Evaluation of Serious Infection in Pediatric Patients with Low Immunoglobulin Levels Receiving Rituximab for Granulomatosis with Polyangiitis or Microscopic Polyangiitis

Introduction: The aim of this work was to assess the impact of prolonged low immunoglobulin (IgG or IgM) serum concentrations on the potential cumulative serious infection (SI) risk in pediatric patients following rituximab treatment for granulomatosis with polyangiitis or microscopic polyangiitis (GPA/MPA) in PePRS. Methods: Patients aged ≥ 2 to < 18 years received four weekly intravenous rituximab infusions of 375 mg/m2 and concomitant glucocorticoid taper. After 6 months, patients could receive further rituximab and/or other immunosuppressants per investigator discretion. Immunoglobulin levels and SIs were assessed throughout the 4.5-year observation period. Prolonged low IgG or IgM was defined as below the lower limit of normal age-specific reference range for ≥ 4 months. Results: A total of 25 patients were included, of whom 19 (76%) had GPA and six (24%) had MPA; 18 (72%) had newly diagnosed disease and seven (28%) had relapsing disease. All 25 patients completed the rituximab induction regimen; 24 completed ≥ 18 months of follow-up. At month 18, eighteen patients (72%) had prolonged low IgG; 19 (76%), prolonged low IgM; and 15 (60%), both. Seven patients (28%) had nine SIs; one occurred during or after prolonged low IgG only, two during or after prolonged low IgM only, and six during or after concurrent prolonged low IgG and IgM. No patients died or discontinued the study due to SI. All patients had complete and sustained peripheral B-cell depletion for ≥ 6 months. Conclusions: The majority of pediatric patients who received rituximab for GPA/MPA with prolonged low immunoglobulin levels did not experience SIs. In patients with SIs, these events were manageable, and the number of SIs did not increase over time or with multiple rituximab treatments. These observations are consistent with the rituximab safety profile in adults with GPA/MPA. Trial registration: ClinicalTrials.gov identifier, NCT01750697

On the functional and toxic effects of Brassica derived products in experimental models

I vegetali appartenenti alla famiglia delle Brassicaceae, sono ricchi di molecole biologicamente attive note per le numerose proprietà salutari. L’effetto di un estratto di germogli di cavolo nero toscano (TBCSE) è stato investigato, in termini chemiopreventivi, sugli enzimi epatici del metabolismo degli xenobiotici e antiossidanti, in ratti trattati con TBCSE. I risultati hanno mostrato un complesso pattern di modulazione, con una prevalente inibizione, del sistema citocromo P450-dipendente, e induzioni significative degli enzimi di fase II (glutatione transferasi e glucuronosiltransferasi) e antiossidanti (catalasi, NAD(P)H:chinone reduttasi, glutatione reduttasi e perossidasi). Successivamente, l’effetto di TBCSE è stato studiato nei confronti delle alterazioni provocate da un’alimentazione iperlipidica nel ratto. Il trattamento si è dimostrato efficace nel contrastare gli effetti deleteri dei grassi presenti nella dieta, come l’iperlipidemia, l’aumento del peso corporeo e del fegato, l’indebolimento delle attività degli enzimi antiossidanti e del potenziale detossificante a livello epatico. Complessivamente, TBCSE emerge essere un promettente prodotto nutraceutico con potenziali effetti chemiopreventivi, e da impiegare come strategia alimentare per contrastare gli effetti correlati ad una dieta iperlipidica. Il consumo di dosi sovralimentari di molecole isolate dalle Brassicaceae, tramite per esempio integratori dietetici, come strategia alimentare preventiva, potrebbe tuttavia rappresentare un rischio per la salute. La potenziale tossicità del sulforafane, glucorafanina, indolo-3-carbinolo, e 3,3'-diindolimetano, è stata valutata in epatociti primari di ratto. La citotossicità e l’induzione di stress ossidativo, osservate a concentrazioni non lontane da quelle che potrebbero essere raggiunte in vivo, insieme ad una forte modulazione dell’espressione genica, riguardante principalmente il metabolismo degli xenobiotici, risposte ad alterazioni dello stato ossidoredutivo, eventi di riparazione del DNA e di proteine, induzione dell’apoptosi, e meccanismi (co)cancerogeni, sottolineano la potenzialità di queste molecole di determinare un rischio tossicologico, in seguito ad un’assunzione prolungata e ad alte dosi.Brassica vegetables are rich in bioactive phytochemicals known for their healthy properties. The chemopreventive potential of sprout extract from Tuscan black cabbage (TBCSE), through modulation of hepatic xenobiotic-metabolizing apparatus and antioxidant defenses, was investigated in rats administered with the extract. A complex, mild modulation pattern, mainly inhibition, of the P450-related monooxygenases as well as significant inductions of phase II (glutathione S-transferase and UDPglucuronosyl-transferase glutathione) and antioxidant enzymes (catalase, NAD(P)H:quinone reductase, glutathione reductase and peroxidase), were recorded. Afterward, the role of TBCSE intake was studied against the alterations from a high fat diet. The extract was able to counteract the hyperlipidaemia, the body and liver weight gains, and the antioxidant as well as the phase II enzymes deregulation, induced by the diet rich in fat. Overall, these results are in support of the potential health-promoting application of TBCSE, as a nutraceutical, to counteract the perturbations associated with a hyperlipidaemic diet, and with chemopreventive properties. A high intake of dietary supplements based on Brassica derived phytochemicals, as alimentary strategy for boosting health, might, nevertheless, be harmful. The potential toxicity of sulforaphane, glucoraphanin, indole-3-carbinol and 3,3’-diindolylmethane, was evaluated in primary rat heapatocytes. The cytotoxicity and the oxidative stress, observed at concentrations, not far from the ones reached in in vivo experiments, along with the strong modulation of gene expression, mainly concerning xenobiotic metabolism, response to cellular redox status alterations, DNA and proteins repair, apoptosis induction, and (co)carcinogenic mechanisms, underline the potential risk deriving from a regular intake of high doses of molecules from Brassicaceae

