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Wong SSN, Yuen LYP, Kan E, Blau N, Rodenburg R, Lam CW, Wong VCN, Mochel F, Wevers RA, Fung CW. CYP2U1: An emerging treatable neurometabolic disease with cerebral folate deficiency in 2 Chinese brothers. Mol Genet Metab Rep 2024; 38:101023. [PMID: 38058766 PMCID: PMC10696413 DOI: 10.1016/j.ymgmr.2023.101023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 11/16/2023] [Accepted: 11/16/2023] [Indexed: 12/08/2023] Open
Abstract
With the rapid advancement of medical technologies in genomic and molecular medicine, the number of treatable neurometabolic diseases is quickly expanding. Spastic paraplegia 56 (SPG56), one of the severe autosomal recessive forms of neurodegenerative disorders caused by pathogenic variants in the CYP2U1 gene, has no reported specific targeted treatment yet. Here we report 2 Chinese brothers with CYP2U1 bi-allelic pathogenic variants with cerebral folate deficiency who were treated for over a decade with folinic acid supplement. Patients have remained stable under therapy.
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Affiliation(s)
- Sheila Suet-Na Wong
- Department of Paediatric and Adolescent Medicine, Hong Kong Children's Hospital, Hong Kong, China
| | - Liz Yuet-Ping Yuen
- Department of Pathology, Hong Kong Children's Hospital, Hong Kong, China
| | - Elaine Kan
- Department of Radiology, Hong Kong Children's Hospital, Hong Kong, China
| | - Nenad Blau
- Divisions of Metabolism, University Children's Hospital, Zürich, Switzerland
| | - Richard Rodenburg
- Translational Metabolic Laboratory, Department Laboratory Medicine, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Ching-wan Lam
- Department of Pathology, The University of Hong Kong, Hong Kong, China
| | - Virginia Chun-Nei Wong
- Department of Paediatric and Adolescent Medicine, The University of Hong Kong, Hong Kong, China
| | - Fanny Mochel
- AP-HP, Pitié-Salpêtrière University Hospital, Department of Medical Genetics, Reference Centers for Adult Neurometabolic Diseases and Adult Leukodystrophies, Paris, France
- INSERM U 1127, CNRS UMR 7225, Sorbonne Universités, UPMC Univ Paris 06 UMR S 1127, Institut du Cerveau, ICM, Paris, France
| | - Ron A. Wevers
- Translational Metabolic Laboratory, Department Laboratory Medicine, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Cheuk-Wing Fung
- Department of Paediatric and Adolescent Medicine, Hong Kong Children's Hospital, Hong Kong, China
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Morgan AE, Salcedo-Sora JE, Mc Auley MT. A new mathematical model of folate homeostasis in E. coli highlights the potential importance of the folinic acid futile cycle in cell growth. Biosystems 2024; 235:105088. [PMID: 38000545 DOI: 10.1016/j.biosystems.2023.105088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 11/17/2023] [Accepted: 11/17/2023] [Indexed: 11/26/2023]
Abstract
Folate (vitamin B9) plays a central role in one-carbon metabolism in prokaryotes and eukaryotes. This pathway mediates the transfer of one-carbon units, playing a crucial role in nucleotide synthesis, methylation, and amino acid homeostasis. The folinic acid futile cycle adds a layer of intrigue to this pathway, due to its associations with metabolism, cell growth, and dormancy. It also introduces additional complexity to folate metabolism. A logical way to deal with such complexity is to examine it by using mathematical modelling. This work describes the construction and analysis of a model of folate metabolism, which includes the folinic acid futile cycle. This model was tested under three in silico growth conditions. Model simulations revealed: 1) the folate cycle behaved as a stable biochemical system in three growth states (slow, standard, and rapid); 2) the initial concentration of serine had the greatest impact on metabolite concentrations; 3) 5-formyltetrahydrofolate cyclo-ligase (5-FCL) activity had a significant impact on the levels of the 7 products that carry the one-carbon donated from folates, and the redox couple NADP/NADPH; this was particularly evident in the rapid growth state; 4) 5-FCL may be vital to the survival of the cells by maintaining low levels of homocysteine, as high levels can induce toxicity; and 5) the antifolate therapeutic trimethoprim had a greater impact on folate metabolism with higher nutrient availability. These results highlight the important role of 5-FCL in intracellular folate homeostasis and mass generation under different metabolic scenarios.
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Affiliation(s)
- Amy E Morgan
- School of Health & Sport Sciences, Hope Park, Liverpool Hope University, Liverpool, L16 9JD, UK.
| | - J Enrique Salcedo-Sora
- Liverpool Shared Research Facilities, GeneMill, University of Liverpool, Liverpool, L69 7ZB, UK
| | - Mark T Mc Auley
- School of Science, Engineering and Environment, University of Salford, Manchester, M5 4NT, UK
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3
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Mazokopakis EE, Papadomanolaki MG, Papadakis JA. The effects of folinic acid and l-methylfolate supplementation on serum total homocysteine levels in healthy adults. Clin Nutr ESPEN 2023; 58:14-20. [PMID: 38056998 DOI: 10.1016/j.clnesp.2023.09.002] [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: 10/31/2022] [Revised: 08/21/2023] [Accepted: 09/05/2023] [Indexed: 12/08/2023]
Abstract
BACKGROUND - AIM Hyperhomocysteinemia is recognized as a risk factor for several diseases and conditions. The aim of this study was to investigate and compare the efficacy of two total homocysteine (tHcy)-lowering treatments including folinic acid or l-methylfolate in healthy Greek adults. METHODS Two hundred and seventy-two healthy Greek adults (143 men, 129 women; mean age±SD: 43.0 ± 15.3 years), with serum tHcy levels ≥10 μmol/L received randomized folinic acid ("Folinic acid Group") or l-methylfolate ("l-methylfolate Group") orally for three months. All subjects with serum cobalamin (Cbl) levels <300 pg/mL additionally received 1 mg hydroxycobalamine intramuscularly twice a week for the first month only. Serum folate, Cbl and tHcy levels were determined using immunoassays methods at the beginning and the end of the study period. The MTHFR C677T and MTHFR A1298C gene polymorphisms were genotyped using polymerase chain reaction and reverse hybridization. RESULTS At the end of the 3-month intervention period, the levels of serum folate and Cbl increased significantly, whereas the levels of serum tHcy decreased significantly in the two groups. The individuals with MTHFR 677TT genotype had a significantly higher reduction in serum tHcy levels than the individuals with the MTHFR 677CC or MTHFR 677CT genotypes. Although the "Folinic acid Group" had a considerably higher increase in their serum folate levels (but not Cbl) than the "l-methylfolate Group", the reduction of serum tHcy levels between the two groups was not substantially different. The individuals with MTHFR 677CT genotype had a statistically significant higher reduction in serum tHcy levels when supplemented with folinic acid rather than l-methylfolate. CONCLUSIONS The administration of folinic acid compared to l-methylfolate caused a higher increase of serum folate levels but no difference in the reduction of serum tHcy levels. The reduction of serum tHcy levels was influenced by the existence of MTHFR C677T and not MTHFR A1298C gene polymorphisms. The individuals with MTHFR 677CT genotype appear to benefit more by folinic acid than l-methylfolate supplementation.
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Affiliation(s)
- Elias E Mazokopakis
- Department of Internal Medicine, Naval Hospital of Crete, Chania, Greece; Private Medical Office of Internal Medicine, Chania, Greece.
| | - Maria G Papadomanolaki
- School of Production Engineering and Management, Technical University of Crete, Chania, Greece
| | - John A Papadakis
- Department of Internal Medicine, University Hospital of Heraklion, Heraklion, Greece
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Ju DT, Huang RFS, Tsai BCK, Su YC, Chiu PL, Chang YM, Padma VV, Ho TJ, Yao CH, Kuo WW, Huang CY. Folic Acid and Folinic Acid Protect Hearts of Aging Triple-transgenic Alzheimer's Disease mice via IGF1R/PI3K/AKT and SIRT1/AMPK Pathways. Neurotox Res 2023; 41:648-659. [PMID: 37707697 DOI: 10.1007/s12640-023-00666-z] [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: 03/25/2023] [Revised: 08/31/2023] [Accepted: 09/06/2023] [Indexed: 09/15/2023]
Abstract
Patients with Alzheimer's disease have increased risk of developing heart disease, which therefore highlights the need for strategies aiming at reducing Alzheimer's disease-related cardiovascular disease. Folic acid and folinic acid are beneficial to the heart. We aimed to investigate the benefits of folic acid and folinic acid in heart of patients with late-stage Alzheimer's disease. Twelve 16-month-old mice of triple-transgenic late-stage Alzheimer's disease were divided into three groups: Alzheimer's disease group, Alzheimer's disease + folic acid group, and Alzheimer's disease + folinic acid group. The mice were administered 12 mg/kg folic acid or folinic acid once daily via oral gavage for 3 months. In the folic acid and folinic acid treatment groups, the intercellular space was reduced, compared with the Alzheimer's disease group. TUNEL assay and western blot images showed that the number of apoptotic cells and the apoptosis-related protein expression were higher in the Alzheimer's disease group than in other two treated groups. Folic acid and folinic acid induced the IGF1R/PI3K/AKT and SIRT1/ AMPK pathways in the hearts of mice with Alzheimer's disease. Our results showed that folic acid and folinic acid treatment increased survival and SIRT1 expression to reduce apoptotic proteins in the heart. The aging mice treated with folinic acid had more IGF1R and SIRT1/AMPK axes to limit myocardial cell apoptosis. In conclusion, folic acid and folinic acid promote cardiac cell survival and prevent apoptosis to inhibit heart damage in aging mice with triple-transgenic late-stage Alzheimer's disease. In particular, folinic acid provides a better curative effect than folic acid.
