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Tripathi SH, Min S, Cody AS, Shukla G, Houssein FA, Howard JS, Hu A, Previtera MJ, Phillips KM, Sedaghat AR. Variability in Minimal Clinically Important Difference Calculation and Reporting in the Otolaryngology Literature. Laryngoscope 2024; 134:2059-2069. [PMID: 37933798 DOI: 10.1002/lary.31145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 08/21/2023] [Accepted: 10/17/2023] [Indexed: 11/08/2023]
Abstract
OBJECTIVE Best practices for calculation of the minimal clinically important difference (MCID) of outcome measures include the use of complementary methodologies (broadly classified as anchor-based and distribution-based) and reporting of the MCID's predictive ability. We sought to determine MCID calculation and reporting patterns within the otolaryngology literature. METHODS A systematic search strategy of Embase, PubMed, and Web of Science databases was developed and implemented to identify studies reporting the determination of an MCID for an outcome measure. Studies specifically within the otolaryngology literature (defined as journals classified as "otorhinolaryngology" in the Journal Citation Reports database) were included. All those journals were additionally searched for relevant articles. RESULTS There were 35 articles that met the inclusion criteria. Of these studies, 88.6% reported MCID of a patient-reported outcome measure and the remainder were for objective outcome measurements. Anchor-based methods were used by 82.9% of studies and distribution-based methods were used by 68.6% of studies. Of all studies, 31.4% utilized anchor-based methods alone, 17.1% utilized distribution-based methods alone, and 51.4% used both methods. Only 25.7% of studies reported the sensitivity (median: 60.8%, range: 40.5%-86.7%) and specificity (median: 80.4%, range: 63.5%-88.0%) of the MCID to detect patients experiencing clinically important change. CONCLUSION Deviation from best practices in MCID calculation and reporting exists within the otolaryngology literature, with almost half of all studies only using one method of MCID calculation and almost three-quarters not reporting the predictive ability (sensitivity/specificity) of the calculated MCID. When predictive ability is reported, however, MCIDs appear to be more specific than sensitive. LEVEL OF EVIDENCE NA Laryngoscope, 134:2059-2069, 2024.
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Affiliation(s)
- Siddhant H Tripathi
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, U.S.A
| | - Susie Min
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, U.S.A
| | - Alexander S Cody
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, U.S.A
| | - Geet Shukla
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, U.S.A
| | - Firas A Houssein
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, U.S.A
| | - John S Howard
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, U.S.A
| | - Alex Hu
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, U.S.A
| | - Melissa J Previtera
- Health Sciences Library, University of Cincinnati College of Medicine, Cincinnati, Ohio, U.S.A
| | - Katie M Phillips
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, U.S.A
| | - Ahmad R Sedaghat
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, U.S.A
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Hayama M, Maeda Y, Obata S, Tsuda T, Takeda K, Nishida T, Inohara H. Understanding hereditary hemorrhagic telangiectasia: From genetic anomalies to systemic manifestations, quality of life, and epistaxis management-Exploring the otolaryngologist's integral role. Auris Nasus Larynx 2024; 51:305-312. [PMID: 38008660 DOI: 10.1016/j.anl.2023.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 10/19/2023] [Accepted: 11/07/2023] [Indexed: 11/28/2023]
Abstract
Hereditary hemorrhagic telangiectasia (HHT), also known as Osler-Rendu-Weber syndrome, is a rare autosomal dominant disorder characterized by vascular malformations. This comprehensive review aimed to provide an overview and summarize various aspects of HHT, including the genetic abnormalities, complications associated with visceral arteriovenous malformations (AVMs), prognosis of HHT, quality of life (QOL), and treatment of epistaxis. In addition, this review highlights the challenges in diagnosing HHT and emphasizes the critical role of otolaryngologists in the early detection of HHT. Otolaryngologists can refer patients with refractory epistaxis for AVM screening to expedite intervention. Mutation of the genes involved in the transforming growth factor-β signaling pathway leads to the incidence of HHT, resulting in the formation of abnormal blood vessel formation. These vascular malformations commonly manifest as telangiectasia on the skin and mucous membranes; however, epistaxis remains the hallmark symptom of HHT. The impact of HHT goes beyond the visible symptoms and often includes the formation of life-threatening visceral AVMs in the lungs, liver, and brain. The prognosis of patients with HHT is closely related to the development of these complications, necessitating timely diagnosis and intervention. Refractory epistaxis diminishes the QOL of patients with HHT. The management of epistaxis ranges from conservative measures to advanced interventions such as prevention, conservative treatments, ablation, surgical procedures, and the administration of anti-angiogenic agents. However, effective management requires a multidisciplinary approach. The diagnosis of HHT remains challenging due to its variable presentation and lack of awareness among physicians. This review highlights the importance of reducing the duration between symptom onset and diagnosis. Otolaryngologists who are experienced in the management of refractory epistaxis can aid in identifying potential cases of HHT. They can facilitate the initiation of screening for visceral AVMs via prompt recognition of the signs and symptoms of HHT, contributing to improved patient outcomes. Early detection and intervention through screening can extend the life expectancy of patients with HHT to levels comparable with that of the general population. In conclusion, this review provides insight into various aspects of HHT and emphasizes the importance of timely diagnosis and intervention in the mitigation of the potentially life-threatening complications associated with this disorder. Otolaryngologists play a critical role in this process, serving as gatekeepers to the identification of cases of HHT and implementation of appropriate screening and management pathways, thereby improving the life expectancy and QOL of patients.
