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Topping J, Taylor A, Nadat F, Crouch S, Ibbotson A, Čermák J, Symeonidis A, Tatic A, Langemeijer S, Hellström-Lindberg E, Culligan D, Garelius HG, Ashcroft J, Nga E, Parker J, Kolade S, McDermott MF, De Witte T, Bowen D, Smith A, Cargo C, Savic S. Inflammatory profile of lower risk myelodysplastic syndromes. Br J Haematol 2024. [PMID: 38772913 DOI: 10.1111/bjh.19530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 05/06/2024] [Indexed: 05/23/2024]
Abstract
The precise link between inflammation and pathogenesis of myelodysplastic syndrome (MDS) is yet to be fully established. We developed a novel method to measure ASC/NLRP3 protein specks which are specific for the NLRP3 inflammasome only. We combined this with cytokine profiling to characterise various inflammatory markers in a large cohort of patients with lower risk MDS in comparison to healthy controls and patients with defined autoinflammatory disorders (AIDs). The ASC/NLRP3 specks were significantly elevated in MDS patients compared to healthy controls (p < 0.001) and these levels were comparable to those found in patients with AIDs. The distribution of protein specks positive only for ASC was different to ASC/NLRP3 ones suggesting that other ASC-containing inflammasome complexes might be important in the pathogenesis of MDS. Patients with MDS-SLD had the lowest levels of interleukin (IL)-1β, tumour necrosis factor (TNF), IL-23, IL-33, interferon (IFN) γ and IFN-α2, compared to other diagnostic categories. We also found that inflammatory cytokine TNF was positively associated with MDS progression to a more aggressive form of disease and IL-6 and IL-1β with time to first red blood cell transfusion. Our study shows that there is value in analysing inflammatory biomarkers in MDS, but their diagnostic and prognostic utility is yet to be fully validated.
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Affiliation(s)
- Joanne Topping
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Adele Taylor
- Epidemiology and Cancer Statistics Group, University of York, York, UK
| | - Fatima Nadat
- Department of Clinical Immunology and Allergy, St James's University Hospital, Leeds, UK
| | - Simon Crouch
- Epidemiology and Cancer Statistics Group, University of York, York, UK
| | - Alice Ibbotson
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Jaroslav Čermák
- Department of Clinical Hematology, Institute of Hematology and Blood Transfusion, Praha, Czech Republic
| | - Argiris Symeonidis
- Division of Hematology, Department of Internal Medicine, University of Patras Medical School, Patras, Greece
| | - Aurelia Tatic
- Center of Hematology and Bone Marrow Transplantation, Fundeni Clinical Institute, Bucharest, Romania
| | - Saskia Langemeijer
- Department of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Eva Hellström-Lindberg
- Division of Hematology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Dominic Culligan
- Department of Haematology, Aberdeen Royal Infirmary, Aberdeen, UK
| | | | - John Ashcroft
- Department of Hematology, Mid Yorkshire Hospitals, Wakefield, UK
| | - Emma Nga
- Department of Haematology, Royal Blackburn Teaching Hospital, Blackburn, Lancashire, UK
| | - Jane Parker
- Northampton General Hospital, Northampton, UK
| | - Seye Kolade
- Department of Haematology, Blackpool Victoria Hospital, Blackpool, Lancashire, UK
| | - Michael F McDermott
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Theo De Witte
- Department of Tumor Immunology, Nijmegen Center for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - David Bowen
- Epidemiology and Cancer Statistics Group, University of York, York, UK
| | - Alexandra Smith
- Epidemiology and Cancer Statistics Group, University of York, York, UK
| | - Catherine Cargo
- Haematological Malignancy Diagnostic Service, St James's University Hospital, Leeds, UK
| | - Sinisa Savic
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- National Institute for Health Research-Leeds Biomedical Research Centre, Leeds, UK
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Wong HMC, Cheung BCS, Yuen VWF, Teoh JYC, Chiu PKF, Ng CF. Patient preference on once-daily oral versus injectable androgen deprivation therapy for Asian patients with advanced prostate cancer. Int Urol Nephrol 2024:10.1007/s11255-024-04028-2. [PMID: 38512441 DOI: 10.1007/s11255-024-04028-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 03/08/2024] [Indexed: 03/23/2024]
Abstract
PURPOSE The study aimed at investigating prostate cancer patients' choice of androgen deprivation treatment (ADT) and possible factors that would affect their preferences of ADT. METHODS This was a single-centre cross-sectional study investigating the usage and preferences of ADT. Consecutives prostate cancer patients who were receiving injectable luteinizing hormone-releasing hormone (LHRH) agonist or antagonist were recruited from the prostate cancer clinic in a tertiary academic hospital. Patients who received bilateral orchidectomy or those who could not consent to the study were excluded. Disease characteristics, treatment information and patient background were documented. The survey collected information related to their change in ADT regimen, preferences on drug usage (routes and frequency of administration) and their reasons. A hypothetical set of three drug formularies was designed. Questions regarding patient preference and the contributing reasons raised in the format of questionnaire. RESULTS 100 patients completed the survey. Most patients started with more frequent injections (3-monthly, 54%; 1-monthly, 38%) and switched to 6-monthly injections (89%) at the time of the survey. Primary reasons for the change were healthcare opinion (72%) and less frequent treatment (51%). Three options of ADT (oral daily, 1-monthly and 6-monthly injection) with the same efficacies and side effect profile were offered: 61% preferred 6-monthly injection, 1% preferred 1-monthly injection and 38% preferred oral regimen. When patients were informed of lower cardiovascular side effects in 1-monthly injection or daily oral drug, patients' preference was 56% (6-monthly), 6% (1-monthly), and 39% (oral). Patients with polypharmacy (more than 5 regular medications) were more inclined to choose injections (p = 0.025). Patient age, educational background, employment status, marriage status and disease status were not found to be statistically significant contributing factors to patient preference. CONCLUSION 6-monthly ADT injection was the preferred ADT despite greater cardiovascular risks. Among 1-monthly or daily oral LHRH antagonist, more patients prefer oral option. Convenience factor was highly valued.
