modulates the activity and trafficking of the defective CF transmembrane conductance regulator protein (CFTR) underlying the CF disease. The role of therapeutic drug monitoring (TDM) of caftor drugs in clinical settings has recently been established. The availability of reliable and robust analytical methods for the quantification of IVA, TEZ, and ELX is essential to support dose-concentration-effect studies. We have developed and validated a new liquid chromatography-tandem mass spectrometry (LC-MS/MS) for the rapid and simultaneous quantification of IVA, TEZ, and ELX from the plasma of CF patients. The method was based on a rapid extraction protocol from 50 μL human plasma and separation on a reversed-phase C-18 HPLC column after the addition of deuterated internal standards. Accurate analyte quantification using multiple reaction monitoring (MRM) detection was then obtained using a Thermofisher Quantiva triple-quadrupole MS coupled to an Ultimate 3000 UHPLC. The method has been validated following international (EMA) guidelines for bioanalytical method validation and has been tested on plasma samples from 62 CF patients treated with the three-drug combination IVA/TEZ/ELX, marketed as Kaftrio® or Trikafta®, in steady-state condition. The assay was linear over wide concentration ranges (0.008-12 mg/L) in plasma for IVA, TEZ, and ELX, suitable for a broad range of plasma concentrations, and accurate and reproducible in the absence of matrix effects. The stability of analytes for at least 30 days at room temperature could allow for cost-effective shipment and storage. On the same day of sample collection, a sweat test was evaluated for 26 associated patients' samples, FEV1 (%) for 58, and BMI was calculated for 62. However, Spearman correlation showed no correlation between Cthrough plasma concentrations of analytes (IVA, TEZ, ELX) and sweat test, FEV1 (%), or BMI. Our method proved to be suitable for TDM and could be helpful in assessing dose-concentration-response correlations in larger studies.
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Mall MA, Brugha R, Gartner S, Legg J, Moeller A, Mondejar-Lopez P, Prais D, Pressler T, Ratjen F, Reix P, Robinson PD, Selvadurai H, Stehling F, Ahluwalia N, Arteaga-Solis E, Bruinsma BG, Jennings M, Moskowitz SM, Noel S, Tian S, Weinstock TG, Wu P, Wainwright CE, Davies JC. Efficacy and Safety of Elexacaftor/ Tezacaftor/Ivacaftor in Children 6 Through 11 Years of Age with Cystic Fibrosis Heterozygous for F508del and a Minimal Function Mutation: A Phase 3b, Randomized, Placebo-controlled Study. Am J Respir Crit Care Med 2022; 206:1361-1369. [PMID: 35816621 PMCID: PMC9746869 DOI: 10.1164/rccm.202202-0392oc] [Citation(s) in RCA: 42] [Impact Index Per Article: 21.0] [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] [Indexed: 12/24/2022] Open
Abstract
Rationale: The triple-combination regimen elexacaftor/tezacaftor/ivacaftor (ELX/TEZ/IVA) was shown to be safe and efficacious in children aged 6 through 11 years with cystic fibrosis and at least one F508del-CFTR allele in a phase 3, open-label, single-arm study. Objectives: To further evaluate the efficacy and safety of ELX/TEZ/IVA in children 6 through 11 years of age with cystic fibrosis heterozygous for F508del and a minimal function CFTR mutation (F/MF genotypes) in a randomized, double-blind, placebo-controlled phase 3b trial. Methods: Children were randomized to receive either ELX/TEZ/IVA (n = 60) or placebo (n = 61) during a 24-week treatment period. The dose of ELX/TEZ/IVA administered was based on weight at screening, with children <30 kg receiving ELX 100 mg once daily, TEZ 50 mg once daily, and IVA 75 mg every 12 hours, and children ⩾30 kg receiving ELX 200 mg once daily, TEZ 100 mg once daily, and IVA 150 mg every 12 hours (adult dose). Measurements and Main Results: The primary endpoint was absolute change in lung clearance index2.5 from baseline through Week 24. Children given ELX/TEZ/IVA had a mean decrease in lung clearance index2.5 of 2.29 units (95% confidence interval [CI], 1.97-2.60) compared with 0.02 units (95% CI, -0.29 to 0.34) in children given placebo (between-group treatment difference, -2.26 units; 95% CI, -2.71 to -1.81; P < 0.0001). ELX/TEZ/IVA treatment also led to improvements in the secondary endpoint of sweat chloride concentration (between-group treatment difference, -51.2 mmol/L; 95% CI, -55.3 to -47.1) and in the other endpoints of percent predicted FEV1 (between-group treatment difference, 11.0 percentage points; 95% CI, 6.9-15.1) and Cystic Fibrosis Questionnaire-Revised Respiratory domain score (between-group treatment difference, 5.5 points; 95% CI, 1.0-10.0) compared with placebo from baseline through Week 24. The most common adverse events in children receiving ELX/TEZ/IVA were headache and cough (30.0% and 23.3%, respectively); most adverse events were mild or moderate in severity. Conclusions: In this first randomized, controlled study of a cystic fibrosis transmembrane conductance regulator modulator conducted in children 6 through 11 years of age with F/MF genotypes, ELX/TEZ/IVA treatment led to significant improvements in lung function, as well as robust improvements in respiratory symptoms and cystic fibrosis transmembrane conductance regulator function. ELX/TEZ/IVA was generally safe and well tolerated in this pediatric population with no new safety findings.
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Affiliation(s)
- Marcus A. Mall
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin and,Berlin Institute of Health at Charité – Universitätsmedizin Berlin, Berlin, Germany;,German Center for Lung Research, Associated Partner, Berlin, Germany
| | - Rossa Brugha
- Great Ormond Street Hospital for Children, London, United Kingdom
| | | | - Julian Legg
- Southampton Children's Hospital, Hampshire, United Kingdom
| | | | | | - Dario Prais
- Schneider Children’s Medical Center of Israel, Petah Tikva, Israel;,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | - Felix Ratjen
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Philippe Reix
- Hôpital Femme Mère-Enfant, Hospices Civils de Lyon, Bron, France
| | - Paul D. Robinson
- The Children’s Hospital at Westmead, Sydney Children’s Hospital Network, Sydney, Australia
| | - Hiran Selvadurai
- The Children’s Hospital at Westmead, Sydney Children’s Hospital Network, Sydney, Australia
| | - Florian Stehling
- Universitätsklinikum Essen, Klinik für Kinderheilkunde III, Essen, Germany
| | - Neil Ahluwalia
- Vertex Pharmaceuticals Incorporated, Boston, Massachussetts
| | | | | | - Mark Jennings
- Vertex Pharmaceuticals Incorporated, Boston, Massachussetts
| | | | - Sabrina Noel
- Vertex Pharmaceuticals Incorporated, Boston, Massachussetts
| | - Simon Tian
- Vertex Pharmaceuticals Incorporated, Boston, Massachussetts
| | | | - Pan Wu
- Vertex Pharmaceuticals Incorporated, Boston, Massachussetts
| | | | - Jane C. Davies
- National Heart and Lung Institute, Imperial College London, London, United Kingdom;,Royal Brompton and Harefield Hospitals, part of Guy’s and St Thomas’ NHS Trust, London, United Kingdom; and,European Cystic Fibrosis Society Lung Clearance Index Core Facility, London, United Kingdom
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11
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Loyd I, Papac N, Hirshburg J, Levin J, Dannelley J, Dorris J, Stratton J, Mehdi N. If At First You Don't Succeed, Trikafta Again. J Pediatr Pharmacol Ther 2022; 27:467-469. [PMID: 35845559 DOI: 10.5863/1551-6776-27.5.467] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 02/18/2022] [Indexed: 01/09/2023]
Abstract
Adverse reactions, including severe cutaneous reactions, to cystic fibrosis transmembrane conductance regulator (CFTR) modulators have been described in the literature. Herein we present a drug eruption in response to elexacaftor/tezcaftor/ivacaftor (brand name, Trikafta) in a 7-year-old male with cystic fibrosis, followed by desensitization and successful continuation. A review of the literature outlining similar cases is provided. Attempting to mitigate and manage drug reactions to CFTR modulators is essential because they represent vital and irreplaceable therapies for individuals with cystic fibrosis (CF).