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Affiliation(s)
- Da-Tong Ju
- Department of Neurological Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Rwei-Fen S Huang
- Graduate Institute of Nutrition and Food Science, Department of Nutritional Science, Fu Jen Catholic University, New Taipei City, Taiwan
| | - Bruce Chi-Kang Tsai
- Cardiovascular and Mitochondrial Related Disease Research Center, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
| | - Yi-Chen Su
- Graduate Institute of Basic Medical Science, China Medical University, Taichung, Taiwan
| | | | | | - V Vijaya Padma
- Department of Biotechnology, Bharathiar University, Coimbatore, India
| | - Tsung-Jung Ho
- Department of Chinese Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
- Integration Center of Traditional Chinese and Modern Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
- School of Post-Baccalaureate Chinese Medicine, College of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Chun-Hsu Yao
- Department of Biomedical Imaging and Radiological Science, China Medical University, Taichung, Taiwan
- School of Chinese Medicine, China Medical University, Taichung, Taiwan
- Biomaterials Translational Research Center, China Medical University Hospital, Taichung, Taiwan
- Department of Bioinformatics and Medical Engineering, Asia University, Taichung, Taiwan
| | - Wei-Wen Kuo
- Department of Biological Science and Technology, China Medical University, Taichung, Taiwan
- Ph.D. Program for Biotechnology Industry, China Medical University, Taichung, Taiwan
| | - Chih-Yang Huang
- Cardiovascular and Mitochondrial Related Disease Research Center, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan.
- Graduate Institute of Biomedical Sciences, China Medical University, Taichung, Taiwan.
- Department of Medical Research, China Medical University Hospital, China Medical University, Taichung, Taiwan.
- Department of Medical Laboratory Science and Biotechnology, Asia University, Taichung, Taiwan.
- Center of General Education, Buddhist Tzu Chi Medical Foundation, Tzu Chi University of Science and Technology, Hualien, Taiwan.
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Potic A, Perrier S, Radovic T, Gavrilovic S, Ostojic J, Tran LT, Thiffault I, Pastinen T, Schiffmann R, Bernard G. Hypomyelination caused by a novel homozygous pathogenic variant in FOLR1: complete clinical and radiological recovery with oral folinic acid therapy and review of the literature. Orphanet J Rare Dis 2023; 18:187. [PMID: 37443037 DOI: 10.1186/s13023-023-02802-6] [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: 01/19/2023] [Accepted: 07/05/2023] [Indexed: 07/15/2023] Open
Abstract
BACKGROUND Neurodegeneration due to cerebral folate transport deficiency is a rare autosomal recessive disorder caused by biallelic pathogenic variants in FOLR1. Onset typically occurs in late infancy and is characterized by psychomotor regression, epilepsy, and a hypomyelinating leukodystrophy on magnetic resonance imaging. If left untreated, progressive neurodegeneration occurs. However, early treatment with folinic acid has been shown to stabilize or reverse neurological features. Approximately thirty patients have been described worldwide. Here, we report the first two cases with genetically proven cerebral folate transport deficiency from South-Eastern Europe, describe the effect of oral folinic acid therapy on clinical and neuroradiological features and review the literature. RESULTS Two siblings presented in childhood with clinical and radiological findings consistent with a hypomyelinating leukodystrophy. Exome sequencing revealed a novel homozygous pathogenic variant in FOLR1 (c.465_466delinsTG; p.W156G), confirming the diagnosis of neurodegeneration due to cerebral folate transport deficiency. Folinic acid treatment was promptly initiated in both patients. The younger sibling was treated early in disease course at 2 years of age, and demonstrated complete recovery in clinical and MRI features. The older sibling, who was 8 years of age at the time of diagnosis and treatment, demonstrated partial but substantial improvements. CONCLUSION We present the first account in the literature that early treatment initiation with oral folinic acid alone can result in complete neurological recovery of both clinical and radiological abnormalities in neurodegeneration due to cerebral folate deficiency. Moreover, through the report of these patients along with review of the literature, we provide information about the natural history of the disease with comparison of treatment effects at different stages of disease progression. This report also reinforces the importance of universal access to genetic testing to ensure prompt diagnoses for treatable disorders.
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Affiliation(s)
- Ana Potic
- Clinic for Child Neurology and Psychiatry, Department of Neurology, University of Belgrade, 6A Dr. Subotica Street, 11000, Belgrade, Serbia.
| | - Stefanie Perrier
- Departments of Neurology and Neurosurgery, McGill University, Montreal, Canada
- Child Health and Human Development Program, Research Institute of the McGill University Health Centre, Montreal, Canada
| | - Tijana Radovic
- University Children's Hospital, Department of Radiology, University of Belgrade, Belgrade, Serbia
| | - Svetlana Gavrilovic
- University Clinical Centre of Serbia, Centre for Radiology and Magnetic Resonance, University of Belgrade, Belgrade, Serbia
| | - Jelena Ostojic
- Faculty of Medicine, Department of Radiology, University of Novi Sad, Novi Sad, Serbia
| | - Luan T Tran
- Departments of Neurology and Neurosurgery, McGill University, Montreal, Canada
- Child Health and Human Development Program, Research Institute of the McGill University Health Centre, Montreal, Canada
| | - Isabelle Thiffault
- Genomic Medicine Center, Children's Mercy Hospital, Kansas City, MO, USA
- University of Missouri Kansas City School of Medicine, Kansas City, MO, USA
- Department of Pathology and Laboratory Medicine, Children's Mercy Hospital, Kansas City, MO, USA
| | - Tomi Pastinen
- Genomic Medicine Center, Children's Mercy Hospital, Kansas City, MO, USA
- University of Missouri Kansas City School of Medicine, Kansas City, MO, USA
| | | | - Geneviève Bernard
- Departments of Neurology and Neurosurgery, McGill University, Montreal, Canada
- Child Health and Human Development Program, Research Institute of the McGill University Health Centre, Montreal, Canada
- Departments of Pediatrics and Human Genetics, McGill University, Montreal, Canada
- Department Specialized Medicine, Division of Medical Genetics, McGill University Health Centre, Montreal, Canada
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Almahmoud R, Mekki M, El-Hattab AW. Cerebral folate deficiency: A report of two affected siblings. Mol Genet Metab Rep 2023; 35:100975. [PMID: 37101857 PMCID: PMC10123369 DOI: 10.1016/j.ymgmr.2023.100975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 04/08/2023] [Accepted: 04/09/2023] [Indexed: 04/28/2023] Open
Abstract
Cerebral folate deficiency (CFD) is a rare progressive neurological condition characterized by normal blood folate level and low 5-methyltetrahydrofolate (5-MTHF) levels in the cerebrospinal fluid. Patients present with different neurological findings including hypotonia and microcephaly. Later, patients develop ataxia, seizures, para or quadri-plagia. Herein, we report two siblings; born to consanguineous parents; who had normal neurological development in early childhood. Subsequently they developed drug-resistant seizures, neurological regression, and spastic quadriplegia. After thorough investigations patients had brain MRI which showed abnormal white matter signals and ventricular dilatation, CSF with low 5-MTHF, and whole exome sequencing (WES) revealed a novel homozygous variant in FOLR1 (c.245A > G; p.Tyr82Cys) consistent with the diagnosis of cerebral folate deficiency. They were treated with folinic acid in addition to standard anti-seizure medications. WES aids in reaching CFD diagnosis due to FOLR1 pathogenic variants. These results can be used for future counselling to prevent recurrence in future pregnancies by preimplantation genetic testing prior to implanting the embryo in the uterus. Treatment with folinic acid was shown to improve the neurological symptoms namely reduced the seizures and spasticity.
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Affiliation(s)
- Rabah Almahmoud
- Department of Clinical Sciences, College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
- Corresponding author at: College of Medicine, University of Sharjah, PO BOX 27272, Sharjah, United Arab Emirates.
| | - Mohammed Mekki
- Department of Pediatrics, AlQassimi Women and Children Hospital, Sharjah, United Arab Emirates
| | - Ayman W. El-Hattab
- Department of Clinical Sciences, College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
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Bhargava M, Kopp CR, Naidu S, Dhibar DP, Saroch A, Khadwal A, Narang T, Jain S, Khullar A, Leishangthem B, Sharma A, Kumar S, Sharma S, Jain S, Dhir V. Comparison of two doses of leucovorin in severe low-dose methotrexate toxicity - a randomized controlled trial. Arthritis Res Ther 2023; 25:82. [PMID: 37208770 DOI: 10.1186/s13075-023-03054-2] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 04/20/2023] [Indexed: 05/21/2023] Open
Abstract
BACKGROUND Leucovorin (folinic acid) is a commonly used antidote for severe toxicity with low-dose methotrexate, but its optimum dose is unclear, varying from 15 to 25 mg every 6-h. METHODS Open-label RCT included patients with severe low-dose (≤ 50 mg/week) methotrexate toxicity defined as WBC ≤ 2 × 10^9/L or platelet ≤ 50 × 10^9/L and randomized them to receive either usual (15 mg) or high-dose (25 mg) intravenous leucovorin given every 6-h. Primary outcome was mortality at 30-days and secondary outcomes were hematological recovery and mucositis recovery. TRIAL REGISTRATION NUMBER CTRI/2019/09/021152. RESULTS Thirty-eight patients were included, most with underlying RA who had inadvertently overdosed MTX (taken daily instead of weekly). At randomization, the median white blood and platelet count were 0.8 × 10^9/L and 23.5 × 10^9/L. 19 patients each were randomized to receive either usual or high-dose leucovorin. Number (%) of deaths over 30-days was 8 (42) and 9 (47) in usual and high-dose leucovorin groups (Odds ratio 1.2, 95% CI 0.3 to 4.5, p = 0.74). On Kaplan-Meier, there was no significant difference in survival between the groups (hazard ratio 1.1, 95% CI 0.4 to 2.9, p = 0.84). On multivariable cox-regression, serum albumin was the only predictor of survival (hazard ratio 0.3, 95% CI 0.1 to 0.9, p = 0.02). There was no significant difference in hematological or mucositis recovery between the two groups. CONCLUSION There was no significant difference in survival or time-to hematological recovery between the two doses of leucovorin. Severe low-dose methotrexate toxicity carried a significant mortality.
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Affiliation(s)
- Mudit Bhargava
- Division of Rheumatology, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Chirag Rajkumar Kopp
- Division of Rheumatology, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Shankar Naidu
- Division of Rheumatology, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Deba Prasad Dhibar
- Division of Emergency Medicine, Department of Internal Medicine Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Atul Saroch
- Division of Emergency Medicine, Department of Internal Medicine Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Alka Khadwal
- Department of Clinical Hematology and Medical Oncology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Tarun Narang
- Department of Dermatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Siddharth Jain
- Division of Rheumatology, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Aastha Khullar
- Division of Rheumatology, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Bidya Leishangthem
- Division of Rheumatology, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Aman Sharma
- Division of Rheumatology, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Susheel Kumar
- Division of Rheumatology, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Shefali Sharma
- Division of Rheumatology, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Sanjay Jain
- Division of Rheumatology, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Varun Dhir
- Division of Rheumatology, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India.
