Effectiveness of asfotase alfa for treatment of adults with hypophosphatasia: results from a global registry.

BACKGROUND: Hypophosphatasia (HPP) is a rare inherited disease caused by deficient activity of tissue-nonspecific alkaline phosphatase. Many adults with HPP have a high burden of disease, experiencing chronic pain, fatigue, limited mobility, and dental issues, contributing to decreased health-related quality of life (HRQoL). HPP may be treated with the enzyme replacement therapy asfotase alfa though real-world data in adults are limited. This analysis was conducted to assess the clinical effectiveness of asfotase alfa among adults in the Global HPP Registry. METHODS: The Global HPP Registry is an observational, prospective, multinational study. Adults ≥ 18 years of age were included in this analysis if they had serum alkaline phosphatase (ALP) activity below the age- and sex-adjusted reference ranges, and/or ALPL variant(s), and received asfotase alfa for ≥ 6 months. Mobility was assessed with the 6-Minute Walk Test (6MWT), and patient-reported outcomes tools were used to assess pain (Brief Pain Inventory-Short Form), quality of life (36-item Short Form Health Survey, version 2 [SF-36v2]), and disability (Health Assessment Questionnaire-Disability Index) at multiple time points from baseline through Month 36. Data were collected as per usual standard of care; patients may not have contributed data at all time points. RESULTS: A total of 190 patients met the inclusion criteria. For patients with ≥ 1 follow-up measurement, the mean distance achieved on 6MWT increased from 404 m (range 60-632 m) at baseline (n = 31) to 484 m at Month 12 (range 240-739 m; n = 18) and remained above baseline through Month 36 (n = 7). Improvements in mean self-reported pain severity scores ranged from - 0.72 (95% CI: - 1.23, - 0.21; n = 38) to - 1.13 (95% CI: - 1.76, - 0.51; n = 26) and were observed at all time points. Improvements in the Physical Component Summary score of SF-36v2 were achieved by Month 6 and sustained throughout follow-up. There was a trend toward improvement in the Mental Component Summary score of SF-36v2 at most time points, with considerable fluctuations from Months 12 (n = 28) through 36 (n = 21). The most frequent adverse events were injection site reactions. CONCLUSIONS: Adults with HPP who received asfotase alfa for ≥ 6 months experienced improvements in mobility, physical function, and HRQoL, which were maintained over 3 years of follow-up. REGISTRATION: NCT02306720; EUPAS13514.

Phase-3 trial of recombinant human alkaline phosphatase for patients with sepsis-associated acute kidney injury (REVIVAL).

PURPOSE: Ilofotase alfa is a human recombinant alkaline phosphatase with reno-protective effects that showed improved survival and reduced Major Adverse Kidney Events by 90 days (MAKE90) in sepsis-associated acute kidney injury (SA-AKI) patients. REVIVAL, was a phase-3 trial conducted to confirm its efficacy and safety. METHODS: In this international double-blinded randomized-controlled trial, SA-AKI patients were enrolled < 72 h on vasopressor and < 24 h of AKI. The primary endpoint was 28-day all-cause mortality. The main secondary endpoint was MAKE90, other secondary endpoints were (i) days alive and free of organ support through day 28, (ii) days alive and out of the intensive care unit (ICU) through day 28, and (iii) time to death through day 90. Prior to unblinding, the statistical analysis plan was amended, including an updated MAKE90 definition. RESULTS: Six hundred fifty patients were treated and analyzed for safety; and 649 for efficacy data (ilofotase alfa n = 330; placebo n = 319). The observed mortality rates in the ilofotase alfa and placebo groups were 27.9% and 27.9% at 28 days, and 33.9% and 34.8% at 90 days. The trial was stopped for futility on the primary endpoint. The observed proportion of patients with MAKE90A and MAKE90B were 56.7% and 37.4% in the ilofotase alfa group vs. 64.6% and 42.8% in the placebo group. Median [interquartile range (IQR)] days alive and free of organ support were 17 [0-24] and 14 [0-24], number of days alive and discharged from the ICU through day 28 were 15 [0-22] and 10 [0-22] in the ilofotase alfa and placebo groups, respectively. Adverse events were reported in 67.9% and 75% patients in the ilofotase and placebo group. CONCLUSION: Among critically ill patients with SA-AKI, ilofotase alfa did not improve day 28 survival. There may, however, be reduced MAKE90 events. No safety concerns were identified.

