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Redonnet-Vernhet I, Mercié P, Lebreton L, Blouin JM, Bronnimann D, Mesli S, Guibet C, Ribeiro E, Gensous N, Duffau P, Gouya L, Richard E. Preventing hyperhomocysteinemia using vitamin B 6 supplementation in Givosiran-treated acute intermittent porphyria: Highlights from a case report and brief literature review. Mol Genet Metab Rep 2024; 39:101076. [PMID: 38601120 PMCID: PMC11004984 DOI: 10.1016/j.ymgmr.2024.101076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 03/19/2024] [Accepted: 03/19/2024] [Indexed: 04/12/2024] Open
Abstract
Acute hepatic porphyrias are inherited metabolic disorders of heme biosynthesis characterized by the accumulation of toxic intermediate metabolites responsible for disabling acute neurovisceral attacks. Givosiran is a newly approved siRNA-based treatment of acute hepatic porphyria targeting the first and rate-limiting δ-aminolevulinic acid synthase 1 (ALAS1) enzyme of heme biosynthetic pathway. We described a 72-year old patient who presented with severe inaugural neurological form of acute intermittent porphyria evolving for several years which made her eligible for givosiran administration. On initiation of treatment, the patient developed a major hyperhomocysteinemia (>400 μmol/L) which necessitated to discontinue the siRNA-based therapy. A thorough metabolic analysis in the patient suggests that hyperhomocysteinemia could be attributed to a functional deficiency of cystathionine β-synthase (CBS) enzyme induced by givosiran. Long-term treatment with vitamin B6, a cofactor of CBS, allowed to normalize homocysteinemia while givosiran treatment was maintained. We review the recently published cases of hyperhomocysteinemia in acute hepatic porphyria and its exacerbation under givosiran therapy. We also discuss the benefits of vitamin B6 supplementation in the light of hypothetic pathophysiological mechanisms responsible for hyperhomocysteinemia in these patients. Our results confirmed the importance of monitoring homocysteine metabolism and vitamin status in patients with acute intermittent porphyria in order to improve management by appropriate vitamin supplementation during givosiran treatment.
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Affiliation(s)
- Isabelle Redonnet-Vernhet
- Univ. Bordeaux, INSERM, MRGM, U1211, F-33076 Bordeaux, France
- Service de Biochimie, Laboratoire de Biologie Médicale de Référence (LBMR) Métabolisme des acides Aminés et Métabolisme de l'hème, Groupe hospitalier Pellegrin, CHU de Bordeaux, France
| | - Patrick Mercié
- Service de Médecine Interne et Immunologie Clinique, Groupe Hospitalier Saint-André, CHU de Bordeaux, F-33075 Bordeaux, France
- Centre de Compétence Maladies Rares Porphyries et Anémies rares du Métabolisme du fer, CHU de Bordeaux, France
- Univ. Bordeaux, INSERM, BRIC, UMR1312, F-33076 Bordeaux, France
- Laboratory of Excellence Gr-Ex, F-75015 Paris, France
| | - Louis Lebreton
- Service de Biochimie, Laboratoire de Biologie Médicale de Référence (LBMR) Métabolisme des acides Aminés et Métabolisme de l'hème, Groupe hospitalier Pellegrin, CHU de Bordeaux, France
| | - Jean-Marc Blouin
- Service de Biochimie, Laboratoire de Biologie Médicale de Référence (LBMR) Métabolisme des acides Aminés et Métabolisme de l'hème, Groupe hospitalier Pellegrin, CHU de Bordeaux, France
- Centre de Compétence Maladies Rares Porphyries et Anémies rares du Métabolisme du fer, CHU de Bordeaux, France
- Univ. Bordeaux, INSERM, BRIC, UMR1312, F-33076 Bordeaux, France
- Laboratory of Excellence Gr-Ex, F-75015 Paris, France
| | - Didier Bronnimann
- Service de Médecine Interne et Maladies Infectieuses, Groupe Hospitalier Saint-André, CHU de Bordeaux, F-33075, France
| | - Samir Mesli
- Service de Biochimie, Laboratoire de Biologie Médicale de Référence (LBMR) Métabolisme des acides Aminés et Métabolisme de l'hème, Groupe hospitalier Pellegrin, CHU de Bordeaux, France
| | - Claire Guibet
- Service de Biochimie, Laboratoire de Biologie Médicale de Référence (LBMR) Métabolisme des acides Aminés et Métabolisme de l'hème, Groupe hospitalier Pellegrin, CHU de Bordeaux, France
- Centre de Compétence Maladies Rares Porphyries et Anémies rares du Métabolisme du fer, CHU de Bordeaux, France
- Univ. Bordeaux, INSERM, BRIC, UMR1312, F-33076 Bordeaux, France
- Laboratory of Excellence Gr-Ex, F-75015 Paris, France
| | - Emmanuel Ribeiro
- Service de Médecine Interne et Immunologie Clinique, Groupe Hospitalier Saint-André, CHU de Bordeaux, F-33075 Bordeaux, France
| | - Noémie Gensous
- Service de Médecine Interne et Immunologie Clinique, Groupe Hospitalier Saint-André, CHU de Bordeaux, F-33075 Bordeaux, France
- Univ-Bordeaux, CNRS UMR5164 Immunoconcept, Bordeaux, France
| | - Pierre Duffau
- Service de Médecine Interne et Immunologie Clinique, Groupe Hospitalier Saint-André, CHU de Bordeaux, F-33075 Bordeaux, France
- Univ-Bordeaux, CNRS UMR5164 Immunoconcept, Bordeaux, France
| | - Laurent Gouya
- Laboratory of Excellence Gr-Ex, F-75015 Paris, France
- Centre de Référence Maladies Rares Porphyries et anémies rares du métabolisme du fer, Centre Français des Porphyries, Hôpital Louis Mourier, AP-HP, Paris, France
| | - Emmanuel Richard
- Service de Biochimie, Laboratoire de Biologie Médicale de Référence (LBMR) Métabolisme des acides Aminés et Métabolisme de l'hème, Groupe hospitalier Pellegrin, CHU de Bordeaux, France
- Centre de Compétence Maladies Rares Porphyries et Anémies rares du Métabolisme du fer, CHU de Bordeaux, France
- Univ. Bordeaux, INSERM, BRIC, UMR1312, F-33076 Bordeaux, France
- Laboratory of Excellence Gr-Ex, F-75015 Paris, France
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Riera-Mestre A, García Morillo JS, Castelbón Fernández J, Hernández-Contreras ME, Aguilera Peiró P, Jacob J, Martínez Valle F, Guillén-Navarro E, Morales-Conejo M. PICO questions and DELPHI methodology for improving the management of patients with acute hepatic porphyria. Rev Clin Esp 2024; 224:272-280. [PMID: 38642893 DOI: 10.1016/j.rceng.2024.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Accepted: 04/05/2024] [Indexed: 04/22/2024]