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Kanmaz S, Simsek E, Yilmaz S, Durmaz A, Serin HM, Gokben S. Cerebral folate transporter deficiency: a potentially treatable neurometabolic disorder. Acta Neurol Belg 2023; 123:121-7. [PMID: 34002331 DOI: 10.1007/s13760-021-01700-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 04/30/2021] [Indexed: 10/21/2022]
Abstract
Cerebral folate deficiency (CFD) syndrome is a rare treatable neurometabolic disorder with low levels of the active form of folaten in cerebrospinal fluid (CSF) arising from different causes such as FOLR1 gene mutations or autoantibodies against the folate receptor-alpha (FR) protein that can block folate transport across the choroid plexus. It is characterized by late infantile onset refractory seizures, ataxia, movement disorder, and unexplained global developmental delay. Here, we report a patient diagnosed with autistic spectrum disorder, followed by refractory myoclonic-atonic seizures, ataxia, and loss of motor skills over time. A homozygous missense (c.665A > G) mutation in FOLR1 gene and extremely low CSF 5-methyltetrahydrofolate level led to the diagnosis of CFD. Although she was initiated on combined oral and intravenous high doses of folinic acid treatment at 6 years of age, mild improvement was achieved in terms of epileptic seizures and motor skills. It is important that CFD should be kept in mind in cases with refractory myoclonic-atonic seizure and folinic acid treatment should be started as soon as possible.
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Apraxine M, Van den Eynde M, De Cuyper A, Pirson F. Hypersensitivity reactions to folinic acid: mechanisms involved based on two case reports and a literature review. Allergy Asthma Clin Immunol 2022; 18:107. [PMID: 36550565 PMCID: PMC9783773 DOI: 10.1186/s13223-022-00752-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 12/09/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Hypersensitivity reactions (HSR) to antineoplastic agents are an increasing problem, especially when they lead to treatment discontinuation, sometimes without any equivalent therapeutic option. HSR to folinic acid (FA), used particularly for the treatment of digestive carcinoma along with oxaliplatin and 5-fluorouracil, are rare. Only seven publications report HSR to FA, mainly confirmed by the disappearance of symptoms after the withdrawal of FA from chemotherapy. Only two papers describe allergy testing. Due to the difficult diagnosis, patients usually receive several further cycles of chemotherapy with progressively more intense symptoms before the withdrawal of FA. CASE PRESENTATION Here we document two cases of HSR to FA, initially misattributed to oxaliplatin. The first patient described successive cycles with first back muscle pain, then chills and facial oedema and finally diffuse erythema with labial edema despite premedication. The allergy assessment highlighted high acute tryptase levels and intradermal tests positive for FA, pointing to an immunoglobulin E (IgE)-mediated mechanism. The second patient also had lower back muscle pain and chills in addition to tachycardia and desaturation during the administration of FA. Skin tests were negative and tryptase levels normal. After withdrawing FA, the symptoms did not recur, thus allowing the patient to continue chemotherapy. The mechanism of FA hypersensitivity is still unclear. The chronology of symptoms suggests an IgE-mediated mechanism that was not documented in the allergy assessment. A non-IgE-mediated mast cell/basophil activation could be involved, through complement activation or through Mas-related G protein-coupled receptors X2 (MRGPRX2) particularly. CONCLUSIONS These two cases of anaphylaxis to FA document the clinical manifestations associated with two different mechanisms of HSR. This paper provided the opportunity to review the limited literature on HSR to FA. Through these cases, we hope to draw the practitioner's attention to FA as a potential agent of severe hypersensitivity, especially if symptoms remain after withdrawing the most suspected chemotherapeutic agents. We want also to stress the importance of allergy testing.
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Affiliation(s)
- Matveï Apraxine
- grid.48769.340000 0004 0461 6320Department of Pulmonology, Cliniques Universitaires Saint-Luc, Brussels, Belgium ,grid.490655.bDepartment of Pulmonology, GHdC, Charleroi, Belgium
| | - Marc Van den Eynde
- grid.48769.340000 0004 0461 6320Department of Oncology, Cliniques Universitaires Saint-Luc, Institut Roi Albert II, Brussels, Belgium
| | - Astrid De Cuyper
- grid.48769.340000 0004 0461 6320Department of Oncology, Cliniques Universitaires Saint-Luc, Institut Roi Albert II, Brussels, Belgium
| | - Françoise Pirson
- grid.48769.340000 0004 0461 6320Department of Pulmonology, Cliniques Universitaires Saint-Luc, Brussels, Belgium ,grid.48769.340000 0004 0461 6320Centre de l’allergie Saint-Luc, Cliniques Universitaires Saint Luc, Brussels, Belgium ,grid.7942.80000 0001 2294 713XIREC-PNEU, UCL Université Catholique de Louvain, Brussels, Belgium
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10
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Jaafar F, Obeid M. Successful Treatment of Cerebral Folate Transporter Deficiency With Intravenous Folinic Acid. Pediatr Neurol 2022; 135:22-4. [PMID: 35970100 DOI: 10.1016/j.pediatrneurol.2022.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 07/05/2022] [Accepted: 07/06/2022] [Indexed: 11/21/2022]
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Lam NSK, Long XX, Li X, Saad M, Lim F, Doery JC, Griffin RC, Galletly C. The potential use of folate and its derivatives in treating psychiatric disorders: A systematic review. Biomed Pharmacother 2021; 146:112541. [PMID: 34953391 DOI: 10.1016/j.biopha.2021.112541] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 12/13/2021] [Accepted: 12/13/2021] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVES To examine the strengths and limitations of existing data to provide guidance for the use of folate supplements as treatment, with or without other psychotropic medications, in various psychiatric disorders. To identify area for further research in terms of the biosynthesis of mechanism of folate and genetic variants in metabolic pathway in human. METHODS A systematic review of published literature following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, to assess whether folate supplements are beneficial in certain psychiatric disorders (depression, bipolar disorder, schizophrenia, autism spectrum disorder, and attention deficit hyperactivity disorder). Methodology of this review is registered with Prospero (Registration number CRD 42021266605). DATA SOURCES Eligible studies were identified using a systematic search of four electronic databases: Embase, Pubmed, PsycINFO, and Cochrane. The search strategy covered the time period from 1974 to August 16th, 2021. Therefore, this review examines randomized control trials or open-label trials completed during this period. RESULTS We identified 23 studies of folate supplements in various psychiatric disorders for critical review. Of these, 9 studies investigated the efficacy of folate supplements in major depressive disorders, 5 studies in schizophrenia, 6 studies in autism spectrum disorder, 2 studies in bipolar affective disorder and 1 study in attention deficit hyperactive disorder. The most consistent finding association of oral levomefolic acid or 5-methylfolate with improvement in clinical outcomes in mental health conditions as mentioned above, especially in major depressive disorder (including postpartum and post-menopausal depression), schizophrenia, autism spectrum disorder, attention deficit hyperactivity disorder and bipolar affective disorder. Folate supplements were well tolerated. LIMITATION Our results are not representative of all types of studies such as case reports or case series studies, nor are they representative of the studies conducted in languages that are not in English or not translated in English. CONCLUSION Increasing evidence from clinical trials consistently demonstrate folate supplements, especially levomefolic acid or 5-methylfolate, may improve clinical outcomes for certain psychiatric diseases, especially as an adjunct pharmacotherapy with minimal side effects.
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Hansson K, Orrling H, Blomgren A, Isaksson A, Schliamser G, Heldrup J, Pronk CJ. Simultaneous determination of folate and methotrexate metabolites in serum by LC-MS/MS during high-dose methotrexate therapy. J Chromatogr B Analyt Technol Biomed Life Sci 2021; 1186:123007. [PMID: 34781107 DOI: 10.1016/j.jchromb.2021.123007] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 10/12/2021] [Accepted: 10/17/2021] [Indexed: 10/19/2022]
Abstract
High-dose methotrexate (HDMTX) is a central component in the treatment of acute lymphoblastic leukemia, osteosarcoma, and some lymphomas and brain tumors. MTX is given at lethal doses and then is followed by rescue treatment with folinic acid (FA). Despite FA rescue, many patients suffer severe toxicity. The pharmacokinetics of FA rescue have not been sufficiently studied. However, optimization of FA rescue could potentially increase anti-tumor effects, whilst decreasing organ toxicity. Here, we describe our efforts to establish and optimize a liquid chromatography tandem mass spectrometric (LC-MS/MS) method for the simultaneous determination of five essential components of the folate cycle, as well as MTX and its two metabolites. The method was applied to 6 individual patients receiving HDMTX, with 3 or 4 measurements for each patient. The method allows analysis of samples that were initially frozen. This notion, together with the test results in the 6 pilot patients, shows the feasibility of this method to study MTX and FA pharmacokinetics during HDMTX treatment. The method has the potential to optimize HDMTX and FA rescue treatment in individual patients.
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Affiliation(s)
- Karin Hansson
- Department of Clinical Chemistry and Pharmacology, Lund University, Sweden
| | - Henrik Orrling
- Childhood Cancer Centre, Skåne University Hospital, Lund, Sweden
| | - Anders Blomgren
- Department of Clinical Chemistry and Pharmacology, Lund University, Sweden
| | - Anders Isaksson
- Department of Clinical Chemistry and Pharmacology, Lund University, Sweden
| | - Gloria Schliamser
- Department of Clinical Chemistry and Pharmacology, Lund University, Sweden
| | - Jesper Heldrup
- Childhood Cancer Centre, Skåne University Hospital, Lund, Sweden
| | - Cornelis Jan Pronk
- Childhood Cancer Centre, Skåne University Hospital, Lund, Sweden; Division of Molecular Hematology and Stem Cell Centre, Lund University, Lund, Sweden; Wallenberg Center for Molecular Medicine, Lund University, Lund, Sweden.