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Affiliation(s)
- Ho-Ming Chris Wong
- Division of Urology, Department of Surgery, Faculty of Medicine, SH Ho Urology Centre, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Bernice Cheuk-Sin Cheung
- Division of Urology, Department of Surgery, Faculty of Medicine, SH Ho Urology Centre, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Violet Wai-Fan Yuen
- Division of Urology, Department of Surgery, Faculty of Medicine, SH Ho Urology Centre, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Jeremy Yuen-Chun Teoh
- Division of Urology, Department of Surgery, Faculty of Medicine, SH Ho Urology Centre, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Peter Ka-Fung Chiu
- Division of Urology, Department of Surgery, Faculty of Medicine, SH Ho Urology Centre, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Chi-Fai Ng
- Division of Urology, Department of Surgery, Faculty of Medicine, SH Ho Urology Centre, The Chinese University of Hong Kong, Hong Kong SAR, China.
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Pfrepper C, Klamroth R, Ettingshausen CE, Petros S, Siegemund A, Siegemund T. Measurement of recombinant porcine factor VIII in patients with congenital haemophilia A and inhibitors in the presence of emicizumab. Haemophilia 2024; 30:545-553. [PMID: 38343119 DOI: 10.1111/hae.14955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 01/23/2024] [Accepted: 01/23/2024] [Indexed: 03/14/2024]
Abstract
INTRODUCTION Recombinant porcine factor VIII (rpFVIII) is a treatment option for break-through bleeds in patients with congenital haemophilia A with inhibitors (CHAwI) on emicizumab. However, there are limited data about the measurement of rpFVIII in the presence of emicizumab. AIM To analyse whether rpFVIII can be measured with a chromogenic assay with bovine component (bCSA) in plasma from CHAwI on emicizumab treatment. METHODS In the first part of the study, FVIII deficient plasma was spiked with rpFVIII, in the second part, commercial plasma from CHAwI was spiked with emicizumab and rpFVIII, and in the third part, plasma from CHAwI on emicizumab treatment was spiked with rpFVIII. FVIII was then measured with bCSA and a chromogenic assay with human component (hCSA). Thrombin generation (TG) and clot-waveform analysis (CWA) were also carried out. RESULTS The recovery of rpFVIII measured with bCSA is approximately 80% and is further influenced by the presence of an anti-porcine inhibitor. rpFVIII assessed with hCSA was influenced by emicizumab. CWA and TG showed a weak correlation with baseline emicizumab concentration, but peak thrombin and CWA correlated well with increasing emicizumab concentrations and rpFVIII activities. CONCLUSION This study indicates that rpFVIII can be measured in the presence of emicizumab with a bCSA. A calibration curve for the measurement of rpFVIII with bCSA should be established.
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Affiliation(s)
- Christian Pfrepper
- Division of Hemostaseology, Department of Hematology, Cellular Therapy, Hemostaseology and Infectiology, University of Leipzig Medical Centre, Leipzig, Germany
| | - Robert Klamroth
- Department for Internal Medicine Vascular Medicine and Hemostaseology Vivantes Klinikum im Friedrichshain, Berlin, Germany
| | | | - Sirak Petros
- Division of Hemostaseology, Department of Hematology, Cellular Therapy, Hemostaseology and Infectiology, University of Leipzig Medical Centre, Leipzig, Germany
- Medical ICU, University of Leipzig Medical Centre, Leipzig, Germany
| | - Annelie Siegemund
- Division of Hemostaseology, Department of Hematology, Cellular Therapy, Hemostaseology and Infectiology, University of Leipzig Medical Centre, Leipzig, Germany
- MVZ Limbach Magdeburg, Magdeburg, Germany
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Kanegane H, Endo A, Okada S, Ohnishi H, Ishimura M, Nishikomori R, Imai K, Nonoyama S, Muramatsu H, Wada T, Kuga A, Sakamoto K, Russo-Schwarzbaum S, Chu LH, McCoy B, Li Z, Yel L. Pharmacokinetics, safety, and efficacy of 20% subcutaneous immunoglobulin (Ig20Gly) administered weekly or every 2 weeks in Japanese patients with primary immunodeficiency diseases: a phase 3, open-label study. Immunother Adv 2024; 4:ltae001. [PMID: 38511087 PMCID: PMC10953624 DOI: 10.1093/immadv/ltae001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 02/29/2024] [Indexed: 03/22/2024] Open
Abstract
This phase 3, open-label, multidose study (NCT04346108) evaluated the pharmacokinetics, safety, tolerability, and efficacy of immunoglobulin subcutaneous (human) 20% solution (Ig20Gly) administered weekly and every 2 weeks in Japanese patients with primary immunodeficiency diseases (PIDs). The study was conducted at eight study sites in Japan and enrolled patients aged ≥2 years with PIDs treated using a stable intravenous immunoglobulin dose for ≥3 months prior to the study. Patients received intravenous immunoglobulin every 3 or 4 weeks at pre-study dose (200-600 mg/kg) for 13 weeks (Epoch 1), subcutaneous Ig20Gly (50-200 mg/kg) once weekly for 24 weeks (Epoch 2), and Ig20Gly (100-400 mg/kg) every 2 weeks for 12 weeks (Epoch 3). The primary endpoint was serum total immunoglobulin G (IgG) trough levels during Epochs 2 and 3. Overall, 17 patients were enrolled (median [range] age: 24 [5-69] years; 59% male) and participated in Epochs 1 and 2; seven patients entered Epoch 3. Serum total IgG trough levels were maintained at >8 g/l: geometric means (95% confidence intervals) at the end of Epochs 2 and 3 were 8.56 (8.03-9.12) g/l and 8.39 (7.89-8.91) g/l, respectively. Related treatment-emergent adverse events were all mild in severity; the most common treatment-emergent adverse events (excluding infections) in Epochs 2 and 3 were injection site swelling (24%) and injection site erythema (18%). This is the first trial to demonstrate the efficacy and favourable safety profile of 20% subcutaneous immunoglobulin administered every 2 weeks in adult and paediatric Japanese patients with PIDs.