Abstract
BACKGROUND Acute hepatic porphyrias (AHPs) are a group of rare diseases that encompasses acute intermittent porphyria, variegate porphyria, hereditary coproporphyria, and 5-aminolaevulinic acid dehydratase deficiency porphyria. Symptoms of AHP are nonspecific which, together with its low prevalence, difficult the diagnosis and follow-up of these patients. MATERIAL AND METHODS This project used DELPHI methodology to answer PICO questions related to management of patients with AHPs. The objective was to reach a consensus among multidisciplinary porhyria experts providing answers to those PICO questions for improving diagnosis and follow-up of patients with AHP. RESULTS Ten PICO questions were defined and grouped in four domains: 1. Biochemical diagnosis of patients with AHP. 2. Molecular tests for patients with AHP. 3. Follow-up of patients with AHP. 4. Screening for long-term complications of patients with AHP. CONCLUSIONS PICO questions and DELPHI methodology have provided a consensus on relevant and controversial issues for improving the management of patients with AHP.
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Affiliation(s)
- A Riera-Mestre
- Servicio de Medicina Interna, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain; Instituto de Investigación Biomédica de Bellvitge (IDIBELL), Hospitalet de Llobregat, Barcelona, Spain; Departamento de Ciencias Clínicas, Facultad de Medicina y Ciencias de la Salud, Universitat de Barcelona, Barcelona, Spain.
| | - J S García Morillo
- Unidad de Enfermedades Autoinmunes y Minoritarias del Adulto, CSUR de Errores Innatos del Metabolismo del Adulto, Servicio de Medicina Interna, Hospital Universitario Virgen del Rocio, Sevilla, Spain
| | - J Castelbón Fernández
- Unidad de Enfermedades Minoritarias y Errores Congénitos del Metabolismo del Adulto (CSUR), Servicio de Medicina Interna, Hospital Universitario 12 de Octubre, Madrid, Spain; Instituto de Investigación Hospital 12 de Octubre (i + 12), Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), unidad 723, Madrid, Spain
| | - M E Hernández-Contreras
- Servicio de Medicina Interna, CSUR de Enfermedades Metabólicas Congénitas para Niños y Adultos, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain; Departamento de Medicina Interna, Facultad de Medicina, Universidad de Murcia (UMU), Murcia, Spain
| | - P Aguilera Peiró
- Servicio de Dermatología, Hospital Clínic de Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red en Enfermedades Raras (CIBERER), Madrid, Spain; Departamento de Medicina. Universitat de Barcelona, Barcelona, Spain; Fundació de Recerca Clínic Barcelona - Institut d'Investigacions Biomèdiques August Pi i Sunyer (FRCB-IDIBAPS), Barcelona, Spain
| | - J Jacob
- Instituto de Investigación Biomédica de Bellvitge (IDIBELL), Hospitalet de Llobregat, Barcelona, Spain; Departamento de Ciencias Clínicas, Facultad de Medicina y Ciencias de la Salud, Universitat de Barcelona, Barcelona, Spain; Servicio de Urgencias, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - F Martínez Valle
- Servicio de Medicina Interna, Hospital Universitari Vall d'Hebrón, Barcelona, Spain
| | - E Guillén-Navarro
- Centro de Investigación Biomédica en Red en Enfermedades Raras (CIBERER), Madrid, Spain; Sección de Genética Médica y Servicio de Pediatría, CSUR de Enfermedades Metabólicas Congénitas para Niños y Adultos, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain; Departamento de Cirugía, Pediatría, Obstetricia y Ginecología, Facultad de Medicina, Universidad de Murcia (UMU), Murcia, Spain; Instituto Murciano de Investigación Biosanitaria Pascual Parrilla (IMIB), Murcia, Spain
| | - M Morales-Conejo
- Unidad de Enfermedades Minoritarias y Errores Congénitos del Metabolismo del Adulto (CSUR), Servicio de Medicina Interna, Hospital Universitario 12 de Octubre, Madrid, Spain; Instituto de Investigación Hospital 12 de Octubre (i + 12), Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), unidad 723, Madrid, Spain
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Castelbón Fernández FJ, Barreda Sánchez M, Arranz Canales E, Hernández Contreras ME, Solares I, Morales Conejo M, Muñoz Cuadrado Á, Casado Gómez A, Yébenes Cortés M, Guillén Navarro E. The burden of disease and quality of life in patients with acute hepatic porphyria: COPHASE study. Med Clin (Barc) 2024; 162:103-111. [PMID: 37838536 DOI: 10.1016/j.medcli.2023.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 08/17/2023] [Accepted: 08/18/2023] [Indexed: 10/16/2023]
Abstract
BACKGROUND Acute hepatic porphyria (AHP) comprises a group of rare genetic diseases characterized by neurovisceral crises that are manifested by abdominal pain and neurological and/or psychological symptoms that interfere with the ability to lead a normal life. Our objective was to determine the burden of the disease in one year and the health-related quality of life (HRQoL) in patients with AHP. RESULTS 28 patients were analyzed. The mean age was 36.6±10.2 years, 89.3% were women, and the average number of crises was 1.9±1.5. The average annual cost per patient was €38,255.40. 80.2% of the costs was direct medical costs, 17.5% was associated with loss of productivity and 2.3% was direct non-medical costs. 85.9% of the total cost corresponded to the crises. The intercrisis period accounted for the remaining 14.1%. The global index of the EQ-5D-5L (HRQoL) was 0.75±0.24. The dimensions of pain/discomfort, anxiety/depression and daily activities were the most affected. Leisure, travel/vacations and household activities were the most affected daily activities. 53.6% of patients required a caregiver due to AHP. 92.9% did not present overload and 7.1% presented extreme overload. CONCLUSIONS Patients with AHP are associated with a high economic impact and an affected HRQoL in the pain/discomfort dimension, with a negative impact on the performance of daily activities and a risk of psychiatric diseases.