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Heuschkel S, Kretschmann T, Teipel R, von Bonin S, Richter S, Quick S, Alakel N, Röllig C, Balaian E, Kroschinsky F, Knoth H, Bornhäuser M, von Bonin M. Half-dose glucarpidase as efficient rescue for toxic methotrexate levels in patients with acute kidney injury. Cancer Chemother Pharmacol 2021. [PMID: 34669022 DOI: 10.1007/s00280-021-04361-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 10/02/2021] [Indexed: 11/21/2022]
Abstract
Purpose High-dose methotrexate (HDMTX)-associated acute kidney injury with delayed MTX clearance has been linked to an excess in MTX-induced toxicities. Glucarpidase is a recombinant enzyme that rapidly hydrolyzes MTX into non-toxic metabolites. The recommended dose of glucarpidase is 50 U/kg, which has never been formally established in a dose finding study in humans. Few case reports, mostly in children, suggest that lower doses of glucarpidase might be equally effective in lowering MTX levels. Methods Seven patients with toxic MTX plasma concentrations following HDMTX therapy were treated with half-dose glucarpidase (mean 25 U/kg, range 17–32 U/kg). MTX levels were measured immunologically as well as by liquid chromatography–mass spectrometry (LC–MS). Toxicities were assessed according to National Cancer Institute—Common Terminology Criteria for Adverse Events (CTCAE) v5.0. Results All patients experienced HDMTX-associated kidney injury (median increase in creatinine levels within 48 h after HDMTX initiation compared to baseline of 251%, range 80–455%) and showed toxic MTX plasma concentrations (range 3.1–182.4 µmol/L) before glucarpidase injection. The drug was administered 42–70 h after HDMTX initiation. Within one day after glucarpidase injection, MTX plasma concentrations decreased by ≥ 97.7% translating into levels of 0.02–2.03 µmol/L. MTX rebound was detected in plasma 42–73 h after glucarpidase initiation, but concentrations remained consistent at < 10 µmol/L. Conclusion Half-dose glucarpidase seems to be effective in lowering MTX levels to concentrations manageable with continued intensified folinic acid rescue. Supplementary Information The online version contains supplementary material available at 10.1007/s00280-021-04361-8.
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14
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Batebi N, Moghaddam HS, Hasanzadeh A, Fakour Y, Mohammadi MR, Akhondzadeh S. Folinic Acid as Adjunctive Therapy in Treatment of Inappropriate Speech in Children with Autism: A Double-Blind and Placebo-Controlled Randomized Trial. Child Psychiatry Hum Dev 2021; 52:928-938. [PMID: 33029705 DOI: 10.1007/s10578-020-01072-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/30/2020] [Indexed: 12/27/2022]
Abstract
This is a double-blind, placebo-controlled randomized trial to investigate the potential therapeutic effects of folinic acid/placebo as an adjuvant to risperidone on inappropriate speech and other behavioral symptoms of autism spectrum disorder (ASD). Fifty-five ASD children (age (mean ± standard deviation) = 13.40 ± 2.00; male/female: 35/20) were evaluated for behavioral symptoms at baseline, week 5, and week 10 using the aberrant behavior checklist-community (ABC-C). Folinic acid dosage was 2 mg/kg up to 50 mg per day for the entire course of the study. The repeated measures analysis showed significant effect for time × treatment interaction on inappropriate speech (F = 3.51; df = 1.61; P = 0.044), stereotypic behavior (F = 4.02; df = 1.37; P = 0.036), and hyperactivity/noncompliance (F = 6.79; df = 1.66; P = 0.003) subscale scores. In contrast, no significant effect for time × treatment interaction was found on lethargy/social withdrawal (F = 1.06; df = 1.57; P = 0.336) and irritability (F = 2.86; df = 1.91; P = 0.064) subscale scores. Our study provided preliminary evidence suggesting that folinic acid could be recommended as a beneficial complementary supplement for alleviating speech and behavioral symptoms in children with ASD.Clinical trial registeration: This trial was registered in the Iranian Registry of Clinical Trials ( www.irct.ir ; No. IRCT20090117001556N114).
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Affiliation(s)
- Neda Batebi
- Psychiatric Research Center, Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Alireza Hasanzadeh
- Psychiatric Research Center, Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Yousef Fakour
- Psychiatric Research Center, Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Reza Mohammadi
- Psychiatric Research Center, Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Shahin Akhondzadeh
- Psychiatric Research Center, Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, Iran. .,Psychiatric Research Center, Roozbeh Psychiatric Hospital, Tehran University of Medical Sciences, South Kargar Street, 13337, Tehran, Iran.
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15
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Stegmann KM, Dickmanns A, Gerber S, Nikolova V, Klemke L, Manzini V, Schlösser D, Bierwirth C, Freund J, Sitte M, Lugert R, Salinas G, Meister TL, Pfaender S, Görlich D, Wollnik B, Groß U, Dobbelstein M. The folate antagonist methotrexate diminishes replication of the coronavirus SARS-CoV-2 and enhances the antiviral efficacy of remdesivir in cell culture models. Virus Res 2021; 302:198469. [PMID: 34090962 PMCID: PMC8180352 DOI: 10.1016/j.virusres.2021.198469] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 05/27/2021] [Accepted: 05/28/2021] [Indexed: 12/19/2022]
Abstract
The search for successful therapies of infections with the coronavirus SARS-CoV-2 is ongoing. We tested inhibition of host cell nucleotide synthesis as a promising strategy to decrease the replication of SARS-CoV-2-RNA, thus diminishing the formation of virus progeny. Methotrexate (MTX) is an established drug for cancer therapy and to induce immunosuppression. The drug inhibits dihydrofolate reductase and other enzymes required for the synthesis of nucleotides. Strikingly, the replication of SARS-CoV-2 was inhibited by MTX in therapeutic concentrations around 1 µM, leading to more than 1000-fold reductions in virus progeny in Vero C1008 (Vero E6) and ~100-fold reductions in Calu-3 cells. Virus replication was more sensitive to equivalent concentrations of MTX than of the established antiviral agent remdesivir. MTX strongly diminished the synthesis of viral structural proteins and the amount of released virus RNA. Virus replication and protein synthesis were rescued by folinic acid (leucovorin) and also by inosine, indicating that purine depletion is the principal mechanism that allows MTX to reduce virus RNA synthesis. The combination of MTX with remdesivir led to synergistic impairment of virus replication, even at 100 nM MTX. The use of MTX in treating SARS-CoV-2 infections still awaits further evaluation regarding toxicity and efficacy in infected organisms, rather than cultured cells. Within the frame of these caveats, however, our results raise the perspective of a two-fold benefit from repurposing MTX for treating COVID-19. Firstly, its previously known ability to reduce aberrant inflammatory responses might dampen respiratory distress. In addition, its direct antiviral activity described here would limit the dissemination of the virus.
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Affiliation(s)
- Kim M Stegmann
- Institute of Molecular Oncology, Göttingen Center of Molecular Biosciences (GZMB), University Medical Center Göttingen, Germany
| | - Antje Dickmanns
- Institute of Molecular Oncology, Göttingen Center of Molecular Biosciences (GZMB), University Medical Center Göttingen, Germany
| | - Sabrina Gerber
- Institute of Molecular Oncology, Göttingen Center of Molecular Biosciences (GZMB), University Medical Center Göttingen, Germany
| | - Vella Nikolova
- Institute of Molecular Oncology, Göttingen Center of Molecular Biosciences (GZMB), University Medical Center Göttingen, Germany
| | - Luisa Klemke
- Institute of Molecular Oncology, Göttingen Center of Molecular Biosciences (GZMB), University Medical Center Göttingen, Germany
| | - Valentina Manzini
- Institute of Molecular Oncology, Göttingen Center of Molecular Biosciences (GZMB), University Medical Center Göttingen, Germany
| | - Denise Schlösser
- Institute of Molecular Oncology, Göttingen Center of Molecular Biosciences (GZMB), University Medical Center Göttingen, Germany
| | - Cathrin Bierwirth
- Institute of Molecular Oncology, Göttingen Center of Molecular Biosciences (GZMB), University Medical Center Göttingen, Germany
| | - Julia Freund
- Institute of Molecular Oncology, Göttingen Center of Molecular Biosciences (GZMB), University Medical Center Göttingen, Germany
| | - Maren Sitte
- NGS Integrative Genomics Core Unit, Institute of Human Genetics, University Medical Center Göttingen, Germany
| | - Raimond Lugert
- Institute of Medical Microbiology, Göttingen Center of Molecular Biosciences (GZMB), University Medical Center Göttingen, Germany
| | - Gabriela Salinas
- NGS Integrative Genomics Core Unit, Institute of Human Genetics, University Medical Center Göttingen, Germany
| | - Toni Luise Meister
- Department of Molecular and Medical Virology, Ruhr University Bochum, Germany
| | - Stephanie Pfaender
- Department of Molecular and Medical Virology, Ruhr University Bochum, Germany
| | - Dirk Görlich
- Max Planck Institute for Biophysical Chemistry, Göttingen, Germany
| | - Bernd Wollnik
- Institute of Human Genetics, University Medical Center Göttingen, Germany
| | - Uwe Groß
- Institute of Medical Microbiology, Göttingen Center of Molecular Biosciences (GZMB), University Medical Center Göttingen, Germany
| | - Matthias Dobbelstein
- Institute of Molecular Oncology, Göttingen Center of Molecular Biosciences (GZMB), University Medical Center Göttingen, Germany.
