Forskningsprosjekter ved NAPOS FoU-dag 23. mai, 2008 Atle Brun Nasjonalt kompetansesenter for porfyrisykdommer Laboratorium for klinisk biokjemi Haukeland Universitetssykehus atle.brun@helse-bergen.no

Intense magesmerter Nevrologiske og psykiske symptomer

FoU ved NAPOS Basalforskning Klinisk epidemiologisk forskning Klinisk anvendt forskning

NAPOS FoU, Oversikt 1 Prosjekt Ansvarlige Periode Evaluering av sikkerhet og effekt ved subkutane bioresorberbare CUV1647-implantat hos pasienter med erytropoietisk protoporfyri Sverre Sandberg, Tore Morken, Solveig Mikalsen, Helse Bergen HF 2007 - 2009 Vevspesifikk regulering av jern- og hem-metabolismen i relasjon til behandling av pasienter med Erytropoietisk protoporfyri Nirmala Ernest Jeyaraj (UiB), Atle Brun, Helse Bergen HF 2007 - 2008 European Porphyria Network (EPNET) Work Package 5: Information about drugs Atle Brun, Helse Bergen HF 2007 - 2010 European Porphyria Network (EPNET) Work Package 6: Network of laboratory centres for prophyria diagnosis Sverre Sandberg, Helse Bergen HF

NAPOS FoU, Oversikt 2 Prosjekt Ansvarlige Periode Porfyrier i Norge Jørild Haugen, Sverre Sandberg, Helse Bergen HF 2006 - 2008 Differentiation between sporadic and familial porphyria cutanea tarda Aasne Karine Aarsand, Helse Bergen HF 2001 - 2008 The excretion of porphyrins and porphyrin precursors in acute attacks of acute intermittent porphyria (AIP) 2005 - 2008 Legemidler og akutte porfyrier: en internasjonal nettbasert legemiddeldatabase Atle Brun, Erik Pomp, Helse Bergen HF 2003 - 2017

NAPOS FoU, Oversikt 3 Prosjekt Ansvarlige Periode Erytropoietisk protoporfyri: Undersøkelse av ferrokelatase aktivitet i intakte, humane retikulocytter Atle Brun, Sverre Sandberg (Helse Bergen HF), Nirthiga Vivekanathan, UiB 2005 - 2008 Protection from phototoxic injury in Erythropoietic Protoporphyria Atle Brun, Helse Bergen HF 2006 - 2008 Nytteverdi av genetiske veiledningssamtaler ved porfyri Birte Lundhaug, Universitetet i Bergen

Symptomer ved Erytropoietisk protoporfyri (EPP) Akutt fotosensitivitet: Soleksponering kan føre til intense smerter i huden etter bare 5-30 min i solen Brennende/ prikkende/sviende smerter på lyseksponerte områder som varer i dager Debuterer vanligvis i tidlig barnealder Forverring av symptomer vår og sommer Huden ser vanligvis normal ut til tross for store smerter Barn og foreldre blir oppfattes som ”hysteriske” Diagnose: ”DOCTORS DELAY”

Hemebiosynthesis Erythropoietic protoporphyria (EPP) Ferrochelatase reduction to 30% Photosensivity from early childhood. Hepatobilary complication 1 2 3 4 Glycin Succinat 5 6 7 Ferrochelatase Fe 8 This is a overview of the hemebiosynthesis. Heme is synthesised by 8 enzymes. An enzymatic defect at each step beside of the first enzym of heme synthsis accompanies each form of porphyria. We are today going to focus on the last enzyme of the heme biosynthesis Ferrochelatse. Ferrochelatse has as a function to incoperate iron into protoporphyrin and produce heme. Defect in FC results in Erythopoietic protoporphyria EPP. Protoporphyrin (PP) + Fe 2+ = Heme

Behandling for å redusere lysømfintligheten Reflekterende solkremer (titan/jern/zink-oxide) Selvbruningskrem (Dihydroxyaceton) Beta-carotene; 180-300 mg/dag (gulskjær i huden) Hos mange pasienter: Liten effekt

 Hudsymptomer selv inne Problem Vindusglass stopper ikke det blå lyset  Hudsymptomer selv inne

Dette gir ofte problemer i hverdagen På arbeidsstedet Skole Hjemme Under transport til og fra arbeid, skole og aktiviteter

Er det mulig spesifikt å stoppe den delen av lysspekteret som påvirker porfyrinene i huden?