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Affiliation(s)
- Hirokazu Kanegane
- Department of Child Health and Development, Tokyo Medical and Dental University, Tokyo, Japan
| | - Akifumi Endo
- Department of Child Health and Development, Tokyo Medical and Dental University, Tokyo, Japan
| | - Satoshi Okada
- Department of Pediatrics, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
| | | | - Masataka Ishimura
- Department of Pediatrics, Kyushu University Hospital, Fukuoka, Japan
| | - Ryuta Nishikomori
- Department of Pediatrics and Child Health, Kurume University Hospital, Fukuoka, Japan
| | - Kohsuke Imai
- Department of Pediatrics, National Defense Medical College, Saitama, Japan
| | - Shigeaki Nonoyama
- Department of Pediatrics, National Defense Medical College, Saitama, Japan
| | - Hideki Muramatsu
- Department of Pediatrics, Nagoya University Hospital, Aichi, Japan
| | - Taizo Wada
- Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University Hospital, Ishikawa, Japan
| | - Atsushi Kuga
- Takeda Pharmaceutical Company Limited, Osaka, Japan
| | - Ko Sakamoto
- Takeda Pharmaceutical Company Limited, Osaka, Japan
| | | | - Liang-Hui Chu
- Takeda Development Center Americas, Inc., Cambridge, MA, USA
| | - Barbara McCoy
- Baxalta Innovations GmbH, a Takeda company, Vienna, Austria
| | - Zhaoyang Li
- Takeda Development Center Americas, Inc., Cambridge, MA, USA
| | - Leman Yel
- Takeda Development Center Americas, Inc., Cambridge, MA, USA
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Kopylov U, Burisch J, Ben-Horin S, Braegger F, Fernández-Nistal A, Lara N, Heinrich HS, Vavricka SR. Impact of Vedolizumab on Extraintestinal Manifestations in Inflammatory Bowel Disease: Results From a Descriptive, Retrospective, Real-world Study. Inflamm Bowel Dis 2023; 29:1713-1722. [PMID: 37158585 PMCID: PMC10628928 DOI: 10.1093/ibd/izad075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Indexed: 05/10/2023]
Abstract
BACKGROUND Patients with inflammatory bowel disease (IBD), including Crohn's disease and ulcerative colitis, may develop extraintestinal manifestations (EIMs). The EMOTIVE study aimed to analyze the effect of vedolizumab on EIMs in a real-world cohort of patients with IBD. METHODS This multicenter, descriptive, retrospective study was conducted in Belgium, Denmark, Israel, the Netherlands, and Switzerland in adults with moderately to severely active IBD and concurrent active EIMs at vedolizumab initiation (index date), with a ≥6-month follow-up after the index date. The primary endpoint was resolution of all EIMs within 6 months of vedolizumab initiation. RESULTS In 99 eligible patients, the most frequent EIMs were arthralgia (69.7%), peripheral spondyloarthritis (21.2%), and axial spondyloarthritis (10.1%). Within 6 and 12 months of vedolizumab initiation, 19.2% and 25.3% of patients reported resolution of all EIMs, while 36.5% and 49.5% of all EIMs were reported to be improved (combination of resolution and partial response), respectively. Vedolizumab treatment persistence at 12 months was 82.8%. Adverse events were reported in 18.2% of patients, with the most frequent being arthralgia (4.0%). CONCLUSIONS This real-world study showed resolution of all EIMs in up to one-fourth of patients with IBD and improvement in up to half of EIMs within 12 months of vedolizumab treatment. Overall, vedolizumab was effective on EIMs in patients with IBD and showed a good safety profile.