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Affiliation(s)
- India Loyd
- College of Medicine (IL), University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Nicole Papac
- Department of Dermatology (NP, JH, JL), University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Jason Hirshburg
- Department of Dermatology (NP, JH, JL), University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Jarad Levin
- Department of Dermatology (NP, JH, JL), University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Jennifer Dannelley
- Department of Pediatrics (JD, JD, NM), University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Janislynn Dorris
- Department of Pediatrics (JD, JD, NM), University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Jason Stratton
- College of Medicine (IL), University of Oklahoma Health Sciences Center, Oklahoma City, OK.,Department of Dermatology (NP, JH, JL), University of Oklahoma Health Sciences Center, Oklahoma City, OK.,Department of Pediatrics (JD, JD, NM), University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Nighat Mehdi
- Department of Pediatrics (JD, JD, NM), University of Oklahoma Health Sciences Center, Oklahoma City, OK
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12
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Abstract
Small molecule chaperones have been exploited as therapeutics for the hundreds of diseases caused by protein misfolding. The most successful examples are the CFTR correctors, which transformed cystic fibrosis therapy. These molecules revert folding defects of the ΔF508 mutant and are widely used to treat patients. To investigate the molecular mechanism of their action, we determined cryo-electron microscopy structures of CFTR in complex with the FDA-approved correctors lumacaftor or tezacaftor. Both drugs insert into a hydrophobic pocket in the first transmembrane domain (TMD1), linking together four helices that are thermodynamically unstable. Mutating residues at the binding site rendered ΔF508-CFTR insensitive to lumacaftor and tezacaftor, underscoring the functional significance of the structural discovery. These results support a mechanism in which the correctors stabilize TMD1 at an early stage of biogenesis, prevent its premature degradation, and thereby allosterically rescuing many disease-causing mutations.
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Affiliation(s)
- Karol Fiedorczuk
- Laboratory of Membrane Biology and Biophysics, The Rockefeller University, New York, NY 10065, USA
| | - Jue Chen
- Laboratory of Membrane Biology and Biophysics, The Rockefeller University, New York, NY 10065, USA; Howard Hughes Medical Institute, Chevy Chase, MD 20815, USA.
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13
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Muilwijk D, Bierlaagh M, van Mourik P, Kraaijkamp J, van der Meer R, van den Bor R, Heijerman H, Eijkemans R, Beekman J, van der Ent K. Prediction of Real-World Long-Term Outcomes of People with CF Homozygous for the F508del Mutation Treated with CFTR Modulators. J Pers Med 2021; 11:jpm11121376. [PMID: 34945848 PMCID: PMC8707616 DOI: 10.3390/jpm11121376] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 12/06/2021] [Accepted: 12/14/2021] [Indexed: 11/16/2022] Open
Abstract
The clinical response to cystic fibrosis transmembrane conductance regulator (CFTR) modulators is variable within people with cystic fibrosis (pwCF) homozygous for the F508del mutation. The prediction of clinical effect in individual patients would be useful to target therapy to those who would benefit from it. A multicenter observational cohort study was conducted including 97 pwCF (F508del/F508del), who started lumacaftor/ivacaftor (LUM/IVA) treatment before June 2018. In order to assess the associations of individual in vivo and in vitro biomarkers with clinical outcomes, we collected clinical data regarding sex, age, and sweat chloride concentration (SwCl) at baseline and after six months of LUM/IVA; the percent predicted forced expiratory volume in 1 s (ppFEV1) and the number of pulmonary exacerbations (PEx) during the three years before up to three years after modulator initiation; and the forskolin-induced swelling (FIS) responses to LUM/IVA, quantified in intestinal organoids. On a group level, the results showed an acute change in ppFEV1 after LUM/IVA initiation (2.34%, 95% CI 0.85–3.82, p = 0.003), but no significant change in annual ppFEV1 decline in the three years after LUM/IVA compared to the three years before (change: 0.11% per year, 95%CI: −1.94–2.19, p = 0.913). Neither of these two outcomes was associated with any of the candidate predictors on an individual level. The median number of pulmonary exacerbations (PEx) per patient year did not significantly change in the three years after LUM/IVA compared to the years before (median: 0.33/patient year, IQR: 0–0.67 before vs. median: 0/patient year, IQR: 0–0.67 after p = 0. 268). The PEx rate after modulator initiation was associated with the PEx rate before (IRR: 2.26, 95%CI: 1.67–3.08, p < 0.001), with sex (males vs. females IRR: 0.36, 95%CI: 0.21–0.63, p = 0.001) and with sweat chloride concentration (SwCl) at baseline (IRR: 0.96, 95%CI: 0.94–0.98, p = 0.001). The change in SwCl was also significant (−22.9 mmol/L (95%CI: −27.1–−18.8, p < 0.001) and was associated with SwCl at baseline (−0.64, 95%CI: −0.90–−0.37, p < 0.001) and with sex (males vs. females 8.32, 95%CI: 1.82–14.82, p = 0.013). In conclusion, ppFEV1 decline after CFTR modulator initiation remains difficult to predict in individual patients in a real-world setting, with limited effectiveness for double CFTR modulator therapies. The PEx rate prior to CFTR modulator treatment initiation, sex and SwCl at baseline could be potential predictors of long-term PEx rate and of changes in SwCl after modulator initiation.
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Affiliation(s)
- Danya Muilwijk
- Department of Pediatric Pulmonology, University Medical Center Utrecht, loc. Wilhelmina Children’s Hospital, Lundlaan 6, 3584 EA Utrecht, The Netherlands; (D.M.); (M.B.); (P.v.M.); (J.K.); (J.B.)
| | - Marlou Bierlaagh
- Department of Pediatric Pulmonology, University Medical Center Utrecht, loc. Wilhelmina Children’s Hospital, Lundlaan 6, 3584 EA Utrecht, The Netherlands; (D.M.); (M.B.); (P.v.M.); (J.K.); (J.B.)
| | - Peter van Mourik
- Department of Pediatric Pulmonology, University Medical Center Utrecht, loc. Wilhelmina Children’s Hospital, Lundlaan 6, 3584 EA Utrecht, The Netherlands; (D.M.); (M.B.); (P.v.M.); (J.K.); (J.B.)
| | - Jasmijn Kraaijkamp
- Department of Pediatric Pulmonology, University Medical Center Utrecht, loc. Wilhelmina Children’s Hospital, Lundlaan 6, 3584 EA Utrecht, The Netherlands; (D.M.); (M.B.); (P.v.M.); (J.K.); (J.B.)
| | - Renske van der Meer
- Department of Pulmonology, Haga Teaching Hospital, Els Borst-Eilersplein 275, 2545 CH The Hague, The Netherlands;
| | - Rutger van den Bor
- Department of Data Science and Biostatistics, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, 3584 EA Utrecht, The Netherlands; (R.v.d.B.); (R.E.)
| | - Harry Heijerman
- Department of Pulmonology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands;
| | - René Eijkemans
- Department of Data Science and Biostatistics, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, 3584 EA Utrecht, The Netherlands; (R.v.d.B.); (R.E.)
| | - Jeffrey Beekman
- Department of Pediatric Pulmonology, University Medical Center Utrecht, loc. Wilhelmina Children’s Hospital, Lundlaan 6, 3584 EA Utrecht, The Netherlands; (D.M.); (M.B.); (P.v.M.); (J.K.); (J.B.)
