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Zhu Z, Bo-Ran Ho B, Chen A, Amrhein J, Apetrei A, Carpenter TO, Lazaretti-Castro M, Colazo JM, McCrystal Dahir K, Geßner M, Gurevich E, Heier CA, Simmons JH, Hunley TE, Hoppe B, Jacobsen C, Kouri A, Ma N, Majumdar S, Molin A, Nokoff N, Ott SM, Peña HG, Santos F, Tebben P, Topor LS, Deng Y, Bergwitz C. An update on clinical presentation and responses to therapy of patients with hereditary hypophosphatemic rickets with hypercalciuria (HHRH). Kidney Int 2024; 105:1058-1076. [PMID: 38364990 PMCID: PMC11106756 DOI: 10.1016/j.kint.2024.01.031] [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: 09/05/2023] [Revised: 12/23/2023] [Accepted: 01/08/2024] [Indexed: 02/18/2024]
Abstract
Pathogenic variants in solute carrier family 34, member 3 (SLC34A3), the gene encoding the sodium-dependent phosphate cotransporter 2c (NPT2c), cause hereditary hypophosphatemic rickets with hypercalciuria (HHRH). Here, we report a pooled analysis of clinical and laboratory records of 304 individuals from 145 kindreds, including 20 previously unreported HHRH kindreds, in which two novel SLC34A3 pathogenic variants were identified. Compound heterozygous/homozygous carriers show above 90% penetrance for kidney and bone phenotypes. The biochemical phenotype for heterozygous carriers is intermediate with decreased serum phosphate, tubular reabsorption of phosphate (TRP (%)), fibroblast growth factor 23, and intact parathyroid hormone, but increased serum 1,25-dihydroxy vitamin D, and urine calcium excretion causing idiopathic hypercalciuria in 38%, with bone phenotypes still observed in 23% of patients. Oral phosphate supplementation is the current standard of care, which typically normalizes serum phosphate. However, although in more than half of individuals this therapy achieves correction of hypophosphatemia it fails to resolve the other outcomes. The American College of Medical Genetics and Genomics score correlated with functional analysis of frequent SLC34A3 pathogenic variants in vitro and baseline disease severity. The number of mutant alleles and baseline TRP (%) were identified as predictors for kidney and bone phenotypes, baseline TRP (%) furthermore predicted response to therapy. Certain SLC34A3/NPT2c pathogenic variants can be identified with partial responses to therapy, whereas with some overlap, others present only with kidney phenotypes and a third group present only with bone phenotypes. Thus, our report highlights important novel clinical aspects of HHRH and heterozygous carriers, raises awareness to this rare group of disorders and can be a foundation for future studies urgently needed to guide therapy of HHRH.
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Affiliation(s)
- Zewu Zhu
- Department of Internal Medicine, Section of Endocrinology, Yale University School of Medicine, New Haven, Connecticut, USA; Department of Urology, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Bryan Bo-Ran Ho
- Department of Internal Medicine, Section of Endocrinology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Alyssa Chen
- Department of Internal Medicine, Section of Endocrinology, Yale University School of Medicine, New Haven, Connecticut, USA; Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
| | - James Amrhein
- Pediatric Endocrinology and Diabetes, School of Medicine Greenville Campus, University of South Carolina, Greenville, South Carolina, USA
| | - Andreea Apetrei
- Caen University Hospital, Department of Genetics, UR7450 Biotargen, Reference Center for Rare Diseases of Calcium and Phosphate Metabolism, OSCAR Network, Caen, France
| | - Thomas Oliver Carpenter
- Department of Internal Medicine, Section of Endocrinology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Marise Lazaretti-Castro
- Division of Endocrinology, Escola Paulista de Medicina-Universidade Federal de Sao Paulo (EPM-UNIFESP), Sao Paulo, Brazil
| | - Juan Manuel Colazo
- Department of Biomedical Engineering, Vanderbilt University, Nashville, Tennessee, USA
| | - Kathryn McCrystal Dahir
- Division of Endocrinology, Program for Metabolic Bone Disorders, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Michaela Geßner
- Pediatric Nephrology, Children's and Adolescents' Hospital, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Evgenia Gurevich
- Schneider Children's Medical Center of Israel, Pediatric Nephrology Institute, Petach Tikva, Israel; Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheva, Israel
| | | | - Jill Hickman Simmons
- Department of Pediatrics, Division of Endocrinology and Diabetes, Vanderbilt University School of Medicine, Vanderbilt University, Nashville, Tennessee, USA
| | - Tracy Earl Hunley
- Division of Pediatric Nephrology, Vanderbilt University Medical Center, Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, Tennessee, USA
| | - Bernd Hoppe
- Division of Pediatric Nephrology, Department of Pediatrics, University of Bonn, Bonn, Germany
| | - Christina Jacobsen
- Division of Endocrinology, Harvard Medical School, Boston, Massachusetts, USA
| | - Anne Kouri
- Pediatric Nephrology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Nina Ma
- Section of Pediatric Endocrinology, Children's Hospital Colorado, Aurora, Colorado, USA; Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Sachin Majumdar
- Department of Internal Medicine, Section of Endocrinology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Arnaud Molin
- Caen University Hospital, Department of Genetics, UR7450 Biotargen, Reference Center for Rare Diseases of Calcium and Phosphate Metabolism, OSCAR Network, Caen, France
| | - Natalie Nokoff
- Department of Pediatrics, Section of Endocrinology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Susan M Ott
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Helena Gil Peña
- Department of Pediatrics, Hospital Universitario Central de Asturias (HUCA), Oviedo, Spain
| | - Fernando Santos
- Department of Pediatrics, Hospital Universitario Central de Asturias (HUCA), Oviedo, Spain
| | - Peter Tebben
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota, USA; Division of Pediatric Endocrinology, Mayo Clinic, Rochester, Minnesota, USA
| | - Lisa Swartz Topor
- Division of Pediatric Endocrinology, Hasbro Children's Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Yanhong Deng
- Yale School of Public Health, New Haven, Connecticut, USA
| | - Clemens Bergwitz
- Department of Internal Medicine, Section of Endocrinology, Yale University School of Medicine, New Haven, Connecticut, USA.
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Goyal A, Tandon N. Burosumab: Current status and future prospects. Best Pract Res Clin Endocrinol Metab 2024; 38:101826. [PMID: 37858479 DOI: 10.1016/j.beem.2023.101826] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2023]
Abstract
Hypophosphatemic rickets/osteomalacia caused by FGF23 excess is conventionally treated with multiple doses of inorganic phosphate salts and active vitamin D analogs. However, conventional therapy targets the consequences of elevated FGF23 and not the elevated FGF23 itself and is associated with poor adherence and long-term complications such as nephrocalcinosis and secondary/tertiary hyperparathyroidism. Burosumab is a fully human IgG1 monoclonal antibody that binds to and neutralises FGF-23, thereby leading to improvement in phosphate homeostasis and healing of rickets and osteomalacia. Data from phase 2 and 3 trials report overall safety and efficacy and Burosumab is now FDA approved for treatment of XLH and TIO in children and adults. Cost and absence of long-term data are major issues with Burosumab which should be addressed in near future. At present, experts recommend Burosumab use in patients with severe disease or those with mild-moderate disease and a failed response to a trial of conventional therapy.
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Affiliation(s)
- Alpesh Goyal
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, Convergence Block, Room no 7002, Seventh Floor, New Delhi 110029, India.
| | - Nikhil Tandon
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, Convergence Block, Room no 7002, Seventh Floor, New Delhi 110029, India.
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Cherian KE, Paul TV. Inherited fibroblast growth factor 23 excess. Best Pract Res Clin Endocrinol Metab 2024; 38:101844. [PMID: 38044258 DOI: 10.1016/j.beem.2023.101844] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2023]
Abstract
Syndromes of inherited fibroblast growth factor 23 (FGF-23) excess encompass a wide spectrum that includes X-linked hypophosphataemia (XLH), autosomal dominant and recessive forms of rickets as well as various syndromic conditions namely fibrous dysplasia/McCune Albright syndrome, osteoglophonic dysplasia, Jansen's chondrodysplasia and cutaneous skeletal hypophosphataemia syndrome. A careful attention to patient symptomatology, family history and clinical features, supported by appropriate laboratory tests will help in making a diagnosis. A genetic screen may be done to confirm the diagnosis. While phosphate supplements and calcitriol continue to be the cornerstone of treatment, in recent times burosumab, the monoclonal antibody against FGF-23 has been approved for the treatment of children and adults with XLH. While health-related outcomes may be improved by ensuring adherence and compliance to prescribed treatment with a smooth transition to adult care, bony deformities may persist in some, and this would warrant surgical correction.
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Vaisbich MH, de Cillo ACP, Silva BCC, DÁlva CB, de Carvalho ÉH, de Almeida JMCM, Marques LLM, Ribeiro M, da Silva MBM, de Medeiros PFV, Mendes PH. Real-world data of Brazilian adults with X-linked hypophosphatemia (XLH) treated with burosumab and comparison with other worldwide cohorts. Mol Genet Genomic Med 2024; 12:e2387. [PMID: 38337160 PMCID: PMC10858313 DOI: 10.1002/mgg3.2387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 12/23/2023] [Accepted: 01/17/2024] [Indexed: 02/12/2024] Open
Abstract
BACKGROUND Disease-related variants in PHEX cause XLH by an increase of fibroblast growth factor 23 (FGF23) circulating levels, resulting in hypophosphatemia and 1,25(OH)2 vitamin D deficiency. XLH manifests in early life with rickets and persists in adulthood with osseous and extraosseous manifestations. Conventional therapy (oral phosphate and calcitriol) improves some symptoms, but evidence show that it is not completely effective, and it can lead to nephrocalcinosis (NC) and hyperparathyroidism (HPT). Burosumab (anti-FGF23 antibody) has shown to be effective and safety in the clinical trials. METHODS The current real-world collaborative study evaluated genetic, clinical and laboratory data of XLH Brazilian adult patients treated with burosumab. RESULTS Nineteen unrelated patients were studied. Patients reported pain, limb deformities and claudication, before burosumab initiation. 78% of them were previously treated with conventional therapy. The severity of the disease was moderate to severe (15 patients with score >5). At the baseline, 3 patients presented NC (16.7%) and 12 HPT (63%). After 16 ± 8.4 months under burosumab, we observed a significant: increase in stature (p = 0.02), in serum phosphate from 1.90 ± 0.43 to 2.67 ± 0.52 mg/dL (p = 0.02); in TmP/GFR from 1.30 ± 0.46 to 2.27 ± 0.64 mg/dL (p = 0.0001), in 1,25 (OH)2 D from 50.5 ± 23.3 to 71.1 ± 19.1 pg/mL (p = 0.03), and a decrease in iPTH from 86.8 ± 37.4 pg/mL to 66.5 ± 31.1 (p = 0.002). Nineteen variants were found (10 novel). HPT tended to develop in patients with truncated PHEX variants (p = 0.06). CONCLUSIONS This study confirms the efficacy and safety of burosumab on XLH adult patients observed in clinical trials. Additionally, we observed a decrease in iPTH levels in patients with moderate to severe HPT at the baseline.
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Affiliation(s)
| | | | - Bárbara Campolina C. Silva
- Hospital Felício Rocho, Osteometabolism Unit of Santa Casa de Belo HorizonteProfessor of Medicine at University Center of Belo Horizonte – UNIBHBelo HorizonteBrazil
| | | | - Érico Higino de Carvalho
- Instituto de Medicina Integrada Professor Fernado Figueira, recifeFederal University of PernambucoRecifeBrazil
| | | | | | - Marcia Ribeiro
- Genetic Unit of Federal University of Rio de JaneiroRio de JaneiroBrazil
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Qian C, Ito N, Tsuji K, Sato S, Kikuchi K, Yoshii T, Miyata T, Asou Y. A PAI-1 antagonist ameliorates hypophosphatemia in the Hyp vitamin D-resistant rickets model mouse. FEBS Open Bio 2024; 14:290-299. [PMID: 38050660 PMCID: PMC10839342 DOI: 10.1002/2211-5463.13745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 11/20/2023] [Accepted: 12/04/2023] [Indexed: 12/06/2023] Open
Abstract
Congenital fibroblast growth factor 23 (FGF23)-related hypophosphatemic rickets/osteomalacia is a rare bone metabolism disorder characterized by hypophosphatemia and caused by genetic abnormalities that result in excessive secretion of FGF23. Hyp mice are a model of X-linked hypophosphatemia (XLH) caused by deletion of the PHEX gene and excessive production of FGF23. The purpose of this study was to investigate the potential of TM5614 as a therapeutic agent for the treatment of congenital FGF23-related hypophosphatemic rickets and osteomalacia in humans by administering TM5614 to Hyp mice and examining its curative effect on hypophosphatemia. After a single oral administration of TM5614 10 mg·kg-1 to female Hyp mice starting at 17 weeks of age, the serum phosphate concentration increased with a peak at 6 h after administration. ELISA confirmed that TM5614 administration decreased the intact FGF23 concentration in the blood. Expression of 25-hydroxyvitamin D-1α-hydroxylase protein encoded by Cyp27b1 mRNA in the kidney was suppressed in Hyp mice, and treatment with 10 mg·kg-1 of TM5614 normalized the expression of 25-hydroxyvitamin D-1α-hydroxylase protein and Cyp27b1 mRNA in the kidneys of these mice. Our data indicate that oral administration of TM5614 ameliorates hypophosphatemia in Hyp mice, suggesting that TM5614 may be an effective treatment for congenital FGF23-related hypophosphatemic rickets and osteomalacia.
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Affiliation(s)
- Cheng Qian
- Department of Orthopedics SurgeryTokyo Medical and Dental UniversityJapan
| | - Nobuaki Ito
- Division of Nephrology and EndocrinologyThe University of Tokyo HospitalJapan
| | - Kunikazu Tsuji
- Department of Orthopedics SurgeryTokyo Medical and Dental UniversityJapan
| | - Shingo Sato
- Department of Orthopedics SurgeryTokyo Medical and Dental UniversityJapan
| | - Katsushi Kikuchi
- Department of Orthopedics SurgeryTokyo Medical and Dental UniversityJapan
| | - Toshitaka Yoshii
- Department of Orthopedics SurgeryTokyo Medical and Dental UniversityJapan
| | - Toshio Miyata
- United Centers for Advanced Research and Translational MedicineTohoku UniversitySendaiJapan
| | - Yoshinori Asou
- Department of Orthopedics SurgeryTokyo Medical and Dental UniversityJapan
- China‐Japan Friendship Institution of MedicineShanghai UniversityChina
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6
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Biasucci G, Donini V, Cannalire G. Rickets Types and Treatment with Vitamin D and Analogues. Nutrients 2024; 16:416. [PMID: 38337700 PMCID: PMC10857029 DOI: 10.3390/nu16030416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 01/15/2024] [Accepted: 01/23/2024] [Indexed: 02/12/2024] Open
Abstract
The definition of "Vitamin D" encompasses a group of fat-soluble steroid compounds of different origins with similar chemical structures and the same biological effects. Vitamin D deficiency and/or a defect in the process of its synthesis or transport predispose individuals to several types of rickets. In addition to cholecalciferol, ergocalciferol, and vitamins D3 and D2, there are also active metabolites for the treatment of this condition which are commercially available. Calcitriol and aphacalcidiol are active metabolites that do not require the renal activation step, which is required with calcifediol, or hepatic activation. The purpose of this review is to summarize current approaches to the treatment of rickets for generalist physicians, focusing on the best vitamin D form to be used in each type, or, in the case of X-linked hypophosphatemic rickets (XLH), on both conventional and innovative monoclonal antibody treatments.
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Affiliation(s)
- Giacomo Biasucci
- Pediatrics and Neonatology Unit, University of Parma, Gugliemo da Saliceto Hospital, 29121 Piacenza, Italy;
- Department of Medicine and Surgery, University of Parma, 43121 Parma, Italy
| | - Valentina Donini
- Unit of Pediatrics, Department of Medicine and Surgery, University of Parma, 43121 Parma, Italy;
| | - Giuseppe Cannalire
- Pediatrics and Neonatology Unit, University of Parma, Gugliemo da Saliceto Hospital, 29121 Piacenza, Italy;
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Sawamura K, Hamajima T, Izawa M, Kaneko H, Kitamura A, Kitoh H. Changes of the lower limb deformity in children with FGF23-related hypophosphatemic rickets treated with Burosumab: a single-center prospective study. J Pediatr Orthop B 2024; 33:90-96. [PMID: 36728857 DOI: 10.1097/bpb.0000000000001054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Fibroblast growth factor 23 (FGF23)-related hypophosphatemic rickets (HPR) are characterized by excess circulating FGF23 and low concentrations of serum phosphorus, leading to skeletal manifestations of rickets, including lower limb deformities in children. The objective of this study was to prospectively evaluate whether treatment with burosumab, a monoclonal antibody neutralizing FGF23, changes lower limb deformities in HPR. Patients who were 15 years of age or younger with a documented clinical diagnosis of HPR, receiving burosumab treatment, and had a minimum follow-up period of one year were included in the study. Various radiological parameters were measured from anteroposterior and lateral radiographs of the bilateral lower limbs taken before administration of burosumab and at 3, 6, 9, and 12 months after treatment for evaluation of lower limb alignment. Outcome was classified as 'improvement', 'no change', or 'deterioration' after 12 months treatment. Five patients (10 limbs), with a mean age of 7.2 years were included in this study. The outcome was 'improvement' in six limbs and 'no change' in four limbs. There were no limbs of 'deterioration'. The improvement in deformities after treatment was more significant in younger patients who originally showed severe lower limb deformities. Older patients with milder deformities, on the other hand, showed less improvement. Burosumab therapy favorably changed lower-limb malalignment in children with FGF23-related HPR.
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Affiliation(s)
- Kenta Sawamura
- Department of Orthopaedic Surgery, Aichi Children's Health and Medical Center, Obu
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Showa-ku, Nagoya
| | - Takashi Hamajima
- Department of Endocrinology and Metabolism, Aichi Children's Health and Medical Center, Obu
| | - Masako Izawa
- Department of Endocrinology and Metabolism, Aichi Children's Health and Medical Center, Obu
| | - Hiroshi Kaneko
- Department of Orthopaedic Surgery, Aichi Children's Health and Medical Center, Obu
| | - Akiko Kitamura
- Department of Orthopaedic Surgery, Aichi Children's Health and Medical Center, Obu
| | - Hiroshi Kitoh
- Department of Orthopaedic Surgery, Aichi Children's Health and Medical Center, Obu
- Department of Comprehensive Pediatric Medicine, Nagoya University Graduate School of Medicine, Showa-ku, Nagoya, Aichi, Japan
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Lira Dos Santos EJ, Nakajima K, Po J, Hanai A, Zhukouskaya V, Biosse Duplan M, Linglart A, Shimada T, Chaussain C, Bardet C. Dental impact of anti-fibroblast growth factor 23 therapy in X-linked hypophosphatemia. Int J Oral Sci 2023; 15:53. [PMID: 38052774 DOI: 10.1038/s41368-023-00259-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Revised: 11/03/2023] [Accepted: 11/05/2023] [Indexed: 12/07/2023] Open
Abstract
Elevated fibroblast growth factor 23 (FGF23) in X-linked hypophosphatemia (XLH) results in rickets and phosphate wasting, manifesting by severe bone and dental abnormalities. Burosumab, a FGF23-neutralizing antibody, an alternative to conventional treatment (phosphorus and active vitamin D analogs), showed significant improvement in the long bone phenotype. Here, we examined whether FGF23 antibody (FGF23-mAb) also improved the dentoalveolar features associated with XLH. Four-week-old male Hyp mice were injected weekly with 4 or 16 mg·kg-1 of FGF23-mAb for 2 months and compared to wild-type (WT) and vehicle (PBS) treated Hyp mice (n = 3-7 mice). Micro-CT analyses showed that both doses of FGF23-mAb restored dentin/cementum volume and corrected the enlarged pulp volume in Hyp mice, the higher concentration resulting in a rescue similar to WT levels. FGF23-mAb treatment also improved alveolar bone volume fraction and mineral density compared to vehicle-treated ones. Histology revealed improved mineralization of the dentoalveolar tissues, with a decreased amount of osteoid, predentin and cementoid. Better periodontal ligament attachment was also observed, evidenced by restoration of the acellular cementum. These preclinical data were consistent with the retrospective analysis of two patients with XLH showing that burosumab treatment improved oral features. Taken together, our data show that the dentoalveolar tissues are greatly improved by FGF23-mAb treatment, heralding its benefit in clinics for dental abnormalities.
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Affiliation(s)
- Elis J Lira Dos Santos
- Université Paris Cité, Institut des maladies musculo-squelettiques, Laboratory Orofacial Pathologies, Imaging and Biotherapies URP2496 and FHU-DDS-Net, Dental School, and Plateforme d'Imagerie du Vivant (PIV), Montrouge, France
| | - Kenta Nakajima
- R&D Division, Kyowa Kirin, Co., Ltd, 3-6-6 Asahi-machi, Machida-shi, Tokyo, Japan
| | - Julien Po
- Université Paris Cité, Institut des maladies musculo-squelettiques, Laboratory Orofacial Pathologies, Imaging and Biotherapies URP2496 and FHU-DDS-Net, Dental School, and Plateforme d'Imagerie du Vivant (PIV), Montrouge, France
| | - Ayako Hanai
- R&D Division, Kyowa Kirin, Co., Ltd, 3-6-6 Asahi-machi, Machida-shi, Tokyo, Japan
| | - Volha Zhukouskaya
- Université Paris Cité, Institut des maladies musculo-squelettiques, Laboratory Orofacial Pathologies, Imaging and Biotherapies URP2496 and FHU-DDS-Net, Dental School, and Plateforme d'Imagerie du Vivant (PIV), Montrouge, France
| | - Martin Biosse Duplan
- Université Paris Cité, Institut Imagine, INSERM UMR 1163, Paris, France
- AP-HP, Reference Center for Rare Disorders of the Calcium and Phosphate Metabolism, Dental Medicine Department, Bretonneau Hospital, GHN-Université Paris Cité, Paris, France
| | - Agnès Linglart
- Paris-Saclay University, AP-HP, INSERM U1185, DMU SEA, Endocrinology and Diabetes for Children, Reference Center for Rare Diseases of the Calcium and Phosphate Metabolism, OSCAR filière, EndoRare, and BOND ERNs, Bicêtre Paris Saclay Hospital, Le Kremlin-Bicêtre, France
| | - Takashi Shimada
- Medical Affairs Department, Kyowa Kirin, Co., Ltd, 1-9-2 Otemachi, Chiyoda-ku, Tokyo, Japan
| | - Catherine Chaussain
- Université Paris Cité, Institut des maladies musculo-squelettiques, Laboratory Orofacial Pathologies, Imaging and Biotherapies URP2496 and FHU-DDS-Net, Dental School, and Plateforme d'Imagerie du Vivant (PIV), Montrouge, France
- AP-HP, Reference Center for Rare Disorders of the Calcium and Phosphate Metabolism, Dental Medicine Department, Bretonneau Hospital, GHN-Université Paris Cité, Paris, France
| | - Claire Bardet
- Université Paris Cité, Institut des maladies musculo-squelettiques, Laboratory Orofacial Pathologies, Imaging and Biotherapies URP2496 and FHU-DDS-Net, Dental School, and Plateforme d'Imagerie du Vivant (PIV), Montrouge, France.