Impressive clinical improvement and disappearance of neuropathic pain in an adult patient with hypophosphatasia treated with asfotase alfa.

Hypophosphatasia (HPP) is a rare disorder, resulting from loss-of-function variants of the ALPL gene encoding non-tissue specific alkaline phosphatase (TNSALP). Presentation varies largely, with increased severity usually occurring with earlier disease onset. Here we describe the clinical improvement of a 57-year-old woman with childhood onset HPP, after initiating treatment with asfotase alfa (Strensiq®). This was started because of the rapid and progressive radiological deterioration of bone structure after placement of nails in both upper legs for spontaneous atypical femur fracture (AFF) - like fractures. Initiation of treatment, not only resulted in stabilization of bone structure on X-rays, but within a few weeks there was a dramatic reduction of burning pain sensations in the lower legs, attributed in retrospect to neuropathic pain, and also almost complete disappearance of headaches. Additionally, unhealed metatarsal fractures finally healed after almost 10 years. Drug efficacy was further evaluated through -quality of life questionnaires and multiple tests conducted by the physiotherapist, and showed clear improvements. Within 3 months after starting asfotase alfa, the patient was able to carry out her daily tasks indoors without relying on a walker and even started electric bike rides for 20 km/day. In conclusion, treatment with asfotase alfa, halted rapid radiological bone deterioration after bilateral intramedullary femoral pen placement and strongly increased quality of life, marked by rapid disappearance of neuropathic pain, reduction in headaches and musculoskeletal pains, and enhanced muscle strength and mobility. The quick and almost complete disappearance of neuropathic pain and headache suggests a relation with disturbed levels of metabolites in HPP.

Un caso de hipofosfatasia perinatal grave con una mutación novedosa / Severe perinatal hypophosphatasia case with a novel mutation

La hipofosfatasia es un trastorno hereditario raro causado por mutaciones en el gen ALPL. Causa defectos en la mineralización ósea y dental, función respiratoria anormal, convulsiones, hipotonía, dolor óseo y nefrocalcinosis. Las formas clínicas se reconocen según la edad al diagnóstico y la gravedad. Presentamos el caso de una lactante con fontanela anterior agrandada, bóveda craneal blanda, fracturas, dificultad respiratoria y convulsiones. El análisis bioquímico mostró hipercalcemia, fosfato sérico normal y fosfatasa alcalina sérica baja. La radiografía mostró hipomineralización, fracturas y callos. La concentración plasmática de piridoxal-5'-fosfato era de 762 mg/l (intervalo normal: 5-50) y la concentración de fosfoetanolamina en orina era de 1015 mmol/l (intervalo normal: 15-341). El análisis del gen ALPL mostró dos mutaciones heterocigotas compuestas, una de las cuales es novedosa. El diagnóstico y tratamiento tempranos de la hipofosfatasia perinatal podría mejorar los resultados y tener un impacto positivo en la sobrevida.

Hypophosphatasia (HPP) is a rare inherited disorder caused by mutations in the ALPL gene. Mineralization defect in bones and teeth, abnormal respiratory function, seizures, hypotonia, bone pain, and nephrocalcinosis can be observed. Clinical forms are usually recognized based on age at diagnosis and severity of features. We present an infant with an enlarged anterior fontanelle, soft calvarium, fractures, respiratory distress, and seizures. Biochemical analysis showed hypercalcemia, normal serum phosphate, and low serum alkaline phosphatase (ALP) levels. X-ray showed hypomineralization, fractures, and callus formations. Plasma pyridoxal 5'-phosphate (PLP) was 762 mg/L (NV : 5-50) and urine phosphoethanolamine (PEA) was 1015 mmol/L (NV : 15-341) and ALPL gene analysis showed two compound heterozygous mutations, one of which is a novel one. Early diagnosis and treatment of perinatal HPP may improve outcomes and might have a positive impact on survival.