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Affiliation(s)
- Francisco Javier Castelbón Fernández
- Consulta de Porfirias, CSUR de errores congénitos del metabolismo, Servicio de Medicina Interna, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - María Barreda Sánchez
- Instituto Murciano de Investigación Biosanitaria Virgen de la Arrixaca (IMIB-Arrixaca), Murcia, Spain
| | - Elena Arranz Canales
- Consulta de Porfirias, CSUR de errores congénitos del metabolismo, Servicio de Medicina Interna, Hospital Universitario 12 de Octubre, Madrid, Spain
| | | | - Isabel Solares
- Consulta de Porfirias, CSUR de errores congénitos del metabolismo, Servicio de Medicina Interna, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Montserrat Morales Conejo
- Consulta de Porfirias, CSUR de errores congénitos del metabolismo, Servicio de Medicina Interna, Hospital Universitario 12 de Octubre, Madrid, Spain
| | | | | | | | - Encarna Guillén Navarro
- Sección Genética Médica, Hospital Clínico Universitario Virgen de la Arrixaca/Universidad de Murcia/IMIB-Arrixaca, Murcia, Spain
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Souza PVS, Afonso G, de Rezende Pinto WBV, de Lima Serrano P, de Mattos Lombardi Badia B, Farias IB, Dos Santos Jorge AC, Machado RIL, Pinto IFN, Barros GB, de Oliveira HB, Calil SR, Franz C, Oliveira ASB. Brazilian registry of patients with porphyria: REBRAPPO study. Orphanet J Rare Dis 2023; 18:49. [PMID: 36890577 PMCID: PMC9996884 DOI: 10.1186/s13023-023-02653-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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: 08/21/2022] [Accepted: 02/27/2023] [Indexed: 03/10/2023] Open
Abstract
BACKGROUND Porphyrias are a rare group of disease due to inherited defects of heme synthesis with important systemic manifestations and great burden of disease for patients and families due to the exceptional course of disease with disabling chronic symptoms interposed by life-threatening acute attacks. Unfortunately, the porphyrias are usually underrecognized reflecting a lack of medical and disease awareness as well as few studies about natural history in large cohorts of patients. The main aim of this article is present consistent data about natural history and burden of disease in a large Brazilian cohort. METHODS We conducted a national cross-sectional registry with retrospective clinical data of Brazilian patients with porphyria collected with Brazilian patients Association with Porphyria in collaboration with a tertiary care center for rare diseases. RESULTS A cohort of 172 patients was analyzed in which 148 (86%) patients had the diagnosis of acute hepatic porphyria [AHP] that needed a mean of 62.04 medical visits and 9.6 years to achieve a definitive diagnosis. About AHP cohort, the most common first clinical manifestation were abdominal pain in 77 (52%) patients and acute muscle weakness in 23 (15.5%) with 73 (49.3%) patients presenting only one attack during disease course and 37 (25%) exhibiting 4 or more attacks in the last year. Of note, 105 patients with AHP reported chronic manifestations and the scores for quality of life are lower when compared with general healthy population. CONCLUSIONS Brazilian patients with AHP had a higher prevalence of chronic disabling manifestations and a poor quality of life like other cohorts and a higher proportion of patients with recurrent attacks than previously reported.
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Affiliation(s)
- Paulo Victor Sgobbi Souza
- Neuromuscular Unit, Department of Neurology and Neurosurgery, Federal University of São Paulo (UNIFESP), Embaú Street, 67, Vila Clementino, São Paulo, SP, 04039-060, Brazil.
| | | | - Wladimir Bocca Vieira de Rezende Pinto
- Neuromuscular Unit, Department of Neurology and Neurosurgery, Federal University of São Paulo (UNIFESP), Embaú Street, 67, Vila Clementino, São Paulo, SP, 04039-060, Brazil
| | - Paulo de Lima Serrano
- Neuromuscular Unit, Department of Neurology and Neurosurgery, Federal University of São Paulo (UNIFESP), Embaú Street, 67, Vila Clementino, São Paulo, SP, 04039-060, Brazil
| | - Bruno de Mattos Lombardi Badia
- Neuromuscular Unit, Department of Neurology and Neurosurgery, Federal University of São Paulo (UNIFESP), Embaú Street, 67, Vila Clementino, São Paulo, SP, 04039-060, Brazil
| | - Igor Braga Farias
- Neuromuscular Unit, Department of Neurology and Neurosurgery, Federal University of São Paulo (UNIFESP), Embaú Street, 67, Vila Clementino, São Paulo, SP, 04039-060, Brazil
| | - Ana Carolina Dos Santos Jorge
- Neuromuscular Unit, Department of Neurology and Neurosurgery, Federal University of São Paulo (UNIFESP), Embaú Street, 67, Vila Clementino, São Paulo, SP, 04039-060, Brazil
| | - Roberta Ismael Lacerda Machado
- Neuromuscular Unit, Department of Neurology and Neurosurgery, Federal University of São Paulo (UNIFESP), Embaú Street, 67, Vila Clementino, São Paulo, SP, 04039-060, Brazil
| | - Icaro França Navarro Pinto
- Neuromuscular Unit, Department of Neurology and Neurosurgery, Federal University of São Paulo (UNIFESP), Embaú Street, 67, Vila Clementino, São Paulo, SP, 04039-060, Brazil
| | - Glenda Barbosa Barros
- Neuromuscular Unit, Department of Neurology and Neurosurgery, Federal University of São Paulo (UNIFESP), Embaú Street, 67, Vila Clementino, São Paulo, SP, 04039-060, Brazil
| | - Helvia Bertoldo de Oliveira
- Neuromuscular Unit, Department of Neurology and Neurosurgery, Federal University of São Paulo (UNIFESP), Embaú Street, 67, Vila Clementino, São Paulo, SP, 04039-060, Brazil
| | - Samia Rogatis Calil
- Neuromuscular Unit, Department of Neurology and Neurosurgery, Federal University of São Paulo (UNIFESP), Embaú Street, 67, Vila Clementino, São Paulo, SP, 04039-060, Brazil
| | - Cibele Franz
- Universidade Federal do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Acary Souza Bulle Oliveira
