Abstract
Background
It has been 15 years since sirolimus, an mTOR inhibitor, received Food and Drug Administration approval to prevent acute rejection in kidney transplantation, and 8 years since its analog everolimus acquired the same status. Since then, these drugs have become more and more utilized and their immunosuppressive and antiproliferative properties have been tested in a great variety of clinical conditions, often achieving excellent results. Despite such positive evidence, the on-label indications for these rapalogs are still very restrictive, especially in children.
Aims
The aims of this study were to describe our center’s experience with sirolimus and everolimus in managing rare pediatric conditions for which mTOR inhibitors have been reported as a therapeutic option, although without conclusive approval from regulatory agencies, and to evaluate safety and tolerability of the treatment at the prescribed doses.
Methods
All the subjects who received off-label sirolimus or everolimus at the Pediatric Department of the IRCCS Burlo Garofolo in the last 13 years were included. For each disease found in our case series, we reviewed the current scientific literature.
Results
Off-label treatment with rapalogs was prescribed in 16 children (11 males, 5 females, median age of 9.5 years, range 1–16 years). Seven had immunologic disorders: four autoimmune lymphoproliferative syndrome (ALPS), one multicentric Castleman disease (mCD), one activated PI3K delta kinase syndrome (APDS), and one immunodysregulation with polyendocrinopathy enteropathy X-linked (IPEX). Eight had proliferative disorders or vascular anomalies: one cystic lymphangioma, two Bannayan–Riley–Ruvalcaba syndrome (BRRS), one blue rubber bleb nevus syndrome (BRBNS), two tuberous sclerosis complex (TSC), and one low-flow mixed arterial and venous malformation. One case had congenital hyperinsulinism (CHI). The average dosage administered was 1 mg/m2 for sirolimus and 7 mg/m2 for everolimus. We experienced a good measurable clinical improvement in 14 patients. Nobody experienced serious adverse events (SAEs). The therapy was interrupted in two cases, for lack of efficacy and poor tolerance in one case and for occurrence of bacterial pneumonia in the other one. A review of the literature identified 101 published reports that met our inclusion criteria.
Conclusions
Although use of mTOR inhibitors has been considered to be complicated, our experience shows that, using low dosages, it is possible to obtain relevant clinical improvements, with a good profile of safety and tolerability.
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Acknowledgements
The study was funded by the IRCCS Burlo Garofolo, RC 24/17.
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Dr Bevacqua has nothing to disclose. Dr Baldo has nothing to disclose. Dr Pastore reports non-financial support from Abbvie, outside the submitted work. Dr Valencic has nothing to disclose. Dr Tommasini reports non-financial support from Novartis pharma, Kedrion, Shire, and CLS Behring, outside the submitted work. Dr Maestro has nothing to disclose. Dr Rabusin has nothing to disclose. Dr Arbo has nothing to disclose. Dr Barbi has nothing to disclose.
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Bevacqua, M., Baldo, F., Pastore, S. et al. Off-Label Use of Sirolimus and Everolimus in a Pediatric Center: A Case Series and Review of the Literature. Pediatr Drugs 21, 185–193 (2019). https://doi.org/10.1007/s40272-019-00337-7
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DOI: https://doi.org/10.1007/s40272-019-00337-7