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Affiliation(s)
- Masaki Hayama
- Department of Otorhinolaryngology, Hyogo Prefectural Nishinomiya Hospital, Nishinomiya City, Hyogo, Japan; Department of Otorhinolaryngology-Head and Neck Surgery, Osaka University Graduate School of Medicine, Suita City, Osaka, Japan.
| | - Yohei Maeda
- Department of Otorhinolaryngology-Head and Neck Surgery, Osaka University Graduate School of Medicine, Suita City, Osaka, Japan; Department of Otorhinolaryngology, Japan Community Healthcare Organization Osaka Hospital, Osaka City, Osaka, Japan
| | - Sho Obata
- Department of Otorhinolaryngology-Head and Neck Surgery, Osaka University Graduate School of Medicine, Suita City, Osaka, Japan
| | - Takeshi Tsuda
- Department of Otorhinolaryngology-Head and Neck Surgery, Osaka University Graduate School of Medicine, Suita City, Osaka, Japan
| | - Kazuya Takeda
- Department of Otorhinolaryngology-Head and Neck Surgery, Osaka University Graduate School of Medicine, Suita City, Osaka, Japan
| | - Takeo Nishida
- Department of Neurosurgery, Hyogo Prefectural Nishinomiya Hospital, Nishinomiya City, Hyogo, Japan; Department of Neurosurgery, Osaka University Graduate School of Medicine, Suita City, Osaka, Japan
| | - Hidenori Inohara
- Department of Otorhinolaryngology-Head and Neck Surgery, Osaka University Graduate School of Medicine, Suita City, Osaka, Japan
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Gong AJ, Bolsegui ML, Lee EE, Mathai SC, Weiss CR. Assessing the Psychometric Validity of the Epistaxis Severity Score: Internal Consistency and Test-Retest Reliability. Am J Rhinol Allergy 2024; 38:38-46. [PMID: 37822162 DOI: 10.1177/19458924231207137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Abstract
BACKGROUND The Epistaxis Severity Score (ESS) is the gold-standard patient-reported outcome measure for evaluating nosebleed severity in patients with hereditary hemorrhagic telangiectasia (HHT). To date, the ESS has been assessed only for content validity and concurrent validity. OBJECTIVE We evaluate the internal consistency and test-retest reliability of the ESS. MATERIALS AND METHODS After receiving institutional review board approval, we sent an online survey battery, including the ESS survey, to 305 (39% male) English-speaking HHT patients ≥18 years old at a single center. Of those, 140 (46%) patients completed the battery, and 110/140 (79%) reported epistaxis. Cronbach's alpha and correlation analyses were used to evaluate internal consistency. For the test-retest reliability evaluation, we recruited 69 HHT patients during HHT clinic to complete 2 self-administered ESS surveys 2 weeks apart. Participants also completed a modified Clinical Global Impression-Improvement scale with readministration of the ESS survey. We calculated the intraclass correlation coefficient in a 2-way mixed model with absolute agreement. RESULTS The ESS survey demonstrated low internal consistency (Cronbach's alpha = 0.495), suggesting that it measured multiple unrelated concepts. Factor analysis revealed 3 latent factors with moderate intercorrelation, suggesting the presence of 3 related but distinct constructs underlying the ESS. However, the ESS demonstrated excellent test-retest reliability (intraclass correlation coefficient = 0.955; 95% CI, 0.91-0.98). CONCLUSION Although the ESS demonstrates high test-retest reliability, it may not adequately assess different dimensions of nosebleed severity. Additional correlated survey questions and sub-scores may be needed to increase internal consistency to accurately measure each component of epistaxis severity. It is necessary to acknowledge epistaxis severity from different dimensions and to consider evaluating individual ESS items separately for a comprehensive understanding.