- Neuromuscular Unit, Department of Neurology and Neurosurgery, Federal University of São Paulo (UNIFESP), Embaú Street, 67, Vila Clementino, São Paulo, SP, 04039-060, Brazil
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Wang B, Ventura P, Takase KI, Thapar M, Cassiman D, Kubisch I, Liu S, Sweetser MT, Balwani M. Disease burden in patients with acute hepatic porphyria: experience from the phase 3 ENVISION study. Orphanet J Rare Dis 2022; 17:327. [PMID: 36028858 PMCID: PMC9419398 DOI: 10.1186/s13023-022-02463-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 07/24/2022] [Indexed: 11/29/2022] Open
Abstract
Background Acute hepatic porphyria (AHP) is a family of four rare genetic diseases, each involving deficiency in a hepatic heme biosynthetic enzyme. Resultant overproduction of the neurotoxic intermediates δ-aminolevulinic acid (ALA) and porphobilinogen (PBG) leads to disabling acute neurovisceral attacks and progressive neuropathy. We evaluated the AHP disease burden in patients aged ≥ 12 years in a post hoc analysis of the Phase 3, randomized, double-blind, placebo-controlled ENVISION trial of givosiran (NCT03338816), an RNA interference (RNAi) therapeutic that targets the enzyme ALAS1 to decrease ALA and PBG production. We analyzed baseline AHP severity via chronic symptoms between attacks, comorbidities, concomitant medications, hemin-associated complications, and quality of life (QOL) and evaluated givosiran (2.5 mg/kg monthly) in patients with and without prior hemin prophylaxis on number and severity of attacks and pain scores during and between attacks. Results Participants (placebo, n = 46; givosiran, n = 48) included patients with low and high annualized attack rates (AARs; range 0–46). At baseline, patients reported chronic symptoms (52%), including nausea, fatigue, and pain; comorbidities, including neuropathy (38%) and psychiatric disorders (47%); concomitant medications, including chronic opioids (29%); hemin-associated complications (eg, iron overload); and poor QOL (low SF-12 and EuroQol visual analog scale scores). A linear relationship between time since diagnosis and AAR with placebo suggested worsening of disease over time without effective treatment. Givosiran reduced the number and severity of attacks, days with worst pain scores above baseline, and opioid use versus placebo. Conclusions Patients with AHP, regardless of annualized attack rates, have considerable disease burden that may partly be alleviated with givosiran.
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Affiliation(s)
- Bruce Wang
- Division of Gastroenterology, Department of Medicine, University of California San Francisco, San Francisco, CA, 94143, USA.
| | - Paolo Ventura
- University of Modena and Reggio Emilia, Modena, Italy
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Wheeden K, Lyon Howe D, Burrell S, Gill L, Chamberlayne J, Williams ER, Simon A, Ko JJ, Mora J, Wells T, Evans C, Paulich M, Meninger S, Lombardelli S. Patient Perspective on Acute Hepatic Porphyria with Sporadic Attacks: A Chronic Disease with Substantial Health-Related Quality of Life Impacts. Adv Ther 2022. [PMID: 35907153 DOI: 10.1007/s12325-022-02172-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 04/25/2022] [Indexed: 11/23/2022]
Abstract
Introduction Acute hepatic porphyria (AHP) is a family of rare metabolic diseases characterized by potentially life-threatening acute attacks and, in some patients, chronic debilitating symptoms. While patients with frequent or recurrent attacks (three or more attacks annually) are known to have reduced health-related quality of life (HRQoL) as most aspects of daily living are impacted, limited data exist in patients with sporadic attacks. This research aims to identify porphyria-related symptoms between attacks, characterize the frequency, severity, and bothersomeness of these symptoms, and more generally understand the burden of this disease in patients who experience attacks sporadically. Methods Patients with AHP with sporadic attacks (AHP-SA) (at least one porphyria attack in the past 2 years, but no more than two attacks per year in the previous 2 years) were recruited, via outreach performed by patient advocacy groups, for participation in qualitative telephone interviews. Interviews were conducted using a semi-structured guide and were audio-recorded, transcribed, anonymized, coded, and analyzed to determine if saturation was reached. Results A total of 14 participants with AHP-SA were interviewed (mean age 45 years, 100% female). The most frequently reported chronic symptoms were fatigue, pain, heartburn, and constipation. The most frequently experienced chronic impacts were difficulty performing daily activities, difficulty exercising, negative impact on work, need for a special diet, anxiety, and depression. Beyond these chronic symptoms and impacts, participants also frequently described flares in their porphyria that were severe, did not qualify in their minds as an acute attack, but were nonetheless more severe than their typical chronic experience. Conclusion Patients with acute hepatic porphyria who experience sporadic attacks face significant chronic symptoms and impacts that frequently require significant pharmacological and clinical treatment. The reported severity of these symptoms and impacts suggests that the humanistic burden of AHP-SA is substantial and may lead to a significant decrease in health-related quality of life in these patients between acute attacks. The presence of flares that do not reach the level of what is considered an acute attack by patients is a unique finding of this study not reported elsewhere and requires additional investigation. Supplementary Information The online version contains supplementary material available at 10.1007/s12325-022-02172-8.
