Intravenous administration of a branched-chain amino-acid-free solution in children and adults with acute decompensation of maple syrup urine disease: a prospective multicentre observational study.

BACKGROUND: Patients with maple syrup urine disease (MSUD) experiencing metabolic decompensations have traditionally been treated with branched-chain amino acid (BCAA)-free mixture via oral or nasogastric administration routes. In some patients, enteral administration is not possible, either because the patient presents with vomiting, coma, or refuses nasogastric administration, thus intravenous (IV) BCAA-free solution is an appropriate intervention for these challenging cases. AIMS: This study aimed to evaluate the effectiveness and safety of managing metabolic decompensations by administering an IV BCAA-free solution. METHODS: This is an observational prospective study of data from MSUD patients hospitalised for decompensation episodes between 2010 and 2016 at 6 centres for rare metabolic diseases in France. RESULTS: A total of 24 patients (16 males; 8 females) experiencing 126 MSUD metabolic decompensation episodes (39 in children; 87 in adults) were admitted to hospital. At presentation, mean leucine plasma concentration was ≥ 381 µmol/L in 113/126 (89.7%) episodes. Children were treated with continuous IV BCAA-free solution at doses of 0.8 to 2.0 g/kg/day, for 4.8 days and adults for 3.8 days at doses of 0.5 to 2.6 g/kg/day. In the efficacy set of 102 analysable episodes leucine concentrations were normalised (to below 381 µmol/L) in 82% (n = 18/22) of episodes in children and in 84% (n = 67/80) of episodes in adults. Mean time to leucine normalisation was 3.0 days. This was significantly (p < 0.001) shorter than the algorithmically predicted time to leucine normalisation with traditional BCAA-free mixture. Duration of hospitalisation was significantly longer for children than for adults (7.1 days in children vs 5.2 days in adults, p = 0.012). No treatment-related adverse events were reported in any patients on IV BCAA-free solution. CONCLUSION: The IV BCAA-free solution is safe and effective in normalising leucine concentrations during MSUD decompensation episodes in both children and adults, offering a practical treatment alternative for those patients who cannot receive BCAA-free mixture via oral or nasogastric routes.

Long-term metabolic follow-up and clinical outcome of 35 patients with maple syrup urine disease.

BACKGROUND: Maple syrup urine disease (MSUD) is a rare disease that requires a protein-restricted diet for successful management. Little is known, however, about the psychosocial outcome of MSUD patients. This study investigates the relationship between metabolic and clinical parameters and psychosocial outcomes in a cohort of patients with neonatal-onset MSUD. METHODS: Data on academic achievement, psychological care, family involvement, and biochemical parameters were collected from the medical records of neonatal MSUD patients treated at Necker Hospital (Paris) between 1964 and 2013. RESULTS: Thirty-five MSUD patients with a mean age of 16.3 (2.1-49.0) years participated. Metabolic decompensations (plasma leucine >380 µmol/L) were more frequent during the first year of life and after 15 years, mainly due to infection and dietary noncompliance, respectively. Leucine levels increased significantly in adulthood: 61.5% of adults were independent and achieved adequate social and professional integration; 56% needed occasional or sustained psychological or psychiatric care (8/19, with externalizing, mood, emotional, and anxiety disorders being the most common). Patients needing psychiatric care were significantly older [mean and standard deviation (SD) 22.6 (7.7) years] than patients needing only psychological follow-up [mean (SD) 14.3 (8.9) years]. Patients with psychological follow-up experienced the highest lifetime number of decompensations; 45% of families had difficulty coping with the chronic disease. Parental involvement was negatively associated with the number of lifetime decompensations. CONCLUSION: Adults had increased levels of plasma leucine, consistent with greater chronic toxicity. Psychological care was associated with age and number of decompensations. In addition, parental involvement appeared to be crucial in the management of MSUD patients.

Efficacy and safety of i.v. sodium benzoate in urea cycle disorders: a multicentre retrospective study.

BACKGROUND: The efficacy and safety of intra-venous (i.v.) sodium benzoate for treating acute episodes of hyperammonemia in urea cycle enzyme disorders (UCD) is well known. However, published data do not provide a clear picture of the benefits and risks of this drug. We report a retrospective multicentre study on the use of i.v. sodium benzoate in patients treated for UCD between 2000 and 2010 in the 6 French reference centres for metabolic diseases. RESULTS: Sixty-one patients with UCDs - 22 ornithine transcarbamylase (20 confirmed, 2 suspected), 18 arginino-succinate synthetase, 15 carbamoyl phosphate synthetase, 3 arginosuccinate lyase, 1 arginase deficiency, 1 N-acetylglutamate synthetase, 1 HHH syndrome - required i.v. sodium benzoate over the course of 95 acute episodes (NH3 > 100 µmol/L or high-risk situations, i.e., gastroenteritis, surgery). Forty out of 61 patients experienced only one episode of decompensation (neonatal coma, 68.6 %). The most frequent cause of late decompensation was infection (55.5 %). A loading dose of i.v. sodium benzoate (median 250 mg/kg over 2 h) was administered for 41/95 acute episodes. The median maintenance dose was 246.1 mg/kg/day, administered via peripheral venous infusion in all cases except one via a central line. The total median duration of i.v. sodium benzoate treatment per episode was 2 days (0-13 days). The median durations of hospitalization in intensive care and metabolic units were 4 days (0-17 days) and 10 days (0-70 days), respectively. Eight patients died during the neonatal coma (n = 6) or surgery (n = 2). The median plasma ammonium level before treatment was 245.5 µmol/L (20.0-2274.0 µmol/L); it decreased to 40.0 µmol/L in patients who were alive (13.0-181.0 µmol/L) at the end of treatment with i.v. sodium benzoate. A decrease in ammonium level to ≤ 100 µmol/L was obtained in 92.8 % of episodes (64/69 of the episodes recorded for the 53 surviving patients). Five patients required another treatment for hyperammonemia (sodium phenylacetate + sodium benzoate, haemofiltration). Eighteen side effects were reported related to the i.v. infusion (local diffusion, oedema). CONCLUSION: This 10-year retrospective study shows that i.v. sodium benzoate associated with an emergency regimen is an effective and safe treatment for acute episodes of UCD.