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Levy-Shraga Y, Levi S, Regev R, Gal S, Brener A, Lebenthal Y, Gillis D, Strich D, Zung A, Cleper R, Borovitz Y, Bello R, Tenenbaum A, Zadik Z, Davidovits M, Zeitlin L, Tiosano D. Linear growth of children with X-linked hypophosphatemia treated with burosumab: a real-life observational study. Eur J Pediatr 2023; 182:5191-5202. [PMID: 37707589 DOI: 10.1007/s00431-023-05190-y] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 08/30/2023] [Accepted: 09/02/2023] [Indexed: 09/15/2023]
Abstract
To assess the long-term efficacy of burosumab for pediatric patients with X-linked hypophosphatemia, focusing on linear growth. This multi-center retrospective study included 35 pediatric patients who began treatment with burosumab between January 2018 and January 2021. We collected clinical data, anthropometric measurements, laboratory results, and Rickets Severity Score (RSS), from 2 years prior to treatment initiation and up to 4 years after. Burosumab was initiated at a mean age of 7.5 ± 4.4 years (range 0.6-15.9), with a mean initial dose of 0.8 ± 0.3 mg/kg, which was subsequently increased to 1.1 ± 0.4 mg/kg. The patients were followed for 2.9 ± 1.4 years (range 1-4) after initiating burosumab. Serum phosphorus levels increased from 2.7 ± 0.8 mg/dl at burosumab initiation to 3.4 ± 0.6 mg/dl after 3 months and remained stable (p < 0.001). Total reabsorption of phosphorus increased from 82.0 ± 6.8 to 90.1 ± 5.3% after 12 months of treatment (p = 0.041). The RSS improved from 1.7 ± 1.0 at burosumab initiation to 0.5 ± 0.6 and 0.3 ± 0.6 after 12 and 24 months, respectively (p < 0.001). Both height z-score and weight z-score improved from burosumab initiation to the end of the study: from - 2.07 ± 1.05 to - 1.72 ± 1.04 (p < 0.001) and from - 0.51 ± 1.12 to - 0.11 ± 1.29 (p < 0.001), respectively. Eight children received growth hormone combined with burosumab treatment. Height z-score improved among those who received growth hormone (from - 2.33 ± 1.12 to - 1.94 ± 1.24, p = 0.042) and among those who did not (from - 2.01 ± 1.01 to - 1.66 ± 1.01, p = 0.001). CONCLUSION Burosumab treatment in a real-life setting improved phosphate homeostasis and rickets severity and enhanced linear growth. WHAT IS KNOWN • Compared to conventional therapy, burosumab treatment has been shown to increase serum phosphate levels and reduce the severity of rickets. • The effect of burosumab on growth is still being study. WHAT IS NEW • Height z-score improved between the start of burosumab treatment and the end of the study (-2.07 ± 1.05 vs. -1.72 ± 1.04, p < 0.001). • Eight children received burosumab combined with growth hormone treatment without side effects during the concomitant treatments.
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Affiliation(s)
- Yael Levy-Shraga
- Pediatric Endocrinology Unit, The Edmond and Lily Safra Children's Hospital, Chaim Sheba Medical Center, Tel Hashomer, 52621, Israel.
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Shelly Levi
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Institute of Pediatric Nephrology, Schneider Children's Medical Center, Petah Tikva, Israel
| | - Ravit Regev
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Pediatric Endocrinology and Diabetes Unit, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Shoshana Gal
- Division of Pediatric Endocrinology, Ruth Rappaport Children's Hospital, Rambam Medical Center, Haifa, Israel
- Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Avivit Brener
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Pediatric Endocrinology and Diabetes Unit, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Yael Lebenthal
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Pediatric Endocrinology and Diabetes Unit, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - David Gillis
- Pediatric Endocrinology Unit, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Hadassah Medical School, Jerusalem, Israel
| | - David Strich
- Faculty of Medicine, Hebrew University of Jerusalem, Hadassah Medical School, Jerusalem, Israel
- Department of Pediatrics, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Amnon Zung
- Faculty of Medicine, Hebrew University of Jerusalem, Hadassah Medical School, Jerusalem, Israel
- Pediatrics Department, Kaplan Medical Center, Rehovot, Israel
| | - Roxana Cleper
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Pediatric Nephrology Unit, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Yael Borovitz
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Institute of Pediatric Nephrology, Schneider Children's Medical Center, Petah Tikva, Israel
| | - Rachel Bello
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- The Shafer Institute for Endocrinology and Diabetes, Schneider Children's Medical Center, Petah Tikva, Israel
| | - Ariel Tenenbaum
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- The Shafer Institute for Endocrinology and Diabetes, Schneider Children's Medical Center, Petah Tikva, Israel
| | - Zvi Zadik
- Faculty of Medicine, Hebrew University of Jerusalem, Hadassah Medical School, Jerusalem, Israel
- Pediatrics Department, Kaplan Medical Center, Rehovot, Israel
| | - Miriam Davidovits
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Institute of Pediatric Nephrology, Schneider Children's Medical Center, Petah Tikva, Israel
| | - Leonid Zeitlin
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Pediatric Orthopedic Department, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Dov Tiosano
- Division of Pediatric Endocrinology, Ruth Rappaport Children's Hospital, Rambam Medical Center, Haifa, Israel
- Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
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10
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Abdullah SJ, Mahwi TO, Mohamad Salih Saeed A, Abdulateef DS, Rahman HS, Ahmed SF, Abdulqader SA. X-Linked Familial Hypophosphatemia: A Case Report of 27-Year Old Male and Review of Literature. Horm Metab Res 2023; 55:653-664. [PMID: 37813097 PMCID: PMC10562047 DOI: 10.1055/a-2159-8429] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 08/15/2023] [Indexed: 10/11/2023]
Abstract
X-linked hypophosphatemia (XLH) associated with short stature during childhood are mostly referred to the hospital and diagnosed as vitamin D deficiency rickets and received vitamin D before adulthood. A case is presented with clinical features of hypophosphatemia from childhood who did not seek medical care for diagnosis and treatment, nor did his mother or two brothers, who have short statures, bone pain, and fractures. The patient was assessed for sociodemographic, hematological, and biochemical parameters together with a genetic assessment. A DEXA scan and X-ray were done to determine the abnormalities and deformities of joints and bones despite clinical examination by an expert physician. All imaging, laboratory parameters, and the genetic study confirmed the diagnosis of XLH. A detailed follow-up of his condition was performed after the use of phosphate tablets and other treatments. X-linked hypophosphatemia needs a good assessment, care, and follow up through a complementary medical team including several specialties. Phosphate tablets in adulthood significantly affects clinical and physical improvement and prevention of further skeletal abnormality and burden on daily activity. The patients should be maintained with an adequate dose of phosphate for better patient compliance. More awareness is needed in society and for health professionals when conducting medical checkups during the presence of stress fractures, frequent dental and gum problems, rickets, short stature, or abnormality in the skeleton or walking to think of secondary causes such as hypophosphatemia. Further investigations including a visit to a specialist is imperative to check for the primary cause of these disturbances.
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Affiliation(s)
| | - Taha Othman Mahwi
- Medicine, University of Sulaimani College of Medicine, Sulaymaniyah,
Kurdistan region, Iraq
| | | | - Darya Saeed Abdulateef
- Medical Education, University of Sulaimani College of Medicine,
Sulaymaniyah, Kurdistan region, Iraq
| | - Heshu Sulaiman Rahman
- Physiology, University of Sulaimani College of Medicine, Sulaymaniyah,
Kurdistan region, Iraq
| | - Shaho Fatah Ahmed
- Endocrine Unit, Internal Medicine, Shar Hospital, Sulaymaniyah,
Kurdistan region, Iraq
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11
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Ariceta G, Beck-Nielsen SS, Boot AM, Brandi ML, Briot K, de Lucas Collantes C, Emma F, Giannini S, Haffner D, Keen R, Levtchenko E, Mӓkitie O, Mughal MZ, Nilsson O, Schnabel D, Tripto-Shkolnik L, Liu J, Williams A, Wood S, Zillikens MC. The International X-Linked Hypophosphatemia (XLH) Registry: first interim analysis of baseline demographic, genetic and clinical data. Orphanet J Rare Dis 2023; 18:304. [PMID: 37752558 PMCID: PMC10523658 DOI: 10.1186/s13023-023-02882-4] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 08/24/2023] [Indexed: 09/28/2023] Open
Abstract
BACKGROUND X-linked hypophosphatemia (XLH) is a rare, hereditary, progressive, renal phosphate-wasting disorder characterized by a pathological increase in FGF23 concentration and activity. Due to its rarity, diagnosis may be delayed, which can adversely affect outcomes. As a chronic disease resulting in progressive accumulation of musculoskeletal manifestations, it is important to understand the natural history of XLH over the patient's lifetime and the impact of drug treatments and other interventions. This multicentre, international patient registry (International XLH Registry) was established to address the paucity of these data. Here we present the findings of the first interim analysis of the registry. RESULTS The International XLH Registry was initiated in August 2017 and includes participants of all ages diagnosed with XLH, regardless of their treatment and management. At the database lock for this first interim analysis (29 March 2021), 579 participants had entered the registry before 30 November 2020 and are included in the analysis (360 children [62.2%], 217 adults [37.5%] and 2 whose ages were not recorded [0.3%]; 64.2% were female). Family history data were available for 319/345 (92.5%) children and 145/187 (77.5%) adults; 62.1% had biological parents affected by XLH. Genetic testing data were available for 341 (94.7%) children and 203 (93.5%) adults; 370/546 (67.8%) had genetic test results; 331/370 (89.5%) had a confirmed PHEX mutation. A notably longer time to diagnosis was observed in adults ≥ 50 years of age (mean [median] duration 9.4 [2.0] years) versus all adults (3.7 [0.1] years) and children (1.0 [0.2] years). Participants presented with normal weight, shorter length or height and elevated body mass index (approximately - 2 and + 2 Z-scores, respectively) versus the general population. Clinical histories were collected for 349 participants (239 children and 110 adults). General data trends for prevalence of bone, dental, renal and joint conditions in all participants were aligned with expectations for a typical population of people with XLH. CONCLUSION The data collected within the International XLH Registry, the largest XLH registry to date, provide substantial information to address the paucity of natural history data, starting with demographic, family history, genetic testing, diagnosis, auxology and baseline data on clinical presentation.
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Affiliation(s)
- Gema Ariceta
- Department of Pediatric Nephrology, Hospital Vall d'Hebron, Universitat Autonoma Barcelona, Barcelona, Spain.
| | - Signe Sparre Beck-Nielsen
- Centre for Rare Diseases, Aarhus University Hospital, Åarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Åarhus, Denmark
| | - Annemieke M Boot
- Department of Pediatrics, Division of Endocrinology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | | | - Karine Briot
- Hôpital Cochin, Service de Rhumatologie, Centre de Référence des Maladies Rares du Métabolisme du Calcium et du Phosphate Filière OSCAR, AP-HP, Paris, France
| | | | - Francesco Emma
- Division of Nephrology, Bambino Gesù Children's Hospital - IRCCS, Rome, Italy
| | - Sandro Giannini
- Department of Medicine, Clinica Medica 1, University of Padova, Padua, Italy
| | - Dieter Haffner
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
| | - Richard Keen
- Royal National Orthopaedic Hospital, Stanmore, UK
| | - Elena Levtchenko
- Department of Pediatric Nephrology and Development and Regeneration, University Hospitals Leuven, University of Leuven, Leuven, Belgium
| | - Outi Mӓkitie
- Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - M Zulf Mughal
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester University Hospital's NHS Trust, Manchester, UK
| | - Ola Nilsson
- Division of Pediatric Endocrinology and Center for Molecular Medicine, Department of Women's and Children's Health, Karolinska Institutet and University Hospital, Stockholm, Sweden
- School of Medical Sciences and Department of Pediatrics, Örebro University and University Hospital, Örebro, Sweden
| | - Dirk Schnabel
- Center for Chronically Sick Children, Pediatric Endocrinology, Charité, University Medicine Berlin, Berlin, Germany
| | - Liana Tripto-Shkolnik
- Division of Endocrinology, Diabetes and Metabolism, Chaim Sheba Medical Center, Tel Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | | | - Sue Wood
- Kyowa Kirin International, Marlow, UK
| | - M Carola Zillikens
- Bone Center, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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12
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Ewert A, Rehberg M, Schlingmann KP, Hiort O, John-Kroegel U, Metzing O, Wühl E, Schaefer F, Kemper MJ, Derichs U, Richter-Unruh A, Patzer L, Albers N, Dunstheimer D, Haberland H, Heger S, Schröder C, Jorch N, Schmid E, Staude H, Weitz M, Freiberg C, Leifheit-Nestler M, Zivicnjak M, Schnabel D, Haffner D. Effects of Burosumab Treatment on Mineral Metabolism in Children and Adolescents With X-linked Hypophosphatemia. J Clin Endocrinol Metab 2023; 108:e998-e1006. [PMID: 37097907 DOI: 10.1210/clinem/dgad223] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 04/05/2023] [Accepted: 04/13/2023] [Indexed: 04/26/2023]
Abstract
CONTEXT Burosumab has been approved for the treatment of children and adults with X-linked hypophosphatemia (XLH). Real-world data and evidence for its efficacy in adolescents are lacking. OBJECTIVE To assess the effects of 12 months of burosumab treatment on mineral metabolism in children (aged <12 years) and adolescents (aged 12-18 years) with XLH. DESIGN Prospective national registry. SETTING Hospital clinics. PATIENTS A total of 93 patients with XLH (65 children, 28 adolescents). MAIN OUTCOME MEASURES Z scores for serum phosphate, alkaline phosphatase (ALP), and renal tubular reabsorption of phosphate per glomerular filtration rate (TmP/GFR) at 12 months. RESULTS At baseline, patients showed hypophosphatemia (-4.4 SD), reduced TmP/GFR (-6.5 SD), and elevated ALP (2.7 SD, each P < .001 vs healthy children) irrespective of age, suggesting active rickets despite prior therapy with oral phosphate and active vitamin D in 88% of patients. Burosumab treatment resulted in comparable increases in serum phosphate and TmP/GFR in children and adolescents with XLH and a steady decline in serum ALP (each P < .001 vs baseline). At 12 months, serum phosphate, TmP/GFR, and ALP levels were within the age-related normal range in approximately 42%, 27%, and 80% of patients in both groups, respectively, with a lower, weight-based final burosumab dose in adolescents compared with children (0.72 vs 1.06 mg/kg, P < .01). CONCLUSIONS In this real-world setting, 12 months of burosumab treatment was equally effective in normalizing serum ALP in adolescents and children, despite persistent mild hypophosphatemia in one-half of patients, suggesting that complete normalization of serum phosphate is not mandatory for substantial improvement of rickets in these patients. Adolescents appear to require lower weight-based burosumab dosage than children.
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Affiliation(s)
- Annika Ewert
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover 30625, Germany
| | - Mirko Rehberg
- Department of Pediatrics, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne 50937, Germany
| | - Karl Peter Schlingmann
- Department of General Pediatrics, Pediatric Nephrology, University Children's Hospital, Münster 48149, Germany
| | - Olaf Hiort
- Division of Pediatric Endocrinology and Diabetes, Department of Pediatrics and Adolescent Medicine, University of Lübeck, Lübeck 23562, Germany
| | | | | | - Elke Wühl
- Division of Pediatric Nephrology, Center for Pediatric and Adolescent Medicine, University Hospital Heidelberg, Heidelberg 69120, Germany
| | - Franz Schaefer
- Division of Pediatric Nephrology, Center for Pediatric and Adolescent Medicine, University Hospital Heidelberg, Heidelberg 69120, Germany
| | - Markus J Kemper
- Asklepios Children's Hospital Hamburg-Heidberg, Hamburg-Heidberg 22417, Germany
| | - Ute Derichs
- University Children's Hospital, Mainz 55131, Germany
| | | | - Ludwig Patzer
- St. Elisabeth and St. Barbara Children's Hospital, Halle/Saale 06110, Germany
| | - Norbert Albers
- Christliches Kinderhospital Osnabrück, Osnabrück 49074, Germany
| | | | - Holger Haberland
- Children's Hospital, Sana Klinikum Lichtenberg, Berlin Lichtenberg 10365, Germany
| | - Sabine Heger
- Kinderkrankenhaus auf der Bult, Hannover 30173, Germany
| | - Carmen Schröder
- University Children's Hospital Greifswald, Greifswald 17475, Germany
| | - Norbert Jorch
- University Children's Hospital, Evangelisches Klinikum Bethel, Bielefeld 33617, Germany
| | - Elmar Schmid
- Clinic for Pediatric Nephrology Hirschaid, Hirschaid 96114, Germany
| | - Hagen Staude
- University Children's Hospital Rostock, Rostock 18057, Germany
| | - Marcus Weitz
- Department of General Pediatrics and Hematology/Oncology, University Children's Hospital, University Hospital Tübingen, Tübingen 72076, Germany
| | - Clemens Freiberg
- Department of Pediatrics and Adolescent Medicine, University Medical Center Göttingen, Göttingen 37075, Germany
| | - Maren Leifheit-Nestler
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover 30625, Germany
| | - Miroslav Zivicnjak
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover 30625, Germany
| | - Dirk Schnabel
- Center for Chronically Sick Children, Pediatric Endocrinology, University Medicine, Charité, Berlin 13353, Germany
| | - Dieter Haffner
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover 30625, Germany
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13
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Chamli A, Souissi A, Frioui R, Alaoui F, Sassi W, Raboudi A, Chelly I, Mokni M. Hereditary vitamin D-resistant rickets associated with alopecia and epidermal cysts. Int J Rheum Dis 2023; 26:1835-1837. [PMID: 37002879 DOI: 10.1111/1756-185x.14679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 02/17/2023] [Accepted: 03/13/2023] [Indexed: 04/03/2023]
Affiliation(s)
- Amal Chamli
- Dermatology Department, La Rabta Hospital, Tunis, Tunisia
- University of Tunis El Manar, Faculty of medicine of Tunis, Tunis, Tunisia
- Dermatology Department, Habib Thameur Hospital, Tunis, Tunisia
| | - Asmahane Souissi
- Dermatology Department, La Rabta Hospital, Tunis, Tunisia
- University of Tunis El Manar, Faculty of medicine of Tunis, Tunis, Tunisia
| | - Refka Frioui
- Dermatology Department, La Rabta Hospital, Tunis, Tunisia
- University of Tunis El Manar, Faculty of medicine of Tunis, Tunis, Tunisia
| | - Fatima Alaoui
- Dermatology Department, La Rabta Hospital, Tunis, Tunisia
- University of Tunis El Manar, Faculty of medicine of Tunis, Tunis, Tunisia
| | - Wiem Sassi
- Dermatology Department, La Rabta Hospital, Tunis, Tunisia
- University of Tunis El Manar, Faculty of medicine of Tunis, Tunis, Tunisia
| | - Asma Raboudi
- Dermatology Department, La Rabta Hospital, Tunis, Tunisia
- University of Tunis El Manar, Faculty of medicine of Tunis, Tunis, Tunisia
| | - Ines Chelly
- University of Tunis El Manar, Faculty of medicine of Tunis, Tunis, Tunisia
- Anatomopathology Department, La Rabta Hospital, Tunis, Tunisia
| | - Mourad Mokni
- Dermatology Department, La Rabta Hospital, Tunis, Tunisia
- University of Tunis El Manar, Faculty of medicine of Tunis, Tunis, Tunisia
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14
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Filler G, Tremblay O, Chen E, Huang SSH, Stein R. Sex differences of burosumab in children with X-linked hypophosphataemic rickets. Pediatr Nephrol 2023; 38:3183-3187. [PMID: 36542147 DOI: 10.1007/s00467-022-05822-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 10/19/2022] [Accepted: 11/07/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND The severity of X-linked hypophosphataemic rickets (XLH) may be affected by genotype and sex. However, burosumab, a fully humanized monoclonal antibody against fibroblast growth factor 23, has the same pediatric dose recommendation for both sexes (0.8 mg/kg every 2 weeks). PATIENTS AND METHODS In a retrospective cohort study, we describe the burosumab response differences by sex in children with XLH. RESULTS We treated 10 children (5 females, mean age at initiation 4.2 ± 3.5 years) with XLH with burosumab. Initial mean serum phosphate was 0.69 ± 0.18 mmol/L in males and 0.86 ± 0.22 mmol/L in females (p = 0.108). The mean ratio of tubular maximum reabsorption rate of phosphate to glomerular filtration rate (TmP/GFR) was 0.55 ± 0.11 mmol/L in males and 0.76 ± 0.23 mmol/L in females (p = 0.06). The mean starting dose of burosumab was 0.83 ± 0.19 mg/kg subcutaneously every 14 days (males: 0.79 ± 0.19 mg/kg; females: 0.87 ± 0.21 mg/kg, n.s.). Two weeks after starting burosumab, serum phosphate differed significantly between males (0.90 ± 0.21 mmol/L) and females (1.27 ± 0.25 mmol/L) (p = 0.018). All males required a dose increase to try to normalize serum phosphate. On day 140 after starting, the average dose in males increased further to 1.24 ± 0.41 mg/kg to achieve a phosphate of 0.87 ± 0.11 mmol/L while females had a normal phosphate and alkaline phosphatase on the starting dose. After a mean of 458 ± 79 days, the mean burosumab dose/kg in males was 1.68 ± 0.61 mg/kg, mean serum phosphate was 1.08 ± 0.23 mmol/L, mean TmP/GFR was 1.01 ± 0.20, mean alkaline phosphatase had normalized to 303.6 ± 40.7U/L, and mean 1.25(OH)2 vitamin D level was 186.4 ± 16.6 nmol/L. CONCLUSIONS Our findings may suggest a sex difference in response to burosumab in XLH patients. Our data suggest that males may require higher doses.