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Affiliation(s)
- Uri Kopylov
- Gastroenterology Institute, Sheba Medical Center, Tel HaShomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Johan Burisch
- Gastrounit, Medical Division, Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark
- Copenhagen Center for Inflammatory Bowel Disease in Children, Adolescents and Adults, Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark
| | - Shomron Ben-Horin
- Gastroenterology Institute, Sheba Medical Center, Tel HaShomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Fiona Braegger
- Takeda Pharmaceuticals International AG, Zürich, Switzerland
| | | | - Nuria Lara
- IQVIA, Real World Evidence Solutions, Barcelona, Spain
| | - Henriette Sophie Heinrich
- Gastroenterology and Hepatology, Clarunis–Universitäres Bauchzentrum Basel, Basel, Switzerland
- Department of Gastroenterology and Hepatology, University Hospital Zürich, Zürich, Switzerland
| | - Stephan R Vavricka
- Department of Gastroenterology and Hepatology, University Hospital Zürich, Zürich, Switzerland
- Center for Gastroenterology and Hepatology AG, Zürich, Switzerland
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Panayi A, Ward K, Benhadji-Schaff A, Ibanez-Lopez AS, Xia A, Barzilay R. Evaluation of a prototype machine learning tool to semi-automate data extraction for systematic literature reviews. Syst Rev 2023; 12:187. [PMID: 37803451 PMCID: PMC10557215 DOI: 10.1186/s13643-023-02351-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 09/13/2023] [Indexed: 10/08/2023] Open
Abstract
BACKGROUND Evidence-based medicine requires synthesis of research through rigorous and time-intensive systematic literature reviews (SLRs), with significant resource expenditure for data extraction from scientific publications. Machine learning may enable the timely completion of SLRs and reduce errors by automating data identification and extraction. METHODS We evaluated the use of machine learning to extract data from publications related to SLRs in oncology (SLR 1) and Fabry disease (SLR 2). SLR 1 predominantly contained interventional studies and SLR 2 observational studies. Predefined key terms and data were manually annotated to train and test bidirectional encoder representations from transformers (BERT) and bidirectional long-short-term memory machine learning models. Using human annotation as a reference, we assessed the ability of the models to identify biomedical terms of interest (entities) and their relations. We also pretrained BERT on a corpus of 100,000 open access clinical publications and/or enhanced context-dependent entity classification with a conditional random field (CRF) model. Performance was measured using the F1 score, a metric that combines precision and recall. We defined successful matches as partial overlap of entities of the same type. RESULTS For entity recognition, the pretrained BERT+CRF model had the best performance, with an F1 score of 73% in SLR 1 and 70% in SLR 2. Entity types identified with the highest accuracy were metrics for progression-free survival (SLR 1, F1 score 88%) or for patient age (SLR 2, F1 score 82%). Treatment arm dosage was identified less successfully (F1 scores 60% [SLR 1] and 49% [SLR 2]). The best-performing model for relation extraction, pretrained BERT relation classification, exhibited F1 scores higher than 90% in cases with at least 80 relation examples for a pair of related entity types. CONCLUSIONS The performance of BERT is enhanced by pretraining with biomedical literature and by combining with a CRF model. With refinement, machine learning may assist with manual data extraction for SLRs.
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Affiliation(s)
- Antonia Panayi
- Takeda Pharmaceuticals International AG, Thurgauerstrasse 130, 8152, Glattpark-Opfikon, Zurich, Switzerland.
| | | | | | | | - Andrew Xia
- Takeda Pharmaceuticals International AG, Thurgauerstrasse 130, 8152, Glattpark-Opfikon, Zurich, Switzerland
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Olsen BC, Opheim R, Kristensen VA, Høivik ML, Lund C, Aabrekk TB, Johansen I, Holten K, Strande V, Bengtson MB, Ricanek P, Detlie TE, Bernklev T, Jelsness-Jørgensen LP, Huppertz-Hauss G. Health-related quality of life in patients with newly diagnosed inflammatory bowel disease: an observational prospective cohort study (IBSEN III). Qual Life Res 2023; 32:2951-2964. [PMID: 37219727 PMCID: PMC10473983 DOI: 10.1007/s11136-023-03435-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/04/2023] [Indexed: 05/24/2023]
Abstract
PURPOSE This unselected, population-based cohort study aimed to determine the level of health-related quality of life (HRQoL) in patients with Crohn's disease (CD) and ulcerative colitis (UC) at the time of diagnosis compared with a reference population and identify the demographic factors, psychosocial measures, and disease activity markers associated with HRQoL. METHODS Adult patients newly diagnosed with CD or UC were prospectively enrolled. HRQoL was measured using the Short Form 36 (SF-36) and Norwegian Inflammatory Bowel Disease Questionnaires. Clinical significance was assessed using Cohen's d effect size and further compared with a Norwegian reference population. Associations between HRQoL and symptom scores, demographic factors, psychosocial measures, and disease activity markers were analyzed. RESULTS Compared with the Norwegian reference population, patients with CD and UC reported significantly lower scores in all SF-36 dimensions, except for physical functioning. Cohen's d effect sizes for men and women in all SF-36 dimensions were at least moderate, except for bodily pain and emotional role for men with UC and physical functioning for both sexes and diagnoses. In the multivariate regression analysis, depression subscale scores ≥ 8 on the Hospital Anxiety and Depression Scale, substantial fatigue, and high symptom scores were associated with reduced HRQoL. CONCLUSION Patients newly diagnosed with CD and UC reported statistically and clinically significantly lower scores in seven of the eight SF-36 dimensions than the reference population. Symptoms of depression, fatigue, and elevated symptom scores were associated with poorer HRQoL.
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Affiliation(s)
- Bjorn Christian Olsen
- Department of Gastroenterology, Skien Hospital, Telemark Hospital Trust, Ulefossvegen 55, 3710, Skien, Norway.