Infovigilance: reporting errors in official drug information sources.

INTRODUCTION: The French drug database Thériaque (http://www.theriaque.org) developed by the (Centre National Hospitalier d'Information sur le Médicament) (CNHIM), is responsible for the dissemination of independent information about all drugs available in France. Each month the CNHIM pharmacists report problems due to inaccuracies in these sources to the French drug agency. In daily practice we devised the term "infovigilance": "Activity of error or inaccuracy notification in information sources which could be responsible for medication errors". The aim of this study was to evaluate the impact of CNHIM infovigilance on the contents of the Summary of Product Characteristics (SPCs). METHOD: The study was a prospective study from 09/11/2001 to 31/12/2002. The problems related to the quality of information were classified into four types (inaccuracy/confusion, error/lack of information, discordance between SPC sections and discordance between generic SPCs). MAIN OUTCOME MEASURES: (1) Number of notifications and number of SPCs integrated into the database during the study period. (2) Percentage of notifications for each type: with or without potential patient impact, with or without later correction of the SPC, per section. RESULTS: 2.7% (85/3151) of SPCs integrated into the database were concerned by a notification of a problem. Notifications according to type of problem were inaccuracy/confusion (32%), error/lack of information (13%), discordance between SPC sections (27%) and discordance between generic SPCs (28%). 55% of problems were evaluated as 'likely to have an impact on the patient' and 45% as 'unlikely to have an impact on the patient'. 22 of problems which have been reported to the French drug agency were corrected and new updated SPCs were published with the corrections. CONCLUSIONS: Our efforts to improve the quality of drug information sources through a continuous "infovigilance" process need to be continued and extended to other information sources.

[ATC and EphMRA classifications: evolution from 1996 to 2003 and comparative analysis]. / Classifications ATC et EphMRA: evolution entre 1996 et 2003 et analyse comparative.

In their daily practice, health practitioners use one or more pharmacotherapeutic classifications. This diversity of classifications impairs the exchange of drug information, while the use of international or European classifications facilitates this diffusion. The "Hospital National Center of Drugs Information" (CNHIM) has integrated ATC (Anatomical Therapeutic Chemical) and EphMRA (European Pharmaceutical Marketing Research Association) classifications into its "Thériaque" database and has given the ATC official status in France by publishing a French translation. The objective of this article was to analyse the evolution of these two classification systems between 1996 and 2003, and to compare their allocations (of codes) with those for the drugs present in Thériaque in January 2002. The ATC comprises 14 principal groups and five levels of hierarchy, while the EphMRA comprises 16 principal groups and three to four levels. In Thériaque, the ATC is linked to active substances and drugs, and the EphMRA to drugs. Data-processing requests have made it possible to make a comparative analysis. Each year, the two classification systems evolve in terms of addition, suppression, modification and subdivision. Two principal differences are evident in the allocations in Thériaque (class EphMRA K "Hospital solutions" versus class ATC B "Blood and blood forming organ"; class EphMRA T "Diagnostic agents" versus class ATC V "Various"). Classifications evolve in parallel or independently, and although they are closely related to one another, they retain their specificities in terms of structure and uses.

Medicines containing pharmaceutical excipients with known effects: a French review.

OBJECTIVE: The 13/01/01 French decree published an official list of brands and their generic drugs and identified 38 groups of excipients with known effects which are responsible for side effects and contraindication respectively. Our objective was to review all medicines marketed in France containing these excipients and to disseminate this information to French health care practitioners. METHOD: The side effects and contraindications regarding these excipients have been documented in the French drug database Thériaque (http://www.theriaque.org). They were documented for each medicine containing these excipients in addition to the data mentioned in the Summary of Product Characteristics (SPC). Results were obtained on 1 June 2001 by using computerised queries from the database. RESULTS: Within the 38 groups, 300 specific excipients and derivatives with known effects were identified. Among the 8900 medicines (100%), 5567 medicines (62.6%) contained one or more of these excipients; 2483 contained 1 excipient, 1819 contained 2 excipients and 1265 contained 3 or more excipients; 410 side effects or contra-indications--were described according to the route of administration and the threshold dose. They were linked to these 5567 medicines; 5818 excipients with a threshold dose were mentioned in the 'composition' sections of these 5567 medicines. Among these 5818 excipients, 3385 quantitative doses were documented in the SPCs or EPARs. CONCLUSION: This review shows the extent of most of the excipients contained in medicines marketed in France. The dissemination of these data offsets the lack of information in the SPCs.