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Affiliation(s)
- Guido Filler
- Departments of Pediatrics, Schulich School of Medicine and Dentistry, University of Western Ontario, 800 Commissioners Road East, E3-206, London, ON, N6A 5W9, Canada.
- Schulich School of Medicine and Dentistry, University of Western Ontario, London, Canada.
- Pathology & Laboratory Medicine, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Canada.
- Children's Health Research Institute, University of Western Ontario, London, Canada.
| | - Olivia Tremblay
- Department of Pharmacy, London Health Sciences Centre, London, Canada
| | - Emily Chen
- Department of Pharmacy, London Health Sciences Centre, London, Canada
| | - Susan Shi Han Huang
- Departments of Pediatrics, Schulich School of Medicine and Dentistry, University of Western Ontario, 800 Commissioners Road East, E3-206, London, ON, N6A 5W9, Canada
- Schulich School of Medicine and Dentistry, University of Western Ontario, London, Canada
- Lilibeth Caberto Kidney Clinical Research Unit, London, ON, Canada
| | - Robert Stein
- Departments of Pediatrics, Schulich School of Medicine and Dentistry, University of Western Ontario, 800 Commissioners Road East, E3-206, London, ON, N6A 5W9, Canada
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15
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Kubota T, Namba N, Tanaka H, Muroya K, Imanishi Y, Takeuchi Y, Kanematsu M, Sun W, Seino Y, Ozono K. Self-Administration of Burosumab in Children and Adults with X-Linked Hypophosphataemia in Two Open-Label, Single-Arm Clinical Studies. Adv Ther 2023; 40:1530-1545. [PMID: 36719566 PMCID: PMC9887240 DOI: 10.1007/s12325-022-02412-x] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 12/15/2022] [Indexed: 02/01/2023]
Abstract
INTRODUCTION X-linked hypophosphataemia (XLH) is a rare, genetic renal phosphate-wasting disease, resulting from excess fibroblast growth factor 23 (FGF23) activity, which has a progressive and profound impact on patients throughout life. The monoclonal anti-FGF23 antibody, burosumab, is a subcutaneous injection indicated for the treatment of XLH in children and adults. Originally, burosumab was approved to be administered by a healthcare professional (HCP), but the option of self-administration would enable patient independence and easier access to treatment. Two open-label, single-arm clinical trials, conducted in Japan and Korea, have assessed the safety and efficacy of self-administration of burosumab in both children and adults with XLH. METHODS In KRN23-003 (n = 15 children aged 1-12 years) and KRN23-004 (n = 5 children aged 3-13 years, n = 4 adults aged 21-65 years), children initially received 0.8 mg/kg of burosumab every 2 weeks and adults initially received 1.0 mg/kg of burosumab every 4 weeks. Self-administration was permitted from Week 4, and patients or carers were provided with training to inject correctly. RESULTS In both trials, burosumab had an acceptable safety profile with mainly mild-to-moderate adverse events. Following self-administration, no patients reported serious treatment-emergent adverse events ≥ grade 3, injection-site reactions or hypersensitivity reactions related to burosumab. Serum phosphate and active vitamin D levels increased from baseline in children and adults. CONCLUSIONS These results indicated that the efficacy and safety of burosumab when administered either by a carer or patient are similar to that when administered by an HCP and show that self-administration is a viable option for patients with XLH. TRIAL REGISTRATION NUMBERS NCT03233126 and NCT04308096.
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Affiliation(s)
- Takuo Kubota
- Department of Paediatrics, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Noriyuki Namba
- Division of Paediatrics and Perinatology, Tottori University Faculty of Medicine, Tottori, Japan
| | - Hiroyuki Tanaka
- Department of Paediatrics, Okayama Saiseikai General Hospital, Okayama, Japan
| | - Koji Muroya
- Department of Endocrinology and Metabolism, Kanagawa Children's Medical Centre, Kanagawa, Japan
| | - Yasuo Imanishi
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Yasuhiro Takeuchi
- Endocrine Centre, Toranomon Hospital, Tokyo, Japan
- Okinaka Memorial Institute for Medical Research, Tokyo, Japan
| | - Masanori Kanematsu
- Kyowa Kirin Co., Ltd., Oteomachi Financial City Grand Cube, 1-9-2 Otemachi, Chiyoda-ku, Tokyo, Japan.
| | - Wei Sun
- Kyowa Kirin, Inc., 212 Carnegie Centre, Princeton, NJ, 08540, USA
| | - Yoshiki Seino
- Department of Paediatrics, Osaka Hospital, Japan Community Healthcare Organisation, Osaka, Japan
| | - Keiichi Ozono
- Department of Paediatrics, Osaka University Graduate School of Medicine, Osaka, Japan
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16
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Dodamani MH, Lila AR, Memon SS, Sarathi V, Arya S, Rane A, Sehemby MK, Garg R, Bhandare VV, Karlekar M, Patil VA, Kunwar A, Bandgar TR. Genotypic Spectrum and its Correlation with Alopecia and Clinical Response in Hereditary Vitamin D Resistant Rickets: Our Experience and Systematic Review. Calcif Tissue Int 2023; 112:483-492. [PMID: 36705686 DOI: 10.1007/s00223-023-01061-8] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 01/14/2023] [Indexed: 01/28/2023]
Abstract
Alopecia in hereditary vitamin D resistant rickets (HVDRR) has some correlation with severe rickets and poor overall response. However, these observations are based on small series. Hence, we aim to assess the genotypic spectrum of HVDRR and its correlation with alopecia and clinical response. Seven genetically-proven HVDDR patients from five unrelated families and 119 probands from systematic review were analysed retrospectively for phenotypic and genotypic data and overall response to therapy. In our cohort mean age at rickets onset was 12 (± 3.4) months. Alopecia was present in all patients but one. All patients had poor overall response to oral high-dose calcium and calcitriol and most required intravenous calcium. Genetic analyses revealed four novel variants. On systematic review, alopecia was present in majority (81.5%) and preceded the onset of rickets. Patients with alopecia had higher serum calcium (7.6 vs.6.9 mg/dl, p = 0.008), lower 1, 25(OH)2 D (200 vs.320 pg/ml, p = 0.03) and similar overall response to oral therapy (28.7% vs. 35.3%, p = 0.56). Alopecia was present in 51.4% of non-truncating (NT) ligand-binding domain (LBD) variants, whereas it was universal in truncating LBD and all DNA binding-domain (DBD) variants. Overall response to oral therapy was highest in LBD-NT (46.4%) as compared to 7.6% in LBD-truncating and 19% in DBD-NT variants. Among LBD-NT variants, those affecting RXR heterodimerization, but not those affecting ligand affinity, were associated with alopecia. Both alopecia and overall response have genotypic correlation. Age at diagnosis and overall response to oral therapy were similar between patients with and without alopecia in genetically proven HVDRR.
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Affiliation(s)
- Manjunath Havalappa Dodamani
- Department of Endocrinology, Seth G.S Medical College & KEM Hospital, Parel, Mumbai, Maharashtra, 4000012, India
| | - Anurag Ranjan Lila
- Department of Endocrinology, Seth G.S Medical College & KEM Hospital, Parel, Mumbai, Maharashtra, 4000012, India
| | - Saba Samad Memon
- Department of Endocrinology, Seth G.S Medical College & KEM Hospital, Parel, Mumbai, Maharashtra, 4000012, India.
| | - Vijaya Sarathi
- Department of Endocrinology, Vydehi Institute of Medical Sciences and Research Centre, Bangalore, Karnataka, India
| | - Sneha Arya
- Department of Endocrinology, Seth G.S Medical College & KEM Hospital, Parel, Mumbai, Maharashtra, 4000012, India
| | - Ankita Rane
- Department of Endocrinology, Seth G.S Medical College & KEM Hospital, Parel, Mumbai, Maharashtra, 4000012, India
| | - Manjeet Kaur Sehemby
- Department of Endocrinology, Seth G.S Medical College & KEM Hospital, Parel, Mumbai, Maharashtra, 4000012, India
| | - Robin Garg
- Department of Endocrinology, Seth G.S Medical College & KEM Hospital, Parel, Mumbai, Maharashtra, 4000012, India
| | | | - Manjiri Karlekar
- Department of Endocrinology, Seth G.S Medical College & KEM Hospital, Parel, Mumbai, Maharashtra, 4000012, India
| | - Virendra A Patil
- Department of Endocrinology, Seth G.S Medical College & KEM Hospital, Parel, Mumbai, Maharashtra, 4000012, India
| | - Ambarish Kunwar
- Department of Biosciences and Bioengineering, Indian Institute of Technology Bombay, Mumbai, India
| | - Tushar R Bandgar
- Department of Endocrinology, Seth G.S Medical College & KEM Hospital, Parel, Mumbai, Maharashtra, 4000012, India
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Sugarman J, Maruri A, Hamilton DJ, Tabatabai L, Luca D, Cimms T, Krolczyk S, Roberts MS, Carpenter TO. The efficacy and safety of burosumab in two patients with cutaneous skeletal hypophosphatemia syndrome. Bone 2023; 166:116598. [PMID: 36341949 DOI: 10.1016/j.bone.2022.116598] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 09/30/2022] [Accepted: 10/24/2022] [Indexed: 11/02/2022]
Abstract
Cutaneous skeletal hypophosphatemia syndrome (CSHS) is an ultra-rare mosaic disorder manifesting as skeletal dysplasia and FGF23-mediated hypophosphatemia, with some experiencing extra-osseous/extra-cutaneous manifestations, including both benign and malignant neoplasms. Like other disorders of FGF23-mediated hypophosphatemia including X-linked hypophosphatemia (XLH) and tumor-induced osteomalacia (TIO), patients with CSHS have low serum phosphorus and active 1,25-dihydroxyvitamin D levels. Current treatment options for patients with CSHS include multiple daily doses of oral phosphorus and one or more daily doses of active vitamin D analog to correct the deficits. Recently, the fully human monoclonal antibody against FGF23 burosumab received US approval for the treatment of XLH and TIO, two rare diseases characterized by FGF23-mediated hypophosphatemia leading to rickets and osteomalacia. Given the similarities between the pathobiologies of these disorders and CSHS, we investigated the impact of burosumab on two patients, one pediatric and one adult, with CSHS who participated in separate, but similarly designed trials. In both the pediatric and adult patients, burosumab therapy was well-tolerated and contributed to clinically meaningful improvements in disease outcomes including normalization of phosphorus metabolism and markers of bone health, and improvements in skeletal abnormalities, fractures, and physical function. Reported adverse events were minimal, with only mild injection site reactions attributed to burosumab therapy. Together, these findings suggest that burosumab therapy is a promising therapeutic option for patients with CSHS.
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Affiliation(s)
- Jeffrey Sugarman
- University of California, San Francisco, San Francisco, CA, USA.
| | - Ann Maruri
- Westside Pediatrics Focus Research and Development, 1477 N 2000 W, Clinton, UT 84015, USA
| | - Dale J Hamilton
- Houston Methodist Hospital and Research Institute; WCM Affiliate, Houston, TX, USA
| | - Laila Tabatabai
- Houston Methodist Hospital and Research Institute; WCM Affiliate, Houston, TX, USA
| | - Diana Luca
- Ultragenyx Pharmaceutical Inc., Novato, CA, USA
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Zagari MC, Chiarello P, Iuliano S, D’Antona L, Rocca V, Colao E, Perrotti N, Greco F, Iuliano R, Aversa A. The Variant p.Ala84Pro Is Causative of X-Linked Hypophosphatemic Rickets: Possible Relationship with Burosumab Swinging Response in Adults. Genes (Basel) 2022; 14:genes14010080. [PMID: 36672821 PMCID: PMC9859156 DOI: 10.3390/genes14010080] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 12/01/2022] [Accepted: 12/23/2022] [Indexed: 12/29/2022] Open
Abstract
Loss of function mutations in the PHEX gene could determine X-linked dominant hypophosphatemia. This is the most common form of genetic rickets. It is characterized by renal phosphate wasting determining an increase in fibroblast growth factor 23 (FGF-23), growth retard, bone deformities and musculoskeletal manifestations. In recent decades, analysis of the PHEX gene has revealed numerous different mutations. However, no clear genotype-phenotype correlations have been reported in patients with hypophosphatemic rickets (XLH). We report two cases of a 28-year-old-male (patient 1) and a 19-year-old male (patient 2) affected by XLH initially treated with phosphate and 1,25-dihydroxyvitamin-D admitted to the Endocrinology unit because of the persistence of muscle weakness, bone pain and fatigue. After phosphate withdrawal, both patients started therapy with burosumab and symptoms ameliorated in three months. However, patient 1's biochemical parameters did not improve as expected so we decided to investigate his genetic asset. We herein describe a possible clinical implication for the missense "de novo" mutation, c.250G>C (p.Ala84Pro) in the PHEX gene, reported in the PHEX database and classified as a variant of uncertain significance (VUS). The clinical implication of this mutation on disease burden and quality of life in adults is still under investigation.
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Affiliation(s)
- Maria Carmela Zagari
- Endocrinology Rare Disease Unit, Department of Experimental and Clinical Medicine, Magna Græcia University, Catanzaro, 88100 Catanzaro, Italy
| | - Paola Chiarello
- Department of Pediatrics, Pugliese-Ciaccio Hospital, Catanzaro, 88100 Catanzaro, Italy
- Department of Experimental and Clinical Medicine, Magna Græcia University of Catanzaro, 88100 Catanzaro, Italy
| | - Stefano Iuliano
- Endocrinology Rare Disease Unit, Department of Experimental and Clinical Medicine, Magna Græcia University, Catanzaro, 88100 Catanzaro, Italy
| | - Lucia D’Antona
- Department of Health Sciences, Magna Græcia University of Catanzaro, 88100 Catanzaro, Italy
| | - Valentina Rocca
- Endocrinology Rare Disease Unit, Department of Experimental and Clinical Medicine, Magna Græcia University, Catanzaro, 88100 Catanzaro, Italy
| | - Emma Colao
- Medical Genetics Unit, Mater Domini University Hospital, Catanzaro, 88100 Catanzaro, Italy
| | - Nicola Perrotti
- Department of Health Sciences, Magna Græcia University of Catanzaro, 88100 Catanzaro, Italy
- Medical Genetics Unit, Mater Domini University Hospital, Catanzaro, 88100 Catanzaro, Italy
| | - Francesca Greco
- Endocrinology Rare Disease Unit, Department of Experimental and Clinical Medicine, Magna Græcia University, Catanzaro, 88100 Catanzaro, Italy
- Department of Human Movement Sciences and Health, University of Rome “Foro Italico”, 00135 Rome, Italy
| | - Rodolfo Iuliano
- Department of Health Sciences, Magna Græcia University of Catanzaro, 88100 Catanzaro, Italy
- Medical Genetics Unit, Mater Domini University Hospital, Catanzaro, 88100 Catanzaro, Italy
- Correspondence: (R.I.); (A.A.)
| | - Antonio Aversa
- Endocrinology Rare Disease Unit, Department of Experimental and Clinical Medicine, Magna Græcia University, Catanzaro, 88100 Catanzaro, Italy
- Correspondence: (R.I.); (A.A.)
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19
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Abstract
Hypophosphatemic rickets typically presents in infancy or early childhood with skeletal deformities and growth plate abnormalities. The most common causes are genetic (such as X-linked hypophosphatemia), and these typically will result in lifelong hypophosphatemia and osteomalacia. Knowledge of phosphate metabolism, including the effects of fibroblast growth factor 23 (FGF23) (an osteocyte produced hormone that downregulates renal phosphate reabsorption and 1,25-dihydroxyvitamin-D (1,25(OH)2D) production), is critical to determining the underlying genetic or acquired causes of hypophosphatemia and to facilitate appropriate treatment. Serum phosphorus should be measured in any child or adult with musculoskeletal complaints suggesting rickets or osteomalacia. Clinical evaluation incudes thorough history, physical examination, laboratory investigations, genetic analysis (especially in the absence of a guiding family history), and imaging to establish etiology and to monitor severity and treatment course. The treatment depends on the underlying cause, but often includes active forms of vitamin D combined with phosphate salts, or anti-FGF23 antibody treatment (burosumab) for X-linked hypophosphatemia. The purpose of this article is to explore the approach to evaluating hypophosphatemic rickets and its treatment options.
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Affiliation(s)
- Sarah A Ackah
- Department of Medicine, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Erik A Imel
- Department of Medicine, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN 46202, USA
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20
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Weber TJ, Imel EA, Carpenter TO, Peacock M, Portale AA, Hetzer J, Merritt JL, Insogna K. Long-term Burosumab Administration Is Safe and Effective in Adults With X-linked Hypophosphatemia. J Clin Endocrinol Metab 2022; 108:155-165. [PMID: 36072994 PMCID: PMC9759172 DOI: 10.1210/clinem/dgac518] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 08/24/2022] [Indexed: 02/03/2023]
Abstract
CONTEXT Burosumab was developed as a treatment option for patients with the rare, lifelong, chronically debilitating, genetic bone disease X-linked hypophosphatemia (XLH). OBJECTIVE Collect additional information on the safety, immunogenicity, and clinical response to long-term administration of burosumab. METHODS UX023-CL203 (NCT02312687) was a Phase 2b, open-label, single-arm, long-term extension study of adult subjects with XLH who participated in KRN23-INT-001 or KRN23-INT-002 studies. The long-term UX023-CL203 study (January 5, 2015 through November 30, 2018) provided data up to 184 weeks. Participants in UX023-CL203 received burosumab based on the last dose in the prior KRN23-INT-001 or KRN23-INT-002 studies (0.3, 0.6, or 1.0 mg/kg given by subcutaneous injection every 4 weeks). At Week 12, burosumab could be titrated upward/downward to achieve fasting serum phosphate levels within the normal range. Primary objectives included long-term safety, the proportion of subjects achieving fasting serum phosphate in the normal range, changes in bone turnover markers, patient-reported outcomes for pain and stiffness, and measures of mobility. RESULTS Fasting serum phosphate levels at the midpoint of the dosing interval (2 weeks postdose, the time of peak effect) were within the normal range in 85% to 100% of subjects. Measures of phosphate metabolism and bone biomarkers generally improved with burosumab therapy, approaching or reaching their respective normal ranges by study end. Improvements in patient-reported outcomes and mobility were sustained throughout the observation period. No new safety findings emerged with longer-term burosumab treatment. CONCLUSION These data support the conclusion that burosumab therapy may be a safe and effective long-term treatment option for adult patients with XLH.
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Affiliation(s)
- Thomas J Weber
- Correspondence: Thomas J. Weber, MD, Division of Endocrinology, Metabolism and Nutrition, 303 Baker House, DUMC 3470, Duke University Medical Center, Durham, NC 27710, USA.
| | - Erik A Imel
- Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | | | - Munro Peacock
- Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | | | - Joel Hetzer
- Ultragenyx Pharmaceutical Inc., Novato, CA 94949, USA
| | | | - Karl Insogna
- Yale University School of Medicine, New Haven, CT 06520, USA
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21
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Méaux MN, Alioli C, Linglart A, Lemoine S, Vignot E, Bertholet-Thomas A, Peyruchaud O, Flammier S, Machuca-Gayet I, Bacchetta J. X-Linked Hypophosphatemia, Not Only a Skeletal Disease But Also a Chronic Inflammatory State. J Clin Endocrinol Metab 2022; 107:3275-3286. [PMID: 36112422 DOI: 10.1210/clinem/dgac543] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Indexed: 02/13/2023]
Abstract
CONTEXT X-linked hypophosphatemia (XLH) is a rare genetic disease caused by a primary excess of fibroblast growth factor 23 (FGF23). FGF23 has been associated with inflammation and impaired osteoclastogenesis, but these pathways have not been investigated in XLH. OBJECTIVE This work aimed to evaluate whether XLH patients display peculiar inflammatory profile and increased osteoclastic activity. METHODS We performed a prospective, multicenter, cross-sectional study analyzing transcript expression of 8 inflammatory markers (Il6, Il8, Il1β, CXCL1, CCL2, CXCR3, Il1R, Il6R) by real-time quantitative polymerase chain reaction on peripheral blood mononuclear cells (PBMCs) purified from total blood samples extracted from patients and healthy control individuals. The effect of native/active vitamin D on osteoclast formation was also assessed in vitro from XLH patients' PBMCs. RESULTS In total, 28 XLH patients (17 children, among them 6 undergoing standard of care [SOC] and 11 burosumab therapy) and 19 controls were enrolled. Expression of most inflammatory markers was significantly increased in PBMCs from XLH patients compared to controls. No differences were observed between the burosumab and SOC subgroups. Osteoclast formation was significantly impaired in XLH patients. XLH mature osteoclasts displayed higher levels of inflammatory markers, being however lower in cells derived from the burosumab subgroup (as opposed to SOC). CONCLUSION We describe for the first time a peculiar inflammatory profile in XLH. Since XLH patients have a propensity to develop arterial hypertension, obesity, and enthesopathies, and because inflammation can worsen these clinical outcomes, we hypothesize that inflammation may play a critical role in these extraskeletal complications of XLH.