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Randi Opheim
- Department of Gastroenterology, Oslo University Hospital, Oslo, Norway
- Department of Nursing Science, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Vendel A Kristensen
- Department of Gastroenterology, Oslo University Hospital, Oslo, Norway
- Unger-Vetlesen Institute, Lovisenberg Diaconal Hospital, Oslo, Norway
| | - Marte Lie Høivik
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Gastroenterology, Oslo University Hospital, Oslo, Norway
| | - Charlotte Lund
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Gastroenterology, Oslo University Hospital, Oslo, Norway
| | - Tone Bergene Aabrekk
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Vestfold Hospital Trust, Research and Development, Tønsberg, Norway
| | - Ingunn Johansen
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Faculty of Health, Welfare and Organisation, Østfold University College, Halden, Norway
| | - Kristina Holten
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Gastroenterology, Østfold Hospital Trust, Sarpsborg, Norway
| | - Vibeke Strande
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Unger-Vetlesen Institute, Lovisenberg Diaconal Hospital, Oslo, Norway
| | | | - Petr Ricanek
- Department of Gastroenterology, Akershus University Hospital, Lørenskog, Norway
| | - Trond Espen Detlie
- Department of Gastroenterology, Akershus University Hospital, Lørenskog, Norway
| | - Tomm Bernklev
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Vestfold Hospital Trust, Research and Development, Tønsberg, Norway
| | - Lars-Petter Jelsness-Jørgensen
- Faculty of Health, Welfare and Organisation, Østfold University College, Halden, Norway
- Department of Gastroenterology, Østfold Hospital Trust, Sarpsborg, Norway
| | - Gert Huppertz-Hauss
- Department of Gastroenterology, Skien Hospital, Telemark Hospital Trust, Ulefossvegen 55, 3710, Skien, Norway
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Speca S, Farhat MM, Jendoubi M, Guerrier T, Sanges S, Staumont-Sallé D, Hachulla E, Dubucquoi S, Sobanski V, Collet A, Launay D. Intravenous immunoglobulins improve skin fibrosis in experimental models of systemic sclerosis. Sci Rep 2023; 13:15102. [PMID: 37700078 PMCID: PMC10497569 DOI: 10.1038/s41598-023-42464-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 09/11/2023] [Indexed: 09/14/2023] Open
Abstract
Systemic sclerosis (SSc) is the most severe systemic autoimmune disease with currently no cure. Intravenous immunoglobulins (IVIg) are an attractive candidate in this disease to counteract inflammation and fibrosis but data are scarce and conflicting. This study, assessed the effects of IVIg in a murine HOCl-induced model of SSc. We showed that IVIg prevented skin inflammation and fibrosis, by mitigating the immune cell infiltration (p = 0.04), proinflammatory cytokines gene overexpression (IL1β, p = 0.04; TNFα, p = 0.04; IL6, p = 0.05), skin and dermal thickening (p = 0.003 at d21 and p = 0.0003 at d42), the expression markers of fibrosis, such as αSMA (p = 0.031 for mRNA and p = 0.05 for protein), collagen (p = 0.05 for mRNA and p = 0.04 for protein, p = 0.05 for the hydroxyproline content) and fibronectin (p = 0.033 for mRNA). Moreover, IVIg prevented HOCl-induced alterations in splenic cell homeostasis. When administered in curative mode, despite their ability to reduce skin and dermal thickness (p < 0.0001 and p = 0.0002), IVIg showed partial or more mixed effects on skin inflammation and established fibrosis. These data favor further clinical trials in SSc patients on the potential efficiency of early and/or repeated IVIg administration.
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Affiliation(s)
- Silvia Speca
- University of Lille, Inserm, CHU Lille, U1286-INFINITE-Institute for Translational Research in Inflammation, Lille, France
| | - Meryem-Maud Farhat
- University of Lille, Inserm, CHU Lille, U1286-INFINITE-Institute for Translational Research in Inflammation, Lille, France
- Département de Médecine Interne Et Immunologie Clinique, Centre de Référence Des Maladies Auto-Immunes Systémiques Rares du Nord Et Nord-Ouest de France (CeRAINO), CHU Lille, Lille, France
| | - Manel Jendoubi
- University of Lille, Inserm, CHU Lille, U1286-INFINITE-Institute for Translational Research in Inflammation, Lille, France
| | - Thomas Guerrier
- University of Lille, Inserm, CHU Lille, U1286-INFINITE-Institute for Translational Research in Inflammation, Lille, France
| | - Sébastien Sanges
- University of Lille, Inserm, CHU Lille, U1286-INFINITE-Institute for Translational Research in Inflammation, Lille, France
- Département de Médecine Interne Et Immunologie Clinique, Centre de Référence Des Maladies Auto-Immunes Systémiques Rares du Nord Et Nord-Ouest de France (CeRAINO), CHU Lille, Lille, France
| | - Delphine Staumont-Sallé
- University of Lille, Inserm, CHU Lille, U1286-INFINITE-Institute for Translational Research in Inflammation, Lille, France
- Service de Dermatologie, CHU Lille, Lille, France
| | - Eric Hachulla
- University of Lille, Inserm, CHU Lille, U1286-INFINITE-Institute for Translational Research in Inflammation, Lille, France
- Département de Médecine Interne Et Immunologie Clinique, Centre de Référence Des Maladies Auto-Immunes Systémiques Rares du Nord Et Nord-Ouest de France (CeRAINO), CHU Lille, Lille, France
| | - Sylvain Dubucquoi
- University of Lille, Inserm, CHU Lille, U1286-INFINITE-Institute for Translational Research in Inflammation, Lille, France
- Institut d'Immunologie, Centre de Biologie Pathologie, CHU Lille, Lille, France
| | - Vincent Sobanski
- University of Lille, Inserm, CHU Lille, U1286-INFINITE-Institute for Translational Research in Inflammation, Lille, France
- Département de Médecine Interne Et Immunologie Clinique, Centre de Référence Des Maladies Auto-Immunes Systémiques Rares du Nord Et Nord-Ouest de France (CeRAINO), CHU Lille, Lille, France
| | - Aurore Collet
- University of Lille, Inserm, CHU Lille, U1286-INFINITE-Institute for Translational Research in Inflammation, Lille, France
- Institut d'Immunologie, Centre de Biologie Pathologie, CHU Lille, Lille, France
| | - David Launay
- University of Lille, Inserm, CHU Lille, U1286-INFINITE-Institute for Translational Research in Inflammation, Lille, France.