- Department of Regenerative Medicine, University Medical Center Utrecht, Uppsalalaan 8, 3584 CT Utrecht, The Netherlands
| | - Kors van der Ent
- Department of Pediatric Pulmonology, University Medical Center Utrecht, loc. Wilhelmina Children’s Hospital, Lundlaan 6, 3584 EA Utrecht, The Netherlands; (D.M.); (M.B.); (P.v.M.); (J.K.); (J.B.)
- Correspondence: ; Tel.: +31-88-7553201
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14
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Goldberg RH, Matthews NH, Hristov AC, Wang F. Urticaria multiforme-like eruption due to a novel agent elexacaftor/ tezacaftor/ivacaftor in a pediatric patient with cystic fibrosis. JAAD Case Rep 2021; 18:71-73. [PMID: 34841028 PMCID: PMC8606295 DOI: 10.1016/j.jdcr.2021.10.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Rebecca H. Goldberg
- University of Michigan Medical School, Ann Arbor, Michigan
- Correspondence to: Rebecca H. Goldberg, BS, University of Michigan Medical School, 1301 Catherine St, Ann Arbor, MI 48109.
| | - Natalie H. Matthews
- Department of Dermatology, University of Michigan Medical School, Ann Arbor, Michigan
| | - Alexandra C. Hristov
- Department of Dermatology, University of Michigan Medical School, Ann Arbor, Michigan
- Department of Pathology, University of Michigan Medical School, Ann Arbor, Michigan
| | - Frank Wang
- Department of Dermatology, University of Michigan Medical School, Ann Arbor, Michigan
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15
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Mederos-Luis E, González-Pérez R, Poza-Guedes P, Álava-Cruz C, Matheu V, Sánchez-Machín I. Toxic epidermal necrolysis induced by cystic fibrosis transmembrane conductance regulator modulators. Contact Dermatitis 2021; 86:224-225. [PMID: 34731505 DOI: 10.1111/cod.14002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 10/29/2021] [Accepted: 11/01/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Elena Mederos-Luis
- Allergy Department, Hospital Universitario de Canarias, Santa Cruz de Tenerife, Spain
| | | | - Paloma Poza-Guedes
- Allergy Department, Hospital Universitario de Canarias, Santa Cruz de Tenerife, Spain
| | - Cristina Álava-Cruz
- Allergy Department, Hospital Universitario de Canarias, Santa Cruz de Tenerife, Spain
| | - Víctor Matheu
- Allergy Department, Hospital Universitario de Canarias, Santa Cruz de Tenerife, Spain
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16
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Fűr G, Bálint ER, Orján EM, Balla Z, Kormányos ES, Czira B, Szűcs A, Kovács DP, Pallagi P, Maléth J, Venglovecz V, Hegyi P, Kiss L, Rakonczay Z. Mislocalization of CFTR expression in acute pancreatitis and the beneficial effect of VX-661 + VX-770 treatment on disease severity. J Physiol 2021; 599:4955-4971. [PMID: 34587656 DOI: 10.1113/jp281765] [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: 04/15/2021] [Accepted: 09/24/2021] [Indexed: 01/15/2023] Open
Abstract
Cystic fibrosis transmembrane conductance regulator (CFTR) has an essential role in maintaining pancreatic ductal function. Impaired CFTR function can trigger acute pancreatitis (AP) and exacerbate disease severity. We aimed to investigate the localization and expression of CFTR during AP, and determined the effects of a CFTR corrector (VX-661) and potentiator (VX-770) on disease severity. AP was induced in FVB/n mice by 6-10 hourly intraperitoneal injections of 50 μg/kg cerulein. Some mice were pre-treated with five to six daily injections of 2 mg/kg VX-661 + VX-770. Control animals were administered physiological saline instead of cerulein and dimethyl sulfoxide instead of VX compounds. AP severity was determined by measuring laboratory and histological parameters; CFTR and CK19 expression was measured. Activity of ion transporters was followed by intracellular pH or fluid secretion measurement of isolated pancreatic intra-/interlobular ducts. Cerulein-induced AP severity was greatest between 12 and 24 h. CFTR mRNA expression was significantly increased 24 h after AP induction. Immunohistochemistry demonstrated disturbed staining morphology of CFTR and CK19 proteins in AP. Mislocalization of CFTR protein was observed from 6 h, while expression increased at 24 h compared to control. Ductal HCO3 - transport activity was significantly increased 6 h after AP induction. AP mice pre-treatment with VX-661 + VX-770 significantly reduced the extent of tissue damage by about 20-30%, but other parameters were unchanged. Interestingly, VX-661 + VX-770 in vitro administration significantly increased the fluid secretion of ducts derived from AP animals. This study described the course of the CFTR expression and mislocalization in cerulein-induced AP. Our results suggest that the beneficial effects of CFTR correctors and potentiators should be further investigated in AP. KEY POINTS: Cystic fibrosis transmembrane conductance regulator (CFTR) is an important ion channel in epithelial cells. Its malfunction has several serious consequences, like developing or aggravating acute pancreatitis (AP). Here, the localization and expression of CFTR during cerulein-induced AP in mice were investigated and the effects of CFTR corrector (VX-661) and a potentiator (VX-770) on disease severity were determined. CFTR mRNA expression was significantly increased and mislocalization of CFTR protein was observed in AP compared to the control group. Interestingly, pre-treatment of AP mice with VX-661 + VX-770 significantly reduced the extent of pancreatic tissue damage by 20-30%. In vitro administration of VX-661 + VX-770 significantly increased the fluid secretion of ducts derived from AP animals. Based on these results, the utilization of CFTR correctors and potentiators should be further investigated in AP.
