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      Standard of care versus new-wave corticosteroids in the treatment of Duchenne muscular dystrophy: Can we do better?

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          Abstract

          Background

          Pharmacological corticosteroid therapy is the standard of care in Duchenne Muscular Dystrophy (DMD) that aims to control symptoms and slow disease progression through potent anti-inflammatory action. However, a major concern is the significant adverse effects associated with long term-use.

          Main

          This review discusses the pros and cons of standard of care treatment for DMD and compares it to novel data generated with the new-wave dissociative corticosteroid, vamorolone. The current status of experimental anti-inflammatory pharmaceuticals is also reviewed, with insights regarding alternative drugs that could provide therapeutic advantage.

          Conclusions

          Although novel dissociative steroids may be superior substitutes to corticosteroids, other potential therapeutics should be explored. Repurposing or developing novel pharmacological therapies capable of addressing the many pathogenic features of DMD in addition to anti-inflammation could elicit greater therapeutic advantages.

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          Most cited references113

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          Dystrophin: the protein product of the Duchenne muscular dystrophy locus.

          The protein product of the human Duchenne muscular dystrophy locus (DMD) and its mouse homolog (mDMD) have been identified by using polyclonal antibodies directed against fusion proteins containing two distinct regions of the mDMD cDNA. The DMD protein is shown to be approximately 400 kd and to represent approximately 0.002% of total striated muscle protein. This protein is also detected in smooth muscle (stomach). Muscle tissue isolated from both DMD-affected boys and mdx mice contained no detectable DMD protein, suggesting that these genetic disorders are homologous. Since mdx mice present no obvious clinical abnormalities, the identification of the mdx mouse as an animal model for DMD has important implications with regard to the etiology of the lethal DMD phenotype. We have named the protein dystrophin because of its identification via the isolation of the Duchenne muscular dystrophy locus.
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            The anti-inflammatory and immunosuppressive effects of glucocorticoids, recent developments and mechanistic insights

            Since the discovery of glucocorticoids in the 1940s and the recognition of their anti-inflammatory effects, they have been amongst the most widely used and effective treatments to control inflammatory and autoimmune diseases. However, their clinical efficacy is compromised by the metabolic effects of long-term treatment, which include osteoporosis, hypertension, dyslipidaemia and insulin resistance/type 2 diabetes mellitus. In recent years, a great deal of effort has been invested in identifying compounds that separate the beneficial anti-inflammatory effects from the adverse metabolic effects of glucocorticoids, with limited effect. It is clear that for these efforts to be effective, a greater understanding is required of the mechanisms by which glucocorticoids exert their anti-inflammatory and immunosuppressive actions. Recent research is shedding new light on some of these mechanisms and has produced some surprising new findings. Some of these recent developments are reviewed here.
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              Dissecting molecular cross-talk between Nrf2 and NF-κB response pathways

              In most tissues, cells are exposed to frequent changes in levels of oxidative stress and inflammation. Nuclear factor (erythroid-derived 2)-like 2 (Nrf2) and nuclear factor-κB (NF-κB) are the two key transcription factors that regulate cellular responses to oxidative stress and inflammation respectively. Pharmacological and genetic studies suggest that there is functional cross-talk between these two important pathways. The absence of Nrf2 can exacerbate NF-κB activity leading to increased cytokine production, whereas NF-κB can modulate Nrf2 transcription and activity, having both positive and negative effects on the target gene expression. This review focuses on the potentially complex molecular mechanisms that link the Nrf2 and NF-κB pathways and the importance of designing more effective therapeutic strategies to prevent or treat a broad range of neurological disorders.
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                Author and article information

                Contributors
                emma.rybalka@vu.edu.au
                Journal
                Orphanet J Rare Dis
                Orphanet J Rare Dis
                Orphanet Journal of Rare Diseases
                BioMed Central (London )
                1750-1172
                4 March 2021
                4 March 2021
                2021
                : 16
                : 117
                Affiliations
                [1 ]GRID grid.1019.9, ISNI 0000 0001 0396 9544, Institute for Health and Sport (IHeS), , Victoria University, ; Melbourne, VIC Australia
                [2 ]GRID grid.508448.5, Australian Institute for Musculoskeletal Science (AIMSS), ; St Albans, VIC Australia
                [3 ]GRID grid.412347.7, ISNI 0000 0004 0509 0981, Division of Neuropediatrics and Developmental Medicine, , University Children’s Hospital of Basel (UKBB), ; Basel, Switzerland
                [4 ]GRID grid.1009.8, ISNI 0000 0004 1936 826X, School of Pharmacy and Pharmacology, , University of Tasmania, ; Hobart, TAS Australia
                Author information
                http://orcid.org/0000-0002-4854-0036
                Article
                1758
                10.1186/s13023-021-01758-9
                7934375
                33663533
                d53734e0-1853-41a3-8c09-5bd21d38c625
                © The Author(s) 2021

                Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

                History
                : 22 December 2020
                : 18 February 2021
                Categories
                Position Statement
                Custom metadata
                © The Author(s) 2021

                Infectious disease & Microbiology
                duchenne muscular dystrophy,corticosteroids,standard of care,anti-inflammatory drugs,anti-inflammation

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