- Département de Médecine Interne Et Immunologie Clinique, Centre de Référence Des Maladies Auto-Immunes Systémiques Rares du Nord Et Nord-Ouest de France (CeRAINO), CHU Lille, Lille, France.
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Spinelli A, Yanai H, Girardi P, Milicevic S, Carvello M, Maroli A, Avedano L. The Impact of Crohn's Perianal Fistula on Quality of Life: Results of an International Patient Survey. Crohns Colitis 360 2023; 5:otad036. [PMID: 37529012 PMCID: PMC10390083 DOI: 10.1093/crocol/otad036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Indexed: 08/03/2023] Open
Abstract
Background Crohn's perianal fistula is a disabling manifestation of Crohn's disease. However, the additional burden of perianal fistula on patients with only Crohn's disease remains to be addressed. This patient-reported survey considered outcomes of two domains: "diagnosis" (eg, symptoms) and "living with the disease" (eg, quality of life, well-being, and relationships). Methods Patients with perianal fistula and Crohn's disease completed an online, self-selective, anonymous, 46-item survey available in 11 languages hosted on the European Federation of Crohn's & Ulcerative Colitis Associations and national patient association websites. The survey was conducted between July and December 2019 in Europe and other regions. Likert scales and closed questions were used to assess outcomes. Results Of the 820 respondents with Crohn's disease (67.2% women; median age, 40.0 years), 532 (64.9%) reported the presence of perianal fistula. Patients with perianal fistula reported a greater impact on overall quality of life (P < .001), well-being (P < .001), relationships (P < .001), social life (P = .001), and work life (P = .012) than patients with only Crohn's disease. Conclusions Perianal fistulas impact several domains of the life of patients with Crohn's disease. These results may help healthcare practitioners plan therapeutic strategies that address the symptomatic and psychological burden experienced by patients with perianal fistulizing Crohn's disease.
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Affiliation(s)
- Antonino Spinelli
- Address correspondence to: Antonino Spinelli, MD, Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Pieve Emanuele, Milan, Italy; Division of Colon and Rectal Surgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, Milan, Italy, Tel: +390282244513, Fax: +390282244590 ()
| | - Henit Yanai
- IBD Center, Division of Gastroenterology, Rabin Medical Center, 4941492 Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, 6997801 Tel Aviv, Israel
| | - Paolo Girardi
- Department of Environmental Science, Informatics and Statistics, Ca’ Foscari University of Venice, 30123 Venice, Italy
| | - Slobodan Milicevic
- Takeda Pharmaceuticals International AG, Glattpark-Opfikon, 8152 Zürich, Switzerland
| | - Michele Carvello
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Pieve Emanuele, Milan, Italy
- Division of Colon and Rectal Surgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, Milan, Italy
| | - Annalisa Maroli
- Division of Colon and Rectal Surgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, Milan, Italy
| | - Luisa Avedano
- European Federation of Crohn’s & Ulcerative Colitis Associations, 1000 Brussels, Belgium
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10
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Thisyakorn U, Saokaew S, Gallagher E, Kastner R, Sruamsiri R, Oliver L, Hanley R. Epidemiology and costs of dengue in Thailand: A systematic literature review. PLoS Negl Trop Dis 2022; 16:e0010966. [PMID: 36534668 PMCID: PMC9810168 DOI: 10.1371/journal.pntd.0010966] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 01/03/2023] [Accepted: 11/19/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Dengue is the fastest-spreading vector-borne viral disease worldwide. In Thailand, dengue is endemic and is associated with a high socioeconomic burden. A systematic literature review was conducted to assess and describe the epidemiological and economic burden of dengue in Thailand. METHODS Epidemiological and economic studies published in English and Thai between 2011-2019 and 2009-2019, respectively, were searched in MEDLINE, Embase, and Evidence-Based Medicines reviews databases. Reports published by the National Ministry of Public Health (MoPH) and other grey literature sources were also reviewed. Identified studies were screened according to predefined inclusion and exclusion criteria. Extracted data were descriptively summarised and reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. RESULTS A total of 155 publications were included in the review (39 journal articles and 116 grey literature). Overall, dengue incidence varied yearly, with the highest rates per 100,000 population in 2013 (dengue fever (DF) 136.6, dengue haemorrhagic fever (DHF) 100.9, dengue shock syndrome (DSS) 3.58) and 2015 (DF 133.1, DHF 87.4, DSS 2.14). Peak incidence coincided with the monsoon season, and annual mortality was highest for DSS, particularly in the age group 15-24-year-olds. The highest dengue incidence rates were reported in children (10-14-year-olds) and young adults (15-24-year-olds), irrespective of dengue case definition. Economic and societal burdens are extensive, with the average cost per case ranging from USD 41 to USD 261, total cost per year estimated at USD 440.3 million, and an average of 7.6 workdays lost for DHF and 6.6 days for DF. CONCLUSIONS The epidemiological, economic, and societal burden of dengue in Thailand is high and underreported due to gaps in national surveillance data. The use of expansion factors (EFs) is recommended to understand the true incidence of dengue and cost-benefit of control measures. Furthermore, as dengue is often self-managed and underreported, lost school and workdays result in substantial underestimation of the true economic and societal burden of dengue. The implementation of integrated strategies, including vaccination, is critical to reduce the disease burden and may help alleviate health disparities and equity challenges posed by dengue.