Paget's disease of bone: an endocrine society clinical practice guideline

OBJECTIVE: The aim of this guideline was to formulate practice guidelines for the diagnosis and treatment of Paget's disease of the bone. PARTICIPANTS: The guideline was developed by an Endocrine Society-appointed Task Force of experts, a methodologist, and a medical writer. EVIDENCE: This evidence-based guideline was developed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system to describe both the strength of recommendations and the quality of evidence. CONSENSUS PROCESS: One group meeting, several conference calls, and e-mail communications enabled consensus. Committees and members of The Endocrine Society and the European Society of Endocrinology reviewed and commented on preliminary drafts of these guidelines. Two systematic reviews were conducted to summarize supporting evidence. CONCLUSIONS: We recommend that plain radiographs be obtained of the pertinent regions of the skeleton in patients with suspected Paget's disease. If the diagnosis is confirmed, we suggest that a radionucleotide bone scan be done to determine the extent of the disease. After diagnosis of Paget's disease, we recommend measurement of serum total alkaline phosphatase or, when warranted, a more specific marker of bone formation or bone resorption to assess the response to treatment or evolution of the disease in untreated patients. We suggest treatment with a bisphosphonate for most patients with active Paget's disease who are at risk for future complications. We suggest a single 5-mg dose of iv zoledronate as the treatment of choice in patients who have no contraindication. In patients with monostotic disease who have a normal serum total alkaline phosphatase, we suggest that a specific marker of bone formation and bone resorption be measured, although these may still be normal. Serial radionuclide bone scans may determine the response to treatment if the markers are normal. We suggest that bisphosphonate treatment may be effective in preventing or slowing the progress of hearing loss and osteoarthritis in joints adjacent to Paget's disease and may reverse paraplegia associated with spinal Paget's disease. We suggest treatment with a bisphosphonate before surgery on pagetic bone.(AU)

On the prediction of Hodgkin lymphoma treatment response

Purpose. The cure rate in Hodgkin lymphoma is high, but the response along with treatment is still unpredictable and highly variable among patients. Detecting those patients who do not respond to treatment at early stages could bring improvements in their treatment. This research tries to identify the main biological prognostic variables currently gathered at diagnosis and design a simple machine learning methodology to help physicians improve the treatment response assessment. Methods. We carried out a retrospective analysis of the response to treatment of a cohort of 263 Caucasians who were diagnosed with Hodgkin lymphoma in Asturias (Spain). For that purpose, we used a list of 35 clinical and biological variables that are currently measured at diagnosis before any treatment begins. To establish the list of most discriminatory prognostic variables for treatment response, we designed a machine learning approach based on two different feature selection methods (Fisher’s ratio and maximum percentile distance) and backwards recursive feature elimination using a nearest-neighbor classifier (k-NN). The weights of the k-NN classifier were optimized using different terms of the confusion matrix (true- and false-positive rates) to minimize risk in the decisions. Results and conclusions. We found that the optimum strategy to predict treatment response in Hodgkin lymphoma consists in solving two different binary classification problems, discriminating first if the patient is in progressive disease; if not, then discerning among complete and partial remission. Serum ferritin turned to be the most discriminatory variable in predicting treatment response, followed by alanine aminotransferase and alkaline phosphatase. The importance of these prognostic variables suggests a close relationship between inflammation, iron overload, liver damage and the extension of the disease (AU)

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Recesión de metástasis óseas diseminadas en un paciente con cáncer de próstata / No disponible

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Variaciones de la enzima fosfatasa alcalina en la pulpa dental / Variations of alkaline phosphatase enzyme in the dental pulp