Absorbsjon spekteret av protoporphyrin PP has is absorbtion maximum around 400 nm. The visual specter of the sun light starts from 400 to 700 nm. PP are seen in the blue colur part of the visual spectrum.

Lysbeskyttende spesialfilm for EPP Velegnet beskyttelse for personer med Erytropoietisk protoporfyri (EPP). Filtrerer bort den blå delen av lysspekteret (350 – 450 nm) som gir hudskadene ved EPP. Resten av spekteret (>470 nm) slipper gjennom.

Lysbeskyttende film Vinduene i hus Bilruter (relativt flate) Beregnet for permanent montering på glass Vinduene i hus Bilruter (relativt flate) Kan også brukes på annen måte Rullegardinløsninger ”Personlig visir”

Hepatobilary complication Protoporphyrin is hepatotoxic. Some EPP patients develop cholestatic liver faliure. Liver transplantation Bone marrow transplantation Protoporphyrin, which also has hepatotoxic properties, is eliminated exclusively via the liver. Some EPP patients develop cholestatic liver failure, in most cases when the disease has already progressed to cirrhosis. Liver transplantation is an established life-saving treatment in this setting. Bone marrow transplantation are curative and had been done do a few EPP patinets, but it is still inn a experimental stage.

40 cm 100 cm 100 cm Here we have Operating light in 100 cm distance. Headlight in 40 cm distance.

Liver transplantation (1) A liver transplantation take 8-12 hours The irradiance of an operating room light is equivalent to the sun (measured in kLux) Liver transplantation in EPP patients: Several fatal events. Complication due to several abdominal bleeding, intestinal perforation peritonitis and sepsis.

Liver transplantation (2) The complications are due to abdominal phototoxicity during the operation How to reduce the phototoxic damage during operation?

Previous experiences in EPP liver transplantation CLS-200-X TA-81 / similar No filter Number of liver transplantation 42 13 4 25 ? Phototox injury 8 2 6 ? 15 % 24 % 42 LT has been described. And there have been done 17 LT with light protecting filter. 25 LT have been done withour any filter and there are has described 24% of phototoxic injury. CLS-200x has been used in 13 of 42 LT and also there it’s described 15% phototoxic injury.

Aim of the study To evaluate the colour perception in the operating area for surgeons when filtered light is used To compare the protective efficacy of different light filters in an experimental model

Acrylate filters Thin, flexible, heat-resistant, pre-glued, easilly applied, commercially available CLS-200X Reflective 61611 TA-81 Deep Amber CLS-200X protect up to 400nm and then lets the light through the filter. So CLS-200X just protect up to 400 nm. Reflective 61611 protect up to 470 nm, TA-81 up to 500 mn (and letting some light through from 400-500 nm). Deep amber protect up to around 550 nm.

Without filter Colour perception without filter

TA-81 Colour perception of TA-81. It has moderate influence on colour perception.

Deep Amber Colour perception with Deep amber. Surgeons found this filter unacceplable due to pronounced distortion of Colour perception, so this filter was omitted from further study.

Aim of the study To evaluate the colour perception in the operating area for surgeons when filtered light is used. To compare in an experimental model the protective efficacy of different light filters.

Experimental model: Protoporthyrin loaded erythrocytes Cuvette 7x7 cm Light path 3mm Operating room light

PP Erythrocytes suspenstion (8x1010) erythrocytes/L Erythrocytes loaded with protoporphyrin

PP PP Hb Cell damage = Hemolysis CLS-200X Reflective 60611 TA-81 In the presence of operating light we get cell damage. With protective light filter it is possible to reduce the cell damage. We have tried 3 different filter separately, so we can evaluate the efficacy of these different filters.