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Poli JG, Paiva G, Freitas F, Mora P, Velarde LGC, Junior JA, Filho JR, Elias KM, Horowitz NS, Braga A, Berkowitz RS. Folinic acid rescue during methotrexate treatment for low-risk gestational trophoblastic neoplasia - How much is just right? Gynecol Oncol 2021; 162:638-644. [PMID: 34266689 DOI: 10.1016/j.ygyno.2021.07.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 06/27/2021] [Accepted: 07/07/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To compare the outcomes of patients with low-risk gestational trophoblastic neoplasia (GTN) treated with 8-day methotrexate (MTX) with two different regimens of folinic acid (FA). METHODS Retrospective cohort study of low-risk GTN followed at Rio de Janeiro Federal University, from January/2000-December/2019 with 8-day MTX with FA at 0.1 mg/kg versus 15 mg fixed dose. RESULTS Among 667 patients with low-risk GTN, 323 were treated with FA at 0.1 mg/kg and 142 with FA at 15 mg fixed dose. The weight-based and fixed dose groups were comparable in terms of clinical profile but did differ in the hCG pretreatment level (8883 versus 5127 IU/L, p < 0.01) and FIGO risk score 5/6 (3.4% versus 18.3%, p < 0.01), respectively. Despite this, there was no difference in the remission rate in first-line treatment (76.8 versus 81%, p = 0.33), although FA at 0.1 mg/kg had a significantly higher number of chemotherapy cycles to remission (5 versus 4, p < 0.01), need to delay chemotherapy due to toxicity (6.8 versus 2.8%, p < 0.01) and time to remission, (12 versus 8 weeks, p < 0.01), respectively. A logistic regression analysis showed that the different FA rescue regimens appeared comparable in terms of achieving remission in first-line chemotherapy for low-risk GTN (OR:5.16, CI95%:0.84-31.64, p = 0.08). CONCLUSION FA with 15 mg fixed dose as compared to 0.1 mg/kg of FA was associated with similar primary remission rate, relapse or death among low-risk GTN treated with 8-day MTX. This regimen is highly practical, reduces visits to health facilities, appears equally safe and may be preferable with the 8-day MTX regimen in the treatment of low-risk GTN.
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Affiliation(s)
- Juliana Gomes Poli
- Rio de Janeiro Trophoblastic Disease Center (Maternity School of Rio de Janeiro Federal University, Antonio Pedro University Hospital of Fluminense Federal University), Postgraduate Program in Perinatal Health, Faculty of Medicine, Maternity School of Rio de Janeiro Federal University. Rio de Janeiro, RJ, Brazil; Postgraduate Program in Medical Sciences, Fluminense Federal University, Niterói, RJ, Brazil
| | - Gabriela Paiva
- Rio de Janeiro Trophoblastic Disease Center (Maternity School of Rio de Janeiro Federal University, Antonio Pedro University Hospital of Fluminense Federal University), Postgraduate Program in Perinatal Health, Faculty of Medicine, Maternity School of Rio de Janeiro Federal University. Rio de Janeiro, RJ, Brazil
| | - Fernanda Freitas
- Rio de Janeiro Trophoblastic Disease Center (Maternity School of Rio de Janeiro Federal University, Antonio Pedro University Hospital of Fluminense Federal University), Postgraduate Program in Perinatal Health, Faculty of Medicine, Maternity School of Rio de Janeiro Federal University. Rio de Janeiro, RJ, Brazil
| | - Paulo Mora
- Rio de Janeiro Trophoblastic Disease Center (Maternity School of Rio de Janeiro Federal University, Antonio Pedro University Hospital of Fluminense Federal University), Postgraduate Program in Perinatal Health, Faculty of Medicine, Maternity School of Rio de Janeiro Federal University. Rio de Janeiro, RJ, Brazil; Postgraduate Program in Medical Sciences, Fluminense Federal University, Niterói, RJ, Brazil; Brazilian National Cancer Institute. Hospital do Câncer 2, Rio de Janeiro, RJ, Brazil
| | | | - Joffre Amim Junior
- Rio de Janeiro Trophoblastic Disease Center (Maternity School of Rio de Janeiro Federal University, Antonio Pedro University Hospital of Fluminense Federal University), Postgraduate Program in Perinatal Health, Faculty of Medicine, Maternity School of Rio de Janeiro Federal University. Rio de Janeiro, RJ, Brazil
| | - Jorge Rezende Filho
- Rio de Janeiro Trophoblastic Disease Center (Maternity School of Rio de Janeiro Federal University, Antonio Pedro University Hospital of Fluminense Federal University), Postgraduate Program in Perinatal Health, Faculty of Medicine, Maternity School of Rio de Janeiro Federal University. Rio de Janeiro, RJ, Brazil
| | - Kevin M Elias
- New England Trophoblastic Disease Center, Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Neil S Horowitz
- New England Trophoblastic Disease Center, Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Antonio Braga
- Rio de Janeiro Trophoblastic Disease Center (Maternity School of Rio de Janeiro Federal University, Antonio Pedro University Hospital of Fluminense Federal University), Postgraduate Program in Perinatal Health, Faculty of Medicine, Maternity School of Rio de Janeiro Federal University. Rio de Janeiro, RJ, Brazil; Postgraduate Program in Medical Sciences, Fluminense Federal University, Niterói, RJ, Brazil; National Academy of Medicine, Young Leadership Physicians Program, Rio de Janeiro, RJ, Brazil.
| | - Ross S Berkowitz
- New England Trophoblastic Disease Center, Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Niinimäki R, Aarnivala H, Banerjee J, Pokka T, Vepsäläinen K, Harila-Saari A. Reduced dose folinic acid rescue after rapid high-dose methotrexate clearance is not associated with increased toxicity in a pediatric cohort. Support Care Cancer 2021. [PMID: 34235555 DOI: 10.1007/s00520-021-06395-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 06/23/2021] [Indexed: 11/24/2022]
Abstract
Purpose Low doses of folinic acid (FA) rescue after high-dose methotrexate (HD-MTX) have been associated with increased toxicity, whereas high doses may be related to a decreased antileukemic effect. The optimal dosage and duration of FA rescue remain controversial. This study was designed to investigate, whether a shorter duration of FA rescue in the setting of rapid HD-MTX clearance is associated with increased toxicity. Methods We reviewed the files of 44 children receiving a total of 350 HD-MTX courses during treatment for acute lymphoblastic leukemia according to the NOPHO ALL-2000 protocol. Following a 5 g/m2 HD-MTX infusion, pharmacokinetically guided FA rescue commenced at hour 42. As per local guidelines, the patients received only one or two 15 mg/m2 doses of FA in the case of rapid MTX clearance (serum MTX ≤ 0.2 μmol/L at hour 42 or hour 48, respectively). Data on MTX clearance, FA dosing, inpatient time, and toxicities were collected. Results Rapid MTX clearance was observed in 181 courses (51.7%). There was no difference in the steady-state MTX concentration, nephrotoxicity, hepatotoxicity, neutropenic fever, or neurotoxicity between courses followed by rapid MTX clearance and those without. One or two doses of FA after rapid MTX clearance resulted in a 7.8-h shorter inpatient time than if a minimum of three doses of FA would have been given. Conclusion A pharmacokinetically guided FA rescue of one or two 15 mg/m2 doses of FA following HD-MTX courses with rapid MTX clearance results in a shorter hospitalization without an increase in toxic effects.
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Gowda VK, Battina M, Shivappa SK, Benakappa N. Treatable Cause of Pancytopenia, Recurrent Infections and Refractory Epilepsy: Secondary to Hereditary Folate Malabsorption (HFM) Due to Novel Pathogenic Variant. Indian J Pediatr 2021; 88:586-588. [PMID: 33146883 DOI: 10.1007/s12098-020-03548-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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Accepted: 10/14/2020] [Indexed: 10/23/2022]
Abstract
Hereditary folate malabsorption (HFM) is a rare disorder of proton-coupled folate transporter deficiency. It is characterized by macrocytic anemia, recurrent infections, and epilepsy. A five-year-old girl presented with recurrent pneumonia, diarrhea, and mouth ulcers. On examination, pallor, microcephaly with spastic quadriparesis was noted. On investigations, leukopenia and thrombocytopenia with megaloblastic bone marrow picture and low folate levels was found. HFM was diagnosed at two years of age and the child was treated with folinic acid. Her diagnosis was confirmed by whole-exome sequencing which revealed a novel pathogenic homozygous frameshift insertion variation (c.620dupG) in the exon 2 of the SLC46A1 gene which was further confirmed by Sanger sequencing. The child improved significantly except for a partial improvement in neurological symptoms.
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Affiliation(s)
- Vykuntaraju K Gowda
- Department of Pediatric Neurology, Indira Gandhi Institute of Child Health, Bangalore, Karnataka, 560029, India.
| | - Manojna Battina
- Department of Pediatric Neurology, Indira Gandhi Institute of Child Health, Bangalore, Karnataka, 560029, India
| | - Sanjay K Shivappa
- Department of Pediatric Medicine, Indira Gandhi Institute of Child Health, Bangalore, Karnataka, India
| | - Naveen Benakappa
- Department of Pediatric Medicine, Indira Gandhi Institute of Child Health, Bangalore, Karnataka, India
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Celkan T, Çifçi Sunamak E. Accidental High-dose Intrathecal Treatment: Late Results of a Patient. Turk J Haematol 2020; 37:64-65. [PMID: 31525837 PMCID: PMC7057754 DOI: 10.4274/tjh.galenos.2019.2019.0283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Affiliation(s)
- Tiraje Celkan
- İstanbul University-Cerrahpaşa Cerrahpaşa Faculty of Medicine, Department of Pediatric Hematology Oncology, İstanbul, Turkey
| | - Evrim Çifçi Sunamak
- Dr. Lütfi Kırdar Kartal Training and Research Hospital, Child Health and Diseases, İstanbul, Turkey
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20
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Lubout CMA, Goorden SMI, van den Hurk K, Jaeger B, Jager NGL, van Koningsbruggen S, Chegary M, van Karnebeek CDM. Successful Treatment of Hereditary Folate Malabsorption With Intramuscular Folinic Acid. Pediatr Neurol 2020; 102:62-66. [PMID: 31371121 DOI: 10.1016/j.pediatrneurol.2019.06.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 06/08/2019] [Accepted: 06/12/2019] [Indexed: 01/28/2023]
Abstract
BACKGROUND Hereditary folate malabsorption is a multisystem disease owing to biallelic variants in the gene encoding the proton-coupled folate transporter. Hereditary folate malabsorption is treated with folinic acid, aimed to restore blood and cerebrospinal fluid folate levels. Little is known as to whether oral or intramuscular supplementation of folinic acid is most effective. METHODS Here we describe a one-year-old boy with hereditary folate malabsorption presenting with the typical features including failure to thrive, aphthous stomatitis, macrocytic anemia along with severe developmental impairment and epilepsy, as well as a magnetic resonance imaging of the brain showing bilateral occipital, cortical calcifications characteristic of hereditary folate malabsorption. We compared the effect of treatment with oral folinic acid versus intramuscular folinic acid supplementation by measuring plasma and cerebrospinal fluid folate levels. RESULTS Compared with oral administration, intramuscular treatment resulted in higher folate levels in blood and, most importantly, normalization of folate levels in cerebrospinal fluid. Clinically, nearly all systemic and neurological symptoms resolved. CONCLUSION Normal cerebrospinal fluid folate levels can be achieved in individuals with hereditary folate malabsorption with intramuscular (but not with oral) administration of folinic acid.