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Marcacci M, Ricci A, Cuoghi C, Marchini S, Pietrangelo A, Ventura P. Challenges in diagnosis and management of acute hepatic porphyrias: from an uncommon pediatric onset to innovative treatments and perspectives. Orphanet J Rare Dis 2022; 17:160. [PMID: 35392955 PMCID: PMC8991793 DOI: 10.1186/s13023-022-02314-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 03/28/2022] [Indexed: 12/17/2022] Open
Abstract
Acute hepatic porphyrias (AHPs) are a family of four rare genetic diseases resulting from a deficiency in one of the enzymes involved in heme biosynthesis. AHP patients can experience potentially life-threatening acute attacks, characterized by severe abdominal pain, along with other signs and symptoms including nausea, mental confusion, hyponatraemia, hypertension, tachycardia and muscle weakness. Some patients also experience chronic manifestations and long-term complications, such as chronic pain syndrome, neuropathy and porphyria-associated kidney disease. Most symptomatic patients have only a few attacks in their lifetime; nevertheless, some experience frequent attacks that result in ongoing symptoms and a significant negative impact on their quality of life (QoL). Initial diagnosis of AHP can be made with a test for urinary porphobilinogen, \documentclass[12pt]{minimal}
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\begin{document}$$\delta$$\end{document}δ-aminolaevulinic acid and porphyrins using a single random (spot) sample. However, diagnosis is frequently missed or delayed, often for years, because the clinical symptoms of AHP are non-specific and mimic other more common disorders. Delayed diagnosis is of concern as some commonly used medications can trigger or exacerbate acute attacks, and untreated attacks can become severe, potentially leading to permanent neurological damage or fatality. Other attack triggers include hormonal fluctuations in women, stress, alcohol and low-calorie diets, which should be avoided in patients where possible. For the management of attacks, intravenous hemin is approved, whereas new therapeutic approaches are currently being investigated as a baseline therapy for prevention of attacks and improvement of QoL. Among these, a novel siRNA-based agent, givosiran, has shown very promising results in a recently concluded Phase III trial and has been approved for the management of AHPs. Here, we propose a challenging case study-with a very unusual pediatric onset of variegate porphyria-as a starting point to summarize the main clinical aspects (namely, clinical manifestations, diagnostic challenges, and therapeutic management) of AHPs, with a focus on the latest therapeutic innovations.
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Affiliation(s)
- Matteo Marcacci
- Department of Surgical and Medical Sciences for Children and Adults, Internal Medicine Unit, University of Modena and Reggio Emilia, Via del Pozzo 71, 41124, Modena, Italy
| | - Andrea Ricci
- Department of Surgical and Medical Sciences for Children and Adults, Internal Medicine Unit, University of Modena and Reggio Emilia, Via del Pozzo 71, 41124, Modena, Italy
| | - Chiara Cuoghi
- Department of Surgical and Medical Sciences for Children and Adults, Internal Medicine Unit, University of Modena and Reggio Emilia, Via del Pozzo 71, 41124, Modena, Italy
| | - Stefano Marchini
- Department of Surgical and Medical Sciences for Children and Adults, Internal Medicine Unit, University of Modena and Reggio Emilia, Via del Pozzo 71, 41124, Modena, Italy
| | - Antonello Pietrangelo
- Department of Surgical and Medical Sciences for Children and Adults, Internal Medicine Unit, University of Modena and Reggio Emilia, Via del Pozzo 71, 41124, Modena, Italy
| | - Paolo Ventura
- Department of Surgical and Medical Sciences for Children and Adults, Internal Medicine Unit, University of Modena and Reggio Emilia, Via del Pozzo 71, 41124, Modena, Italy.
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Anderson KE, Desnick RJ, Stewart MF, Ventura P, Bonkovsky HL. Acute Hepatic Porphyrias: "Purple Flags"-Clinical Features That Should Prompt Specific Diagnostic Testing. Am J Med Sci 2022; 363:1-10. [PMID: 34606756 DOI: 10.1016/j.amjms.2021.09.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 06/15/2021] [Accepted: 09/28/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND Porphyrias are a group of rare diseases leading to dysregulation in heme biosynthesis and the accumulation of heme precursors, including porphyrinogens, which in their oxidized states [porphyrins] are reddish or purple. Acute hepatic porphyrias (AHP) comprise four diseases that cause acute debilitating neurovisceral attacks. Despite diagnostic advances, AHP is often undiagnosed or misdiagnosed due to a lack of disease awareness, low clinical suspicion, variable presentation, and nonspecific symptoms that mimic more common diseases. Delays in diagnosis and treatment increase the risk of serious acute and chronic complications. METHODS In order to assess whether symptoms alone or in combination might be utilized as important indicators or "purple flags" that, when present, should alert clinicians to suspect AHP and pursue specific diagnostic testing, we conducted a comprehensive review of the literature on AHP, including cohort studies and case reports over two epochs, from 1980 to 2006 and from 2012 to 2018. RESULTS We found that severe abdominal pain, with or without acute central nervous system manifestations and peripheral neuropathy, continues to be the most frequent symptom. Hyponatremia, change in urine color, and certain chronic symptoms were also identified as features that should raise suspicion of AHP. To improve diagnosis of AHP, clinicians need to take a broad perspective, including demographic data and medical history, into consideration. CONCLUSIONS The clinical features of AHP continue to be severe pain, especially pain in the abdomen. Other features that should raise suspicion are autonomic, peripheral, or central neuropathies, hyponatremia, and red-purple urine color.
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Affiliation(s)
- Karl E Anderson
- Division of Gastroenterology & Hepatology, Department of Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Robert J Desnick
- Department of Genetics and Genomic Medicine, Icahn School of Medicine at Mt. Sinai, New York, NY, USA
| | - M Felicity Stewart
- Salford Royal NHS Foundation Trust, Salford, UK; Division of Medical Education, University of Manchester, Manchester, UK
| | - Paolo Ventura
- Internal Medicine Unit, Policlinico Hospital, Department of Medical and Surgical Sciences for Children and Adults, University of Modena and Reggio Emilia, Modena, Italy
| | - Herbert L Bonkovsky
- Section on Gastroenterology & Hepatology, Department of Medicine, Wake Forest University School of Medicine/North Carolina Baptist Hospital, Nutrition Research Center, Winston-Salem, NC, USA..