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Affiliation(s)
- Usa Thisyakorn
- Tropical Medicine Cluster, Chulalongkorn University, Bangkok, Thailand
| | - Surasak Saokaew
- Center of Health Outcomes Research and Therapeutic Safety (Cohorts), School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand
- Unit of Excellence on Clinical Outcomes Research and IntegratioN (UNICORN), School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand
- Division of Social and Administrative Pharmacy, Department of Pharmaceutical Care, School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand
| | | | - Randee Kastner
- Takeda Vaccines Inc., Cambridge, Massachusetts, United States of America
| | | | - Louisa Oliver
- Adelphi Values, Bollington, Macclesfield, United Kingdom
| | - Riona Hanley
- Takeda Pharmaceuticals International AG, Zurich, Switzerland
- * E-mail:
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11
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Jamil MA, Singer H, Al-Rifai R, Nüsgen N, Rath M, Strauss S, Andreou I, Oldenburg J, El-Maarri O. Molecular Analysis of Fetal and Adult Primary Human Liver Sinusoidal Endothelial Cells: A Comparison to Other Endothelial Cells. Int J Mol Sci 2020; 21:E7776. [PMID: 33096636 PMCID: PMC7589710 DOI: 10.3390/ijms21207776] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 10/14/2020] [Accepted: 10/16/2020] [Indexed: 01/27/2023] Open
Abstract
In humans, Factor VIII (F8) deficiency leads to hemophilia A and F8 is largely synthesized and secreted by the liver sinusoidal endothelial cells (LSECs). However, the specificity and characteristics of these cells in comparison to other endothelial cells is not well known. In this study, we performed genome wide expression and CpG methylation profiling of fetal and adult human primary LSECs together with other fetal primary endothelial cells from lung (micro-vascular and arterial), and heart (micro-vascular). Our results reveal expression and methylation markers distinguishing LSECs at both fetal and adult stages. Differential gene expression of fetal LSECs in comparison to other fetal endothelial cells pointed to several differentially regulated pathways and biofunctions in fetal LSECs. We used targeted bisulfite resequencing to confirm selected top differentially methylated regions. We further designed an assay where we used the selected methylation markers to test the degree of similarity of in-house iPS generated vascular endothelial cells to primary LSECs; a higher similarity was found to fetal than to adult LSECs. In this study, we provide a detailed molecular profile of LSECs and a guide to testing the effectiveness of production of in vitro differentiated LSECs.
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Affiliation(s)
- Muhammad Ahmer Jamil
- Institute of Experimental Hematology and Transfusion Medicine, University of Bonn, Venusberg-Campus 1, 53127 Bonn, Germany; (M.A.J.); (H.S.); (R.A.-R.); (N.N.); (M.R.); (J.O.)
| | - Heike Singer
- Institute of Experimental Hematology and Transfusion Medicine, University of Bonn, Venusberg-Campus 1, 53127 Bonn, Germany; (M.A.J.); (H.S.); (R.A.-R.); (N.N.); (M.R.); (J.O.)
| | - Rawya Al-Rifai
- Institute of Experimental Hematology and Transfusion Medicine, University of Bonn, Venusberg-Campus 1, 53127 Bonn, Germany; (M.A.J.); (H.S.); (R.A.-R.); (N.N.); (M.R.); (J.O.)
| | - Nicole Nüsgen
- Institute of Experimental Hematology and Transfusion Medicine, University of Bonn, Venusberg-Campus 1, 53127 Bonn, Germany; (M.A.J.); (H.S.); (R.A.-R.); (N.N.); (M.R.); (J.O.)
| | - Melanie Rath
- Institute of Experimental Hematology and Transfusion Medicine, University of Bonn, Venusberg-Campus 1, 53127 Bonn, Germany; (M.A.J.); (H.S.); (R.A.-R.); (N.N.); (M.R.); (J.O.)
| | | | | | - Johannes Oldenburg
- Institute of Experimental Hematology and Transfusion Medicine, University of Bonn, Venusberg-Campus 1, 53127 Bonn, Germany; (M.A.J.); (H.S.); (R.A.-R.); (N.N.); (M.R.); (J.O.)
| | - Osman El-Maarri
- Institute of Experimental Hematology and Transfusion Medicine, University of Bonn, Venusberg-Campus 1, 53127 Bonn, Germany; (M.A.J.); (H.S.); (R.A.-R.); (N.N.); (M.R.); (J.O.)