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Affiliation(s)
- Gabriella Fűr
- Department of Pathophysiology, University of Szeged, Szeged, Hungary
| | - Emese Réka Bálint
- Department of Pathophysiology, University of Szeged, Szeged, Hungary
| | - Erik Márk Orján
- Department of Pathophysiology, University of Szeged, Szeged, Hungary
| | - Zsolt Balla
- Department of Pathophysiology, University of Szeged, Szeged, Hungary
| | | | - Beáta Czira
- Department of Pathophysiology, University of Szeged, Szeged, Hungary
| | - Attila Szűcs
- Department of Pathophysiology, University of Szeged, Szeged, Hungary
| | | | - Petra Pallagi
- First Department of Medicine, University of Szeged, Szeged, Hungary.,Momentum Epithelial Cell Signalling and Secretion Research Group, Hungarian Academy of Sciences-University of Szeged, Szeged, Hungary
| | - József Maléth
- First Department of Medicine, University of Szeged, Szeged, Hungary.,Momentum Epithelial Cell Signalling and Secretion Research Group, Hungarian Academy of Sciences-University of Szeged, Szeged, Hungary
| | - Viktória Venglovecz
- Department of Pharmacology and Pharmacotherapy, University of Szeged, Szeged, Hungary
| | - Péter Hegyi
- Institute for Translational Medicine and First Department of Medicine, University of Pécs, Pécs, Hungary.,Momentum Translational Gastroenterology Research Group, Hungarian Academy of Sciences-University of Szeged, Szeged, Hungary.,Szentágothai Research Centre, University of Pécs, Pécs, Hungary
| | - Lóránd Kiss
- Department of Pathophysiology, University of Szeged, Szeged, Hungary
| | - Zoltán Rakonczay
- Department of Pathophysiology, University of Szeged, Szeged, Hungary
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17
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Zemanick ET, Taylor-Cousar JL, Davies J, Gibson RL, Mall MA, McKone EF, McNally P, Ramsey BW, Rayment JH, Rowe SM, Tullis E, Ahluwalia N, Chu C, Ho T, Moskowitz SM, Noel S, Tian S, Waltz D, Weinstock TG, Xuan F, Wainwright CE, McColley SA. A Phase 3 Open-Label Study of Elexacaftor/ Tezacaftor/Ivacaftor in Children 6 through 11 Years of Age with Cystic Fibrosis and at Least One F508del Allele. Am J Respir Crit Care Med 2021; 203:1522-1532. [PMID: 33734030 PMCID: PMC8483230 DOI: 10.1164/rccm.202102-0509oc] [Citation(s) in RCA: 129] [Impact Index Per Article: 43.0] [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] [Indexed: 12/11/2022] Open
Abstract
Rationale: Elexacaftor/tezacaftor/ivacaftor (ELX/TEZ/IVA) was shown to be efficacious and safe in patients ≥12 years of age with cystic fibrosis and at least one F508del-CFTR (cystic fibrosis transmembrane conductance regulator) allele, but it has not been evaluated in children <12 years of age. Objectives: To assess the safety, pharmacokinetics, and efficacy of ELX/TEZ/IVA in children 6 through 11 years of age with F508del–minimal function or F508del-F508del genotypes. Methods: In this 24-week open-label phase 3 study, children (N = 66) weighing <30 kg received 50% of the ELX/TEZ/IVA adult daily dose (ELX 100 mg once daily, TEZ 50 mg once daily, and IVA 75 mg every 12 h) whereas children weighing ⩾30 kg received the full adult daily dose (ELX 200 mg once daily, TEZ 100 mg once daily, and IVA 150 mg every 12 h). Measurements and Main Results: The primary endpoint was safety and tolerability. The safety and pharmacokinetic profiles of ELX/TEZ/IVA were generally consistent with those observed in older patients. The most commonly reported adverse events included cough, headache, and pyrexia; in most of the children who had adverse events, these were mild or moderate in severity. Through Week 24, ELX/TEZ/IVA treatment improved the percentage of predicted FEV1 (10.2 percentage points; 95% confidence interval [CI], 7.9 to 12.6), Cystic Fibrosis Questionnaire–Revised respiratory domain score (7.0 points; 95% CI, 4.7 to 9.2), lung clearance index2.5 (−1.71 units; 95% CI, −2.11 to −1.30), and sweat chloride (−60.9 mmol/L; 95% CI, −63.7 to −58.2); body mass index-for-age z-score increased over the 24-week treatment period when compared with the pretreatment baseline. Conclusions: Our results show ELX/TEZ/IVA is safe and efficacious in children 6 through 11 years of age with at least one F508del-CFTR allele, supporting its use in this patient population. Clinical trial registered with www.clinicaltrials.gov (NCT03691779).
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Affiliation(s)
- Edith T Zemanick
- Department of Pediatrics, University of Colorado Anschutz Medical Campus and Children's Hospital Colorado, Aurora, Colorado
| | | | - Jane Davies
- National Heart and Lung Institute, Imperial College London, National Institute for Health Research Imperial Biomedical Research Centre and Royal Brompton and Harefield National Health Service Foundation Trust, London, United Kingdom
| | - Ronald L Gibson
- University of Washington/Seattle Children's Hospital, Seattle, Washington
| | - Marcus A Mall
- Department of Pediatric Pulmonology, Immunology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health, Berlin, Germany.,German Center for Lung Research, Berlin, Germany
| | - Edward F McKone
- St. Vincent's University Hospital and University College, Dublin, Ireland
| | - Paul McNally
- Children's Health Ireland and Royal College of Surgeons in Ireland University of Medicine and Health Sciences, Dublin, Ireland
| | - Bonnie W Ramsey
- University of Washington/Seattle Children's Hospital, Seattle, Washington
| | - Jonathan H Rayment
- British Columbia Children's Hospital, Vancouver, British Columbia, Canada
| | - Steven M Rowe
- University of Alabama at Birmingham, Birmingham, Alabama
| | | | - Neil Ahluwalia
- Vertex Pharmaceuticals Incorporated, Boston, Massachusetts
| | - Chenghao Chu
- Vertex Pharmaceuticals Incorporated, Boston, Massachusetts
| | - Thang Ho
- Vertex Pharmaceuticals Incorporated, Boston, Massachusetts
| | | | - Sabrina Noel
- Vertex Pharmaceuticals Incorporated, Boston, Massachusetts
| | - Simon Tian
- Vertex Pharmaceuticals Incorporated, Boston, Massachusetts
| | - David Waltz
- Vertex Pharmaceuticals Incorporated, Boston, Massachusetts
| | | | - Fengjuan Xuan
- Vertex Pharmaceuticals Incorporated, Boston, Massachusetts
| | | | - Susanna A McColley
- Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois; and.,Northwestern University Feinberg School of Medicine, Chicago, Illinois
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18
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Vonk SEM, van der Meer-Vos M, Bos LDJ, Neerincx AH, Majoor CJ, Maitland-van der Zee AH, Mathôt RAA, Kemper EM. Quantitative Method for the Analysis of Ivacaftor, Hydroxymethyl Ivacaftor, Ivacaftor Carboxylate, Lumacaftor, and Tezacaftor in Plasma and Sputum Using Liquid Chromatography With Tandem Mass Spectrometry and Its Clinical Applicability. Ther Drug Monit 2021; 43:555-563. [PMID: 33165217 PMCID: PMC8277188 DOI: 10.1097/ftd.0000000000000829] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 09/01/2020] [Indexed: 01/13/2023]
Abstract
BACKGROUND The novel cystic fibrosis transmembrane conductance regulator (CFTR) modulators, ivacaftor, lumacaftor, and tezacaftor, are the first drugs directly targeting the underlying pathophysiological mechanism in cystic fibrosis (CF); however, independent studies describing their pharmacokinetics are lacking. The aim of this study was to develop a quantification method for ivacaftor and its 2 main metabolites, lumacaftor and tezacaftor, in plasma and sputum using liquid chromatography with tandem mass spectrometry. METHODS The developed method used a small sample volume (20 µL) and simple pretreatment method; protein precipitation solution and internal standard were added in one step to each sample. Liquid chromatography with tandem mass spectrometry was performed for a total run time of 6 minutes. The method was validated by assessing selectivity, carryover, linearity, accuracy and precision, dilution, matrix effects, and stability. RESULTS The selectivity was good as no interference from matrices was observed. In the concentration range from 0.01 to 10.0 mg/L, calibration curves were linear with a correlation coefficient >0.9997 for all compounds. The within-run and between-run accuracy were between 99.7% and 116% at the lower limit of quantitation (LLOQ) and between 95.8% and 112.9% for all concentrations above LLOQ for all analytes in plasma and sputum. Within-run and between-run precisions were <12.7% for LLOQ and <6.7% for the higher limit of quantitation. Samples were stable, with no significant degradation at examined temperatures and time points. Clinical applicability was revealed by analyzing samples from 2 patients with CF. CONCLUSIONS The presented method enables simultaneous quantification of ivacaftor, lumacaftor, and tezacaftor in plasma and sputum and is an improvement over previous methods because it uses smaller sample volumes, a simple pretreatment protocol, and includes tezacaftor. In future studies, it can be applied for examining pharmacokinetics characteristics of new CF transmembrane conductance regulator modulators.