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Affiliation(s)
- Marie-Noëlle Méaux
- Service de Néphrologie, Rhumatologie et Dermatologie Pédiatriques, Centre de Référence des Maladies Rares du Calcium et du Phosphore, Centre de Référence des Maladies Rénales Rares Filières Maladies Rares ORKID, OSCAR et ERN ERK-Net, CHU de Lyon, 69 500 Bron, France
- INSERM, UMR 1033, Faculté de Médecine Lyon Est, Université Claude Bernard Lyon 1, 69 008 Lyon, France
| | - Candide Alioli
- INSERM, UMR 1033, Faculté de Médecine Lyon Est, Université Claude Bernard Lyon 1, 69 008 Lyon, France
| | - Agnès Linglart
- AP-HP, Université Paris Saclay, INSERM, Service d'endocrinologie et diabète de l'enfant, Centre de Référence des Maladies Rares du Calcium et du Phosphore, Filière de Santé Maladies Rares OSCAR, ERN endoRARE et BOND, Plateforme d'expertise des maladies rares Paris Saclay, Hôpital Bicêtre Paris-Saclay, 94 270 Le Kremlin-Bicêtre, France
| | - Sandrine Lemoine
- Département de Néphrologie, Service d'exploration Fonctionnelle rénale, Hôpital Edouard Herriot, 69 003 Lyon, France
- Faculté de Médecine Lyon Est, Université Claude Bernard Lyon 1, 69 003 Lyon, France
| | - Emmanuelle Vignot
- Faculté de Médecine Lyon Est, Université Claude Bernard Lyon 1, 69 003 Lyon, France
- Service de Rhumatologie, Hôpital Edouard Herriot, 69 003 Lyon, France
| | - Aurélia Bertholet-Thomas
- Service de Néphrologie, Rhumatologie et Dermatologie Pédiatriques, Centre de Référence des Maladies Rares du Calcium et du Phosphore, Centre de Référence des Maladies Rénales Rares Filières Maladies Rares ORKID, OSCAR et ERN ERK-Net, CHU de Lyon, 69 500 Bron, France
- INSERM, UMR 1033, Faculté de Médecine Lyon Est, Université Claude Bernard Lyon 1, 69 008 Lyon, France
| | - Olivier Peyruchaud
- INSERM, UMR 1033, Faculté de Médecine Lyon Est, Université Claude Bernard Lyon 1, 69 008 Lyon, France
| | - Sacha Flammier
- Service de Néphrologie, Rhumatologie et Dermatologie Pédiatriques, Centre de Référence des Maladies Rares du Calcium et du Phosphore, Centre de Référence des Maladies Rénales Rares Filières Maladies Rares ORKID, OSCAR et ERN ERK-Net, CHU de Lyon, 69 500 Bron, France
| | - Irma Machuca-Gayet
- INSERM, UMR 1033, Faculté de Médecine Lyon Est, Université Claude Bernard Lyon 1, 69 008 Lyon, France
| | - Justine Bacchetta
- Service de Néphrologie, Rhumatologie et Dermatologie Pédiatriques, Centre de Référence des Maladies Rares du Calcium et du Phosphore, Centre de Référence des Maladies Rénales Rares Filières Maladies Rares ORKID, OSCAR et ERN ERK-Net, CHU de Lyon, 69 500 Bron, France
- INSERM, UMR 1033, Faculté de Médecine Lyon Est, Université Claude Bernard Lyon 1, 69 008 Lyon, France
- Faculté de Médecine Lyon Est, Université Claude Bernard Lyon 1, 69 003 Lyon, France
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22
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Roumpou A, Yavropoulou MP, Chronopoulos E, Kassi E. Novel Therapeutic Agents for Rare Diseases of Calcium and Phosphate Metabolism. Horm Metab Res 2022; 54:645-657. [PMID: 36049757 DOI: 10.1055/a-1917-0519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
The last decade has been revolutionary regarding the management of rare bone diseases caused by impaired calcium and phosphate metabolism. Elucidation of the underlying genetic basis and pathophysiologic alterations has been the determinant factor for the development of new, disease-specific treatment agents. The phosphaturic hormone Fibroblast Growth Factor 23 (FGF23) possesses a critical role in the pathogenesis of various hypophosphatemic disorders. Among them, the genetic disorder of X-linked hypophosphatemia and the acquired syndrome of tumor-induced osteomalacia, although very rare, have attracted the scientific community's attention towards designing an FGF23-inhibitor as a potential specific therapy. The monoclonal antibody burosumab was approved for the treatment of children and adult patients with X-linked hypophosphatemia and recently for tumor-induced osteomalacia patients, demonstrating benefits regarding their symptoms, biochemical profile and bone mineralization status. Asfotase alfa is a hydroxyapatite-targeted recombinant alkaline phosphatase, an enzymatic replacement therapy, substituting the defective activity of tissue non-specific alkaline phosphatase, in patients suffering from hypophosphatasia. Promising data regarding its favorable effect on survival rate, bone quality, fracture healing, muscle strength, mobility, respiratory function, and general quality of life have led to the approval of the drug for the treatment of childhood-onset hypophosphatasia. Given the high costs of treatment for both agents and their limited clinical use until now, more data are needed to define patients' characteristics that make them ideal candidates for therapy. Long-term safety issues also need to be clarified.
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Affiliation(s)
- Afroditi Roumpou
- Division of Endocrinology, Metabolism and Diabetes, First Department of Pediatrics, "Aghia Sofia" Children's Hospital, National and Kapodistrian University of Athens School of Medicine, Athens, Greece
- Laboratory for Research of the Musculoskeletal System, National and Kapodistrian University of Athens School of Medicine, Athens, Greece
| | - Maria P Yavropoulou
- Centre of Expertise for Rare Endocrine Diseases, C.E.R.E.D. Disorders of Calcium & Phosphate Metabolism, First Department of Propaedeutic and Internal Medicine, Laiko Hospital, National and Kapodistrian University of Athens School of Medicine, Athens, Greece
| | - Efstathios Chronopoulos
- Laboratory for Research of the Musculoskeletal System, National and Kapodistrian University of Athens School of Medicine, Athens, Greece
| | - Eva Kassi
- Laboratory for Research of the Musculoskeletal System, National and Kapodistrian University of Athens School of Medicine, Athens, Greece
- Centre of Expertise for Rare Endocrine Diseases, C.E.R.E.D. Disorders of Calcium & Phosphate Metabolism, First Department of Propaedeutic and Internal Medicine, Laiko Hospital, National and Kapodistrian University of Athens School of Medicine, Athens, Greece
- Department of Biological Chemistry, National and Kapodistrian University of Athens, Athens, Greece
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23
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Brandi ML, Jan de Beur S, Briot K, Carpenter T, Cheong HI, Cohen-Solal M, Crowley RK, Eastell R, Imanishi Y, Imel EA, Ing SW, Insogna K, Ito N, Javaid K, Kamenicky P, Keen R, Kubota T, Lachmann RH, Perwad F, Pitukcheewanont P, Portale A, Ralston SH, Tanaka H, Weber TJ, Yoo HW, Sun W, Williams A, Nixon A, Takeuchi Y. Efficacy of Burosumab in Adults with X-linked Hypophosphatemia (XLH): A Post Hoc Subgroup Analysis of a Randomized Double-Blind Placebo-Controlled Phase 3 Study. Calcif Tissue Int 2022; 111:409-418. [PMID: 35927518 DOI: 10.1007/s00223-022-01006-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 07/05/2022] [Indexed: 11/30/2022]
Abstract
The anti-fibroblast growth factor 23 monoclonal antibody burosumab corrects hypophosphatemia in adults with X-linked hypophosphatemia (XLH) and improves pain, stiffness, physical function, and fatigue. This post hoc subgroup analysis used data from the 24-week placebo-controlled period of a phase 3 study in 134 adults with XLH (ClinicalTrials.gov NCT02526160), to assess whether the benefits of burosumab are evident in 14 clinically relevant subgroups defined by baseline demographic and functional criteria, including sex, Brief Pain Inventory-short form (BPI-SF) Average And Worst Pain, region, race, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC®) Stiffness, Physical Function and Pain domains and total score, use of opioid/other pain medication, active fractures/pseudo-fractures, and 6-min walk test distance. There were no statistically significant interactions between any of the subgroups and treatment arm for any endpoint. Higher proportions of subjects achieved mean serum phosphate concentration above the lower limit of normal (the primary endpoint) with burosumab than with placebo in all subgroups. For the key secondary endpoints (WOMAC Stiffness and Physical Function; BPI-SF Worst Pain) individual subgroup categories showed improvements with burosumab relative to placebo. For additional efficacy endpoints, burosumab was favored in some subgroups but differences were not significant and confidence intervals were wide. For some endpoints the treatment effect is small at 24 weeks in all subjects. This subgroup analysis shows that burosumab was largely superior to placebo across endpoints in the 14 clinically relevant subgroup variables at 24 weeks and is likely to benefit all symptomatic adults with active XLH.
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Affiliation(s)
| | - Suzanne Jan de Beur
- Division of Endocrinology and Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Karine Briot
- Department of Rheumatology, Cochin Hospital, Paris University, Paris, France
| | - Thomas Carpenter
- Department of Pediatrics and Department of Orthopedics and Rehabilitation, Yale School of Medicine, New Haven, CT, USA
| | - Hae Il Cheong
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Republic of Korea
| | - Martine Cohen-Solal
- Department of Rheumatology, Lariboisière Hospital, INSERM U1132 BIOSCAR, and University of Paris, Paris, France
| | - Rachel K Crowley
- Department of Endocrinology, St Vincent's University Hospital, and University College Dublin School of Medicine and Medical Science, Dublin, Ireland
| | - Richard Eastell
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
| | - Yasuo Imanishi
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Erik A Imel
- Department of Medicine and Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Steven W Ing
- Division of Endocrinology, Diabetes, and Metabolism, Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Karl Insogna
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Nobuaki Ito
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, Japan
| | - Kassim Javaid
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, National Institute for Health Research Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Peter Kamenicky
- Endocrine Physiology and Pathophysiology, INSERM, Paris-Saclay University, and Bicêtre Hospital, Paris, France
| | - Richard Keen
- Metabolic Bone Disease Unit, Royal National Orthopaedic Hospital NHS Trust, London, UK
| | - Takuo Kubota
- Department of Pediatrics, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Robin H Lachmann
- Charles Dent Metabolic Unit, National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, London, UK
| | - Farzana Perwad
- Division of Nephrology, Department of Pediatrics, University of California San Francisco, San Francisco, USA
| | - Pisit Pitukcheewanont
- Department of Pediatric Endocrinology, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, USA
| | - Anthony Portale
- Division of Nephrology, Department of Pediatrics, University of California San Francisco, San Francisco, USA
| | - Stuart H Ralston
- Rheumatology and Bone Diseases Unit, Medical Research Council Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, UK
| | - Hiroyuki Tanaka
- Department of Pediatrics, Okayama Saiseikai General Hospital, Okayama, Japan
| | - Thomas J Weber
- Division of Endocrinology, Metabolism and Nutrition, Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Han-Wook Yoo
- Department of Pediatrics, Asan Medical Center Children's Hospital, Seoul, Republic of Korea
| | - Wei Sun
- Biostatistics Department, Kyowa Kirin Pharmaceutical Development, Inc., Princeton, NJ, USA
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Abstract
CONTEXT Autosomal recessive hypophosphatemic rickets (ARHR) are rare, heritable renal phosphate-wasting disorders that arise from overexpression of the bone-derived phosphaturic hormone fibroblast growth factor 23 (FGF23) leading to impaired bone mineralization (rickets and osteomalacia). Inactivating mutations of Dentin matrix protein 1 (DMP1) give rise to ARHR type 1 (ARHR1). Short stature, prominent bowing of the legs, fractures/pseudofractures, and severe enthesopathy are prominent in this patient population. Traditionally, treatment consists of oral phosphate replacement and the addition of calcitriol but this approach is limited by modest efficacy and potential renal and gastrointestinal side effects. OBJECTIVE The advent of burosumab (Crysvita), a fully humanized monoclonal antibody to FGF23 for the treatment of X-linked hypophosphatemia and tumor-induced osteomalacia, offers a unique opportunity to evaluate its safety and efficacy in patients with ARHR1. RESULTS Monthly administration of burosumab to 2 brothers afflicted with the disorder resulted in normalization of serum phosphate, healing of pseudofracture, diminished fatigue, less bone pain, and reduced incapacity arising from the extensive enthesopathy and soft tissue fibrosis/calcification that characterizes this disorder. No adverse effects were reported following burosumab administration. CONCLUSION The present report highlights the beneficial biochemical and clinical outcomes associated with the use of burosumab in patients with ARHR1.
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Affiliation(s)
- Xiuying Bai
- Lady Davis Institute for Medical Research, CIUSSS de Centre-Ouest-de-l’île-de-Montréal, Jewish General Hospital, McGill University, Montréal, Quebec, H3T 1E2, Canada
| | - Mark Levental
- Department of Radiology, CIUSSS de Centre-Ouest-de-l’île-de-Montréal, Jewish General Hospital, McGill University, Montréal, Quebec, H3T 1E2, Canada
| | - Andrew C Karaplis
- Correspondence: Andrew C. Karaplis, MD, PhD, Lady Davis Institute for Medical Research, 3755 Cote Steve Catherine, Montreal, QC, H3T 1E2, Canada.
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Arcidiacono T, Foligno N, Vezzoli G. Efficacy of burosumab in healing a long-standing femoral fracture in an adult patient with X-linked hypophosphatemic rickets. Endocrine 2022; 77:566-567. [PMID: 35633487 DOI: 10.1007/s12020-022-03092-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 05/19/2022] [Indexed: 11/03/2022]
Affiliation(s)
- Teresa Arcidiacono
- IRCCS San Raffaele Scientific Institute, Vita Salute San Raffaele University, 20132, Milan, Italy
| | - Nadia Foligno
- IRCCS San Raffaele Scientific Institute, Vita Salute San Raffaele University, 20132, Milan, Italy
| | - Giuseppe Vezzoli
- IRCCS San Raffaele Scientific Institute, Vita Salute San Raffaele University, 20132, Milan, Italy.
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González-Lamuño D, Lorente Rodríguez A, Luis Yanes MI, Marín-Del Barrio S, Martínez Díaz-Guerra G, Peris P. Clinical practice recommendations for the diagnosis and treatment of X-linked hypophosphatemia: A consensus based on the ADAPTE method. Med Clin (Barc) 2022; 159:152.e1-152.e12. [PMID: 34953573 DOI: 10.1016/j.medcli.2021.07.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 07/20/2021] [Accepted: 07/21/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND OBJECTIVE The objective of this project was to adapt to our setting following a systematic process based on the ADAPTE method the first clinical practice guidelines on X-linked hypophosphatemia (XLH) that were published in 2019. MATERIALS AND METHODS The adaptation of the guidelines to our application and implementation setting was carried out in three phases -start-up, adaptation, and finalization- by a group of experts involved in the management of patients with XLH. RESULTS Following the original guide, the recommendations agreed by the group that elaborated the guidelines for diagnosis, frequency and scope of visits and specific follow-up in children and adults are presented. On the other hand, recommendations are established for both age groups with conventional treatment, as well as with burosumab in children or adults and those related to the controversial use of growth hormone in children. Suggestions are also proposed regarding the monitoring and management of musculoskeletal disorders and orthopedic treatment in children, dental health and hearing, and neurosurgical complications. Finally, a series of questions and areas are raised in order to deepen the possible future investigation. CONCLUSIONS These recommendations constitute the systematic adaptation to our setting of the first evidence-based clinical practice guide for the diagnosis and management of XLH and we hope that they can contribute to the adequate management of the disease.
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Affiliation(s)
- Domingo González-Lamuño
- Departamento de Ciencias Médicas y Quirúrgicas, Universidad de Cantabria-Hospital Universitario Marqués de Valdecilla, Asociación Española para el Estudio de los Errores Congénitos del Metabolismo (AECOM), Santander, Cantabria, España.
| | - Ana Lorente Rodríguez
- servicio de Cirugía Oral y Maxilofacial, Hospital la Vall d'Hebron, Barcelona, España
| | - María Isabel Luis Yanes
- Servicio de Nefrología, Hospital Universitario Nuestra Señora de Candelaria, Asociación Española de Nefrología Pediátrica (AENP), Santa Cruz de Tenerife, Islas Canarias, España
| | - Silvia Marín-Del Barrio
- Servicio de Endocrinología Pediátrica, Hospital Sant Joan de Déu, Sociedad Española de Endocrinología Pediátrica (SEEP), Esplugues de Llobregat, Barcelona, España
| | - Guillermo Martínez Díaz-Guerra
- Servicio de Endocrinología y Nutrición, Hospital Universitario 12 de Octubre, Sociedad Española de Investigación Ósea y Metabolismo Mineral (SEIOMM), Madrid, España
| | - Pilar Peris
- Servicio de Reumatología, Hospital Clinic, Universidad de Barcelona, Sociedad Española de Investigación Ósea y Metabolismo Mineral (SEIOMM), Barcelona, España
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Jurca CM, Iuhas O, Kozma K, Petchesi CD, Zaha DC, Bembea M, Jurca S, Paul C, Jurca AD. Effects of Burosumab Treatment on Two Siblings with X-Linked Hypophosphatemia. Case Report and Literature Review. Genes (Basel) 2022; 13:genes13081392. [PMID: 36011303 PMCID: PMC9407333 DOI: 10.3390/genes13081392] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 08/01/2022] [Accepted: 08/03/2022] [Indexed: 11/16/2022] Open
Abstract
X-linked hypophosphatemia (XLH) or vitamin D-resistant rickets (MIM#307800), is a monogenic disorder with X-linked inheritance. It is caused by mutations present in the Phosphate Regulating Endopeptidase Homolog X-Linked (PHEX) gene responsible for the degradation of the bone-derived hormone fibroblast growth factor 23 (FGF23) into inactive fragments, but the entire mechanism is currently unclear. The inactivation of the gene prevents the degradation of FGF23, causing increased levels of FGF23, which leads to decreased tubular reabsorbtion of phosphorus. Clinical aspects are growth delay, limb deformities, bone pain, osteomalacia, dental anomalies, and enthesopathy. Laboratory evaluation shows hypophosphatemia, elevated alkaline phosphatase (ALP), and normal serum calcium levels, whereas parathormone (PTH) may be normal or increased and FGF23 greatly increased. Conventional treatment consists of administration of oral phosphate and calcitriol. Treatment with Burosumab, a monoclonal antibody that binds to FGF23, reducing its activity, was approved in 2018. Methods. We describe a case of two siblings, a girl and a boy, diagnosed with XLH, monitored by the Genetic Department of the County Emergency Clinical Hospital since 2019. The clinical picture is suggestive for XLH, both siblings exhibiting short stature, lower limb curvature, bone pain, marked walking weakness, and fatigue. Radiological aspects showed marked deformity of the lower limbs: genu varum in the girl, genu varum and valgum in the boy. Laboratory investigations showed hypophosphathemia, hyperphosphaturia, elevated ALP, normal PTH, and highly increased FGF23 in both. DNA analysis performed on the two siblings revealed a nonsense mutation in exone 5 of the PHEX gene: NM_000444.6(PHEX):c.565C > T (p.Gln189Ter). Results. At the age of 13½ on 7 June 2021, the two children started treatment with Burosumab in therapeutic doses and were monitored clinically and biochemically at regular intervals according to the protocol established by the Endocrinology Commission of the Romanian Health Ministry. Conclusions. The first results of the Burosumab treatment in the two siblings are extremely encouraging and suggest a favorable long-term evolution under this treatment.
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Affiliation(s)
- Claudia Maria Jurca
- Faculty of Medicine and Pharmacy, Department of Preclinical Disciplines, 1 December Sq., University of Oradea, 410081 Oradea, Romania
- Regional Center of Medical Genetics Bihor, County Emergency Clinical Hospital Oradea, Romania, (Part of ERN THACA), 410469 Oradea, Romania
| | - Oana Iuhas
- Regional Center of Medical Genetics Bihor, County Emergency Clinical Hospital Oradea, Romania, (Part of ERN THACA), 410469 Oradea, Romania
| | - Kinga Kozma
- Faculty of Medicine and Pharmacy, Department of Preclinical Disciplines, 1 December Sq., University of Oradea, 410081 Oradea, Romania
- Regional Center of Medical Genetics Bihor, County Emergency Clinical Hospital Oradea, Romania, (Part of ERN THACA), 410469 Oradea, Romania
| | - Codruta Diana Petchesi
- Faculty of Medicine and Pharmacy, Department of Preclinical Disciplines, 1 December Sq., University of Oradea, 410081 Oradea, Romania
- Correspondence:
| | - Dana Carmen Zaha
- Faculty of Medicine and Pharmacy, Department of Preclinical Disciplines, 1 December Sq., University of Oradea, 410081 Oradea, Romania
| | - Marius Bembea
- Faculty of Medicine and Pharmacy, Department of Preclinical Disciplines, 1 December Sq., University of Oradea, 410081 Oradea, Romania
| | - Sanziana Jurca
- Faculty of Medicine and Pharmacy, Department of Preclinical Disciplines, 1 December Sq., University of Oradea, 410081 Oradea, Romania
| | - Corina Paul
- Department of Pediatrics, Victor Babes University of Medicine and Pharmacy, 300041 Timisoara, Romania
| | - Alexandru Daniel Jurca
- Faculty of Medicine and Pharmacy, Department of Preclinical Disciplines, 1 December Sq., University of Oradea, 410081 Oradea, Romania
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Ward LM, Glorieux FH, Whyte MP, Munns CF, Portale AA, Högler W, Simmons JH, Gottesman GS, Padidela R, Namba N, Cheong HI, Nilsson O, Mao M, Chen A, Skrinar A, Roberts MS, Imel EA. Effect of Burosumab Compared With Conventional Therapy on Younger vs Older Children With X-linked Hypophosphatemia. J Clin Endocrinol Metab 2022; 107:e3241-e3253. [PMID: 35533340 PMCID: PMC9282253 DOI: 10.1210/clinem/dgac296] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Indexed: 11/19/2022]
Abstract
CONTEXT Younger age at treatment onset with conventional therapy (phosphate salts and active vitamin D; Pi/D) is associated with improved growth and skeletal outcomes in children with X-linked hypophosphatemia (XLH). The effect of age on burosumab efficacy and safety in XLH is unknown. OBJECTIVE This work aimed to explore the efficacy and safety of burosumab vs Pi/D in younger (< 5 years) and older (5-12 years) children with XLH. METHODS This post hoc analysis of a 64-week, open-label, randomized controlled study took place at 16 academic centers. Sixty-one children aged 1 to 12 years with XLH (younger, n = 26; older, n = 35) participated. Children received burosumab starting at 0.8 mg/kg every 2 weeks (younger, n = 14; older, n = 15) or continued Pi/D individually titrated per recommended guidelines (younger, n = 12; older, n = 20). The main outcome measure included the least squares means difference (LSMD) in Radiographic Global Impression of Change (RGI-C) rickets total score from baseline to week 64. RESULTS The LSMD in outcomes through 64 weeks on burosumab vs conventional therapy by age group were as follows: RGI-C rickets total score (younger, +0.90; older, +1.07), total Rickets Severity Score (younger, -0.86; older, -1.44), RGI-C lower limb deformity score (younger, +1.02; older, +0.91), recumbent length or standing height Z-score (younger, +0.20; older, +0.09), and serum alkaline phosphatase (ALP) (younger, -31.15% of upper normal limit [ULN]; older, -52.11% of ULN). On burosumab, dental abscesses were not reported in younger children but were in 53% of older children. CONCLUSION Burosumab appears to improve outcomes both in younger and older children with XLH, including rickets, lower limb deformities, growth, and ALP, compared with Pi/D.