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12
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Goring S, Taylor A, Müller K, Li TJJ, Korol EE, Levy AR, Freemantle N. Characteristics of non-randomised studies using comparisons with external controls submitted for regulatory approval in the USA and Europe: a systematic review. BMJ Open 2019; 9:e024895. [PMID: 30819708 PMCID: PMC6398650 DOI: 10.1136/bmjopen-2018-024895] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVES Non-randomised clinical trial designs involving comparisons against external controls or specific standards can be used to support regulatory submissions for indications in diseases that are rare, with high unmet need, without approved therapies and/or where placebo is considered unethical. The objective of this review was to summarise the characteristics of non-randomised trials submitted to the European Medicines Agency (EMA) or Food and Drug Administration (FDA) for indications in haematological cancers, haematological non-malignant conditions, stem cell transplants or rare metabolic diseases. METHODS We conducted systematic searches of EMA databases of conditional approvals, exceptional circumstances, or orphan drug designations and FDA inventories of orphan drug designations, accelerated approvals, breakthrough therapy, fast-track and priority approvals. Products were included if reviewed by at least one agency between 2005 and 2017, the primary evidence base was non-randomised trial(s) and the indication was for haematological cancers, stem cell transplantation, haematological conditions or rare metabolic conditions. RESULTS We identified 43 eligible indication-specific products using non-randomised study designs involving comparisons with external controls, submitted to the EMA (n=34) and/or FDA (n=41). Of the 43 indication-specific products, 4 involved matching external controls to the population of a non-randomised interventional study using individual patient-level data (IPD), 12 referred to external controls without IPD and 27 did not explicitly reference external controls. The FDA approved 98% of submissions, with 56% accelerated approvals; most required postapproval confirmatory randomised controlled trials (RCT). The EMA approved 79% of submissions, with a quarter of approvals conditional on completion of a postapproval RCT or additional non-randomised trials. CONCLUSIONS There has been a large increase in submissions to the EMA and FDA using non-randomised study designs involving comparisons with external controls in recent years. This study demonstrated that regulators may be willing to approve such submissions, although approvals are often conditional on further confirmatory evidence from postapproval studies.
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Affiliation(s)
- Sarah Goring
- Epidemiology, ICON, Vancouver, British Columbia, Canada
| | - Aliki Taylor
- Global Outcomes Research, Takeda Pharmaceuticals International, London, UK
| | | | | | - Ellen E Korol
- Epidemiology, ICON, Vancouver, British Columbia, Canada
| | - Adrian R Levy
- Department of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Nick Freemantle
- Institute of Clinical Trials and Methodology, University College London, London, UK
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13
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Cryer B, Drossman DA, Chey WD, Webster L, Habibi S, Wang M. Analysis of Nausea in Clinical Studies of Lubiprostone for the Treatment of Constipation Disorders. Dig Dis Sci 2017; 62:3568-3578. [PMID: 28849329 PMCID: PMC5694526 DOI: 10.1007/s10620-017-4680-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Accepted: 07/11/2017] [Indexed: 12/23/2022]
Abstract
BACKGROUND Lubiprostone is a ClC-2 chloride channel activator approved for the treatment of chronic idiopathic constipation (CIC) and opioid-induced constipation (OIC) in adults and irritable bowel syndrome with constipation (IBS-C) in women. Lubiprostone is generally well tolerated, with nausea being the most common adverse event. AIMS To characterize nausea with lubiprostone using pooled results from clinical studies in patients with CIC, OIC, or IBS-C. METHODS Data from three 3- and 4-week placebo-controlled studies and three long-term open-label studies were pooled for the CIC analysis. The OIC and IBS-C analyses each used pooled data from three 12-week placebo-controlled studies and one 36-week open-label extension study. RESULTS The populations included the following numbers of patients: CIC, 316 (placebo) and 1113 (lubiprostone 24 mcg twice daily [BID]); OIC, 652 (placebo) and 889 (lubiprostone 24 mcg BID); and IBS-C, 435 (placebo) and 1011 (lubiprostone 8 mcg BID). The incidence of nausea in lubiprostone-treated patients ranged from 11.4 to 31.1%, with the highest incidence in patients with CIC. Among patients with any nausea, most reported only mild or moderate severity (96.5-99.1% across indications) and only one event (83.6-88.7%); most events occurred within the first 5 days of treatment. CONCLUSIONS Nausea was the most common adverse event following the treatment with lubiprostone. Event rates varied by indication and dose, and the majority of nausea adverse events were mild to moderate in severity. Nausea events predominantly occurred early in the treatment period in all of the pooled study populations.
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Affiliation(s)
- Byron Cryer
- Internal Medicine, Veterans Affairs North Texas Health Care System, University of Texas Southwestern Medical School, 5323 Harry Hines Blvd, Dallas, TX 75390 USA
| | - Douglas A. Drossman
- UNC Center for Functional GI and Motility Disorders, University of North Carolina at Chapel Hill, 55 Vilcom Center Drive, Suite 110, Chapel Hill, NC 27514 USA
| | - William D. Chey
- Internal Medicine, University of Michigan School of Medicine, 3912 Taubman Center SPC 5362, Ann Arbor, MI 48109 USA
| | - Lynn Webster
- PRA Health Sciences, 3838 S 700 E Suite 202, Salt Lake City, UT 84106 USA
| | - Sepideh Habibi
- Drug Safety, Sucampo Pharma Americas, LLC, 4520 East-West Highway, Bethesda, MD 20814 USA
| | - Martin Wang
- Biostatistics, Sucampo Pharma Americas, LLC, 4520 East-West Highway, Bethesda, MD 20814 USA
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