En las últimas décadas, numerosas investigaciones se han dedicado al estudio de los mecanismos potenciales implicados en el desarrollo de la caries dental y su prevención, sin embargo, a pesar de haber disminuido gradualmente el índice de caries en la población, son muchos los pacientes que necesitan tratarse la caries dental, tal es así que continuamente se están utilizando diferentes materiales en la búsqueda de aquel que ante una agresión a la pulpa, ayude a una respuesta biológica de la misma, conservando de esta forma su integridad. De ahí la importancia de la actividad de la fosfatasa alcalina de la pulpa en el proceso carioso, como una reacción ante el hidróxido de calcio que continuamente se está usando en toda la red docente-asistencial del país. Se seleccionaron 50 dientes monorradiculares, con pulpa viva y con caries de segundo, tercer y cuarto grado y 50 dientes sanos de pacientes de diferentes edades. Se extrajo la pulpa de cada diente y se realizaron improntas (3 por cada muestra), una de las cuales se procesó para obtener orientación morfológica, y las otras 2 para valorar la actividad de la fosfatasa alcalina. Para esto se utilizaron 2 métodos: el de calcio cobalto y el de alpha naftol fosfato de Gomori. Como resultado, se obtuvo que la pulpa tiene más actividad enzimática en caries profunda y que la edad del paciente no determina el aumento o disminución de dicha actividad(AU)

Variaciones de la enzima fosfatasa alcalina en la pulpa dental / Variations of alkaline phosphatase enzyme in the dental pulp

En las últimas décadas, numerosas investigaciones se han dedicado al estudio de los mecanismos potenciales implicados en el desarrollo de la caries dental y su prevención, sin embargo, a pesar de haber disminuido gradualmente el índice de caries en la población, son muchos los pacientes que necesitan tratarse la caries dental, tal es así que continuamente se están utilizando diferentes materiales en la búsqueda de aquel que ante una agresión a la pulpa, ayude a una respuesta biológica de la misma, conservando de esta forma su integridad. De ahí la importancia de la actividad de la fosfatasa alcalina de la pulpa en el proceso carioso, como una reacción ante el hidróxido de calcio que continuamente se está usando en toda la red docente-asistencial del país. Se seleccionaron 50 dientes monorradiculares, con pulpa viva y con caries de segundo, tercer y cuarto grado y 50 dientes sanos de pacientes de diferentes edades. Se extrajo la pulpa de cada diente y se realizaron improntas (3 por cada muestra), una de las cuales se procesó para obtener orientación morfológica, y las otras 2 para valorar la actividad de la fosfatasa alcalina. Para esto se utilizaron 2 métodos: el de calcio cobalto y el de alpha naftol fosfato de Gomori. Como resultado, se obtuvo que la pulpa tiene más actividad enzimática en caries profunda y que la edad del paciente no determina el aumento o disminución de dicha actividad(AU)

In the last decades, numerous investigations have been made on the study of potential mechanisms involved in the development of dental caries and their prevention. However, in spite of the gradual reduction of dental caries in the population, a lot of patients need to have their dental caries treated and different materials are continuously used searching for one that before the aggression to the pulp helps it to give a biological response, conserving this way its integrity. That's why the activity of the alkaline phosphatase of the pulp in the caries process is important as a reaction to the calcium hydroxide that is constantly utilized in the teaching-health service network of the country. 50 monoradicular teeth with living pulp and with caries of second, third and fourth degree, and 50 sound teeth from patients of different ages were selected. The pulp of each tooth was extracted and impressions were made (3 per sample). One of them was processed to obtain morphological guidance and the other two to assess the activity of alkaline phosphatase. The cobalt calcium method and Gomori's alpha naphthol phosphate method were used to this end. As a result, it was proved that the pulp has a higher enzymatic activity in deep caries and that the age of the patient does not determine the increase or decrease of this activity(AU)

Hipofosfatasia: nuevas perspectivas terapéuticas / Hypophosphatasia: new therapeutic approaches