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Affiliation(s)
| | | | - Lieuwe D J Bos
- Respiratory Medicine, and
- Intensive Care, Amsterdam University Medical Centers, Amsterdam, the Netherlands
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19
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Redman AW, Yoo M, Freswick P, Thompson K. Acute Pancreatitis in a Previously Exocrine Pancreatic Insufficient Cystic Fibrosis Patient Who Had Improved Pancreatic Function After Being Treated With Lumacaftor/Ivacaftor. JPGN Rep 2021; 2:e096. [PMID: 37205952 PMCID: PMC10191563 DOI: 10.1097/pg9.0000000000000096] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 04/21/2021] [Indexed: 05/21/2023]
Abstract
Exocrine pancreatic insufficiency (EPI) is a common complication of cystic fibrosis (CF). While previously considered to be irreversible, recent reported cases document improved pancreatic function in CF patients with mild mutations after ivacaftor treatment alone. We report a 12-year-old female with homozygous F508del CF and EPI who developed acute pancreatitis after 3 years on lumacaftor/ivacaftor and subsequently had improved pancreatic function. As CF therapies advance, some EPI CF patients with more severe CF transmembrane conductance regulator mutations may see improved pancreatic function and subsequently develop pancreatitis.
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Affiliation(s)
- Alexander W. Redman
- From the Internal Medicine/Pediatrics Residency, Spectrum Health/Michigan State University, Grand Rapids, MI
| | - Michelle Yoo
- Pediatrics Residency, Spectrum Health/Michigan State University, Grand Rapids, MI
| | - Peter Freswick
- Pediatric Gastroenterology, Helen DeVos Children’s Hospital, Grand Rapids, MI
| | - Karen Thompson
- Pediatric Pulmonology, Helen DeVos Children’s Hospital, Grand Rapids, MI
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20
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Zaher A, ElSaygh J, Elsori D, ElSaygh H, Sanni A. A Review of Trikafta: Triple Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) Modulator Therapy. Cureus 2021; 13:e16144. [PMID: 34268058 PMCID: PMC8266292 DOI: 10.7759/cureus.16144] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [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] [Accepted: 07/03/2021] [Indexed: 11/17/2022] Open
Abstract
Cystic fibrosis (CF) is a potentially fatal genetic disease that causes serious lung damage. With time, researchers have a more complete understanding of the molecular-biological defects that underlie CF. This knowledge is leading to alternative approaches regarding the treatment of this condition. Trikafta is the third FDA-approved drug that targets the F508del mutation of the CFTR gene. The drug is a combination of three individual drugs which are elexacaftor (ELX), tezacaftor (TEZ), and ivacaftor (IVA). This trio increases the activity of the cystic fibrosis transmembrane conductance regulator (CFTR) protein and reduces the mortality and morbidity rates in CF patients. The effectiveness of Trikafta, seen in clinical trials, outperforms currently available therapies in terms of lung function, quality of life, sweat chloride reduction, and pulmonary exacerbation reduction. The safety and efficacy of CFTR modulators in children with CF have also been studied. Continued evaluation of patient data is needed to confirm its long-term safety and efficacy. In this study, we will focus on reviewing data from clinical trials regarding the benefits of CFTR modulator therapy. We address the impact of Trikafta on lung function, pulmonary exacerbations, and quality of life. Adverse events of the different CFTR modulators are discussed.
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Affiliation(s)
- Anas Zaher
- Internal Medicine, University of Debrecen, Debrecen, HUN
| | - Jude ElSaygh
- Internal Medicine, University of Debrecen, Debrecen, HUN
| | - Dalal Elsori
- Pediatrics, Rhode Island Hospital, Brown University, Rhode Island, USA
| | - Hassan ElSaygh
- Internal Medicine, University of Debrecen, Debrecen, HUN
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21
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Anderson JD, Liu Z, Odom LV, Kersh L, Guimbellot JS. CFTR function and clinical response to modulators parallel nasal epithelial organoid swelling. Am J Physiol Lung Cell Mol Physiol 2021; 321:L119-L129. [PMID: 34009038 DOI: 10.1152/ajplung.00639.2020] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
In vitro biomarkers to assess cystic fibrosis transmembrane conductance regulator activity are desirable for precision modulator selection and as a tool for clinical trials. Here, we describe an organoid swelling assay derived from human nasal epithelia using commercially available reagents and equipment and an automated imaging process. Cells were collected in nasal brush biopsies, expanded in vitro, and cultured as spherical organoids or as monolayers. Organoids were used in a functional swelling assay with automated measurements and analysis, whereas monolayers were used for short-circuit current measurements to assess ion channel activity. Clinical data were collected from patients on modulators. Relationships between swelling data and short-circuit current, as well as between swelling data and clinical outcome measures, were assessed. The organoid assay measurements correlated with short-circuit current measurements for ion channel activity. The functional organoid assay distinguished individual responses as well as differences between groups. The organoid assay distinguished incremental drug responses to modulator monotherapy with ivacaftor and combination therapy with ivacaftor, tezacaftor, and elexacaftor. The swelling activity paralleled the clinical response. In conclusion, an in vitro biomarker derived from patients' cells can be used to predict responses to drugs and is likely to be useful as a preclinical tool to aid in the development of novel treatments and as a clinical trial outcome measure for a variety of applications, including gene therapy or editing.
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Affiliation(s)
- Justin D Anderson
- Gregory Fleming James Cystic Fibrosis Research Center, University of Alabama at Birmingham, Birmingham, Alabama.,Division of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Zhongyu Liu
- Gregory Fleming James Cystic Fibrosis Research Center, University of Alabama at Birmingham, Birmingham, Alabama.,Division of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - L Victoria Odom
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Latona Kersh
- Gregory Fleming James Cystic Fibrosis Research Center, University of Alabama at Birmingham, Birmingham, Alabama
| | - Jennifer S Guimbellot
- Gregory Fleming James Cystic Fibrosis Research Center, University of Alabama at Birmingham, Birmingham, Alabama.,Division of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
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22
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Abstract
Cystic fibrosis (CF) is a rare genetic disease that affects several organs, but lung disease is the major cause of morbidity and mortality. The gene responsible for CF, the CFTR (Cystic Fibrosis Transmembrane Conductance Regulator) gene, has been discovered in 1989. Since then, gene therapy i.e., defective gene replacement by a functional one, remained the ultimate goal but unfortunately, it has not yet been achieved. However, patients care and symptomatic treatments considerably increased CF patients’ life expectancy ranging from 5 years old in the 1960s to 40 today. In the last decade, research works on CFTR protein structure and activity led to the development of new drugs which, by readdressing CFTR to the plasma membrane (correctors) or by enhancing its transport activity (potentiators), allow, alone or in combination, an improvement of CF patients’ lung function and quality of life. While expected, it is not yet known whether taking these drugs from an early age and for years will improve the quality of life of CF patients in the long term and further increase their life expectancy. Besides, these molecules are not available (specific variants of CFTR) or accessible (national health policies) for all patients and there is still no curative treatment. Another alternative that could benefit from new technologies, such as gene therapy, is therefore still attractive, although it is not yet offered to patients. Faced with the development of new CFTR correctors and potentiators, the question arises as to whether there is still a place for gene therapy and this is discussed in this perspective.
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Affiliation(s)
- J Mercier
- Sorbonne Université, Inserm, Centre de Recherche, Saint Antoine, F-75012, Paris, France
| | - M Ruffin
- Sorbonne Université, Inserm, Centre de Recherche, Saint Antoine, F-75012, Paris, France
| | - H Corvol
- Sorbonne Université, Inserm, Centre de Recherche, Saint Antoine, F-75012, Paris, France.,Pneumologie Pédiatrique, APHP, Hôpital Trousseau, Paris, France
| | - L Guillot
- Sorbonne Université, Inserm, Centre de Recherche, Saint Antoine, F-75012, Paris, France
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23
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Middleton PG, Taylor-Cousar JL. Development of elexacaftor - tezacaftor - ivacaftor: Highly effective CFTR modulation for the majority of people with Cystic Fibrosis. Expert Rev Respir Med 2021; 15:723-735. [PMID: 33249928 DOI: 10.1080/17476348.2021.1855980] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Introduction: Cystic fibrosis (CF), the most common life-shortening inherited disorder in people of European descent, also occurs in other ethnicities. The identification of the disease, the isolation of the causative gene, termed the cystic fibrosis transmembrane conductance regulator (CFTR) and the improved survival from comprehensive multidisciplinary treatment is one of the success stories of modern medicine. Survival has increased dramatically over the last 50 years, from 10 years in the 1960s to 30 years in the 1990s and approximately 50 years currently.Areas covered: This review will examine the development of highly effective modulators for CF which will revolutionize therapy for more than 90% of the people with CF. This review summarizes the development of triple combination CFTR modulator elexacaftor-tezacaftor-ivacaftor.Expert opinion: The development of this highly effective CFTR modulator for the majority of people with CF will likely change the landscape of CF care. The challenge is to now find highly effective therapy for the remaining 10% of the people with CF who may need other therapeutic agents to correct their primary defect.