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Affiliation(s)
- Charlotte M A Lubout
- Department of Pediatric Metabolic Diseases, Emma Children's Hospital, Amsterdam Gastro-Enterology & Metabolism Research Institute, Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - Susanna M I Goorden
- Department of Clinical Chemistry, Laboratory of Genetic Metabolic Diseases, Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - Karin van den Hurk
- Department of Clinical Chemistry, OLVG Lab BV, Amsterdam, The Netherlands
| | - Bregje Jaeger
- Department of Pediatric Neurology, Emma Children's Hospital, Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - Nynke G L Jager
- Department of Clinical Pharmacology and Pharmacy, Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | | | - Malika Chegary
- Department of Pediatrics, OLVG, Amsterdam, The Netherlands
| | - Clara D M van Karnebeek
- Department of Pediatric Metabolic Diseases, Emma Children's Hospital, Amsterdam Gastro-Enterology & Metabolism Research Institute, Amsterdam University Medical Centres, Amsterdam, The Netherlands; Department of Clinical Genetics, Amsterdam University Medical Centres, Amsterdam, The Netherlands.
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Cooper C, Bryant M, Hogan N, Johann TW. Investigations of Amino Acids in the 5-Formyltetrahydrofolate Binding Site of 5,10-Methenyltetrahydrofolate Synthetase from Mycoplasma pneumonia. Protein J 2019; 38:409-418. [PMID: 31401777 DOI: 10.1007/s10930-019-09861-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
5,10-Methenyltetrahydrofolate synthetase plays a significant role in folate metabolism by catalyzing the conversion of 5-formyltetrahydrofolate into 5,10-methenyltetrahydrofolate. The enzyme is important in some forms of chemotherapy, and it has been implicated in resistance to antifolate antibiotics. A co-crystal structure of the enzyme (1U3G) and primary sequence analysis were used to select highly conserved amino acids in close proximity to bound 5-formyltetrahydrofolate. The amino acids were then investigated using site directed mutagenesis and kinetics. Y123, E55, and F118 were concluded to be important for binding 5-formyltetrahydrofolate in the active site and/or for substrate turnover of the enzyme. Replacement of E55 or Y123 with alanine resulted in no detectable activity. The more subtle replacement of E55 with glutamine was also inactive suggesting an ionic interaction with 5-formyltetrahydrofolate. Mutations to F118 resulted in substantial increases in apparent Km for both 5-formyltetrahydrofolate and ATP, but did not substantially affect catalytic turnover. Outside the active site, the replacement of Q144 with alanine yielded an enzyme that bound the substrates of ATP and 5-formyltetrahydrofolate with higher apparent Km values than the wild-type enzyme, but demonstrated a 3.1 fold increase in kcat.
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Affiliation(s)
- Casey Cooper
- Edward Via College of Osteopathic Medicine, 2265 Kraft Drive, Blacksburg, VA, 24060, USA
| | - Matthew Bryant
- Personal Genome Diagnostics, 2809 Boston Street, Suite 503, Baltimore, MD, 21224, USA
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Król J, Nawrot U, Bartoszewicz M. Activity of base analogues (5-fluorouracil, 5-flucytosine) against planktonic cells and mature biofilm of Candida yeast. Effect of combination with folinic acid. J Mycol Med 2019; 29:147-153. [PMID: 31023592 DOI: 10.1016/j.mycmed.2019.04.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 03/15/2019] [Accepted: 04/09/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND The increasing number of Candida infections, especially those caused by non-C. albicans species and resistant strains, is a serious medical problem. OBJECTIVES In this study, the antifungal activity of base analogues, 5-flucytosine (5-FC) and 5-fluorouracil (5-FU), was tested against planktonic cells as well as against mature biofilm. METHODS Tests were performed according the EUCAST methodology. Antibiofilm effectiveness of tested drugs was determined by the crystal violet staining method. The cytotoxicity assays was performed according to the ISO 10993-5 norm. RESULTS 5-FC and 5-FU were effective against fifteen fluconazole resistant Candida glabrata strains with an average minimal inhibitory concentration (MIC) of 0.152mg/L and 0.39mg/L, respectively. Folinic acid (folinate- e.g., leucovorin) is a common drug used in oncology simultaneously with 5-FU. In our tests folinate was able to lower MIC for 5-FC from 0.152 to 0.058mg/L (P<0.05). In the biofilm assay 5-FU and 5-FC alone did not induce any changes in the biomass of mature biofilm. Addition of folinate to each base analogue resulted in up to 90% reduction of biomass. Viability tests show that a concentration of 64mg/L of 5-FC and 5-FU supplemented with folinate can be fungicidal against mature biofilms of some Candida isolates. No cytotoxic effect was found for combination of FOL and 5-FC. CONCLUSION Therapy of 5-FU+folinate is well known in cancer treatment, in this study we reveal the beneficial effect of folinate on antifungal activity of 5-FC as well as the antifungal potential of 5-FU+folinate.
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Affiliation(s)
- J Król
- Department of Pharmaceutical Microbiology and Parasitology, Wroclaw Medical University, Borowska 211a, 50-556 Wrocław, Poland; Cytostatic laboratory, Lower Silesian Oncology Center, Wrocław, Poland.
| | - U Nawrot
- Department of Pharmaceutical Microbiology and Parasitology, Wroclaw Medical University, Borowska 211a, 50-556 Wrocław, Poland
| | - M Bartoszewicz
- Department of Pharmaceutical Microbiology and Parasitology, Wroclaw Medical University, Borowska 211a, 50-556 Wrocław, Poland
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Tabassum S, AlAsmari A, AlSaman AA. Widening the phenotypic spectrum - Non epileptic presentation of folate transporter deficiency. J Clin Neurosci 2018; 59:341-344. [PMID: 30420205 DOI: 10.1016/j.jocn.2018.10.075] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Accepted: 10/15/2018] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Folate is essential for production of DNA, neurotransmitters and myelin and regulation of genetic activity. A specific transporter protein is required to transport folate from blood to CSF. Various inherited brain-specific folate transport defects have been recognized due to mutation in Folate Receptor alpha (FOLR1). FOLR1 mutation is one of the vitamin responsive encephalopathies and is inherited as an autosomal recessive condition. It has a wide spectrum of phenotype, commonly presenting as epileptic encephalopathy. Less frequently the condition may manifest with subtle hypotonia, movement disorder as tremors, ataxia or intellectual disability and autistic spectrum disorder. We present a case of folate transporter deficiency with non-epileptic manifestations, presenting with tremors, speech delay and stable white matter changes in MRI brain. OBJECTIVE We present a case of Folate transporter defect with Non-epileptic presentation. CONCLUSION Folate transporter deficiency has a wide range of presenting symptoms. Presentation with slowly progressive atypical symptoms, stable white matter changes in brain MRI that does not fit a specific diagnosis, should raise a high suspicion of FOLR1 mutation, even in absence of seizures. Since folate transporter deficiency is a treatable neurodegenerative disorder, early diagnosis and supplementation with folinic acid is vital.
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Affiliation(s)
- Sadia Tabassum
- National Neurosciences Institute, King Fahad Medical City, Riyadh, Saudi Arabia.
| | - Ali AlAsmari
- Department of Medical Genetics, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Abdul Aziz AlSaman
- National Neurosciences Institute, King Fahad Medical City, Riyadh, Saudi Arabia
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Rodan LH, Qi W, Ducker GS, Demirbas D, Laine R, Yang E, Walker MA, Eichler F, Rabinowitz JD, Anselm I, Berry GT. 5,10-methenyltetrahydrofolate synthetase deficiency causes a neurometabolic disorder associated with microcephaly, epilepsy, and cerebral hypomyelination. Mol Genet Metab 2018; 125:118-126. [PMID: 30031689 PMCID: PMC6557438 DOI: 10.1016/j.ymgme.2018.06.006] [Citation(s) in RCA: 8] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 06/12/2018] [Accepted: 06/12/2018] [Indexed: 10/28/2022]
Abstract
Folate metabolism in the brain is critically important and serves a number of vital roles in nucleotide synthesis, single carbon metabolism/methylation, amino acid metabolism, and mitochondrial translation. Genetic defects in almost every enzyme of folate metabolism have been reported to date, and most have neurological sequelae. We report 2 patients presenting with a neurometabolic disorder associated with biallelic variants in the MTHFS gene, encoding 5,10-methenyltetrahydrofolate synthetase. Both patients presented with microcephaly, short stature, severe global developmental delay, progressive spasticity, epilepsy, and cerebral hypomyelination. Baseline CSF 5-methyltetrahydrolate (5-MTHF) levels were in the low-normal range. The first patient was treated with folinic acid, which resulted in worsening cerebral folate deficiency. Treatment in this patient with a combination of oral L-5-methyltetrahydrofolate and intramuscular methylcobalamin was able to increase CSF 5-MTHF levels, was well tolerated over a 4 month period, and resulted in subjective mild improvements in functioning. Measurement of MTHFS enzyme activity in fibroblasts confirmed reduced activity. The direct substrate of the MTHFS reaction, 5-formyl-THF, was elevated 30-fold in patient fibroblasts compared to control, supporting the hypothesis that the pathophysiology of this disorder is a manifestation of toxicity from this metabolite.
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Affiliation(s)
- Lance H Rodan
- Division of Genetics and Genomics, The Manton Center for Orphan Disease Research, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA; Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Wanshu Qi
- Division of Genetics and Genomics, The Manton Center for Orphan Disease Research, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Gregory S Ducker
- Lewis-Sigler Institute for Integrative Genomics, Department of Chemistry, Princeton University, Princeton, NJ, USA
| | - Didem Demirbas
- Division of Genetics and Genomics, The Manton Center for Orphan Disease Research, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Regina Laine
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Edward Yang
- Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Melissa A Walker
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Florian Eichler
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Joshua D Rabinowitz
- Lewis-Sigler Institute for Integrative Genomics, Department of Chemistry, Princeton University, Princeton, NJ, USA
| | - Irina Anselm
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Gerard T Berry
- Division of Genetics and Genomics, The Manton Center for Orphan Disease Research, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.