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Ventura P, Bonkovsky HL, Gouya L, Aguilera‐Peiró P, Montgomery Bissell D, Stein PE, Balwani M, Anderson DKE, Parker C, Kuter DJ, Monroy S, Oh J, Ritchie B, Ko JJ, Hua Z, Sweetser MT, Sardh E. Efficacy and safety of givosiran for acute hepatic porphyria: 24-month interim analysis of the randomized phase 3 ENVISION study. Liver Int 2022; 42:161-172. [PMID: 34717041 PMCID: PMC9299194 DOI: 10.1111/liv.15090] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 10/21/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Upregulation of hepatic delta-aminolevulinic acid synthase 1 with accumulation of potentially toxic heme precursors delta-aminolevulinic acid and porphobilinogen is fundamental to the pathogenesis of acute hepatic porphyria. AIMS evaluate long-term efficacy and safety of givosiran in acute hepatic porphyria. METHODS Interim analysis of ongoing ENVISION study (NCT03338816), after all active patients completed their Month 24 visit. Patients with acute hepatic porphyria (≥12 years) with recurrent attacks received givosiran (2.5 mg/kg monthly) (n = 48) or placebo (n = 46) for 6 months (double-blind period); 93 received givosiran (2.5 mg or 1.25 mg/kg monthly) in the open-label extension (continuous givosiran, n = 47/48; placebo crossover, n = 46/46). Endpoints included annualized attack rate, urinary delta-aminolevulinic acid and porphobilinogen levels, hemin use, daily worst pain, quality of life, and adverse events. RESULTS Patients receiving continuous givosiran had sustained annualized attack rate reduction (median 1.0 in double-blind period, 0.0 in open-label extension); in placebo crossover patients, median annualized attack rate decreased from 10.7 to 1.4. Median annualized days of hemin use were 0.0 (double-blind period) and 0.0 (open-label extension) for continuous givosiran patients and reduced from 14.98 to 0.71 for placebo crossover patients. Long-term givosiran led to sustained lowering of delta-aminolevulinic acid and porphobilinogen and improvements in daily worst pain and quality of life. Safety findings were consistent with the double-blind period. CONCLUSIONS Long-term givosiran has an acceptable safety profile and significantly benefits acute hepatic porphyria patients with recurrent attacks by reducing attack frequency, hemin use, and severity of daily worst pain while improving quality of life.
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Affiliation(s)
- Paolo Ventura
- Department of Surgical and Medical Sciences for Children and Adults, Internal Medicine UnitUniversity of Modena and Reggio EmiliaModenaItaly
| | - Herbert L. Bonkovsky
- Section on Gastroenterology and HepatologyWake Forest University/North Carolina Baptist Medical CenterWinston‐SalemNCUSA
| | | | | | | | | | - Manisha Balwani
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount SinaiNew YorkNYUSA
| | | | | | - David J. Kuter
- Center for HematologyMassachusetts General HospitalBostonMAUSA
| | | | - Jeeyoung Oh
- Konkuk University Medical CenterSeoulSouth Korea
| | | | | | | | | | - Eliane Sardh
- Porphyria Centre Sweden, Centre for Inherited Metabolic Diseases, Karolinska Institutet, Karolinska University HospitalStockholmSweden
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Gilles A, Vermeersch S, Vermeersch P, Wolff F, Cotton F, Tilleux S, Cassiman D. Expert consensus statement on acute hepatic porphyria in Belgium. Acta Clin Belg 2021; 77:735-741. [PMID: 34369323 DOI: 10.1080/17843286.2021.1961056] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Acute hepatic porphyrias (AHP) are a group of four different rare to ultra-rare, severely debilitating, and sometimes fatal diseases that significantly impact patients' lives: 5-aminolevulinic acid (ALA) dehydratase deficiency porphyria (ADP), acute intermittent porphyria (AIP), hereditary coproporphyria (HCP), and variegate porphyria (VP). Based on literature estimates, a conservative estimate of the number of AHP patients in Belgium requiring treatment, defined as patients experiencing recurrent attacks and/or chronic debilitating symptoms, is likely limited to 11-34 patients. These patients face a considerable unmet need, as there is currently no pharmaceutical treatment available that effectively prevents attacks and has an impact on other chronic symptoms of the disease.A panel consisting of the two European Porphyria Network1 (EPNet) centers in Belgium (Center for inborn errors of metabolism of UZ Leuven and the 'Centre Belge des Porphyries' of Erasme Hospital and LHUB-ULB) participated in an advisory board on 24 January 2020. Representatives of the sponsoring pharmaceutical company, Alnylam Pharmaceuticals, organized and attended the meeting. The objective of the meeting was to obtain expert input on the state-of-the-art clinical practice of AHP in Belgium. Following this meeting, this expert consensus statement was drafted, in collaboration with and coordinated by the EPNet centers in Belgium. This statement provides an overview of the state-of-the art in AHP, by means of a concise overview of AHP pathophysiology, clinical manifestations, and burden of disease, (Belgian) epidemiology, treatments, and proposed organization of care.