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Affiliation(s)
- Peter G Middleton
- Cystic Fibrosis Unit, Ludwig Engel Centre for Respiratory Research, Westmead Millennium Institute, University of Sydney at Westmead, Westmead, Australia
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24
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Dagenais RVE, Su VCH, Quon BS. Real-World Safety of CFTR Modulators in the Treatment of Cystic Fibrosis: A Systematic Review. J Clin Med 2020; 10:E23. [PMID: 33374882 DOI: 10.3390/jcm10010023] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 12/14/2020] [Accepted: 12/15/2020] [Indexed: 12/14/2022] Open
Abstract
Cystic fibrosis transmembrane conductance regulator (CFTR) modulator therapies target the underlying cause of cystic fibrosis (CF), and are generally well-tolerated; however, real-world studies indicate the frequency of discontinuation and adverse events (AEs) may be higher than what was observed in clinical trials. The objectives of this systematic review were to summarize real-world AEs reported for market-available CFTR modulators (i.e., ivacaftor (IVA), lumacaftor/ivacaftor (LUM/IVA), tezacaftor/ivacaftor (TEZ/IVA), and elexacaftor/tezacaftor/ivacaftor (ELX/TEZ/IVA)), and to identify ways in which the pharmacist on CF healthcare teams may contribute to mitigating and managing these AEs. The MEDLINE, EMBASE, CINAHL, and Web of Science Core Collection online databases were searched from 2012 to 1 Aug 2020. Full manuscripts or conference abstracts of observational studies, case series, and case reports were eligible for inclusion. The included full manuscripts and conference abstracts comprised of 54 observational studies, 5 case series, and 9 case reports. The types of AEs reported generally aligned with what have been observed in clinical trials. LUM/IVA was associated with a higher frequency of respiratory-related AE and discontinuation in real-world studies. A signal for mental health and neurocognitive AEs was identified with all 4 CFTR modulators. A systematic approach to monitoring for AEs in people with CF on CFTR modulators in the real-world setting is necessary to help better understand potential AEs, as well as patient characteristics that may be associated with higher risk of certain AEs. Pharmacists play a key role in the safe initiation and monitoring of people with CF on CFTR modulator therapies.
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Douglas JE, Civantos AM, Locke TB, Sweis AM, Hadjiliadis D, Hong G, Dorgan DJ, Kohanski MA, Palmer JN, Adappa ND. Impact of novel CFTR modulator on sinonasal quality of life in adult patients with cystic fibrosis. Int Forum Allergy Rhinol 2020; 11:201-203. [PMID: 33070454 DOI: 10.1002/alr.22716] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 09/30/2020] [Accepted: 10/02/2020] [Indexed: 12/13/2022]
Affiliation(s)
- Jennifer E Douglas
- Department of Otorhinolaryngology-Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania Health System, Philadelphia, PA
| | - Alyssa M Civantos
- Department of Otorhinolaryngology-Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania Health System, Philadelphia, PA
| | - Tran B Locke
- Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, TX
| | - Auddie M Sweis
- Division of Otolaryngology-Head and Neck Surgery, NorthShore University Health System, The University of Chicago, Pritzker School of Medicine, Chicago, IL
| | - Denis Hadjiliadis
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Gina Hong
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Daniel J Dorgan
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Michael A Kohanski
- Department of Otorhinolaryngology-Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania Health System, Philadelphia, PA
| | - James N Palmer
- Department of Otorhinolaryngology-Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania Health System, Philadelphia, PA
| | - Nithin D Adappa
- Department of Otorhinolaryngology-Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania Health System, Philadelphia, PA
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Guerra L, Favia M, Di Gioia S, Laselva O, Bisogno A, Casavola V, Colombo C, Conese M. The preclinical discovery and development of the combination of ivacaftor + tezacaftor used to treat cystic fibrosis. Expert Opin Drug Discov 2020; 15:873-891. [PMID: 32290721 DOI: 10.1080/17460441.2020.1750592] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Cystic Fibrosis (CF) is caused by mutations in the Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) gene. The most common mutation, F508del, induces protein misprocessing and loss of CFTR function. The discovery through in vitro studies of the CFTR correctors (i.e. lumacaftor, tezacaftor) that partially rescue the misprocessing of F508del-CFTR with the potentiator ivacaftor is promising in giving an unprecedented clinical benefit in affected patients. AREAS COVERED Online databases were searched using key phrases for CF and CFTR modulators. Tezacaftor-ivacaftor treatment has proved to be safer than lumacaftor-ivacaftor, although clinical efficacy is similar. Further clinical efficacy has ensued with the introduction of triple therapy, i.e. applying second-generation correctors, such as VX-569 and VX-445 (elexacaftor) to tezacaftor-ivacaftor. The triple combinations will herald the availability of etiologic therapies for patients for whom no CFTR modulators are currently applied (i.e. F508del/minimal function mutations) and enhance CFTR modulator therapy for patients homozygous for F508del. EXPERT OPINION CF patient-derived tissue models are being explored to determine donor-specific response to current approved and future novel CFTR modulators for F508del and other rare mutations. The discovery and validation of biomarkers of CFTR modulation will complement these studies in the long term and in real-life world.
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Affiliation(s)
- Lorenzo Guerra
- Department of Biosciences, Biotechnologies and Biopharmaceutics, University of Bari , Bari, Italy
| | - Maria Favia
- Department of Biosciences, Biotechnologies and Biopharmaceutics, University of Bari , Bari, Italy
| | - Sante Di Gioia
- Department of Medical and Surgical Sciences, University of Foggia , Foggia, Italy
| | - Onofrio Laselva
- Programme in Molecular Medicine, Research Institute, Hospital for Sick Children , Toronto, Ontario, Canada.,Department of Physiology, University of Toronto , Toronto, Ontario, Canada
| | - Arianna Bisogno
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Centro Regionale di Riferimento per la Fibrosi Cistica, Università degli Studi di Milano , Milan, Italy
| | - Valeria Casavola
- Department of Biosciences, Biotechnologies and Biopharmaceutics, University of Bari , Bari, Italy
| | - Carla Colombo
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Centro Regionale di Riferimento per la Fibrosi Cistica, Università degli Studi di Milano , Milan, Italy
| | - Massimo Conese
- Department of Medical and Surgical Sciences, University of Foggia , Foggia, Italy
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Ridley K, Condren M. Elexacaftor- Tezacaftor-Ivacaftor: The First Triple-Combination Cystic Fibrosis Transmembrane Conductance Regulator Modulating Therapy. J Pediatr Pharmacol Ther 2020; 25:192-197. [PMID: 32265602 DOI: 10.5863/1551-6776-25.3.192] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Elexacaftor-tezacaftor-ivacaftor is a newly approved triple-combination cystic fibrosis transmembrane conductance regulator (CFTR) modulating therapy that contains 2 correctors and a potentiator of the CFTR channel. Its labeled indication for use is for persons 12 years of age and older with at least 1 F508del mutation for the CFTR gene. This drug combination provides potential therapy to many patients who had previously been excluded from CFTR modulation therapy due to the nature of their genetic mutations. The efficacy demonstrated in clinical trials surpasses the currently available therapies related to lung function, quality of life, sweat chloride reduction, and reducing exacerbations. The most common adverse events seen in clinical trials included rash and headache, and laboratory monitoring is recommended to evaluate liver function. Continued evaluation of patient data is needed to confirm its long-term safety and efficacy. Elexacaftor-tezacaftor-ivacaftor is a monumental and encouraging therapy for cystic fibrosis; however, approximately 10% of the CF population are not candidates for this or any other CFTR modulation therapy.