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Duman N, Duman R, Tosun M, Akıcı M, Göksel E, Gökçe B, Alagöz O. Topical folinic acid enhances wound healing in rat model. Adv Med Sci 2018; 63:347-52. [PMID: 30092503 DOI: 10.1016/j.advms.2018.04.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Revised: 01/25/2018] [Accepted: 04/26/2018] [Indexed: 01/10/2023]
Abstract
PURPOSE Folic acid is an essential vitamin participating in DNA synthesis and repair. Recently folic acid has been shown to stimulate DNA-repair capacity in dermal fibroblasts in response to injury. Thus, the present study aimed to investigate the effects of topical folinic acid, a 5-formyl derivative of tetrahydrofolic acid, on wound healing using rat wound model. MATERIALS AND METHODS A rat wound model was established, and the wound healing was evaluated by macroscopic and histological analyses among vehicle control, 2.5% folinic acid, 1% folinic acid, and dexpanthenol treatment groups. While an image-analysis program was used to evaluate macroscopic wound closure, connective tissue properties, mast cell numbers, and the expressions of matrix metalloproteinase 1 (MMP-1) and 9 (MMP-9) were evaluated by microscopy. RESULTS The 2.5% folinic acid-treated group exhibited enhanced wound healing by increased reepithelialization, neo-vessel formation, inflammatory cell migration, collagen deposition and progressive mast cell increase. Furthermore, 2.5% folinic acid induced higher expressions of MMP-1 and MMP-9. CONCLUSIONS Folinic acid enhances both macroscopic and microscopic wound healing in rat wound model.
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Cansu DÜ, Teke HÜ, Bodakçi E, Korkmaz C. How should we manage low-dose methotrexate-induced pancytopenia in patients with rheumatoid arthritis? Clin Rheumatol 2018; 37:3419-25. [PMID: 30056523 DOI: 10.1007/s10067-018-4242-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 07/12/2018] [Accepted: 07/24/2018] [Indexed: 01/28/2023]
Abstract
Low-dose methotrexate (ld-MTX) that is administered during rheumatoid arthritis (RA) treatment has hematological adverse effects such as pancytopenia, although rare. Although well-established and widely used for hematological adverse effects caused by high-dose MTX, leucovorin (folinic acid) treatment does not have an agreed-upon administration for ld-MTX-induced pancytopenia. Here, we aimed to figure out whether there was any difference in response time between the regimens with and without folinic acid prescribed to our patients who developed pancytopenia while on MTX therapy, and to identify risk factors for its development. Our cases were collectively assessed together with other rare cases available in the literature that were reported in a similar manner with an explicitly indicated response time, in days. Thereupon, we looked for any difference in response time between the regimens with and without folinic acid. In total, ten of our patients experienced pancytopenia while on ld-MTX treatment. Mean day on which hematological response was achieved was as follows: 7 days in one patient on folic acid monotherapy, 6 days in three patients on granulocyte-colony stimulating factor (G-CSF) monotherapy, 4.5 days in two patients on leucovorin monotherapy, and 4 days in the remaining three patients who were treated with G-CSF + folinic acid/leucovorin. When we collectively evaluated our patients and the patients with an explicitly stated response duration in the literature (15 patients) and compared regimens including folinic acid to those without folinic acid, duration until response/recovery from pancytopenia was significantly shorter in folinic acid group than that in the group without folinic acid (5.47 ± 2.9 days vs 10 ± 3.77 days, p = 0.002). Treatment modalities including folinic acid (leucovorin) either with or without G-CSF result in a shorter recovery/response time compared to other agents. Leucovorin should definitely be considered and applied in rescue therapy for ld-MTX-associated side effects.
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Cohen IJ. Neurotoxicity after high-dose methotrexate (MTX) is adequately explained by insufficient folinic acid rescue. Cancer Chemother Pharmacol 2017; 79:1057-1065. [PMID: 28455583 DOI: 10.1007/s00280-017-3304-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [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: 11/20/2016] [Accepted: 04/11/2017] [Indexed: 11/26/2022]
Abstract
PURPOSE To challenge the view that the dose of folinic acid rescue after high-dose methotrexate (MTX) has no significance in the prevention of neurotoxicity and to present the minority view that neurotoxicity can be prevented by an adequate dose of folinic acid, without compromising treatment results. Several fallacies that led to the misunderstanding of post MTX neurotoxicity are presented. METHODS Data mining using search engines was used to find relevant publications, and an e-mail survey of more than 60 authors of articles in this field was performed. All relevant articles identified were read in their entirety. RESULTS Examples of clinical studies with neurotoxicity following inadequate rescue are given. Some studies demonstrated no neurotoxicity when adequate doses of folinic acid rescue were started 24-36 h after the start of HDMTX rescue even after mega doses of MTX. Rescue started after 42 h was associated with neurotoxicity except in patients with low serum MTX levels after 24 and 36 h. ALL protocols with neurotoxicity, especially BFM-like protocols, are presented. Protocol is reported in which single protocol changes prevented neurotoxicity. CONCLUSIONS From the published data, when folinic acid rescue is given in a sufficiently high enough dose and is started 24-36 h after the beginning of the methotrexate exposure, and virtually all forms of post MTX neurotoxicity can be prevented without compromising therapeutic results.
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Affiliation(s)
- Ian Joseph Cohen
- The Rina Zaizov Department of Pediatric Hematology-Oncology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.
- Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel.
- , 139 Shir Hashirim St., 44814, Elkana, Israel.
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Khadem Sadigh M, Zakerhamidi MS, Seyed Ahmadian SM, Johari-Ahar M, Zare Haghighi L. Environment effect on spectral and charge distribution characteristics of some drugs of folate derivatives. Spectrochim Acta A Mol Biomol Spectrosc 2017; 171:10-17. [PMID: 27458760 DOI: 10.1016/j.saa.2016.07.034] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Revised: 07/16/2016] [Accepted: 07/19/2016] [Indexed: 06/06/2023]
Abstract
Molecular surrounding media as an important factor can effect on the operation of wide variety of drugs. For more study in this paper, spectral properties of Methotrexate and Folinic acid have been studied in various solvents. Our results show that the photo-physical of solute molecules depend strongly on solute-solvent interactions and active groups in their chemical structures. In order to investigate the contribution of specific and nonspecific interactions on the various properties of drug molecules, the linear solvation energy relationships concept is used. Moreover, charge distribution characteristics of used samples with various resonance structures in solvent environments were calculated by means of solvatochromic method. The high value of dipole moments in excited state show that local intramolecular charge transfer can occur by excitation. These results about molecular interactions can be extended to biological systems and can indicate completely the behaviors of Methotrexate and Folinic acid in polar solvents such as water in body system.
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Affiliation(s)
- M Khadem Sadigh
- Research Institute for Applied Physics and Astronomy, University of Tabriz, Tabriz, Iran.
| | - M S Zakerhamidi
- Research Institute for Applied Physics and Astronomy, University of Tabriz, Tabriz, Iran
| | - S M Seyed Ahmadian
- Department of Chemistry, Faculty of Basic Sciences, Azarbaijan Shahid Madani University, Tabriz, Iran
| | - M Johari-Ahar
- Department of Medicinal Chemistry, School of Pharmacy, Ardabil University of Medical Sciences (ArUMS), Ardabil, Iran
| | - L Zare Haghighi
- Department of Chemistry, Faculty of Basic Sciences, Azarbaijan Shahid Madani University, Tabriz, Iran
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Ramakrishnan KA, Pengelly RJ, Gao Y, Morgan M, Patel SV, Davies EG, Ennis S, Faust SN, Williams AP. Precision Molecular Diagnosis Defines Specific Therapy in Combined Immunodeficiency with Megaloblastic Anemia Secondary to MTHFD1 Deficiency. J Allergy Clin Immunol Pract 2016; 4:1160-1166.e10. [PMID: 27707659 DOI: 10.1016/j.jaip.2016.07.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Revised: 07/06/2016] [Accepted: 07/08/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND Methylenetetrahydrofolate dehydrogenase (MTHFD1) deficiency has recently been reported to cause a folate-responsive syndrome displaying a phenotype that includes megaloblastic anemia and severe combined immunodeficiency. OBJECTIVE To describe our investigative approach to the molecular diagnosis and evaluation of immune dysfunction in a family with MTHFD1 deficiency. METHODS The methods used were exome sequencing and analysis of variants in genes involved in the folate metabolic pathway in a family with 2 affected siblings. Routine laboratory and research data were analyzed to gain an in-depth understanding of innate, humoral, and cell-mediated immune function before and after folinic acid supplementation. RESULTS Interrogation of exome data for concordant variants between the siblings in the genes involved in folate metabolic pathway identified a heterozygous mutation in exon 3 of the MTHFD1 gene that was shared with their mother. In view of highly suggestive phenotype, we extended our bioinformatics interrogation for structural variants in the MTHFD1 gene by manual evaluation of the exome data for sequence depth coverage of all the exons. A deletion involving exon 13 that was shared with their father was identified. Routine laboratory data showed lymphopenia involving all subsets and poor response to vaccines. In vitro analysis of dendritic cell and lymphocyte function was comparable to that in healthy volunteers. Treatment with folinic acid led to immune reconstitution, enabling discontinuation of all prophylactic therapies. CONCLUSIONS Exome sequencing demonstrated MTHFD1 deficiency as a novel cause of a combined immunodeficiency. Folinic acid was established as precision therapy to reverse the clinical and laboratory phenotype of this primary immunodeficiency.