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Affiliation(s)
- Leanne M Ward
- Correspondence: Leanne M. Ward, MD, Pediatrics, University of Ottawa, Ottawa, Ontario, Canada, Rm 250H, 401 Smyth Rd, Ottawa, Ontario, K1H 8L1, Canada.
| | - Francis H Glorieux
- Shriners Hospitals for Children, Canada, McGill University, Montreal, Quebec H4A OA9, Canada
| | - Michael P Whyte
- Shriners Hospitals for Children St Louis, St Louis, Missouri 63110,USA
| | - Craig F Munns
- Child Health Research Centre, The University of Queensland, Brisbane, Queensland 4072, Australia
- Department of Endocrinology and Diabetes, Queensland Children’s Hospital, Brisbane, Queensland 4101, Australia
| | - Anthony A Portale
- Department of Pediatrics, University of California, San Francisco, San Francisco, California 94143, USA
| | - Wolfgang Högler
- Department of Pediatrics and Adolescent Medicine, Johannes Kepler University Linz, Linz 4040, Austria
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, B15 2TT, UK
| | - Jill H Simmons
- Department of Pediatrics, Division of Endocrinology and Diabetes, Vanderbilt University School of Medicine, Vanderbilt University, 680-8570 Nashville, Tennessee, 63110, USA
| | - Gary S Gottesman
- Shriners Hospitals for Children St Louis, St Louis, Missouri 63110, USA
| | - Raja Padidela
- Department of Paediatric Endocrinology, Royal Manchester Children’s Hospital, Manchester M13 9WL, UK
| | - Noriyuki Namba
- Department of Pediatrics, Osaka Hospital, Japan
- Community Healthcare Organization
- Osaka University Graduate School of Medicine, Osaka 553-0003, Japan
- Division of Pediatrics and Perinatology, Tottori University Faculty of Medicine, Yonago, Japan
| | - Hae Il Cheong
- Department of Pediatrics, Seoul National University Children’s Hospital, Seoul 14068, South Korea
| | - Ola Nilsson
- Division of Pediatric Endocrinology and Center for Molecular Medicine, Karolinska Institutet, Stockholm 17177, Sweden
- School of Medical Sciences, Department of Pediatrics, Örebro University and University Hospital, Örebro S-703 62, Sweden
| | - Meng Mao
- Ultragenyx Pharmaceutical Inc, Novato, California 94949, USA
| | - Angel Chen
- Ultragenyx Pharmaceutical Inc, Novato, California 94949, USA
| | - Alison Skrinar
- Ultragenyx Pharmaceutical Inc, Novato, California 94949, USA
| | | | - Erik A Imel
- Department of Medicine and Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indianapolis 46202, USA
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Jin C, Zhang C, Ni X, Zhao Z, Xu L, Wu B, Chi Y, Jiajue R, Jiang Y, Wang O, Li M, Xing X, Meng X, Xia W. The efficacy and safety of different doses of calcitriol combined with neutral phosphate in X-linked hypophosphatemia: a prospective study. Osteoporos Int 2022; 33:1385-1395. [PMID: 35088103 PMCID: PMC9106624 DOI: 10.1007/s00198-021-06221-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 10/19/2021] [Indexed: 11/03/2022]
Abstract
UNLABELLED The present study was the first prospective cohort evaluated the efficacy and safety of different doses of calcitriol in XLH children. The results suggested that a dose of 40 ng/kg/day calcitriol, compared with 20 ng/kg/day, was more effective in relieving the rickets, with similar safety outcomes. Further investigations were expected to set more dose groups. INTRODUCTION Dose recommended for calcitriol in X-linked hypophosphatemia (XLH) varies in different studies. Therefore, we aimed to compare the efficacy as well as the safety of 20 ng/kg/d and 40 ng/kg/d calcitriol in Chinese XLH pediatrics population. METHODS A 2-year, randomized, open-label, prospective study recruited 68 XLH children, which were randomized to receive either 40 ng/kg/day or 20 ng/kg/day calcitriol. Efficacy endpoints were the total Thacher ricket severity score (RSS) change from baseline to month 12 and 24, the difference in serum TALP level, fasting serum phosphate level, body height Z-score, and frequency of dental abscess. Safety assessments were done using renal ultrasound nephrocalcinosis grades (0-4), fasting serum and 24 h urine calcium level, and the occurrence of hyperparathyroidism. RESULTS The decrease in the total RSS from baseline was more significant in the high-dose group at 12 (difference 0.87, p = 0.049) and 24 month (difference 1.23, p = 0.011). The serum TALP level was significantly lower in the high-dose group at 6 months. Pi level, height Z-score change, frequency of dental abscess and ratio of de novo nephrocalcinosis were comparable. A lower incidence of secondary hyperparathyroidism was seen in the high-dose group (p < 0.0001). CONCLUSION For the first time in this prospective cohort, 40 ng/kg/d calcitriol was shown to be the more effective therapy in XLH children than the 20 ng/kg/d. Moreover, 40 ng/kg/d calcitriol was not associated with increasing adverse events. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT 03,820,518.
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Affiliation(s)
- C Jin
- Department of Endocrinology, Key Laboratory of Endocrinology, NHC, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Shuaifuyuan No. 1, Dongcheng District, Beijing, 100730, China
| | - C Zhang
- Department of Endocrinology, Key Laboratory of Endocrinology, NHC, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Shuaifuyuan No. 1, Dongcheng District, Beijing, 100730, China
| | - X Ni
- Department of Endocrinology, Key Laboratory of Endocrinology, NHC, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Shuaifuyuan No. 1, Dongcheng District, Beijing, 100730, China
| | - Z Zhao
- Department of Endocrinology, Key Laboratory of Endocrinology, NHC, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Shuaifuyuan No. 1, Dongcheng District, Beijing, 100730, China
| | - L Xu
- Department of Endocrinology, Key Laboratory of Endocrinology, NHC, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Shuaifuyuan No. 1, Dongcheng District, Beijing, 100730, China
| | - B Wu
- Department of Endocrinology, Key Laboratory of Endocrinology, NHC, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Shuaifuyuan No. 1, Dongcheng District, Beijing, 100730, China
| | - Y Chi
- Department of Endocrinology, Key Laboratory of Endocrinology, NHC, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Shuaifuyuan No. 1, Dongcheng District, Beijing, 100730, China
| | - R Jiajue
- Department of Endocrinology, Key Laboratory of Endocrinology, NHC, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Shuaifuyuan No. 1, Dongcheng District, Beijing, 100730, China
| | - Y Jiang
- Department of Endocrinology, Key Laboratory of Endocrinology, NHC, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Shuaifuyuan No. 1, Dongcheng District, Beijing, 100730, China
| | - O Wang
- Department of Endocrinology, Key Laboratory of Endocrinology, NHC, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Shuaifuyuan No. 1, Dongcheng District, Beijing, 100730, China
| | - Mei Li
- Department of Endocrinology, Key Laboratory of Endocrinology, NHC, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Shuaifuyuan No. 1, Dongcheng District, Beijing, 100730, China
| | - X Xing
- Department of Endocrinology, Key Laboratory of Endocrinology, NHC, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Shuaifuyuan No. 1, Dongcheng District, Beijing, 100730, China
| | - X Meng
- Department of Endocrinology, Key Laboratory of Endocrinology, NHC, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Shuaifuyuan No. 1, Dongcheng District, Beijing, 100730, China
| | - W Xia
- Department of Endocrinology, Key Laboratory of Endocrinology, NHC, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Shuaifuyuan No. 1, Dongcheng District, Beijing, 100730, China.
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Trombetti A, Al-Daghri N, Brandi ML, Cannata-Andía JB, Cavalier E, Chandran M, Chaussain C, Cipullo L, Cooper C, Haffner D, Harvengt P, Harvey NC, Javaid MK, Jiwa F, Kanis JA, Laslop A, Laurent MR, Linglart A, Marques A, Mindler GT, Minisola S, Yerro MCP, Rosa MM, Seefried L, Vlaskovska M, Zanchetta MB, Rizzoli R. Interdisciplinary management of FGF23-related phosphate wasting syndromes: a Consensus Statement on the evaluation, diagnosis and care of patients with X-linked hypophosphataemia. Nat Rev Endocrinol 2022; 18:366-384. [PMID: 35484227 DOI: 10.1038/s41574-022-00662-x] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/10/2022] [Indexed: 12/17/2022]
Abstract
X-linked hypophosphataemia (XLH) is the most frequent cause of hypophosphataemia-associated rickets of genetic origin and is associated with high levels of the phosphaturic hormone fibroblast growth factor 23 (FGF23). In addition to rickets and osteomalacia, patients with XLH have a heavy disease burden with enthesopathies, osteoarthritis, pseudofractures and dental complications, all of which contribute to reduced quality of life. This Consensus Statement presents the outcomes of a working group of the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases, and provides robust clinical evidence on management in XLH, with an emphasis on patients' experiences and needs. During growth, conventional treatment with phosphate supplements and active vitamin D metabolites (such as calcitriol) improves growth, ameliorates leg deformities and dental manifestations, and reduces pain. The continuation of conventional treatment in symptom-free adults is still debated. A novel therapeutic approach is the monoclonal anti-FGF23 antibody burosumab. Although promising, further studies are required to clarify its long-term efficacy, particularly in adults. Given the diversity of symptoms and complications, an interdisciplinary approach to management is of paramount importance. The focus of treatment should be not only on the physical manifestations and challenges associated with XLH and other FGF23-mediated hypophosphataemia syndromes, but also on the major psychological and social impact of the disease.
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Affiliation(s)
- Andrea Trombetti
- Division of Bone Diseases, Department of Medicine, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
- Division of Geriatrics, Department of Rehabilitation and Geriatrics, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Nasser Al-Daghri
- Chair for Biomarkers of Chronic Diseases, Biochemistry Department, College of Science, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | | | - Jorge B Cannata-Andía
- Hospital Universitario Central de Asturias (HUCA), Oviedo, Spain
- Universidad de Oviedo, Oviedo, Spain
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain
- Retic REDinREN-RICORS, 2040-ISCIII, Madrid, Spain
| | - Etienne Cavalier
- Department of Clinical Chemistry, University of Liege, CHU de Liège, Liège, Belgium
| | - Manju Chandran
- Complicated Metabolic Bone Disorders Clinic, Osteoporosis and Bone Metabolism Unit, Department of Endocrinology, Singapore General Hospital, Singapore, Singapore
| | - Catherine Chaussain
- Université de Paris, Institut des maladies musculo-squelettiques, URP2496, UFR Odontologie, Montrouge, France
- AP-HP, FHU DDS-Net, Centre de Référence des Maladies Rares du Métabolisme du Calcium et du Phosphore, Service médecine bucco-dentaire, Hôpital Bretonneau, GH Paris Nord Université de Paris, Paris, France
| | - Lucia Cipullo
- Patient representative with XLH, Geneva, Switzerland
| | - Cyrus Cooper
- MRC Lifecourse Epidemiology Centre, University of Southampton, Southampton, UK
- NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK
- NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Dieter Haffner
- Department of Paediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
| | - Pol Harvengt
- XLH Belgium, Belgian association of patients with XLH (a member of the International XLH Alliance), Waterloo, Belgium
| | - Nicholas C Harvey
- MRC Lifecourse Epidemiology Centre, University of Southampton, Southampton, UK
- NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | | | - Famida Jiwa
- Chair of the Committee of Patients Societies at the International Osteoporosis Foundation, Osteoporosis Canada, Toronto, Canada
| | - John A Kanis
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Sheffield, UK
| | - Andrea Laslop
- Scientific Office, Federal Office for Safety in Health Care, Vienna, Austria
| | - Michaël R Laurent
- Centre for Metabolic Bone Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Agnès Linglart
- Paris-Saclay University, INSERM U1185, Le Kremlin-Bicêtre, France
- AP-HP, endocrinology and diabetes for children, Reference centre for rare diseases of calcium and phosphate metabolism, OSCAR network, Platform of expertise for rare diseases of Paris Saclay Hospital, Bicêtre Paris Saclay Hospital, Le Kremlin-Bicêtre, France
| | - Andréa Marques
- Rheumatology Department, Centro Hospitalar Universitário de Coimbra, Coimbra, Portugal
- Health Sciences Research Unit: Nursing (UICiSA:E), Nursing School of Coimbra, Coimbra, Portugal
| | - Gabriel T Mindler
- Department of Paediatric Orthopaedics, Orthopaedic Hospital Speising, Vienna, Austria
- Vienna Bone and Growth Center, Vienna, Austria
| | - Salvatore Minisola
- Department of Clinical, Internal, Anaesthesiologic and Cardiovascular Sciences, 'Sapienza', Rome University, Rome, Italy
| | | | - Mario Miguel Rosa
- Departamento de Neurociências, Laboratório de Farmacologia Clínica E Terapêutica Faculdade de Medicina da Universidade de Lisboa, Lisbon, Portugal
| | - Lothar Seefried
- Orthopedic Department, University of Würzburg, Würzburg, Germany
| | - Mila Vlaskovska
- Medical Faculty, Department of Pharmacology, Medical University Sofia, Sofia, Bulgaria
| | - María Belén Zanchetta
- Instituto de Investigaciones Metabólicas (IDIM), Universidad del Salvador, Buenos Aires, Argentina
| | - René Rizzoli
- Division of Bone Diseases, Department of Medicine, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland.
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Jazbinšek S, Koce M, Kotnik P. Novel Treatment Options in Childhood Bone Diseases. Horm Res Paediatr 2022; 96:590-598. [PMID: 35235937 DOI: 10.1159/000523868] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 02/17/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Several novel treatment options have recently become available in childhood bone diseases. The purpose of this article is to provide an update on some of the therapeutic agents used in the treatment of pediatric osteoporosis, X-linked hypophosphatemic rickets, and achondroplasia (ACH). SUMMARY Vitamin D3 and Ca supplementation remains the basis of childhood osteoporosis treatment. Bisphosphonate (BP) therapy is the main antiresorptive therapeutic option, while denosumab, a human monoclonal IgG2 antibody with high affinity and specificity for a primary regulator of bone resorption - RANKL, represents a possible alternative. Its potent inhibition of bone resorption and turnover process leads to continuous increase of bone mineral density throughout the treatment also in the pediatric population. With a half-life much shorter than BPs, its effects are rapidly reversible upon discontinuation. Safety and dosing concerns in children remain. Novel treatment options have recently become available in two rare bone diseases. Burosumab, a monoclonal antibody against FGF-23, has been approved for the treatment of children with X-linked hypophosphatemic rickets older than 1 year. It presents an effective, more etiology-based treatment for rickets compared to conventional therapy, without the need for multiple daily oral phosphate supplementation. Its long-term efficacy and safety are currently being investigated. After years of anticipation, a novel treatment option for ACH has become available. C-type natriuretic peptide analog vosoritide effectively increases proportional growth and has a reasonable safety profile in children >2 years. Its effect on other features of the disease and the final height is yet to be determined. Several other treatment options for ACH exploring different therapeutic approaches are currently being investigated. KEY MESSAGES Denosumab is effective in the treatment of childhood-onset osteoporosis; however, further studies are necessary to determine the optimal treatment protocol. Burosumab is more etiology-based and convenient in comparison to conventional treatment of X-linked hypophospha--temic rickets in children and adults. Vosoritide importantly changes the natural course of achondroplasia, at least in the short term.
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Affiliation(s)
- Sončka Jazbinšek
- Division of Pediatrics, Department of Pediatric Endocrinology, Diabetes and Metabolism, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Maša Koce
- Division of Pediatrics, Department of Pediatric Endocrinology, Diabetes and Metabolism, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Primož Kotnik
- Division of Pediatrics, Department of Pediatric Endocrinology, Diabetes and Metabolism, University Medical Centre Ljubljana, Ljubljana, Slovenia
- Division of Pediatrics, Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
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Linglart A, Imel EA, Whyte MP, Portale AA, Högler W, Boot AM, Padidela R, van’t Hoff W, Gottesman GS, Chen A, Skrinar A, Scott Roberts M, Carpenter TO. Sustained Efficacy and Safety of Burosumab, a Monoclonal Antibody to FGF23, in Children With X-Linked Hypophosphatemia. J Clin Endocrinol Metab 2022; 107:813-824. [PMID: 34636899 PMCID: PMC8851952 DOI: 10.1210/clinem/dgab729] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Indexed: 11/19/2022]
Abstract
PURPOSE In X-linked hypophosphatemia (XLH), excess fibroblast growth factor-23 causes hypophosphatemia and low calcitriol, leading to musculoskeletal disease with clinical consequences. XLH treatment options include conventional oral phosphate with active vitamin D, or monotherapy with burosumab, a monoclonal antibody approved to treat children and adults with XLH. We have previously reported outcomes up to 64 weeks, and here we report safety and efficacy follow-up results up to 160 weeks from an open-label, multicenter, randomized, dose-finding trial of burosumab for 5- to 12-year-old children with XLH. METHODS After 1 week of conventional therapy washout, patients were randomized 1:1 to burosumab every 2 weeks (Q2W) or every 4 weeks (Q4W) for 64 weeks, with dosing titrated based on fasting serum phosphorus levels between baseline and week 16. From week 66 to week 160, all patients received Q2W burosumab. RESULTS Twenty-six children were randomized initially into each Q2W and Q4W group and all completed treatment to week 160. In 41 children with open distal femoral and proximal tibial growth plates (from both treatment groups), total Rickets Severity Score significantly decreased by 0.9 ± 0.1 (least squares mean ± SE; P < 0.0001) from baseline to week 160. Fasting serum phosphorus increases were sustained by burosumab therapy throughout the study, with an overall population mean (SD) of 3.35 (0.39) mg/dL, within the pediatric normal range (3.2-6.1 mg/dL) at week 160 (mean change from baseline P < 0.0001). Most adverse events were mild to moderate in severity. MAIN CONCLUSIONS In children with XLH, burosumab administration for 160 weeks improved phosphate homeostasis and rickets and was well-tolerated. Long-term safety was consistent with the reported safety profile of burosumab. CLINICALTRIALS.GOV NCT02163577.
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Affiliation(s)
- Agnès Linglart
- AP-HP, Endocrinology and Diabetes for Children, Reference Center for Rare Disorders of the Calcium and Phosphate Metabolism, and Filière OSCAR, Bicêtre Paris Saclay Hospital, Le Kremlin-Bicêtre, France
- Paris-Saclay University, INSERM 1189, Le Kremlin-Bicêtre, France
- Correspondence: Agnès Linglart, 78, rue du Général Leclerc, 94270 Le Kremlin Bicêtre, France.
| | - Erik A Imel
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Michael P Whyte
- Shriners Hospitals for Children – St. Louis, MO, USA
- Division of Bone and Mineral Diseases, Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | | | - Wolfgang Högler
- Johannes Kepler University Linz, Linz, Austria
- University of Birmingham, Birmingham, UK
| | - Annemieke M Boot
- University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Raja Padidela
- Royal Manchester Children’s Hospital and Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | | | | | - Angel Chen
- Ultragenyx Pharmaceutical Inc., Novato, CA, USA
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Fuente R, García-Bengoa M, Fernández-Iglesias Á, Gil-Peña H, Santos F, López JM. Cellular and Molecular Alterations Underlying Abnormal Bone Growth in X-Linked Hypophosphatemia. Int J Mol Sci 2022; 23:ijms23020934. [PMID: 35055123 PMCID: PMC8778463 DOI: 10.3390/ijms23020934] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 01/12/2022] [Accepted: 01/13/2022] [Indexed: 12/21/2022] Open
Abstract
X-linked hypophosphatemia (XLH), the most common form of hereditary hypophosphatemic rickets, is caused by inactivating mutations of the phosphate-regulating endopeptidase gene (PHEX). XLH is mainly characterized by short stature, bone deformities and rickets, while in hypophosphatemia, normal or low vitamin D levels and low renal phosphate reabsorption are the principal biochemical aspects. The cause of growth impairment in patients with XLH is not completely understood yet, thus making the study of the growth plate (GP) alterations necessary. New treatment strategies targeting FGF23 have shown promising results in normalizing the growth velocity and improving the skeletal effects of XLH patients. However, further studies are necessary to evaluate how this treatment affects the GP as well as its long-term effects and the impact on adult height.