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28
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Lee SE, Farzal Z, Daniels MLA, Thorp BD, Zanation AM, Senior BA, Ebert CS, Kimple AJ. Cystic Fibrosis Transmembrane Conductance Regulator Modulator Therapy: A Review for the Otolaryngologist. Am J Rhinol Allergy 2020; 34:573-580. [PMID: 32168995 PMCID: PMC7573678 DOI: 10.1177/1945892420912368] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Background Cystic fibrosis (CF) is a genetic disease that may result in multiple systemic disorders and potentially fatal severe respiratory compromise. However, the advent of CF transmembrane conductance regulator (CFTR) modulators has changed the management of CF for patients with select mutations. Although clinical trials have highlighted increased pulmonary function and decreased exacerbations as a result of these novel therapies, their effect on the sinuses has not been well-described. Objective Our objective is to review the CFTR modulators to provide otolaryngologists, physicians who frequently care for patients with CF, a basic understanding of these drugs and their effects on chronic rhinosinusitis (CRS) in patients with CF. Methods The clinically approved and available CFTR modulators and specific indications for their use are reviewed. Additionally, a systematic review of these therapies and effects on CRS in CF was performed. Results Four Food and Drug Administration approved CFTR modulators are available for patients with CF. Current drugs are approved for gating, residual function, or F508del mutations. Multiple reports describe CFTR modulators’ increase in transepithelial ion transport in nasal epithelial cultures; however, clinical studies regarding effects of these modulators on sinonasal health are limited to 5 studies that present new data of the effects of CFTR modulators in CRS. Conclusions CFTR modulators have changed management of CF. Initial studies of these medications demonstrate promising results in CF; however, there is a paucity of literature describing the effect of CFTR modulators on CF-associated CRS, although initial results are encouraging.
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Affiliation(s)
- Saangyoung E Lee
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Zainab Farzal
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - M Leigh Anne Daniels
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Brian D Thorp
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Adam M Zanation
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Brent A Senior
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Charles S Ebert
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Adam J Kimple
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Jarosz-Griffiths HH, Scambler T, Wong CH, Lara-Reyna S, Holbrook J, Martinon F, Savic S, Whitaker P, Etherington C, Spoletini G, Clifton I, Mehta A, McDermott MF, Peckham D. Different CFTR modulator combinations downregulate inflammation differently in cystic fibrosis. eLife 2020; 9:54556. [PMID: 32118580 PMCID: PMC7062465 DOI: 10.7554/elife.54556] [Citation(s) in RCA: 67] [Impact Index Per Article: 16.8] [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: 01/03/2020] [Accepted: 02/28/2020] [Indexed: 12/14/2022] Open
Abstract
Previously, we showed that serum and monocytes from patients with CF exhibit an enhanced NLRP3-inflammasome signature with increased IL-18, IL-1β, caspase-1 activity and ASC speck release (Scambler et al. eLife 2019). Here we show that CFTR modulators down regulate this exaggerated proinflammatory response following LPS/ATP stimulation. In vitro application of ivacaftor/lumacaftor or ivacaftor/tezacaftor to CF monocytes showed a significant reduction in IL-18, whereas IL-1β was only reduced with ivacaftor/tezacaftor. Thirteen adults starting ivacaftor/lumacaftor and eight starting ivacaftor/tezacaftor were assessed over three months. Serum IL-18 and TNF decreased significantly with treatments, but IL-1β only declined following ivacaftor/tezacaftor. In (LPS/ATP-stimulated) PBMCs, IL-18/TNF/caspase-1 were all significantly decreased and IL-10 was increased with both combinations. Ivacaftor/tezacaftor alone showed a significant reduction in IL-1β and pro-IL-1β mRNA. This study demonstrates that these CFTR modulator combinations have potent anti-inflammatory properties, in addition to their ability to stimulate CFTR function, which could contribute to improved clinical outcomes.
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Affiliation(s)
- Heledd H Jarosz-Griffiths
- Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, United Kingdom.,Leeds Cystic Fibrosis Trust Strategic Research Centre, University of Leeds, Leeds, United Kingdom
| | - Thomas Scambler
- Leeds Cystic Fibrosis Trust Strategic Research Centre, University of Leeds, Leeds, United Kingdom.,Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, United Kingdom
| | - Chi H Wong
- Leeds Cystic Fibrosis Trust Strategic Research Centre, University of Leeds, Leeds, United Kingdom.,Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, United Kingdom
| | - Samuel Lara-Reyna
- Leeds Cystic Fibrosis Trust Strategic Research Centre, University of Leeds, Leeds, United Kingdom.,Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, United Kingdom
| | - Jonathan Holbrook
- Leeds Cystic Fibrosis Trust Strategic Research Centre, University of Leeds, Leeds, United Kingdom.,Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, United Kingdom
| | - Fabio Martinon
- Leeds Cystic Fibrosis Trust Strategic Research Centre, University of Leeds, Leeds, United Kingdom.,Department of Biochemistry, University of Lausanne, Epalinges, Switzerland
| | - Sinisa Savic
- Leeds Cystic Fibrosis Trust Strategic Research Centre, University of Leeds, Leeds, United Kingdom.,Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, United Kingdom.,Department of Clinical Immunology and Allergy, St James's University Hospital, Leeds, United Kingdom
| | - Paul Whitaker
- Adult Cystic Fibrosis Unit, St James's University Hospital, Leeds, United Kingdom
| | | | - Giulia Spoletini
- Adult Cystic Fibrosis Unit, St James's University Hospital, Leeds, United Kingdom
| | - Ian Clifton
- Adult Cystic Fibrosis Unit, St James's University Hospital, Leeds, United Kingdom
| | - Anil Mehta
- Division of Medical Sciences, University of Dundee, Dundee, United Kingdom
| | - Michael F McDermott
- Leeds Cystic Fibrosis Trust Strategic Research Centre, University of Leeds, Leeds, United Kingdom.,Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, United Kingdom
| | - Daniel Peckham
- Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, United Kingdom.,Leeds Cystic Fibrosis Trust Strategic Research Centre, University of Leeds, Leeds, United Kingdom.,Adult Cystic Fibrosis Unit, St James's University Hospital, Leeds, United Kingdom
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30
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Elexacaftor/ tezacaftor/ivacaftor (Trikafta) for cystic fibrosis. Med Lett Drugs Ther 2020; 62:5-7. [PMID: 31999662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
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Lommatzsch ST, Taylor-Cousar JL. The combination of tezacaftor and ivacaftor in the treatment of patients with cystic fibrosis: clinical evidence and future prospects in cystic fibrosis therapy. Ther Adv Respir Dis 2019; 13:1753466619844424. [PMID: 31027466 PMCID: PMC6487765 DOI: 10.1177/1753466619844424] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [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] [Indexed: 12/26/2022] Open
Abstract
Years of tremendous study have dawned a new era for the treatment of cystic fibrosis (CF). For years CF care was rooted in the management of organ dysfunction resulting from the mal-effects of absent anion transport through the CF transmembrane regulator (CFTR) protein. CFTR, an adenosine triphosphate binding anion channel, has multiple functions, but primarily regulates the movement of chloride anions, thiocyanate and bicarbonate across luminal cell membranes. Additional roles include effects on other electrolyte channels such as the epithelial sodium channel (ENaC) and on pulmonary innate immunity. Inappropriate luminal anion movement leads to elevated sweat chloride concentrations, dehydrated airway surface liquid, overall viscous mucous production, and inspissated bile and pancreatic secretions. As a result, patients develop the well-known CF symptoms and disease-defining complications such as chronic cough, oily stools, recurrent pulmonary infections, bronchiectasis, chronic sinusitis and malnutrition. Traditionally, CF has been symptomatically managed, but over the past 6 years those with CF have been offered a new mode of therapy; CFTR protein modulation. These medications affect the basic defect in CF: abnormal CFTR function. Ivacaftor, approved for use in the United States in 2012, is the first medication in CF history to improve CFTR function at the molecular level. Its study and approval were followed by two additional CFTR modulators, lumacaftor/ivacaftor and tezacaftor/ivacaftor. To effectively use currently available CF therapies, clinicians should be familiar with the side effects of the drugs and their impacts on patient outcomes. As many new modulators are on the horizon, this information will equip providers to discuss the benefits and shortcomings of modulator therapy especially in the context of limited healthcare resources.