Cell damage with different filters Without filter CLS-200X Reflective 61611 TA-81 Light protection efficacy 10% hemolysis No filter 1 CLS X 1,25 60611 X 2 TA-81 X 2,6 With the presence of filters the cell damage will occur a bit later than without the filter. CLS give 1,25 protection, 60611 double protec and TA-81 2,6 protection in 10% hemolysis. Protection from phototoxic injury during surgery in Erythropoietic Protoporphyria Wahlin S., Srikanthan N., Hamre B., Harper P., Brun A. Liver Transplant In press

Legemidler og porfyri

Symptomer ved ulike porfyrisykdommer Akutte porfyrier Anfall med akutte symptomer: Abdominalsmerter Pareser Psykiske symptomer Unormal lysømfintlighet: Blemmer/vulnerabel hud på lyseksponerte områder Unormal lysømfintlighet - hudsmerter

Anfall med akutte symptomer kan utløses av: Psykisk stress / fysiske påkjenninger LEGEMIDLER Søvnmangel Sult / slanking Infeksjoner Kvinner: Menstruasjon syklus / P-piller Alvorlig medisinsk tilstand Frisk Porfyri: Sjelden sykdom  Ofte manglende kompetanse Feildiagnostisering / feilbehandling

Problemet: Legemidler og porfyri (1) Høyst vanlige legemidler kan utløse et alvorlig anfall hos personer med disposisjon for akutt porfyri Felleskatalogen mangler opplysninger om at en lang rekke legemidler er kontraindiserte ved akutte porfyrier

Problemet: Legemidler og porfyri (2) Informasjon om hvilke legemidler som er trygge å bruke: Svært vanskelig tilgjengelig –særlig i akuttsituiasjoner Lite oppdatert med hensyn til nye legemidler Tildels motstridende informasjon fra forskjellige kilder Mangel på viktig medisinsk informasjon gir stor fare for medisinsk feilbehandling

Målet: NAPOS ble opprettet av Sosial og helsedepartementet i 1999 Startet arbeidet med problemområdet legemidler og akutt porfyri Målet: Utvikle en legemiddeldatabase Brukervennlig, klinisk databaseverktøy Lett tilgjengelig på internet Forhindre medisinsk feilbehandling som kan utløse alvorlige anfall

Samarbeid: Norge - Sverige Farmasøyt IT-ingeniør Porfyri-spesialist Tverrfaglig gruppe Porfyri-spesialist: Stig Thunell Samarbeids-produkt Legemiddel-database for akutt porfyri A computer program for drugs with search possibilities and other functions = +

Eksempel 1 Kvinne, 32 år gammel Symptomer på kraftig blærebetennelse Oppsøker sin fastlege for å få behandling Legen vil behandle med legemidlet Selexid Er Selexid et trygt legemiddel å bruke? A female patient, aged 32, is suffering from ulcerative colitis. Her doctor finds indications to start Sulfasalazine medication but she has also a Variegate porphyria Is then sulfasalzine a safe drug for her ? (Klikk) The Drug Database will easily give the answer: You simply fill in the medication in question (Klikk) (Klikk) and the search engine will tell you that (Klikk) Selexid

Brukervennlig, klinisk databaseverktøy Lett tilgjengelig på web (www.drugs-porphyria.org) Omfatter nær alle legemidler på det nordiske markedet Ekspertsystem Viser evidens og rasjonale for samtlige klassifiserte legemidler Stor internasjonal interesse

Hvem er målgruppen for en porfyri legemiddel database? Allmennpraktiserende leger Leger på sykehus Personale ved nasjonale porfyri kompetansesentra Personer som har fått stilt diagnosen akutt porfyri

Akutte porfyrisykdommer forekommer relativt sjeldent Nødvendig og hensiktsmessig å arbeide INTERNASJONALT