La hipofosfatasia es una enfermedad hereditaria caracterizada por una deficiencia de fosfatasa alcalina no específica de tejido, que genera una mineralización anormal del tejido óseo y dental. La presentación clínica es muy variable, desde formas neonatales con alta mortalidad, hasta variantes más leves del adulto con fracturas por fragilidad y osteomalacia. El diagnóstico bioquímico se basa en la determinación de valores séricos bajos de fosfatasa alcalina e incremento sérico o urinario de fosfoetanolamina, piridoxal 5’-fosfato y pirofosfato inorgánico. El tratamiento ha sido muy heterogéneo y con resultados limitados. Recientes avances abren nuevas líneas de investigación en esta compleja enfermedad. Actualmente, la administración de hormona paratiroidea en la hipofosfatasia del adulto y el tratamiento de sustitución enzimático, en el que se utiliza una novedosa forma soluble de fosfatasa alcalina recombinante humana en las formas clínicas más graves, constituyen los tratamientos con mejores perspectivas (AU)

Hypophosphatasia is a rare inborn error of metabolism characterized by a deficiency of tissue non-specific alkaline phosphatase (bone, liver and kidney) which leads to abnormal mineralization of skeletal and dental tissues. There are several forms of hypophosphatasia with wide variations in severity ranging from high-mortality neonatal presentation to mild forms in adults associated with fragility fractures and osteomalacia. The biochemical diagnosis is based on measurement of low levels of serum alkaline phophatase and increased serum or urine concentrations of phosphoethalnolamine, pyridoxal 5’-phosphate and inorganic pyrophosphate. To date, therapy has been quite heterogeneous with quite limited outcomes. The recent progress in research leads to new therapeutic approaches for this complex disease. The administration of parathyroid hormone in adult hypophosphatasia and enzyme replacement therapy using a novel soluble recombinant form of human alkaline phosphatase for severe forms of hypophosphatasia are currently the most promising approaches (AU)

Marcadores bioquímicos de remodelado óseo: aspectos descriptivos / Biochemical markers of bone turnover: descriptives aspects

La osteoporosis posmenopáusica es un problema de salud pública mundial, y su principal causa es la deficiencia estrogénica. El metabolismo óseo presenta dos actividades opuestas: la formación de hueso nuevo por el osteoblasto y la degradación o resorción de hueso viejo por el osteoclasto. Dado que estas actividades cursan con el vertido a la circulación de una serie de productos, los denominados marcadores bioquímicos de remodelado óseo, nosotros podemos estimar la tasa de ambos procesos determinando los valores séricos o urinarios de estos productos en el laboratorio. Estos marcadores son una poderosa herramienta para el ginecólogo, ya que su determinación es fácil de realizar, es barata, puede ser repetida a menudo y refleja el metabolismo óseo en un momento dado. En los últimos años se han desarrollado marcadores más específicos como los telopéptidos del colágeno tipo I (CTx y NTx), y se están introduciendo métodos automatizados para su determinación que disminuyen la variabilidad intra e interensayo, aunque existen diversas fuentes de variabilidad que deben tenerse en cuenta a la hora de evaluar su uso (AU)

Erythrocyte alkaline phosphatase in patients with myotonic muscle disorders / Fosfatasa alcalina en eritrocitos de pacientes con enfermedades musculares miotónicas

The allosteric behavior of the p-nitrophenyl-phosphatase (EC.3.1.3.1) from membrane erythrocytes was investigated in the following mulltisystemic diseases: myotonic dystrophy limb-girdle muscular dystrophy, Charcot-Marie-Tooth and juvenile spinal muscular atrophy; in myotonia congenita. which is not a multisystemic disease, and in healthy controls. The Hill coefficient in F-inhibition in controls was different from that in multisystemic diseases patients but not from that in myotonia congenita patients. Changes in the cooperative type kinetics would suggest that the interaction membrane-enzyme in controls and in patients with neuromuscular disorders is only different for multisystemic diseases