On Enzyme-Based Anticancer Molecular Dietary Manipulations

Evidence from both epidemiological and experimental observations has fuelled the belief that the high consumption of fruits and vegetables rich in nutrients and phytochemicals may help prevent cancer and heart disease in humans. This concept has been drastically simplified from the dietary approaches to the use of single bioactive components both as a single supplement or in functional foods to manipulate xenobiotic metabolism. These procedures, which aim to induce mutagen/carcinogen detoxification or inhibit their bioactivation, fail to take into account the multiple and paradoxical biological outcomes of enzyme modulators that make their effects unpredictable. Here, we show that the idea that the physiological roles of specific catalysts may be easily manipulated by regular long-term administration of isolated nutrients and other chemicals derived from food plants is not viable. In contrast, we claim that the consumption of healthy diets is most likely to reduce mutagenesis and cancer risk, and that both research endeavours and dietary recommendations should be redirected away from single molecules to dietary patterns as a main strategy for public health policy

Effect of sprout extract from Tuscan black cabbage on xenobiotic-metabolizing and antioxidant enzymes in rat liver

In recent years, health protection by natural products has received considerable attention, and a multitude of nutraceuticals have been characterized and their use promoted. Dietary consumption of Cruciferous vegetables, rich in glucosinolates (GLs), and their myrosinase-mediated hydrolysis products isothiocyanates (ITCs), were associated with reductions in cancer risk. In this study, the chemo-preventive potential of sprout extract of Tuscan black cabbage (Brassica oleracea L. var. acephala subvar. Laciniata L.) (TBCSE), through modulation of the xenobiotic-metabolizing apparatus and antioxidant defenses, was investigated in Sprague-Dawley rat liver. TBCSE was administered either orally or intraperitoneally, at a dose of 15 mg/kg b.w., daily for twenty-one consecutive days, in the absence or presence of exogenous myrosinase, -thioglucoside glucohydrolase (MYR), to distinguish the effects of intact GLs and ITCs, in the context of the extract. A complex, mild modulation pattern of P450-related monooxygenases was observed, mainly regarding CYP content (up to 36% loss), NADPH cytochrome (P450) c-reductase (up to 26% loss), CYP1A1 (up to 23% loss), but no evident distinctions among the effects of the extracts containing GLs or ITCs, were noted. In contrast, significant inductions of phase-II enzymes (up to 107% for UDPglucuronosyl- transferase, and up to 36% for glutathione S-transferase) were recorded only where the GLs to ITCs conversion had occurred. A boosting effect on catalase (up to 38%), NAD(P)H:quinone reductase (up to 70%), glutathione reductase and glutathione peroxidase (up to 10%) was also recorded, suggesting an indirect antioxidant capacity of the extracts. Overall, the general phase-I inhibition, together with the up-regulation of detoxifying phase-II and antioxidant enzymes, exerted by the TBCSE supplementation, seem to be in line with the classical chemopreventive theory, but whether the addition of exogenous MYR is relevant, still remains to be clarified. These results are in support of the potential health-promoting application of TBCSE, as a nutraceutical