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Affiliation(s)
- Rocío Fuente
- Division of Pediatrics, Department of Medicine, Faculty of Medicine, University of Oviedo, 33006 Oviedo, Spain; (R.F.); (M.G.-B.); (Á.F.-I.); (H.G.-P.); (F.S.)
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Spain
- Institute of Physiology, Center for Integrative Human Physiology (ZIHP), University of Zurich, Winterthurerstrasse 190, CH-8057 Zurich, Switzerland
| | - María García-Bengoa
- Division of Pediatrics, Department of Medicine, Faculty of Medicine, University of Oviedo, 33006 Oviedo, Spain; (R.F.); (M.G.-B.); (Á.F.-I.); (H.G.-P.); (F.S.)
- Research Center for Emerging Infections and Zoonoses (RIZ), University of Veterinary Medicine Hannover, 30559 Hanover, Germany
| | - Ángela Fernández-Iglesias
- Division of Pediatrics, Department of Medicine, Faculty of Medicine, University of Oviedo, 33006 Oviedo, Spain; (R.F.); (M.G.-B.); (Á.F.-I.); (H.G.-P.); (F.S.)
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Spain
| | - Helena Gil-Peña
- Division of Pediatrics, Department of Medicine, Faculty of Medicine, University of Oviedo, 33006 Oviedo, Spain; (R.F.); (M.G.-B.); (Á.F.-I.); (H.G.-P.); (F.S.)
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Spain
- Department of Pediatrics, Hospital Universitario Central de Asturias (HUCA), 33011 Oviedo, Spain
| | - Fernando Santos
- Division of Pediatrics, Department of Medicine, Faculty of Medicine, University of Oviedo, 33006 Oviedo, Spain; (R.F.); (M.G.-B.); (Á.F.-I.); (H.G.-P.); (F.S.)
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Spain
- Department of Pediatrics, Hospital Universitario Central de Asturias (HUCA), 33011 Oviedo, Spain
| | - José Manuel López
- Department of Morphology and Cellular Biology, Faculty of Medicine, University of Oviedo, 33006 Oviedo, Spain
- Correspondence:
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Merz LM, Buerger F, Ziegelasch N, Zenker M, Wieland I, Lipek T, Wallborn T, Terliesner N, Prenzel F, Siekmeyer M, Dittrich K. A Case Report: First Long-Term Treatment With Burosumab in a Patient With Cutaneous-Skeletal Hypophosphatemia Syndrome. Front Endocrinol (Lausanne) 2022; 13:866831. [PMID: 35600592 PMCID: PMC9120998 DOI: 10.3389/fendo.2022.866831] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 03/18/2022] [Indexed: 11/28/2022] Open
Abstract
Epidermal nevus syndromes encompass a highly heterogeneous group of systemic disorders, characterized by epidermal nevi, and a spectrum of neuromuscular, ocular, and bone abnormalities. Cutaneous-skeletal hypophosphatemia syndrome (CSHS) constitutes a specific sub-entity in which elevated levels of fibroblast growth factor-23 cause hypophosphatemic rickets that are, to date, not amenable to causal therapy. Here, we report the first long-term follow-up of causal treatment with burosumab in a 3-year-old female patient with CSHS. 4 weeks after initiation of burosumab treatment, serum phosphate normalized to age-appropriate levels. Furthermore, long-term follow-up of 42 months revealed significant improvement of linear growth and gross physical functions, including respiratory insufficiency. Radiographic rickets severity as well as subjective bone pain were strongly reduced, and no side effects were observed over the course of treatment. In summary, we, here, report about a successful treatment of hypophosphatemic rickets in CSHS with burosumab over the time course of 42 months. In our patient, burosumab showed convincing efficacy and safety profile, without any loss of effect or increase of dose.
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Affiliation(s)
- Lea Maria Merz
- Department of Pediatric Nephrology and Pulmonology, University Hospital Leipzig, Leipzig, Germany
- *Correspondence: Lea Maria Merz,
| | - Florian Buerger
- Boston Children’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Niels Ziegelasch
- Department of Pediatric Nephrology and Pulmonology, University Hospital Leipzig, Leipzig, Germany
| | - Martin Zenker
- Faculty of Medicine, University Hospital Magdeburg, Magdeburg, Germany
| | - Ilse Wieland
- Faculty of Medicine, University Hospital Magdeburg, Magdeburg, Germany
| | - Tobias Lipek
- Department of Pediatric Nephrology and Pulmonology, University Hospital Leipzig, Leipzig, Germany
| | - Tillmann Wallborn
- Department of Pediatric Nephrology, St. Georg Hospital, Leipzig, Germany
| | - Nicolas Terliesner
- Department of Pediatric Nephrology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Freerk Prenzel
- Department of Pediatric Nephrology and Pulmonology, University Hospital Leipzig, Leipzig, Germany
| | - Manuela Siekmeyer
- Department of Pediatric Nephrology and Pulmonology, University Hospital Leipzig, Leipzig, Germany
| | - Katalin Dittrich
- Department of Pediatric Nephrology and Pulmonology, University Hospital Leipzig, Leipzig, Germany
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Mughal MZ, Baroncelli GI, de Lucas-Collantes C, Linglart A, Magnolato A, Raimann A, Santos F, Schnabel D, Shaw N, Nilsson O. Burosumab for X-linked hypophosphatemia in children and adolescents: Opinion based on early experience in seven European countries. Front Endocrinol (Lausanne) 2022; 13:1034580. [PMID: 36798486 PMCID: PMC9928183 DOI: 10.3389/fendo.2022.1034580] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 11/11/2022] [Indexed: 02/03/2023] Open
Abstract
Given the relatively recent introduction of burosumab in the management of X-linked hypophosphatemia (XLH), there is limited real-world data to guide its use in clinical practice. As a group of European physicians experienced with burosumab treatment in clinical practice, we convened with the objective of sharing these practice-based insights on the use of burosumab in children and adolescents with XLH. We attended two virtual meetings, then discussed key questions via Within3, a virtual online platform. Points of discussion related to patient selection criteria, burosumab starting dose, dose titration and treatment monitoring. Our discussions revealed that criteria for selecting children with XLH varied across Europe from all children above 1 year to only children with overt rickets despite conventional treatment being eligible. We initiated burosumab dosing according to guidance in the Summary of Product Characteristics, an international consensus statement from 2019 and local country guidelines. Dose titration was primarily guided by serum phosphate levels, with some centers also using the ratio of tubular maximum reabsorption of phosphate to glomerular filtration rate (TmP/GFR). We monitored response to burosumab treatment clinically (growth, deformities, bone pain and physical functioning), radiologically (rickets and deformities) and biochemically (serum phosphate, alkaline phosphatase, 1,25-dihydroxyvitamin D, 25-hydroxyvitamin D, urine calcium-creatinine ratio and TmP/GFR). Key suggestions made by our group were initiation of burosumab treatment in children as early as possible, from the age of 1 year, particularly in those with profound rickets, and a need for clinical studies on continuation of burosumab throughout adolescence and into adulthood.
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Affiliation(s)
- M. Zulf Mughal
- Department of Paediatric Endocrinology and Metabolic Bone Diseases, Royal Manchester Children’s Hospital, Manchester, United Kingdom
- The Faculty of Biology, Medicine, and Health, University of Manchester, Manchester, United Kingdom
- *Correspondence: M. Zulf Mughal,
| | - Giampiero I. Baroncelli
- Division of Pediatrics, Endocrine Unit, ERN-BOND Representative, Department of Obstetrics, Gynecology and Pediatrics, University-Hospital, Pisa, Italy
| | - Carmen de Lucas-Collantes
- Servicio Nefrología, Hospital Infantil Universitario Niño Jesús, Universidad Autónoma de Madrid, Madrid, Spain
| | - Agnès Linglart
- AP-HP, Endocrinology and Diabetes for Children, Reference Center for Rare Disorders of Calcium and Phosphate Metabolism, Filière OSCAR, Bicêtre Paris Saclay Hospital, Paris, France
- Platform of Expertise for Rare Disorders, INSERM, Physiologie et Physiopathologie Endocriniennes, Paris Saclay University, Paris, France
| | - Andrea Magnolato
- Department of Pediatrics, Institute for Maternal and Child Health – IRCCS “Burlo Garofolo”, Trieste, Italy
| | - Adalbert Raimann
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Pulmonology, Allergology and Endocrinology, Medical University of Vienna, Vienna, Austria
- Vienna Bone and Growth Center, Vienna, Austria
| | - Fernando Santos
- Hospital Universitario Central de Asturias (HUCA), University of Oviedo, Oviedo, Spain
| | - Dirk Schnabel
- Center for Chronic Sick Children, Pediatric Endocrinology, Charitè, University Medicine, Berlin, Germany
| | - Nick Shaw
- Department of Endocrinology and Diabetes, Birmingham Women’s and Children’s NHS Foundation Trust, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom
| | - Ola Nilsson
- Division of Pediatric Endocrinology, Department of Women’s and Children’s Health , Karolinska Institutet and University Hospital, Stockholm, Sweden
- School of Medical Sciences, Department of Pediatrics, Örebro University and University Hospital, Örebro, Sweden
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Brener R, Zeitlin L, Lebenthal Y, Brener A. Dental health of pediatric patients with X-linked hypophosphatemia (XLH) after three years of burosumab therapy. Front Endocrinol (Lausanne) 2022; 13:947814. [PMID: 36051396 PMCID: PMC9425915 DOI: 10.3389/fendo.2022.947814] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 07/18/2022] [Indexed: 11/13/2022] Open
Abstract
An inactivating PHEX gene mutation with the resultant accumulation of several mineralization-inhibiting proteins (e.g., FGF23) causes skeletal and dental morbidity in X-linked hypophosphatemia (XLH). This prospective case-control study explored the effect of burosumab, an anti-FGF23 antibody, on dental health of children with XLH. Ten children (age 4.3-15 years) with XLH underwent burosumab treatment per protocol. Assessment of their dental status at treatment initiation and after 1 and 3 years of treatment included clinical, laboratory and radiographic evaluation of rickets and dentition. Orthopantomographic examinations of ten healthy sex- and age-matched controls were selected for comparison. Coronal and pulp dimensions of a selected permanent mandibular molar were measured with Planmeca Romexis® software. One year of treatment led to improvement of height z-score (p=0.019) and healing of the rickets (p<0.001) in the XLH patients, and those achievements were maintained after three years of treatment. Dental morphology of XLH patients, distinguished by increased pulp-coronal ratios compared to controls (p=0.002), remained larger after the first year of treatment (p<0.001) and did not attain the decrease expected with age after three years of treatment. Five patients had a history of recurrent dental abscesses, with three having undergone at least one episode during the year before burosumab initiation. One patient sustained recurrent abscesses throughout three years of treatment. The persistence of the unique dental morphology of XLH patients undergoing burosumab therapy, as evidenced by excessively larger pulp dimensions, supports the role of other PHEX gene-related local mineralization inhibitors, such as osteopontin, in the pathogenesis of dental morbidity.
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Affiliation(s)
- Rafi Brener
- The Endodontic Unit, Galilee College of Dental Sciences, Galilee Medical Center, Nahariya, Israel
- Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
| | - Leonid Zeitlin
- The Metabolic Bone Disease Unit, Dana-Dwek Children’s Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yael Lebenthal
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- The Pediatric Endocrinology and Diabetes Unit, Dana-Dwek Children’s Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Avivit Brener
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- The Pediatric Endocrinology and Diabetes Unit, Dana-Dwek Children’s Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- *Correspondence: Avivit Brener,
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Mindler GT, Stauffer A, Kranzl A, Penzkofer S, Ganger R, Radler C, Haeusler G, Raimann A. Persistent Lower Limb Deformities Despite Amelioration of Rickets in X-Linked Hypophosphatemia (XLH) - A Prospective Observational Study. Front Endocrinol (Lausanne) 2022; 13:866170. [PMID: 35399930 PMCID: PMC8987359 DOI: 10.3389/fendo.2022.866170] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Accepted: 02/22/2022] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Gait deviations, lower limb pain and joint stiffness represent key symptoms in patients with X-linked hypophosphatemia (XLH, OMIM 307800), a rare disorder of mineral homeostasis. While the pathomechanism for rickets is well understood, the direct role of PHEX (Phosphate-regulating neutral endopeptidase) deficiency in non-rachitic features including complex deformities, skull and dental affections remains unclear. FGF23-inhibiting antibody treatment can normalize serum phosphate levels and to improve rickets in XLH patients. However, linear growth remains impaired and effects on lower limb deformity and gait are insufficiently studied. AIMS To characterize and evaluate the course of lower limb deformity in a case series of pediatric XLH patients receiving Burosumab therapy. METHODS Comparative assessment of planar radiographs, gait analysis, biochemical and clinical features of pediatric patients before and ≥12 months after initiation of FGF23-inhibiting was performed prospectively. Lower limb maltorsion was quantified by torsional MRI and gait analysis. Standardized deformity analysis of lower limb anteroposterior radiographs was conducted. RESULTS Seven patients (age 9.0 +/-3.6 years) were eligible for this study. All patients received conventional treatment before onset of antibody treatment. Maltorsion of the femur was observed in 8/14 legs using torsional MRI (mean antetorsion 8.79°). Maltorsion of the tibia was observed in 9/14 legs (mean external torsion 2.8°). Gait analysis confirmed MRI findings with femoral external malrotation prior to and one year after onset of Burosumab therapy. Internal foot progression (intoeing gait) remained pathological in all cases (mean 2.2°). Knee rotation was pathologically internal 10/14 legs. Mean mechanical axis deviation (MAD) of 16.1mm prior to Burosumab changed in average by 3.9mm. Three children underwent guided growth procedures within the observation period. Mild postprocedural rebound of frontal axis deviation was observed under Burosumab treatment in one patient. CONCLUSIONS This is the first study to investigate lower limb deformity parameters quantitatively in children with XLH receiving Burosumab. One year of Burosumab therapy was associated with persistent maltorsion and frontal axis deviation (varus/valgus) despite improved rickets in this small, prospective uncontrolled study.
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Affiliation(s)
- Gabriel T. Mindler
- Department of Pediatric Orthopaedics, Orthopaedic Hospital Speising, Vienna, Austria
- Vienna Bone and Growth Center, Vienna, Austria
| | - Alexandra Stauffer
- Department of Pediatric Orthopaedics, Orthopaedic Hospital Speising, Vienna, Austria
- Vienna Bone and Growth Center, Vienna, Austria
| | - Andreas Kranzl
- Vienna Bone and Growth Center, Vienna, Austria
- Laboratory for Gait and Movement Analysis, Orthopaedic Hospital Speising, Vienna, Austria
| | - Stefan Penzkofer
- MRI Institute Bader, Orthopaedic Hospital Speising, Vienna, Austria
| | - Rudolf Ganger
- Department of Pediatric Orthopaedics, Orthopaedic Hospital Speising, Vienna, Austria
- Vienna Bone and Growth Center, Vienna, Austria
| | - Christof Radler
- Department of Pediatric Orthopaedics, Orthopaedic Hospital Speising, Vienna, Austria
- Vienna Bone and Growth Center, Vienna, Austria
| | - Gabriele Haeusler
- Vienna Bone and Growth Center, Vienna, Austria
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Pulmonology, Allergology and Endocrinology, Medical University of Vienna, Vienna, Austria
| | - Adalbert Raimann
- Vienna Bone and Growth Center, Vienna, Austria
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Pulmonology, Allergology and Endocrinology, Medical University of Vienna, Vienna, Austria
- *Correspondence: Adalbert Raimann,
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Fortin CA, Girard L, Bonenfant C, Leblanc J, Cruz-Marino T, Blackburn ME, Desmeules M, Bouchard L. Benefits of Newborn Screening for Vitamin D-Dependant Rickets Type 1A in a Founder Population. Front Endocrinol (Lausanne) 2022; 13:887371. [PMID: 35600579 PMCID: PMC9120640 DOI: 10.3389/fendo.2022.887371] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 03/28/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Vitamin D-dependant rickets type 1A (VDDR1A) is a rare autosomal recessive disorder caused by pathogenic variants in the CYP27B1 gene. This gene is essential for vitamin D activation. Although VDDR1A is a rare condition worldwide, its prevalence is high in the Saguenay-Lac-Saint-Jean (SLSJ) region due to a founder effect. Daily intake of calcitriol before the onset of clinical manifestations can prevent them in affected children. METHODS A genetic screening test was developed and validated for the CYP27B1 gene c.262del pathogenic variant. Newborn screening was implemented in the SLSJ region for this variant, and the feasibility and acceptability were assessed. Sixteen medical records of children affected with VDDR1A were reviewed to document the consequences of the disease at diagnosis. RESULTS A total of 2000 newborns were tested for VDDR1A. Most families (96.5%) accepted the genetic test. We found a carrier rate of 1/29 for the c.262delG variant in our cohort, which is suggestive of a founder effect. We identified one child affected with VDDR1A and treatment was initiated before the onset of clinical manifestations. On average, children with VDDR1A were diagnosed at 13.8 ± 5 months of age, they had a significant failure to thrive at diagnosis, among other harmful health consequences. CONCLUSION Our study showed that in our population, the newborn genetic screening program is safe and feasible, it has high acceptability, and it is efficient to identify affected children. VDDR1A health consequences can be prevented by early initiation of treatment. Therefore, screening programs should be available for populations where it is deemed as beneficial from a public health perspective.
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Affiliation(s)
- Carol-Ann Fortin
- Biochemistry and Functional Genomics Department, Faculty of Medicine and Health Sciences (FMHS), Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Lysanne Girard
- Biochemistry and Functional Genomics Department, Faculty of Medicine and Health Sciences (FMHS), Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Chloé Bonenfant
- Biochemistry and Functional Genomics Department, Faculty of Medicine and Health Sciences (FMHS), Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Josianne Leblanc
- Department of Laboratory Medicine, Centre intégré universitaire de santé et de services sociaux (CIUSSS) du Saguenay-Lac-Saint-Jean – Hôpital de Chicoutimi, Chicoutimi, QC, Canada
| | - Tania Cruz-Marino
- Department of Laboratory Medicine, Centre intégré universitaire de santé et de services sociaux (CIUSSS) du Saguenay-Lac-Saint-Jean – Hôpital de Chicoutimi, Chicoutimi, QC, Canada
| | | | - Mathieu Desmeules
- Medicine Department, FHMS, Université de Sherbrooke, Sherbrooke, QC, Canada
- Clinique des maladies métaboliques, CIUSSS du Saguenay-Lac-Saint-Jean – Hôpital de Chicoutimi, Chicoutimi, QC, Canada
- *Correspondence: Luigi Bouchard, ; Mathieu Desmeules,
| | - Luigi Bouchard
- Biochemistry and Functional Genomics Department, Faculty of Medicine and Health Sciences (FMHS), Université de Sherbrooke, Sherbrooke, QC, Canada
- Department of Laboratory Medicine, Centre intégré universitaire de santé et de services sociaux (CIUSSS) du Saguenay-Lac-Saint-Jean – Hôpital de Chicoutimi, Chicoutimi, QC, Canada
- *Correspondence: Luigi Bouchard, ; Mathieu Desmeules,
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Takashi Y, Toyokawa K, Oda N, Muta Y, Yokomizo H, Fukumoto S, Kawanami D. Combined treatment by burosumab and a calcimimetic can ameliorate hypophosphatemia due to excessive actions of FGF23 and PTH in adult XLH with tertiary hyperparathyroidism: A case report. Front Endocrinol (Lausanne) 2022; 13:1004624. [PMID: 36531500 PMCID: PMC9751939 DOI: 10.3389/fendo.2022.1004624] [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] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 11/15/2022] [Indexed: 12/05/2022] Open
Abstract
INTRODUCTION X-linked hypophosphatemia (XLH) is the most prevalent type of heritable fibroblast growth factor 23 (FGF23)-related hypophosphatemic rickets. Recently, anti-FGF23 antibody, burosumab, has become clinically available. We herein report a patient with adult XLH and tertiary hyperparathyroidism. CASE PRESENTATION The serum phosphate level and tubular maximum reabsorption of phosphate per glomerular filtration rate (TmP/GFR) remained low, despite burosumab treatment. While the influence of the relationship between FGF23 and parathyroid hormone (PTH) on the phosphaturic effect is unclear, it was considered that a high level of PTH due to tertiary hyperparathyroidism remains to suppress renal phosphate reabsorption. A calcimimetic, evocalcet, increased the serum phosphate level and TmP/GFR. DISCUSSION AND CONCLUSION Therefore, it is important to evaluate the presence of secondary-tertiary hyperparathyroidism in patients whose serum phosphate level does not increase with burosumab treatment.
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Affiliation(s)
- Yuichi Takashi
- Department of Endocrinology and Diabetes Mellitus, Fukuoka University School of Medicine, Fukuoka, Japan
- *Correspondence: Yuichi Takashi,
| | - Kyoko Toyokawa
- Department of Endocrinology and Diabetes Mellitus, Fukuoka University School of Medicine, Fukuoka, Japan
| | - Naoki Oda
- Department of Endocrinology and Diabetes Mellitus, Fukuoka University School of Medicine, Fukuoka, Japan
| | - Yoshimi Muta
- Department of Endocrinology and Diabetes Mellitus, Fukuoka University School of Medicine, Fukuoka, Japan
| | - Hisashi Yokomizo
- Department of Endocrinology and Diabetes Mellitus, Fukuoka University School of Medicine, Fukuoka, Japan
| | - Seiji Fukumoto
- Department of Molecular Endocrinology, Fujii Memorial Institute of Medical Sciences, Institute of Advanced Medical Sciences, Tokushima University, Tokushima, Japan
| | - Daiji Kawanami
- Department of Endocrinology and Diabetes Mellitus, Fukuoka University School of Medicine, Fukuoka, Japan
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Abstract
PURPOSE OF REVIEW X-linked hypophosphatemia and tumor-induced osteomalacia are diseases characterized by hypophosphatemia with impaired proximal tubular phosphate reabsorption. Complete resection of responsible tumors is the first-line therapy for patients with tumor-induced osteomalacia. In contrast, phosphate and active vitamin D have been used for patients with X-linked hypophosphatemia and inoperable ones with tumor-induced osteomalacia. The purpose of this review is to summarize the pathogenesis of these diseases and discuss about the new treatment. RECENT FINDINGS Excessive FGF23 production has been shown to underline several kinds of hypophosphatemic rickets/osteomalacia including X-linked hypophosphatemia and tumor-induced osteomalacia. Burosumab, an anti-FGF23 monoclonal antibody, was approved for clinical use, while the indications of burosumab are different depending on countries. The inhibition of excessive FGF23 activity has been approved as a new therapy for several kinds of hypophosphatemic diseases. Further studies are necessary to clarify the long-term effects and safety of burosumab.