European Porphyria Network EU project (2007 – 2010) Set up a functional network of specialist porphyria centres to provide better healthcare for patients and their families

This online drug reporting system will complement the drug database for Acute Porphyria www.drugs-porphyria.org

Expansion of the database Drug porphyrinogenicity monographs Core elements National drug database 13 database 14 database 15 2009 National drug database 10 database 11 database 12 General information 2008 National drug database 7 database 8 database 9 Database programming The database consists of several elements: Drug data files – linked to ATC-codes, Drug safety classification Database programming General information and at last: Drug porphyrinogenicity monographs These are the core elements in the drug database --- to which it is possible to connect several national databases: Databases for Norway, Sweden, and The United Kingdom are currently available. The first expansions in the EPNET project will be databases adapted for France, Switzerland and Finland. In 2008 Poland, The Netherlands, Italy, Spain, and Belgium will be implemented - followed by Germany, Ireland, Czech Republic, and Hungary in 2009 National drug database 4 database 5 database 6 Drug safety classification 2007 National drug database 1 database 2 database 3 Drug data files (ATC-system)

European Porphyria Network Use the network to collect clinical reports about drug use among persons with acute porphyria: Drug reports - Attack precipitated ? - Used without problems? Follow-ups by pharmacists at 4 porphyria centres: We have used the collaborating network of specialist porphyria centres established in this project to increase the number of clinical drug reports. At 4 porphyria centres: - Cardiff, UK - Paris, France - Bergen, Norway - Warsaw, Poland follow-up information on whether a drug has precipitated an attack - or was used uneventfully is collected by part-time employed pharmacists. Cardiff, UK Paris, France Bergen, Norway Warsaw, Poland

Drug reports in acute porphyria Pharmacists collect detailed follow-up information on porphyria patients concerning the use of drugs High quality and reliable reports After having received a question about drugs and acute porphyria, the pharmacists contact the patient after 1 month and 3 months to determine whether the advice was followed, Whether there were any adverse reactions to the drug and to take a complete drug history of the patient combined with necessary clinical and biochemical data. In this way we will force forward high quality and reliable reports Reports on 558 drugs have been collected so far Status: Reports on 558 drugs collected so far

Drug reports: Further developments in acute porphyria Online drug reporting system TRANSFORM Drug report forms The number of drug reports will increase to several thousand ….and to be able to extract all relevant data - and be in complete control, it was necessary to have a modern system. We have just finished the work of transforming this paper drug reporting form into a user friendly, online drug report form communicating with a database for clinical reports. Based on two case stories, I will now give you an overview on how this drug reporting system works.

Patient information M A We are then asked for patient information: 08 1960 We are then asked for patient information: --- Initials ----Gender ----Date of birth ----Porphyria diagnosis -----What the porphyria diagnosis is based on This reporting system also demands that the porphyria diagnosis is verified by a EPI approved porphyrinologist -with electronic signature and date ---Next NOR-SS 15 04 2008

Complement www.drugs-porphyria.org This online drug reporting system will complement the drug database for Acute Porphyria

Drug porphyrinogenicity Database Clinical drug reports Validation Porphyria online drug reporting system UPDATE Drug porphyrinogenicity MONOGRAPHS I have tried to visualize how these two systems will act together: ----- For the online drug reporting system we have put up a mailbox on a server ------ which will receive the reports generated in Cardiff ----- and in Warsaw ---- and hopefully in Paris ( ) After some testing we intend to make this system available for all partners of the EPNET project ----- so that you all can contribute with valuable clinical drug reports ----- We will consecutively validate the incoming reports, which will be stored in a separate database for clinical drug reports ----- These data will then be used to update the Drug porphyrinogenicity monographs and safety classification of the drug database ----- and then you can all take advantage of having high quality drug information easily accessible

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Fagmiljø ved NAPOS 2 Farmasøyter i 50% stilling 6 Leger (tilknyttet) 1 Genetisk veileder 2 Spesialkonsulent / prosjektkonsulent 1 Kunnskapskoordinator 1 Kontorleder