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Affiliation(s)
- Axelle Gilles
- Dept of Clinical Hematology, Cliniques universitaires de Bruxelles, Erasme Hospital
| | | | | | - Fleur Wolff
- Department of Clinical Chemistry, Laboratoire Hospitalier Universitaire de Bruxelles (LHUB-ULB), Université Libre de Bruxelles (ULB), Brussels, Belgium
- Centre Belge de Porphyries, Erasme Hospital, Université Libre de Bruxelles
| | - Frederic Cotton
- Department of Clinical Chemistry, Laboratoire Hospitalier Universitaire de Bruxelles (LHUB-ULB), Université Libre de Bruxelles (ULB), Brussels, Belgium
- Centre Belge de Porphyries, Erasme Hospital, Université Libre de Bruxelles
| | | | - David Cassiman
- Dienst Maag-Darm-Leverziekten en Metabool Centrum, UZ Leuven, Belgium
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Abstract
Porphyrias are a set of rare inherited metabolic disorders, each of them representing a defect in one of the eight enzymes in the haem biosynthetic pathway resulting in the accumulation of organic compounds called porphyrins. Acute hepatic porphyrias (AHP) are those in which the enzyme deficiency occurs in the liver, of which acute intermittent porphyria is by far the most common subtype. Neurology of the AHP is still challenging in practice, and patients rarely receive the correct diagnosis early in the disease course. For AHP, which primarily affects the central and peripheral nervous system, the cause of symptoms seems to be the increased production of neurotoxic precursors, in particular delta-aminolaevulinic acid and porphobilinogen. Neurological complications usually result from severe episodes of acute attacks. The neurologic hallmark of porphyrias is an acute predominantly motor axonal neuropathy resembling a Guillain-Barré syndrome that generally occurs after the onset of other clinical features such as abdominal pain and central nervous system manifestations. Neuropsychiatric syndromes, seizures, encephalopathy, and cerebrovascular disorders are among the possible central nervous system presentations. Therapeutic approach to AHP is divided into management and prophylaxis of an acute attack, including long standing options such as intravenous hematin and new therapeutic agents such as givosiran.
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Affiliation(s)
- Miguel Oliveira Santos
- Neurology, Department of Neurosciences and Mental Health, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisboa, Portugal; Institute of Physiology Unit, Instituto de Medicina Molecular, Faculty of Medicine, University of Lisbon, Lisbon, Portugal.
| | - Miguel Leal Rato
- Neurology, Department of Neurosciences and Mental Health, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisboa, Portugal; Institute of Pharmacology and Neurosciences, Faculty of Medicine, University of Lisbon, Lisbon, Portugal
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Gill L, Burrell S, Chamberlayne J, Lombardelli S, Mora J, Mason N, Schurer M, Merkel M, Meninger S, Ko JJ. Patient and caregiver experiences of living with acute hepatic porphyria in the UK: a mixed-methods study. Orphanet J Rare Dis 2021; 16:187. [PMID: 33902669 PMCID: PMC8074407 DOI: 10.1186/s13023-021-01816-2] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 04/06/2021] [Indexed: 12/21/2022] Open
Abstract
Background This study used quantitative and qualitative research methods to analyze how acute hepatic porphyria (AHP) affects patients with varying annualized porphyria attack rates. The overall impact of AHP on patients and caregivers, including their quality of life, was explored. The nature and treatment of acute attacks, experiences of long-term heme arginate treatment and access to other appropriate treatment, and the extent of and treatment for chronic symptoms were also investigated within this study.
Methods Patient and caregiver data were collected via an online survey of members of the British Porphyria Association, followed by an optional 1-h telephone interview. Results Thirty-eight patients and 10 caregivers responded to the survey. Of those, 10 patients and three caregivers completed follow-up interviews. Overall, 19 patients (50%) had experienced an acute attack within the previous 2 years, and the severity and types of symptoms experienced during or between acute attacks varied considerably. There were no clear definitions among patients for ‘mild’ or ‘severe’ attacks. Treatments and treatment settings used to manage attacks also varied. Following unsatisfactory care experiences at hospitals, some patients reported avoiding further hospital services for later attacks. Therefore, using settings of care as a measure of attack severity should be avoided. Ninety-four percent of patients also experienced chronic symptoms, which were as varied as acute attacks. Pain was the predominant chronic symptom and was managed with opioids in severe cases. Regardless of AAR, porphyria heavily impacted the daily lives of patients and caregivers. Although patients experiencing frequent attacks generally endured a greater impact on their daily life, patients with less frequent attacks also experienced impacts on all domains (social, leisure activities, relationship with family, relationships, psychological wellbeing, finances, employment, and study). Caregivers were most affected in the finance, relationships with family, and employment domains, and just over half of the caregivers reported a moderate impact on their psychological wellbeing. Conclusions/implications The burden of illness with AHP is high across all patients, regardless of frequency of attacks, and AHP negatively affects patients and caregivers alike. Supplementary Information The online version contains supplementary material available at 10.1186/s13023-021-01816-2.
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Affiliation(s)
- Liz Gill
- British Porphyria Association, Durham, UK
| | | | | | - Stephen Lombardelli
- Alnylam Pharmaceuticals, Alnylam UK Ltd, Braywick Gate, Maidenhead, SL6 1DA, UK.
| | | | - Nicola Mason
- BresMed Health Solutions Ltd, Steele City House, Sheffield, UK
| | - Marieke Schurer
- BresMed Netherlands B.V, HNK Utrecht CS, Utrecht, Netherlands
| | | | | | - John J Ko
- Alnylam Pharmaceuticals, Cambridge, MA, USA
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Baravelli CM, Aarsand AK, Sandberg S, Tollånes MC. Sick leave, disability, and mortality in acute hepatic porphyria: a nationwide cohort study. Orphanet J Rare Dis 2020; 15:56. [PMID: 32085780 PMCID: PMC7035738 DOI: 10.1186/s13023-019-1273-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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: 08/26/2019] [Accepted: 12/03/2019] [Indexed: 11/10/2022] Open
Abstract
Background Acute hepatic porphyria (AHP) consists of three rare metabolic disorders. We investigated the risk of long-term sick leave, disability pension, and premature death in individuals with AHP compared to the general population. Methods In a nationwide cohort study from 1992 to 2017, records of 333 persons (total person-years = 6728) with a confirmed AHP diagnosis were linked to several national compulsory registries (reference population = 5,819,937). We conducted survival analyses to assess additional risk. Results Persons with AHP had higher risks of accessing long-term sick leave (adjusted hazard ratio (aHR): 1.5, 95% confidence interval (CI): 1.3, 1.7) and disability pension (aHR: 1.9, CI: 1.5, 2.4). The risk was highest in persons who had been hospitalised for acute attacks, while no additional risk was observed in asymptomatic AHP gene mutation carriers. The median age when accessing disability pension was 45 years, 21 years younger than the general population. AHP was associated with increased risk of mortality due to hepatocellular carcinoma (adjusted mortality rate ratio (aMRR): 84.4, CI: 37.8, 188.2), but no overall increased risk of premature death was observed. Conclusions Persons with symptomatic AHP were at increased risk of accessing long-term sick leave and disability pension but not of premature death.