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Affiliation(s)
- Yuichi Takashi
- Department of Endocrinology and Diabetes Mellitus, Fukuoka University School of Medicine, Fukuoka, Japan
| | - Daiji Kawanami
- Department of Endocrinology and Diabetes Mellitus, Fukuoka University School of Medicine, Fukuoka, Japan
| | - Seiji Fukumoto
- Department of Molecular Endocrinology, Fujii Memorial Institute of Medical Sciences, Institute of Advanced Medical Sciences, Tokushima University, 3-18-15 Kuramoto-cho, Tokushima, 770-8503, Japan.
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Abstract
BACKGROUND Conventional treatment of X-linked hypophosphatemia with oral phosphate and calcitriol can heal rickets, but it does not always raise serum phosphate concentrations significantly, nor does it always normalize linear growth. Some clinical trials suggest that combining recombinant human growth hormone therapy with conventional treatment improves growth velocity, phosphate retention, and bone mineral density, but some clinical trials suggest that it appears to aggravate the pre-existent disproportionate stature of such children. This is an updated version of a previously published review. OBJECTIVES To determine whether recombinant human growth hormone therapy for children with X-linked hypophosphatemia is associated with changes in longitudinal growth, mineral metabolism, endocrine function, renal function, bone mineral density, body proportions, and also with any adverse effects. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register which comprises references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings. In addition, we searched the Cochrane Central Register of Controlled Trials, Ovid MEDLINE and the reference lists of identified trials and other reviews. We also undertook some additional handsearching of relevant journals and conference proceedings. Date of the most recent search: 12 January 2021 SELECTION CRITERIA: All randomized controlled studies or quasi-randomized controlled studies comparing growth hormone (alone or combined with conventional treatment) with either placebo or conventional treatment alone in children with X-linked hypophosphatemia. DATA COLLECTION AND ANALYSIS Two authors independently assessed studies for risk of bias and extracted data from eligible studies. GRADE criteria were used to assess the certainty of the evidence for each outcome. MAIN RESULTS We included two studies (20 participants) in the review. In one cross-over study, results showed that recombinant human growth hormone therapy may improve the height standard deviation (SDS) score (z score), but we are unsure whether the intervention was the reason behind a transient increase in serum phosphate and tubular maximum for phosphate reabsorption. In the second, parallel study, treatment may also have improved the height SDS from baseline in the rhGH group compared to the control group, although no significant difference was seen between groups after three years, MD 0.50 SDS (95 % CI -0.54 to 1.54) (low-certainty evidence). The treatment was possibly well-tolerated during both studies with only transient adverse effects seen in three participants (low-certainty evidence). We are uncertain whether growth hormone improves serum phosphate levels or change in TmP/GFR (very low-certainty evidence). The treatment may make little or no difference to alkaline phosphatase levels (low-certainty evidence). AUTHORS' CONCLUSIONS We do not have enough high-certainty evidence to recommend the use of recombinant human growth hormone therapy in children with X-linked hypophosphatemia.
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Affiliation(s)
- Sherie Smith
- Division of Child Health, Obstetrics & Gynaecology (COG), School of Medicine, University of Nottingham, Nottingham, UK
| | - Tracey Remmington
- Department of Women's and Children's Health, University of Liverpool, Liverpool, UK
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Zhukouskaya VV, Mannes I, Chaussain C, Kamenický P, Audrain C, Lambert AS, Nevoux J, Wicart P, Briot K, Di Rocco F, Trabado S, Prié D, Di Somma C, Colao A, Adamsbaum C, Rothenbuhler A, Linglart A. Magnetic resonance imaging is a valuable tool to evaluate the therapeutic efficacy of burosumab in children with X-linked hypophosphatemia. Eur J Endocrinol 2021; 185:475-484. [PMID: 34292170 DOI: 10.1530/eje-21-0429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 07/21/2021] [Indexed: 11/08/2022]
Abstract
PURPOSE To examine the MRI diagnostic performance in the assessment of therapeutic response to burosumab in children with X-linked hypophosphatemia (XLH). DESIGN Prospective longitudinal open cohort. PATIENTS Seventeen children with XLH, average age of 10.2 ± 2.7 years, had a knee MRI at baseline and after 1 year of burosumab. INTERVENTION Children received burosumab at an average dose of 1.4 ± 0.5 mg/kg during 1 year for the treatment of severe rickets (the target serum phosphate ≥ 1.2 mmol/L (≥3.7 mg/dL). The primary endpoint was the change from baseline to 12 months in rachitic lesions on knee MRI. Secondary endpoints were changes in biochemical parameters of phosphate and alkaline phosphatase (ALP). RESULTS One year of treatment with burosumab significantly reduced radiological disease activity on knee MRI (by 44 ± 29% in the transverse extent of widening) which was accompanied by a significant reduction in biochemical activity, namely in serum ALP activity, by 28 ± 17%. Additionally, MRI parameters after 1 year of treatment with burosumab (the maximum width of medial physis at 12 months and the change from baseline in the maximum width of lateral physis) were associated with ALP activity at 12 months. CONCLUSION We suggest that MRI is a valuable and quantitative tool to evaluate the therapeutic response to burosumab. MRI could be an excellent alternative to standard bone radiographs for evaluation of the rachitic lesions in a clinical setting avoiding repeated exposition to ionizing radiation.
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Affiliation(s)
- Volha V Zhukouskaya
- AP-HP, Reference Center for Rare Disorders of the Calcium and Phosphate Metabolism, Filière OSCAR, EndoRare, BOND ERN and Platform of Expertise for Rare Diseases Paris-Saclay, Bicêtre Paris-Saclay Hospital, Le Kremlin-Bicêtre, France
- Genethon, Paris-Saclay University, Univ Evry, Inserm, Integrare research unit UMR_S951, Evry, France
- Division of Endocrinology, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
- Université de Paris, Institut des maladies musculo-squelettiques, Laboratory Orofacial Pathologies, Imaging and Biotherapies URP2496 and FHU-DDS-Net, Dental School, and Plateforme d'Imagerie du Vivant (PIV), Montrouge, France
| | - Inès Mannes
- AP-HP, Department of Pediatric Radiology, Bicêtre Paris-Saclay Hospital, Le Kremlin-Bicêtre, France
- University Paris Saclay, Le Kremlin-Bicêtre, France
| | - Catherine Chaussain
- AP-HP, Reference Center for Rare Disorders of the Calcium and Phosphate Metabolism, Filière OSCAR, EndoRare, BOND ERN and Platform of Expertise for Rare Diseases Paris-Saclay, Bicêtre Paris-Saclay Hospital, Le Kremlin-Bicêtre, France
- AP-HP, Reference Center for Rare Disorders of the Calcium and Phosphate Metabolism, Dental Medicine Department, Bretonneau Hospital, GHN-Université de Paris, Paris, France
- Université de Paris, Paris, France
- Université de Paris, Institut des maladies musculo-squelettiques, Laboratory Orofacial Pathologies, Imaging and Biotherapies URP2496 and FHU-DDS-Net, Dental School, and Plateforme d'Imagerie du Vivant (PIV), Montrouge, France
| | - Peter Kamenický
- AP-HP, Reference Center for Rare Disorders of the Calcium and Phosphate Metabolism, Filière OSCAR, EndoRare, BOND ERN and Platform of Expertise for Rare Diseases Paris-Saclay, Bicêtre Paris-Saclay Hospital, Le Kremlin-Bicêtre, France
- University Paris Saclay, Le Kremlin-Bicêtre, France
- AP-HP, Department of Endocrinology and Reproductive Diseases, Bicêtre Paris-Saclay Hospital, Le Kremlin-Bicêtre, France
| | - Christelle Audrain
- AP-HP, Reference Center for Rare Disorders of the Calcium and Phosphate Metabolism, Filière OSCAR, EndoRare, BOND ERN and Platform of Expertise for Rare Diseases Paris-Saclay, Bicêtre Paris-Saclay Hospital, Le Kremlin-Bicêtre, France
| | - Anne-Sophie Lambert
- AP-HP, Reference Center for Rare Disorders of the Calcium and Phosphate Metabolism, Filière OSCAR, EndoRare, BOND ERN and Platform of Expertise for Rare Diseases Paris-Saclay, Bicêtre Paris-Saclay Hospital, Le Kremlin-Bicêtre, France
- AP-HP, Departments of Endocrinology and Diabetology for Children and Adolescent Medicine, Bicêtre Paris-Saclay Hospital, Le Kremlin-Bicêtre, France
| | - Jérôme Nevoux
- AP-HP, Reference Center for Rare Disorders of the Calcium and Phosphate Metabolism, Filière OSCAR, EndoRare, BOND ERN and Platform of Expertise for Rare Diseases Paris-Saclay, Bicêtre Paris-Saclay Hospital, Le Kremlin-Bicêtre, France
- University Paris Saclay, Le Kremlin-Bicêtre, France
- AP-HP, Department of ORL, Bicêtre Paris-Saclay Hospital, Le Kremlin Bicêtre, France
| | - Philippe Wicart
- AP-HP, Reference Center for Rare Disorders of the Calcium and Phosphate Metabolism, Filière OSCAR, EndoRare, BOND ERN and Platform of Expertise for Rare Diseases Paris-Saclay, Bicêtre Paris-Saclay Hospital, Le Kremlin-Bicêtre, France
- Université de Paris, Paris, France
- AP-HP, Department of Pediatric Orthopaedic Surgery, Necker - Sick Kids University Hospital, Paris, France
| | - Karine Briot
- AP-HP, Reference Center for Rare Disorders of the Calcium and Phosphate Metabolism, Filière OSCAR, EndoRare, BOND ERN and Platform of Expertise for Rare Diseases Paris-Saclay, Bicêtre Paris-Saclay Hospital, Le Kremlin-Bicêtre, France
- Université de Paris, Paris, France
- AP-HP, Department of Rheumatology Hospital Cochin, Paris, France
| | - Federico Di Rocco
- AP-HP, Reference Center for Rare Disorders of the Calcium and Phosphate Metabolism, Filière OSCAR, EndoRare, BOND ERN and Platform of Expertise for Rare Diseases Paris-Saclay, Bicêtre Paris-Saclay Hospital, Le Kremlin-Bicêtre, France
- Pediatric Neurosurgery, Hospital Femme Mere Enfant, Hospices Civiles de Lyon and University Claude Bernard Lyon, Bron Cedex, France
- Reference Center for Craniosynostosis, INSERM 1033, Lyon, France
| | - Séverine Trabado
- University Paris Saclay, Le Kremlin-Bicêtre, France
- AP-HP, Department of Molecular Genetics, Pharmacogenetics and Hormonology, Bicêtre Paris-Saclay Hospital, Le Kremlin-Bicêtre, France
| | - Dominique Prié
- Université de Paris, Paris, France
- AP-HP, Hôpital Necker Enfants Malades, INSERM U1151, Paris, France
| | - Carolina Di Somma
- Division of Endocrinology, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Annamaria Colao
- Division of Endocrinology, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Catherine Adamsbaum
- AP-HP, Reference Center for Rare Disorders of the Calcium and Phosphate Metabolism, Filière OSCAR, EndoRare, BOND ERN and Platform of Expertise for Rare Diseases Paris-Saclay, Bicêtre Paris-Saclay Hospital, Le Kremlin-Bicêtre, France
- AP-HP, Department of Pediatric Radiology, Bicêtre Paris-Saclay Hospital, Le Kremlin-Bicêtre, France
- University Paris Saclay, Le Kremlin-Bicêtre, France
| | - Anya Rothenbuhler
- AP-HP, Reference Center for Rare Disorders of the Calcium and Phosphate Metabolism, Filière OSCAR, EndoRare, BOND ERN and Platform of Expertise for Rare Diseases Paris-Saclay, Bicêtre Paris-Saclay Hospital, Le Kremlin-Bicêtre, France
- AP-HP, Departments of Endocrinology and Diabetology for Children and Adolescent Medicine, Bicêtre Paris-Saclay Hospital, Le Kremlin-Bicêtre, France
| | - Agnès Linglart
- AP-HP, Reference Center for Rare Disorders of the Calcium and Phosphate Metabolism, Filière OSCAR, EndoRare, BOND ERN and Platform of Expertise for Rare Diseases Paris-Saclay, Bicêtre Paris-Saclay Hospital, Le Kremlin-Bicêtre, France
- University Paris Saclay, Le Kremlin-Bicêtre, France
- AP-HP, Departments of Endocrinology and Diabetology for Children and Adolescent Medicine, Bicêtre Paris-Saclay Hospital, Le Kremlin-Bicêtre, France
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Lim R, Shailam R, Hulett R, Skrinar A, Nixon A, Williams A, Nixon M, Thacher TD. Validation of the Radiographic Global Impression of Change (RGI-C) score to assess healing of rickets in pediatric X-linked hypophosphatemia (XLH). Bone 2021; 148:115964. [PMID: 33878504 DOI: 10.1016/j.bone.2021.115964] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 04/13/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Rickets is a primary manifestation of pediatric X-linked hypophosphatemia (XLH) - a rare progressive hereditary phosphate-wasting disease. Severity is quantified from radiographs using the Rickets Severity Scale (RSS). The Radiographic Global Impression of Change (RGI-C) is a complementary assessment in which a change score is assigned based on differences in the appearance of rickets on pairs of radiographs compared side by side. OBJECTIVE The current study evaluated the reliability, validity, and sensitivity to change of the RGI-C specifically in pediatric XLH. METHODS The reliability, validity, and sensitivity to change of the RGI-C were evaluated using data from two studies in pediatric XLH (113 children aged 1-12 years) in which burosumab treatment significantly improved rickets severity. Intra-rater and inter-rater reliability were assessed by three pediatric radiologists. RESULTS Intra-rater reliability for RGI-C global score was >90% for agreement within 1 point, with weighted kappa values >0.5, indicating moderate to almost perfect agreement. Inter-rater reliability was also >90% (0.47-0.52 for all reader pairs; moderate agreement). The RGI-C global score showed significant relationships with changes from baseline to week 64 in serum phosphorus (r = -0.397), alkaline phosphatase (-0.611), total RSS (-0.672), standing height (0.268), and patient-reported global functioning (0.306) and comfort/pain functioning (0.409). Based on standardized response means, RGI-C global scores were sensitive to change in RSS, differentiating between those considered improved and greatly improved. Results for validity and sensitivity to change were similar for the RGI-C wrist, knee, and standing long leg scores. CONCLUSION The RGI-C is a reliable, valid, and sensitive measure in pediatric XLH, and complementary to the RSS.
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Affiliation(s)
- Ruth Lim
- Massachusetts General Hospital, Harvard Medical School, MA, USA.
| | | | - Rebecca Hulett
- Washington University School of Medicine, St Louis, MO, USA
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Ozden A, Doneray H. The genetics and clinical manifestations of patients with vitamin D dependent rickets type 1A. J Pediatr Endocrinol Metab 2021; 34:781-789. [PMID: 33823104 DOI: 10.1515/jpem-2020-0691] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Accepted: 02/12/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Vitamin D dependent rickets type 1A (VDDR-1A) is a very rare autosomal recessive disorder caused by mutations in the CYP27B1, which encodes vitamin D 1α-hydroxylase. We report the genetics and clinical manifestations of nine patients with VDDR-1A and compare our patients to other cases with the same mutations in the literature. METHODS The clinical presentations, clinical and laboratory findings and treatment modalities of the patients were evaluated retrospectively. RESULTS The mean age of the patients at the time of diagnosis was 39.9 months (range: 4.5-111). At the time of diagnosis, six patients had received stoss vitamin D therapy. Clinical findings related to rickets were obvious in seven patients and unclear in two patients. Except for one case, all patients had laboratory findings of rickets. A novel variant and four previously reported mutations in CYP27B1 were identified. The mean calcitriol and elemental calcium dose were 45.5 ng/kg/day (range: 20-70) and 75.6 mg/kg/day (range: 45-125), respectively. CONCLUSIONS We found a novel compound heterozygous mutation consisting of a reported duplication [(p.F443Pfs*24 (c.1319_1325 dup CCCACCC)] in exon 8 and a novel deletion [p.D507Efs*34 (c.1521 delC)] in exon 9. Our study suggests that the clinical manifestations and laboratory findings of the patients with VDDR1A are variable even among the patients with the same mutation.
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Affiliation(s)
- Ayse Ozden
- Department of Pediatric Endocrinology, Erzurum Regional Training & Research Hospital, Erzurum, Turkey
| | - Hakan Doneray
- Department of Pediatric Endocrinology, Ataturk University Faculty of Medicine, Erzurum, Turkey
- Clinical Research Development and Design Application and Research Center, Ataturk University, Erzurum, Turkey
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Abstract
PURPOSE OF REVIEW X-Linked hypophosphatemia (XLH) is the most common genetic cause of rickets. This review describes advances in the management of XLH using burosumab which was FDA approved for treating children with XLH in 2018. RECENT FINDINGS Elevated FGF23 in XLH leads to systemic hypophosphatemia and several musculoskeletal manifestations, including rachitic bone deformities, impaired growth, dental abscesses, insufficiency fractures, osteoarthritis, and enthesopathy, with lifelong consequences for physical function and quality of life. Burosumab treatment has demonstrated clinical improvement of rickets and growth in children, including during a randomized controlled trial compared with conventional therapy. Burosumab also improved pseudofracture healing in adults. Burosumab led to greater improvement in rickets and growth than conventional therapy. However, many questions remain regarding the impact of burosumab on several outcomes, including final height, nephrocalcinosis, dental disease, enthesopathy, and surgical interventions.
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Affiliation(s)
- Erik A Imel
- Department of Medicine, Indiana University School of Medicine, 1120 West Michigan Street, CL 365, Indianapolis, IN, 46202-5111, USA.
- Department of Pediatrics, Indiana University School of Medicine, 1120 West Michigan Street, CL 365, Indianapolis, IN, 46202-5111, USA.
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Xiao Z, Liu J, Liu SH, Petridis L, Cai C, Cao L, Wang G, Chin AL, Cleveland JW, Ikedionwu MO, Carrick JD, Smith JC, Quarles LD. Novel Small Molecule Fibroblast Growth Factor 23 Inhibitors Increase Serum Phosphate and Improve Skeletal Abnormalities in Hyp Mice. Mol Pharmacol 2021; 101:408-421. [PMID: 35339985 PMCID: PMC11033927 DOI: 10.1124/molpharm.121.000471] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 03/20/2022] [Indexed: 11/22/2022] Open
Abstract
Excess fibroblast growth factor (FGF) 23 causes hereditary hypophosphatemic rickets, such as X-linked hypophosphatemia (XLH) and tumor-induced osteomalacia (TIO). A small molecule that specifically binds to FGF23 to prevent activation of the fibroblast growth factor receptor/α-Klotho complex has potential advantages over the currently approved systemically administered FGF23 blocking antibody. Using structure-based drug design, we previously identified ZINC13407541 (N-[[2-(2-phenylethenyl)cyclopenten-1-yl]methylidene]hydroxylamine) as a small molecule antagonist for FGF23. Additional structure-activity studies developed a series of ZINC13407541 analogs with enhanced drug-like properties. In this study, we tested in a preclinical Hyp mouse homolog of XLH a direct connect analog [(E)-2-(4-(tert-butyl)phenyl)cyclopent-1-ene-1-carbaldehyde oxime] (8n), which exhibited the greatest stability in microsomal assays, and [(E)-2-((E)-4-methylstyryl)benzaldehyde oxime] (13a), which exhibited increased in vitro potency. Using cryo-electron microscopy structure and computational docking, we identified a key binding residue (Q156) of the FGF23 antagonists, ZINC13407541, and its analogs (8n and 13a) in the N-terminal domain of FGF23 protein. Site-directed mutagenesis and bimolecular fluorescence complementation-fluorescence resonance energy transfer assay confirmed the binding site of these three antagonists. We found that pharmacological inhibition of FGF23 with either of these compounds blocked FGF23 signaling and increased serum phosphate and 1,25-dihydroxyvitamin D [1,25(OH)2D] concentrations in Hyp mice. Long-term parenteral treatment with 8n or 13a also enhanced linear bone growth, increased mineralization of bone, and narrowed the growth plate in Hyp mice. The more potent 13a compound had greater therapeutic effects in Hyp mice. Further optimization of these FGF23 inhibitors may lead to versatile drugs to treat excess FGF23-mediated disorders. SIGNIFICANCE STATEMENT: This study used structure-based drug design and medicinal chemistry approaches to identify and optimize small molecules with different stability and potency, which antagonize excessive actions of fibroblast growth factor 23 (FGF23) in hereditary hypophosphatemic rickets. The findings confirmed that these antagonists bind to the N-terminus of FGF23 to inhibit its binding to and activation of the fibroblast growth factor receptors/α-Klotho signaling complex. Administration of these lead compounds improved phosphate homeostasis and abnormal skeletal phenotypes in a preclinical Hyp mouse model.