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Abstract
Introduction: Cystic fibrosis (CF) is a complex, multi-system, genetic disease affecting over 70,000 people worldwide. The underlying defect is a mutation in the CFTR gene. Dysfunctional CFTR protein results in abnormal anion movement across epithelial membranes in affected organs. There has been a paradigm shift in CF treatment over the last decade with the advent of CFTR modulation, treatments which target this underlying genetic defect and have the potential to change the course of CF clinical disease.Areas covered: Available CFTR modulators in current clinical practice are reviewed in this article, with a direct comparison and summary of relevant pivotal clinical trials. The approval of ivacaftor and subsequent development of lumacaftor and tezacaftor dual combinations represents an exciting development in CF management in recent years.Expert opinion: Tezacaftor/ivacaftor (tez/iva) appears to have a more favorable adverse event and drug-drug interaction profile than lumacaftor/ivacaftor. Tez/iva has been approved, alongside Phe508del, for a large number of 'residual function' CFTR mutations, with some based on response to in vitro culture. Dual therapy with tez/iva has paved the way for triple CFTR modulation currently in clinical trials with an ultimate view to provide modulation therapy to the majority of CF genotypes in the future.
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Affiliation(s)
- Sarah L Paterson
- Manchester Adult Cystic Fibrosis Centre, Manchester NHS Foundation Trust, Wythenshawe Hospital, Wythenshawe, UK.,Division of Infection Immunity & Respiratory Medicine, Faculty of Biology Medicine and Health, University of Manchester, Manchester, UK
| | - Peter J Barry
- Manchester Adult Cystic Fibrosis Centre, Manchester NHS Foundation Trust, Wythenshawe Hospital, Wythenshawe, UK.,Division of Infection Immunity & Respiratory Medicine, Faculty of Biology Medicine and Health, University of Manchester, Manchester, UK
| | - Alexander R Horsley
- Manchester Adult Cystic Fibrosis Centre, Manchester NHS Foundation Trust, Wythenshawe Hospital, Wythenshawe, UK.,Division of Infection Immunity & Respiratory Medicine, Faculty of Biology Medicine and Health, University of Manchester, Manchester, UK
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Shiferaw D, Faruqi S. Profile of tezacaftor/ivacaftor combination and its potential in the treatment of cystic fibrosis. Ther Clin Risk Manag 2019; 15:1029-1040. [PMID: 31692517 PMCID: PMC6710479 DOI: 10.2147/tcrm.s165027] [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: 03/17/2019] [Accepted: 06/16/2019] [Indexed: 11/23/2022] Open
Abstract
Cystic fibrosis (CF) is a life-limiting autosomal recessive disease caused by dysfunction of the cystic fibrosis transmembrane conductance regulator (CFTR) ion channel. Management of CF has traditionally relied upon managing complications of CFTR protein dysfunction and this has led to a steady improvement in survival of CF patients. However, the landscape of CF care has changed substantially over the last decade with the discovery of CFTR modulators that aim to increase or potentially restore the function of the disease-causing CFTR protein. This narrative review summarizes the development of CFTR therapies so far with emphasis on tezacaftor/ivacaftor combination therapy. We have also summarized the Phase II results of triple combination therapy which promises an effective CFTR modulator therapy for more than 90% of CF patients.
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Affiliation(s)
- Dejene Shiferaw
- Department of Respiratory Medicine, Hull University Teaching Hospitals NHS Trust, CottinghamHU16 5JQ, UK
| | - Shoaib Faruqi
- Department of Respiratory Medicine, Hull University Teaching Hospitals NHS Trust, CottinghamHU16 5JQ, UK
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Tezacaftor/Ivacaftor (Symdeko) for cystic fibrosis. Med Lett Drugs Ther 2018; 60:174-6. [PMID: 30335045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
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Abstract
INTRODUCTION Cystic fibrosis (CF) is the most common, life-limiting autosomal recessive disease in Caucasians, and is caused by defects in production of the CFTR ion channel. Until recently, there were no available treatments targeting the disease-causing defects in CFTR but newly developed CFTR modulators are changing the course of disease in CF. The newest modulator, tezacaftor, is a CFTR corrector that was recently approved by the FDA to be used in combination with the first approved CFTR potentiator, ivacaftor. Areas covered: A detailed review of the clinical trials and published literature, focusing on safety and efficacy, leading to the approval of tezacaftor in CF. Expert commentary: Recent trials have demonstrated that the combination of tezacaftor-ivacaftor is a slightly superior combination to its predecessor, lumacaftor-ivacaftor, with respect to an increase in FEV1, adverse event profile, and drug-drug interactions. It is also approved for a large number of non-F508del, residual function mutations that are predicted to respond based on in vitro testing. The horizon for continued improvements in CFTR-targeted treatments is promising, with three-drug combinations currently in Phase 3 clinical trials, and other drugs with novel mechanisms of action being studied. Within the next 5 years, the vast majority of patients with CF are expected to have a modulator approved for their genotype.
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Affiliation(s)
- Marc A Sala
- a Division of Pulmonary and Critical Care Medicine, Feinberg School of Medicine , Northwestern University , Chicago , IL , USA
| | - Manu Jain
- a Division of Pulmonary and Critical Care Medicine, Feinberg School of Medicine , Northwestern University , Chicago , IL , USA
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Abstract
INTRODUCTION Cystic fibrosis (CF) outcomes and survival have improved over the last century primarily due to advancements in antibiotics, nutritional, and pulmonary therapies. Reviewed here are the significant unmet needs that exist for individuals with CF. Areas covered: With the recent development of medications that address the underlying defect in the CF protein, there is hope that there will be continued improvement in CF outcomes. However, there remains a need to prevent or stop progression of CF-related complications, as the CF protein is important to several body systems. As end stage lung disease is the primary cause of mortality in CF, a need exists for advancements in pulmonary therapies to reduce time burden, identification of best practices for the treatment of pulmonary exacerbations, further development of anti-infective and anti-inflammatory therapies, and appropriately timed referral for lung transplantation at end-stage lung disease. Extra-pulmonary complications are increasingly recognized and better understanding of such problems as CF related liver disease is needed. Expert commentary: While CFTR modulators are available for the majority of CF patients, there remains a need for effective therapies to address infection, inflammation, irreversible lung disease, and extrapulmonary complications of CF.
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Affiliation(s)
- Natalie E West
- a Department of Medicine, Division of Pulmonary and Critical Care Medicine , Johns Hopkins University , Baltimore , USA
| | - Patrick A Flume
- b Departments of Medicine and Pediatrics , Medical University of South Carolina , Charleston , SC , USA
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