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Affiliation(s)
- Kesava A Ramakrishnan
- Academic Unit of Clinical and Experimental Sciences, Faculty of Medicine and Institute for Life Sciences, University of Southampton and National Institute for Health Research (NIHR) Biomedical Respiratory Unit, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Reuben J Pengelly
- Academic Unit of Human Development and Health, Human Genetics and Genomic Medicine, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Yifang Gao
- Academic Unit of Cancer Sciences, Faculty of Medicine and Institute for Life Sciences, University of Southampton, and Cancer Research UK (CRUK) National Institute for Health Research (NIHR) Experimental Cancer Medicine Centre, Southampton, United Kingdom
| | - Mary Morgan
- Southampton National Institute for Health Research (NIHR) Wellcome Trust Clinical Research Facility and Department of Paediatric Medicine, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Sanjay V Patel
- Southampton National Institute for Health Research (NIHR) Wellcome Trust Clinical Research Facility and Department of Paediatric Medicine, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - E Graham Davies
- Department of Paediatric Immunology, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, United Kingdom
| | - Sarah Ennis
- Academic Unit of Human Development and Health, Human Genetics and Genomic Medicine, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Saul N Faust
- Academic Unit of Clinical and Experimental Sciences, Faculty of Medicine and Institute for Life Sciences, University of Southampton and National Institute for Health Research (NIHR) Biomedical Respiratory Unit, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom; Southampton National Institute for Health Research (NIHR) Wellcome Trust Clinical Research Facility and Department of Paediatric Medicine, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom.
| | - Anthony P Williams
- Academic Unit of Cancer Sciences, Faculty of Medicine and Institute for Life Sciences, University of Southampton, and Cancer Research UK (CRUK) National Institute for Health Research (NIHR) Experimental Cancer Medicine Centre, Southampton, United Kingdom; Department of Allergy, Asthma and Clinical Immunology, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
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Kunzmann V, Herrmann K, Bluemel C, Kapp M, Hartlapp I, Steger U. Intensified Neoadjuvant Chemotherapy with Nab-Paclitaxel plus Gemcitabine Followed by FOLFIRINOX in a Patient with Locally Advanced Unresectable Pancreatic Cancer. Case Rep Oncol 2014; 7:648-55. [PMID: 25408659 PMCID: PMC4209279 DOI: 10.1159/000367966] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
The prognosis of patients with locally advanced pancreatic cancer can be improved if secondary complete (R0) resection is possible. In patients initially staged as unresectable this may be achieved with neoadjuvant treatment which is usually chemoradiotherapy based. We report the case of a 46-year-old patient with an unresectable, locally advanced pancreatic cancer (pT4 Nx cM0 G2) who was treated with a sequential neoadjuvant chemotherapy regimen consisting of 2 cycles of nab-paclitaxel plus gemcitabine followed by 4 cycles of FOLFIRINOX. Neoadjuvant chemotherapy resulted in secondary resectability (R0 resection). After 2 cycles of nab-paclitaxel plus gemcitabine, the patient already had a complete metabolic remission as measured by integrated fludeoxyglucose (18F) positron emission tomography and computerized tomography. After a follow-up of 18 months the patient is alive without progression of disease. We propose to assess the clinical benefit of sequencing the combinations nab-paclitaxel plus gemcitabine and FOLFIRINOX as neoadjuvant therapy for patients with locally advanced and initially unresectable pancreatic cancer in a controlled clinical trial.
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Affiliation(s)
- Volker Kunzmann
- Departments of Medical Oncology, University of Würzburg, Würzburg, Germany
| | - Ken Herrmann
- Departments of Nuclear Medicine, University of Würzburg, Würzburg, Germany
| | - Christina Bluemel
- Departments of Nuclear Medicine, University of Würzburg, Würzburg, Germany
| | - Markus Kapp
- Departments of Medical Oncology, University of Würzburg, Würzburg, Germany
| | - Ingo Hartlapp
- Departments of Medical Oncology, University of Würzburg, Würzburg, Germany
| | - Ulrich Steger
- Departments of Surgery, University of Würzburg, Würzburg, Germany
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Gratieri T, Kalia YN. Targeted local simultaneous iontophoresis of chemotherapeutics for topical therapy of head and neck cancers. Int J Pharm 2013; 460:24-7. [PMID: 24219856 DOI: 10.1016/j.ijpharm.2013.10.053] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2013] [Revised: 10/28/2013] [Accepted: 10/31/2013] [Indexed: 02/03/2023]
Abstract
The objective was to investigate the feasibility of using buccal iontophoresis for the simultaneous delivery of chemotherapeutic agents with a view to developing a new approach to treat head and neck cancers. Short duration cathodal iontophoresis of 5-fluorouracil (5-FU; 20mM) and leucovorin (LV; 10 mM) at 1 mA/cm(2) for 10 or 20 min from aqueous solution and a 2% hydroxyethyl cellulose gel at pH 7.6 was evaluated using bovine mucosa in vitro. Iontophoresis resulted in a statistically significant increase in the mucosal deposition of both drugs as compared to passive diffusion (Student's t-test, α=0.05); in each case, drug delivery was selective for deposition with no permeation being observed. After 20 min of iontophoresis, there was an ~ 8-fold enhancement for 5-FU (1.46 ± 0.86 and 11.93 ± 3.81 μg/cm(2), respectively) and a 3-fold increase for LV (8.31 ± 2.44 and 25.08 ± 6.89 μg/cm(2), respectively) when using aqueous solutions. The same trend was observed when the gel was applied for 10 min; passive delivery of 5-FU from the gel resulted in non-detectable levels in the mucosa, while 4.62 ± 1.76 μg/cm(2) were deposited in the mucosa following iontophoresis. Similarly, iontophoretic delivery of LV from the gel resulted in ~ 3-fold higher deposition as compared to passive diffusion (6.71 ± 1.36 and 21.12 ± 9.94 μg/cm(2), respectively). No drug permeation was observed in either case. In conclusion, iontophoresis can be used for targeted topical delivery of chemotherapeutics to the buccal mucosa and may enable less invasive local therapy of head and neck cancers.
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Affiliation(s)
- Taís Gratieri
- Faculdade de Ciências da Saúde, Universidade de Brasília. Campus Universitário Darcy Ribeiro, s/n 70910-900 Brasília, DF, Brazil; School of Pharmaceutical Sciences, University of Geneva and University of Lausanne, 30 Quai Ernest Ansermet, 1211 Geneva, Switzerland
| | - Yogeshvar N Kalia
- School of Pharmaceutical Sciences, University of Geneva and University of Lausanne, 30 Quai Ernest Ansermet, 1211 Geneva, Switzerland.
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de Broucker T, Leclercq D, Jarquin S, Henry C. Acute leukoencephalopathy due to pyrimethamine. An insight into methotrexate neurotoxicity? J Neurol Sci 2013; 335:201-3. [PMID: 24157308 DOI: 10.1016/j.jns.2013.09.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2013] [Revised: 09/22/2013] [Accepted: 09/23/2013] [Indexed: 10/26/2022]
Abstract
A unique case of pyrimethamine-related stroke-like leukoencephalopathy is described. The imputability of the drug is discussed as well as the similarities with the well-known methotrexate neurotoxicity. Owing to the same mode of action of both drugs by inhibition of the enzyme dihydrofolate reductase, this case is highly suggestive of the pathogenetic role of methylation pathway blockade on myelin synthesis resulting in delayed demyelination. This complication could be avoided by a concurrent folinic acid supplementation.
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Affiliation(s)
- Thomas de Broucker
- Service de Neurologie, Hôpital Delafontaine, 2, rue du Dr Delafontaine, 93200 Saint-Denis, France.
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Yanar F, Agcaoglu O, Sarici IS, Ozcinar B, Gok AF, Gunay K, Ertekin C. Clinical challenges in drug induced pancreatitis: Presentation of two cases and review of the literature. Int J Surg Case Rep 2013; 4:708-10. [PMID: 23810919 DOI: 10.1016/j.ijscr.2013.02.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2012] [Revised: 01/02/2013] [Accepted: 02/28/2013] [Indexed: 01/07/2023] Open
Abstract
INTRODUCTION A wide variety of drugs have been reported to cause pancreatitis. Although the incidence of drug induced acute pancreatitis is low, the disease is associated with substantial morbidity and mortality, which makes timely identification of the causative agent important. PRESENTATION OF CASE Herein, we report two patients with clinical, biochemical, and radiological evidence of acute pancreatitis. There were no etiologic factors except their prescribed drugs. DISCUSSION The majority of patients with acute pancreatitis recover uneventfully, but there remains an uncontrollable risk of mortality. It is prudent to withdraw a medication with a known association with acute pancreatitis. Necessity of multi-drug regimens especially in oncological patients however, presents a challenge. CONCLUSION Corticosteroid pulse therapy was easily detectable as the causative agent in our first case, but combined anti-neoplastic drug therapy and additional multi-drug regimen presented great difficulties in identifying single causative agent in our second patient.
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Abstract
Acute methotrexate toxicity rarely presents as medical emergency in form of multiorgan failure. Acute pneumonitis following low-dose methotrexate is rarely reported in literature. It is important to recognize this, as the drug must be discontinued immediately and rescue measures in form of folinic acid and hydration instituted promptly.
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Affiliation(s)
- Saurabh Saigal
- Department of Critical Care Medicine, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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Lorenzo GD, Rea A, Carlomagno C, Pepe S, Palmieri G, Labianca R, Chirianni A, Stefano AD, Esposito V, Placido SD, Montesarchio V. Activity and safety of pegylated liposomal doxorubicin, 5-fluorouracil and folinic acid in inoperable hepatocellular carcinoma: A phase II study. World J Gastroenterol 2007; 13:6553-7. [PMID: 18161926 PMCID: PMC4611295 DOI: 10.3748/wjg.v13.i48.6553] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To improve the results of New therapeutic strategies in hepatocellular carcinoma (HCC). We have conducted a phase II study with pegylated liposomal doxorubicin (PLD), 5-fluorouracil (5FU) and folinic acid (FA).
METHODS: Thirty-one patients with hystologically-confirmed, inoperable HCC, received combination chemotherapy with PLD 25 mg/mq on d 1, 5FU 1200 mg/mq in 48 h continuous infusion, and oral FA 30 mg on d 1 and 2 every 3 wk until disease progression or intolerable toxicity.
RESULTS: The median age was 65 years (range 41-82) and 28 patients were hepatitis C virus seropositive (90%). The majority of patients were Child-Pugh Class B (55%). Two patients showed a partial response (PR), and 16 had stable disease (SD). With a median follow-up of 14 mo, the median time to progression of all evaluable patients was 4 mo (95% CI 1.7-7). Median overall survival was 9 mo (95% CI 3-24 mo). After 1 year, 9 of 18 PR/SD patients were alive. Chemotherapy was well tolerated.
CONCLUSION: PLD/FU/FA combination seems capable of achieving durable stabilization of HCC. The manageable toxicity supports a role for combination with other anticancer agents.
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