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Affiliation(s)
- Zhousheng Xiao
- Department of Medicine, College of Medicine (Z.X., C.C., L.C., G.W.W., L.D.Q.) and Department of Pharmaceutical Sciences, College of Pharmacy (J.L.), University of Tennessee Health Science Center, Memphis, Tennessee; University of Tennessee (UT)/Oak Ridge National Laboratory (ORNL) Center for Molecular Biophysics, Oak Ridge National Laboratory, Oak Ridge, Tennessee (S.H.L., L.P., J.C.S.); Department of Biochemistry and Cellular and Molecular Biology, University of Tennessee, Knoxville, Tennessee (L.P., J.C.S.); and Department of Chemistry, Tennessee Technological University, Cookeville, Tennessee (A.L.C., J.W.C., M.O.I., J.D.C.)
| | - Jiawang Liu
- Department of Medicine, College of Medicine (Z.X., C.C., L.C., G.W.W., L.D.Q.) and Department of Pharmaceutical Sciences, College of Pharmacy (J.L.), University of Tennessee Health Science Center, Memphis, Tennessee; University of Tennessee (UT)/Oak Ridge National Laboratory (ORNL) Center for Molecular Biophysics, Oak Ridge National Laboratory, Oak Ridge, Tennessee (S.H.L., L.P., J.C.S.); Department of Biochemistry and Cellular and Molecular Biology, University of Tennessee, Knoxville, Tennessee (L.P., J.C.S.); and Department of Chemistry, Tennessee Technological University, Cookeville, Tennessee (A.L.C., J.W.C., M.O.I., J.D.C.)
| | - Shih-Hsien Liu
- Department of Medicine, College of Medicine (Z.X., C.C., L.C., G.W.W., L.D.Q.) and Department of Pharmaceutical Sciences, College of Pharmacy (J.L.), University of Tennessee Health Science Center, Memphis, Tennessee; University of Tennessee (UT)/Oak Ridge National Laboratory (ORNL) Center for Molecular Biophysics, Oak Ridge National Laboratory, Oak Ridge, Tennessee (S.H.L., L.P., J.C.S.); Department of Biochemistry and Cellular and Molecular Biology, University of Tennessee, Knoxville, Tennessee (L.P., J.C.S.); and Department of Chemistry, Tennessee Technological University, Cookeville, Tennessee (A.L.C., J.W.C., M.O.I., J.D.C.)
| | - Loukas Petridis
- Department of Medicine, College of Medicine (Z.X., C.C., L.C., G.W.W., L.D.Q.) and Department of Pharmaceutical Sciences, College of Pharmacy (J.L.), University of Tennessee Health Science Center, Memphis, Tennessee; University of Tennessee (UT)/Oak Ridge National Laboratory (ORNL) Center for Molecular Biophysics, Oak Ridge National Laboratory, Oak Ridge, Tennessee (S.H.L., L.P., J.C.S.); Department of Biochemistry and Cellular and Molecular Biology, University of Tennessee, Knoxville, Tennessee (L.P., J.C.S.); and Department of Chemistry, Tennessee Technological University, Cookeville, Tennessee (A.L.C., J.W.C., M.O.I., J.D.C.)
| | - Chun Cai
- Department of Medicine, College of Medicine (Z.X., C.C., L.C., G.W.W., L.D.Q.) and Department of Pharmaceutical Sciences, College of Pharmacy (J.L.), University of Tennessee Health Science Center, Memphis, Tennessee; University of Tennessee (UT)/Oak Ridge National Laboratory (ORNL) Center for Molecular Biophysics, Oak Ridge National Laboratory, Oak Ridge, Tennessee (S.H.L., L.P., J.C.S.); Department of Biochemistry and Cellular and Molecular Biology, University of Tennessee, Knoxville, Tennessee (L.P., J.C.S.); and Department of Chemistry, Tennessee Technological University, Cookeville, Tennessee (A.L.C., J.W.C., M.O.I., J.D.C.)
| | - Li Cao
- Department of Medicine, College of Medicine (Z.X., C.C., L.C., G.W.W., L.D.Q.) and Department of Pharmaceutical Sciences, College of Pharmacy (J.L.), University of Tennessee Health Science Center, Memphis, Tennessee; University of Tennessee (UT)/Oak Ridge National Laboratory (ORNL) Center for Molecular Biophysics, Oak Ridge National Laboratory, Oak Ridge, Tennessee (S.H.L., L.P., J.C.S.); Department of Biochemistry and Cellular and Molecular Biology, University of Tennessee, Knoxville, Tennessee (L.P., J.C.S.); and Department of Chemistry, Tennessee Technological University, Cookeville, Tennessee (A.L.C., J.W.C., M.O.I., J.D.C.)
| | - Guangwei Wang
- Department of Medicine, College of Medicine (Z.X., C.C., L.C., G.W.W., L.D.Q.) and Department of Pharmaceutical Sciences, College of Pharmacy (J.L.), University of Tennessee Health Science Center, Memphis, Tennessee; University of Tennessee (UT)/Oak Ridge National Laboratory (ORNL) Center for Molecular Biophysics, Oak Ridge National Laboratory, Oak Ridge, Tennessee (S.H.L., L.P., J.C.S.); Department of Biochemistry and Cellular and Molecular Biology, University of Tennessee, Knoxville, Tennessee (L.P., J.C.S.); and Department of Chemistry, Tennessee Technological University, Cookeville, Tennessee (A.L.C., J.W.C., M.O.I., J.D.C.)
| | - Ai Lin Chin
- Department of Medicine, College of Medicine (Z.X., C.C., L.C., G.W.W., L.D.Q.) and Department of Pharmaceutical Sciences, College of Pharmacy (J.L.), University of Tennessee Health Science Center, Memphis, Tennessee; University of Tennessee (UT)/Oak Ridge National Laboratory (ORNL) Center for Molecular Biophysics, Oak Ridge National Laboratory, Oak Ridge, Tennessee (S.H.L., L.P., J.C.S.); Department of Biochemistry and Cellular and Molecular Biology, University of Tennessee, Knoxville, Tennessee (L.P., J.C.S.); and Department of Chemistry, Tennessee Technological University, Cookeville, Tennessee (A.L.C., J.W.C., M.O.I., J.D.C.)
| | - Jacob W Cleveland
- Department of Medicine, College of Medicine (Z.X., C.C., L.C., G.W.W., L.D.Q.) and Department of Pharmaceutical Sciences, College of Pharmacy (J.L.), University of Tennessee Health Science Center, Memphis, Tennessee; University of Tennessee (UT)/Oak Ridge National Laboratory (ORNL) Center for Molecular Biophysics, Oak Ridge National Laboratory, Oak Ridge, Tennessee (S.H.L., L.P., J.C.S.); Department of Biochemistry and Cellular and Molecular Biology, University of Tennessee, Knoxville, Tennessee (L.P., J.C.S.); and Department of Chemistry, Tennessee Technological University, Cookeville, Tennessee (A.L.C., J.W.C., M.O.I., J.D.C.)
| | - Munachi O Ikedionwu
- Department of Medicine, College of Medicine (Z.X., C.C., L.C., G.W.W., L.D.Q.) and Department of Pharmaceutical Sciences, College of Pharmacy (J.L.), University of Tennessee Health Science Center, Memphis, Tennessee; University of Tennessee (UT)/Oak Ridge National Laboratory (ORNL) Center for Molecular Biophysics, Oak Ridge National Laboratory, Oak Ridge, Tennessee (S.H.L., L.P., J.C.S.); Department of Biochemistry and Cellular and Molecular Biology, University of Tennessee, Knoxville, Tennessee (L.P., J.C.S.); and Department of Chemistry, Tennessee Technological University, Cookeville, Tennessee (A.L.C., J.W.C., M.O.I., J.D.C.)
| | - Jesse D Carrick
- Department of Medicine, College of Medicine (Z.X., C.C., L.C., G.W.W., L.D.Q.) and Department of Pharmaceutical Sciences, College of Pharmacy (J.L.), University of Tennessee Health Science Center, Memphis, Tennessee; University of Tennessee (UT)/Oak Ridge National Laboratory (ORNL) Center for Molecular Biophysics, Oak Ridge National Laboratory, Oak Ridge, Tennessee (S.H.L., L.P., J.C.S.); Department of Biochemistry and Cellular and Molecular Biology, University of Tennessee, Knoxville, Tennessee (L.P., J.C.S.); and Department of Chemistry, Tennessee Technological University, Cookeville, Tennessee (A.L.C., J.W.C., M.O.I., J.D.C.)
| | - Jeremy C Smith
- Department of Medicine, College of Medicine (Z.X., C.C., L.C., G.W.W., L.D.Q.) and Department of Pharmaceutical Sciences, College of Pharmacy (J.L.), University of Tennessee Health Science Center, Memphis, Tennessee; University of Tennessee (UT)/Oak Ridge National Laboratory (ORNL) Center for Molecular Biophysics, Oak Ridge National Laboratory, Oak Ridge, Tennessee (S.H.L., L.P., J.C.S.); Department of Biochemistry and Cellular and Molecular Biology, University of Tennessee, Knoxville, Tennessee (L.P., J.C.S.); and Department of Chemistry, Tennessee Technological University, Cookeville, Tennessee (A.L.C., J.W.C., M.O.I., J.D.C.)
| | - Leigh Darryl Quarles
- Department of Medicine, College of Medicine (Z.X., C.C., L.C., G.W.W., L.D.Q.) and Department of Pharmaceutical Sciences, College of Pharmacy (J.L.), University of Tennessee Health Science Center, Memphis, Tennessee; University of Tennessee (UT)/Oak Ridge National Laboratory (ORNL) Center for Molecular Biophysics, Oak Ridge National Laboratory, Oak Ridge, Tennessee (S.H.L., L.P., J.C.S.); Department of Biochemistry and Cellular and Molecular Biology, University of Tennessee, Knoxville, Tennessee (L.P., J.C.S.); and Department of Chemistry, Tennessee Technological University, Cookeville, Tennessee (A.L.C., J.W.C., M.O.I., J.D.C.)
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47
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Vandewalle B, Amorim M, Ramos D, Azevedo S, Alves I, Francisco T, Pinto H, Sousa S. Value-based decision-making for orphan drugs with multiple criteria decision analysis: burosumab for the treatment of X-linked hypophosphatemia. Curr Med Res Opin 2021; 37:1021-1030. [PMID: 33733971 DOI: 10.1080/03007995.2021.1904861] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Burosumab is an orphan medicinal product (OMP) approved in Europe for the treatment of X-linked hypophosphatemia (XLH). The aim of this study was to assess the value of burosumab versus conventional therapy for the treatment of paediatric XLH, through a multi-criteria decision analysis (MCDA) framework for health technology assessment (HTA) of OMPs in Portugal. METHODS The MCDA framework considered 14 criteria related to disease burden, therapeutic value and economic burden. A multidisciplinary panel of national stakeholders participated in a two-phase exercise. In the first phase, relative weights and part-worth utilities for the criteria and their levels were elicited and a reimbursement likelihood function was calibrated through adaptive conjoint analysis. In the second phase, burosumab and conventional therapy were assessed against the criteria, providing a global value score (0-100) and reimbursement likelihood (0-100%) for both. RESULTS Of the 14 criteria, disease burden, therapeutic value and economic burden criteria represented 27.29%, 57.17% and 15.53% of the total weight in the decision, respectively. All disease burden and some therapeutic value criteria, typically not included in traditional HTA, represented 47.88% of the total weight. Burosumab was unanimously considered superior to conventional therapy, with an average (range) global value score of 84.96 (82.48-86.54) against 48.06 (43.37-57.68), and reimbursement likelihood of 97.50% (96.78%-98.32%) against 43.66% (31.48%-68.73%), respectively. CONCLUSIONS MCDA represents a powerful tool in HTA decision-making for OMPs. The results of this MCDA acknowledge burosumab as a disease-modifying drug, deemed superior to conventional therapy for the treatment of paediatric XLH.
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Affiliation(s)
| | | | | | | | - Inês Alves
- Associação Nacional de Displasias Ósseas, Évora, Portugal
| | - Telma Francisco
- Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal
| | - Helena Pinto
- Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Sérgio Sousa
- Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
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48
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Padidela R, Whyte MP, Glorieux FH, Munns CF, Ward LM, Nilsson O, Portale AA, Simmons JH, Namba N, Cheong HI, Pitukcheewanont P, Sochett E, Högler W, Muroya K, Tanaka H, Gottesman GS, Biggin A, Perwad F, Williams A, Nixon A, Sun W, Chen A, Skrinar A, Imel EA. Patient-Reported Outcomes from a Randomized, Active-Controlled, Open-Label, Phase 3 Trial of Burosumab Versus Conventional Therapy in Children with X-Linked Hypophosphatemia. Calcif Tissue Int 2021; 108:622-633. [PMID: 33484279 PMCID: PMC8064984 DOI: 10.1007/s00223-020-00797-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 12/14/2020] [Indexed: 12/11/2022]
Abstract
Changing to burosumab, a monoclonal antibody targeting fibroblast growth factor 23, significantly improved phosphorus homeostasis, rickets, lower-extremity deformities, mobility, and growth versus continuing oral phosphate and active vitamin D (conventional therapy) in a randomized, open-label, phase 3 trial involving children aged 1-12 years with X-linked hypophosphatemia. Patients were randomized (1:1) to subcutaneous burosumab or to continue conventional therapy. We present patient-reported outcomes (PROs) from this trial for children aged ≥ 5 years at screening (n = 35), using a Patient-Reported Outcomes Measurement Information System (PROMIS) questionnaire and SF-10 Health Survey for Children. PROMIS pain interference, physical function mobility, and fatigue scores improved from baseline with burosumab at weeks 40 and 64, but changed little with continued conventional therapy. Pain interference scores differed significantly between groups at week 40 (- 5.02, 95% CI - 9.29 to - 0.75; p = 0.0212) but not at week 64. Between-group differences were not significant at either week for physical function mobility or fatigue. Reductions in PROMIS pain interference and fatigue scores from baseline were clinically meaningful with burosumab at weeks 40 and 64 but not with conventional therapy. SF-10 physical health scores (PHS-10) improved significantly with burosumab at week 40 (least-squares mean [standard error] + 5.98 [1.79]; p = 0.0008) and week 64 (+ 5.93 [1.88]; p = 0.0016) but not with conventional therapy (between-treatment differences were nonsignificant). In conclusion, changing to burosumab improved PRO measures, with statistically significant differences in PROMIS pain interference at week 40 versus continuing with conventional therapy and in PHS-10 at weeks 40 and 64 versus baseline.Trial registration: ClinicalTrials.gov NCT02915705.
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Affiliation(s)
- Raja Padidela
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, UK.
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.
| | - Michael P Whyte
- Shriners Hospitals for Children -Washington University School of Medicine in St Louis, St Louis, MO, USA
| | - Francis H Glorieux
- Shriners Hospital for Children - Canada, McGill University, Montreal, QC, Canada
| | - Craig F Munns
- The University of Sydney Children's Hospital Westmead Clinical School, The Children's Hospital at Westmead, Westmead, NSW, Australia
- Department of Endocrinology, The Children's Hospital at Westmead, Westmead, NSW, Australia
| | - Leanne M Ward
- Department of Pediatrics, University of Ottawa, Ottawa, ON, Canada
- Division of Endocrinology and Metabolism, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Ola Nilsson
- Division of Pediatric Endocrinology & Center for Molecular Medicine, Karolinska Institute, Stockholm, Sweden
- School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Anthony A Portale
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA, USA
| | - Jill H Simmons
- Departments of Pediatrics, Division of Endocrinology and Diabetes, Vanderbilt University School of Medicine, Vanderbilt University, Nashville, TN, USA
| | - Noriyuki Namba
- Department of Pediatrics, Osaka Hospital, Japan Community Healthcare Organization, Osaka, Japan
- Department of Pediatrics, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Hae Il Cheong
- Seoul National University Children's Hospital, Seoul, Republic of Korea
| | - Pisit Pitukcheewanont
- Center of Endocrinology, Diabetes and Metabolism, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Etienne Sochett
- Department of Paediatrics, Hospital for Sick Children, Toronto, ON, Canada
| | - Wolfgang Högler
- Department of Paediatrics and Adolescent Medicine, Johannes Kepler University Linz, Linz, Austria
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Koji Muroya
- Department of Endocrinology and Metabolism, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Hiroyuki Tanaka
- Okayama Saiseikai General Hospital Outpatient Center, Okayama, Japan
| | | | - Andrew Biggin
- The University of Sydney Children's Hospital Westmead Clinical School, The Children's Hospital at Westmead, Westmead, NSW, Australia
| | - Farzana Perwad
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA, USA
| | | | | | - Wei Sun
- Kyowa Kirin Pharmaceutical Development, Princeton, NJ, USA
| | - Angel Chen
- Ultragenyx Pharmaceutical, Novato, CA, USA
| | | | - Erik A Imel
- Department of Medicine and Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
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49
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Liu C, Li X, Zhao Z, Chi Y, Cui L, Zhang Q, Ping F, Chai X, Jiang Y, Wang O, Li M, Xing X, Xia W. Iron deficiency plays essential roles in the trigger, treatment, and prognosis of autosomal dominant hypophosphatemic rickets. Osteoporos Int 2021; 32:737-745. [PMID: 32995940 DOI: 10.1007/s00198-020-05649-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Accepted: 09/17/2020] [Indexed: 12/19/2022]
Abstract
UNLABELLED By analyzing iron status of 14 ADHR patients, we found that iron deficiency was an important trigger of ADHR. Correcting iron deficiency significantly improved patients' symptoms. Meanwhile, patients' serum phosphate showed positive correlations with iron metabolism parameters and hemoglobin-related parameters, suggesting the necessity of monitoring and correcting the iron status in ADHR. INTRODUCTION Autosomal dominant hypophosphatemic rickets (ADHR) is unique for its incomplete penetrance, variety of disease onsets, and waxing and waning phenotypes. Iron deficiency is a trigger of ADHR. This study aimed to clarify the role of iron deficiency in ADHR. METHODS Data of clinical manifestations and laboratory examinations were collected from patients among eight kindreds with ADHR. Multiple regression and Pearson's correlation tests were performed to test the relationships of serum phosphate levels and other laboratory variables during the patients' follow-ups. RESULTS Among 23 ADHR patients with fibroblast growth factor 23 (FGF23) mutations, 14 patients presented with obvious symptoms. Ten patients had iron deficiency at the onset of ADHR, coinciding with menarche, menorrhagia, pregnancy, and chronic gastrointestinal bleeding. Two patients who did not have their iron status tested presented with symptoms after abortion and pregnancy in one patient each, which suggested that they also had iron deficiency at onset. Patients were treated with ferrous succinate tablets, vitamin C, and neutral phosphate and calcitriol. With correction of the iron status, the patients' symptoms showed notable improvement, with increased serum phosphate levels. Two patients' FGF23 levels also declined to the normal range. There were strong correlations between serum phosphate and serum iron levels (r = 0.7689, p < 0.0001), serum ferritin levels (r = 0.5312, p = 0.002), iron saturation (r = 0.7907, p < 0.0001), and transferrin saturation (r = 0.7875, p < 0.001). We also examined the relationships between serum phosphate levels and hemoglobin-related indices, which were significant (hemoglobin: r = 0.71, p < 0.0001; MCV: r = 0.7589, p < 0.0001; MCH: r = 0.8218, p < 0.0001; and MCHC: r = 0.7751, p < 0.0001). Longitudinal data of six patients' follow-up also showed synchronous changes in serum phosphate with serum iron levels. CONCLUSIONS Iron deficiency plays an important role in triggering ADHR. Monitoring and correcting the iron status are helpful for diagnosing and treating ADHR. Iron metabolism parameters and hemoglobin-related parameters are positively correlated with serum phosphate levels in patients with ADHR and iron deficiency, and these might serve as good indicators of prognosis of ADHR.
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Affiliation(s)
- C Liu
- Department of Endocrinology, NHC Key Laboratory of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - X Li
- Department of Endocrinology, NHC Key Laboratory of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Z Zhao
- Department of Endocrinology, NHC Key Laboratory of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
- Department of Geriatrics, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China
| | - Y Chi
- Department of Endocrinology, NHC Key Laboratory of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - L Cui
- Department of Endocrinology, NHC Key Laboratory of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Q Zhang
- Department of Endocrinology, NHC Key Laboratory of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - F Ping
- Department of Endocrinology, NHC Key Laboratory of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - X Chai
- Department of Endocrinology, NHC Key Laboratory of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Y Jiang
- Department of Endocrinology, NHC Key Laboratory of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - O Wang
- Department of Endocrinology, NHC Key Laboratory of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - M Li
- Department of Endocrinology, NHC Key Laboratory of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - X Xing
- Department of Endocrinology, NHC Key Laboratory of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - W Xia
- Department of Endocrinology, NHC Key Laboratory of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China.
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50
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Abstract
FGF23 is a phosphaturic hormone produced by bone. FGF23 reduces serum phosphate by suppressing proximal tubular phosphate reabsorption and intestinal phosphate absorption. After the identification of FGF23, several kinds of hypophosphatemic rickets/osteomalacia such as X-linked hypophosphatemia (XLH) and tumor-induced osteomalacia (TIO) have been shown to be caused by excessive actions of FGF23. Circulatory FGF23 is high in patients with these hypophosphatemic diseases while FGF23 is rather low in those with chronic hypophosphatemia from other causes such as vitamin D deficiency. These results indicate that FGF23 measurement is useful for the differential diagnosis of hypophosphatemia. Chemiluminescent enzyme immunoassay for FGF23 has been approved for clinical use in Japan. The first choice treatment for patients with TIO is complete removal of responsible tumors. However, it is not always possible to find and completely remove responsible tumors. Phosphate and active vitamin D have been used for patients with hypophosphatemic diseases caused by excessive actions of FGF23 including TIO patients with unresectable tumors. However, these medications have limited effects and several adverse events. The inhibition of excessive FGF23 actions has been considered to be a novel therapy for these hypophosphatemic diseases. Human MAB for FGF23, burosumab, has been shown to improve biochemical abnormalities, roentgenological signs of rickets, growth, fracture healing and impaired mineralization in patients with XLH. Burosumab has been approved in several countries including Europe, North America and Japan. Long-term effects of burosumab need to be addressed in future studies.
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Affiliation(s)
- Seiji Fukumoto
- Fujii Memorial Institute of Medical Sciences, Institute of Advanced Medical Sciences, Tokushima University, Tokushima, Tokushima, Japan
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