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Affiliation(s)
- Carl Michael Baravelli
- Norwegian Porphyria Centre (NAPOS), Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, P.O.Box 1400, N-5021, Bergen, Norway. .,Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway.
| | - Aasne Karine Aarsand
- Norwegian Porphyria Centre (NAPOS), Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, P.O.Box 1400, N-5021, Bergen, Norway.,Norwegian Organisation for Quality Improvement of Laboratory Examinations (NOKLUS), Haraldsplass Deaconess Hospital, Bergen, Norway
| | - Sverre Sandberg
- Norwegian Porphyria Centre (NAPOS), Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, P.O.Box 1400, N-5021, Bergen, Norway.,Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway.,Norwegian Organisation for Quality Improvement of Laboratory Examinations (NOKLUS), Haraldsplass Deaconess Hospital, Bergen, Norway
| | - Mette Christophersen Tollånes
- Norwegian Organisation for Quality Improvement of Laboratory Examinations (NOKLUS), Haraldsplass Deaconess Hospital, Bergen, Norway
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Yarra P, Faust D, Bennett M, Rudnick S, Bonkovsky HL. Benefits of prophylactic heme therapy in severe acute intermittent porphyria. Mol Genet Metab Rep 2019; 19:100450. [PMID: 30733921 PMCID: PMC6358544 DOI: 10.1016/j.ymgmr.2019.01.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [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: 08/07/2018] [Accepted: 01/13/2019] [Indexed: 12/18/2022] Open
Abstract
Acute intermittent porphyria (AIP), an autosomal dominant inborn error of metabolism, is the most common and severe form of the acute porphyrias. Attacks of severe abdominal pain, often with hypertension, tachycardia, are cardinal features of AIP, often requiring hospital admissions. Frequent recurrent attacks of AIP, defined as >3 attacks in one year, during which at least one attack requires intravenous heme therapy, are associated with significant morbidity, lost productivity, and health care burden. We report two patients with such frequent attacks of AIP, who have been managed with prophylactic heme therapy on a weekly basis. We describe results particularly in relation to symptom control, biochemical findings, health care costs, quality of life, and utilization of resources. During 11-month duration of weekly prophylactic heme infusions, we observed a 100% decrease in acute attacks and inpatient admissions in one subject and a 75% decrease in the other. During this time, we also observed a significant decrease in the number of emergency room visits. The decrease in number of acute attacks requiring hospital admission was associated with significantly decreased health care costs and improved quality of life. Reduction of both emergency room visits and hospital admissions decreased the utilization of health care services. Outpatient weekly infusions were also noted to be associated with better reimbursements and reduced overall costs of health care for the subjects. Both our subjects also endorsed better symptom control, quality of life and better understanding of disease. Thus, prophylactic heme therapy, through a multi-disciplinary approach, decreases the incidence of acute attacks, decreases health care costs and leads to better patient satisfaction and quality of life.
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Affiliation(s)
- Pradeep Yarra
- Department of Medicine, Wake Forest University/NC Baptist Medical Center, Winston-Salem, NC, United States
| | - Denise Faust
- Department of Medicine, Wake Forest University/NC Baptist Medical Center, Winston-Salem, NC, United States
| | - Mary Bennett
- Department of Pharmacy, Wake Forest University/NC Baptist Medical Center, Winston-Salem, NC, United States
| | - Sean Rudnick
- Department of Medicine, Wake Forest University/NC Baptist Medical Center, Winston-Salem, NC, United States
| | - Herbert L. Bonkovsky
- Department of Medicine, Wake Forest University/NC Baptist Medical Center, Winston-Salem, NC, United States
- Corresponding author at: E-112, NRC, Wake Forest University School of Medicine, 1 Medical Center Blvd, Winston-Salem, NC 27157, United States.
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Naik H, Stoecker M, Sanderson SC, Balwani M, Desnick RJ. Experiences and concerns of patients with recurrent attacks of acute hepatic porphyria: A qualitative study. Mol Genet Metab 2016; 119:278-283. [PMID: 27595545 PMCID: PMC5083146 DOI: 10.1016/j.ymgme.2016.08.006] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [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: 06/13/2016] [Revised: 08/22/2016] [Accepted: 08/22/2016] [Indexed: 01/05/2023]
Abstract
BACKGROUND The acute hepatic porphyrias (AHPs) are rare inborn errors of heme biosynthesis, characterized clinically by life-threatening acute neurovisceral attacks. Patients with recurrent attacks have a decreased quality of life (QoL); however, no interactive assessment of these patients' views has been reported. We conducted guided discussions regarding specific topics, to explore patients' disease experience and its impact on their lives. METHODS Sixteen AHP patients experiencing acute attacks were recruited to moderator-led online focus groups. Five groups (3-4 patients each) were conducted and thematic analyses to identify, examine, and categorize patterns in the data was performed. RESULTS All patients identified prodromal symptoms that began days prior to acute severe pain; the most common included confusion ("brain fog"), irritability, and fatigue. Patients avoided hospitalization due to prior poor experiences with physician knowledge of AHPs or their treatment. All patients used complementary and alternative medicine treatments to avoid hospitalization or manage chronic pain and 81% reported varying degrees of effectiveness. All patients indicated their disease impacted personal relationships due to feelings of isolation and difficulty adjusting to the disease's limitations. CONCLUSION Patients with recurrent attacks recognize prodromal warning symptoms, attempt to avoid hospitalization, turn to alternative treatments, and have markedly impaired QoL. Counseling and individualized support is crucial for AHP patients with recurrent attacks.
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Affiliation(s)
- Hetanshi Naik
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY 10029, Unites States.
| | - Mikayla Stoecker
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY 10029, Unites States.
| | - Saskia C Sanderson
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY 10029, Unites States.
| | - Manisha Balwani
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY 10029, Unites States.
| | - Robert J Desnick
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY 10029, Unites States.
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