Evaluation of Serious Infection in Pediatric Patients with Low Immunoglobulin Levels Receiving Rituximab for Granulomatosis with Polyangiitis or Microscopic Polyangiitis

Introduction The aim of this work was to assess the impact of prolonged low immunoglobulin (IgG or IgM) serum concentrations on the potential cumulative serious infection (SI) risk in pediatric patients following rituximab treatment for granulomatosis with polyangiitis or microscopic polyangiitis (GPA/MPA) in PePRS. Methods Patients aged >= 2 to = 4 months. Results A total of 25 patients were included, of whom 19 (76%) had GPA and six (24%) had MPA; 18 (72%) had newly diagnosed disease and seven (28%) had relapsing disease. All 25 patients completed the rituximab induction regimen; 24 completed >= 18 months of follow-up. At month 18, eighteen patients (72%) had prolonged low IgG; 19 (76%), prolonged low IgM; and 15 (60%), both. Seven patients (28%) had nine SIs; one occurred during or after prolonged low IgG only, two during or after prolonged low IgM only, and six during or after concurrent prolonged low IgG and IgM. No patients died or discontinued the study due to SI. All patients had complete and sustained peripheral B-cell depletion for >= 6 months. Conclusions The majority of pediatric patients who received rituximab for GPA/MPA with prolonged low immunoglobulin levels did not experience SIs. In patients with SIs, these events were manageable, and the number of SIs did not increase over time or with multiple rituximab treatments. These observations are consistent with the rituximab safety profile in adults with GPA/MPA

Phase IIa Global Study Evaluating Rituximab for the Treatment of Pediatric Patients With Granulomatosis With Polyangiitis or Microscopic Polyangiitis

ObjectiveTo assess the safety, tolerability, pharmacokinetics, and efficacy of rituximab (RTX) in pediatric patients with granulomatosis with polyangiitis (GPA) or microscopic polyangiitis (MPA).MethodsThe Pediatric Polyangiitis Rituximab Study was a phase IIa, international, open-label, single-arm study. During the initial 6-month remission-induction phase, patients received intravenous infusions of RTX (375 mg/m2 body surface area) and glucocorticoids once per week for 4 weeks. During the follow-up period, patients could receive further treatment, including RTX, for GPA or MPA. The safety, pharmacokinetics, pharmacodynamics, and exploratory efficacy outcomes with RTX were evaluated.ResultsTwenty-five pediatric patients with new-onset or relapsing disease were enrolled at 11 centers (19 with GPA [76%] and 6 with MPA [24%]). The median age was 14 years (range 6-17 years). All patients completed the remission-induction phase. During the overall study period (≤4.5 years), patients received between 4 and 28 infusions of RTX. All patients experienced ≥1 adverse event (AE), mostly grade 1 or grade 2 primarily infusion-related reactions. Seven patients experienced 10 serious AEs, and 17 patients experienced 31 infection-related AEs. No deaths were reported. RTX clearance correlated with body surface area. The body surface area-adjusted RTX dosing regimen resulted in similar exposure in both pediatric and adult patients with GPA or MPA. Remission, according to the Pediatric Vasculitis Activity Score, was achieved in 56%, 92%, and 100% of patients by months 6, 12, and 18, respectively.ConclusionIn pediatric patients with GPA or MPA, RTX is well tolerated and effective, with an overall safety profile comparable to that observed in adult patients with GPA or MPA who receive treatment with RTX. RTX is associated with a positive risk/benefit profile in pediatric patients with active GPA or MPA