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Affiliation(s)
- Anna J Gong
- Division of Interventional Radiology, Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Hospital, Baltimore, MD
| | - Marisabel Linares Bolsegui
- Division of Interventional Radiology, Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Hospital, Baltimore, MD
| | | | - Stephen C Mathai
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD
| | - Clifford R Weiss
- Division of Interventional Radiology, Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Hospital, Baltimore, MD
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Gong AJ, Garg T, Khalil A, Gowda PC, Mathai SC, Rowan NR, Merlo CA, Weiss CR. Health-Related Quality of Life Outcome Measures in Individuals With Hereditary Hemorrhagic Telangiectasia: A Scoping Review. Am J Rhinol Allergy 2024; 38:60-76. [PMID: 37855028 DOI: 10.1177/19458924231207123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2023]
Abstract
BACKGROUND Studies evaluating health-related quality of life (HRQOL) in patients with hereditary hemorrhagic telangiectasia (HHT) have expanded rapidly in the past decade. These studies have evaluated QOL aspects ranging from the general QOL for patients living with HHT to intervention-specific outcomes. However, few tools have been fully validated across the spectrum of disease manifestations and interventions in HHT. OBJECTIVE In this scoping review, we aim to map the literature on HHT-QOL metrics, identify gaps, inform future QOL research, and facilitate future metric development. METHODS We analyzed articles in English that assessed at least 1 measure of general HRQOL, including physical health, mental health, social health, or intervention-specific QOL in patients with HHT. Searches across 2 bibliographic databases (PubMed and Scopus) yielded 186 articles after duplicates were removed. Sixty-three studies met eligibility criteria: 22 prospective studies (34.9%), 20 retrospective studies (31.7%), 12 cross-sectional studies (17.5%), 6 randomized controlled trials or secondary analyses of a randomized controlled trials (9.5%), 2 qualitative studies (3.2%), and 1 case-control study (1.6%). Two additional studies-1 prospective and 1 cross-sectional study-were identified at the October 2022 14th International HHT Conference and included, making a total of 65 studies. RESULTS The 65 eligible studies used 30 QOL instruments. Twenty studies characterized baseline HRQOL, and 45 studies evaluated QOL before and after treatment. Of those 45 studies, 37 evaluated HRQOL before and after therapies targeting epistaxis and nasal symptoms, 4 targeted therapies for liver arteriovenous malformations and high-output heart failure, 3 evaluated therapies for both epistaxis and gastrointestinal bleeding, and 1 evaluated treatment targeting gastrointestinal bleeding alone. CONCLUSIONS Comparison of results across studies remains challenging given the heterogeneity in outcomes measures. Further development of HHT-specific patient-reported outcomes instruments that capture the global illness experience of HHT is needed.
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Affiliation(s)
- Anna J Gong
- Division of Interventional Radiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Tushar Garg
- Division of Interventional Radiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Adham Khalil
- Division of Interventional Radiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Prateek C Gowda
- Division of Interventional Radiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Stephen C Mathai
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nicholas R Rowan
- Department of Otolaryngology-Head and Neck Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Christian A Merlo
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Clifford R Weiss
- Division of Interventional Radiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Peterson AM, Miller B, Ioerger P, Hentati F, Doering MM, Kallogjeri D, Piccirillo JF. Most-Cited Patient-Reported Outcome Measures Within Otolaryngology-Revisiting the Minimal Clinically Important Difference: A Review. JAMA Otolaryngol Head Neck Surg 2023; 149:261-276. [PMID: 36729451 PMCID: PMC10729312 DOI: 10.1001/jamaoto.2022.4703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Importance Patient-reported outcome measures (PROMs) allow clinicians and researchers to assess health-related information from a patient's perspective. These measures have been used more frequently over the last several decades, but an associated minimal clinically important difference (MCID) is needed to optimize their utility. This narrative review identified the top 100 most-cited otolaryngology-related PROM development and validation publications and assessed the presence and characteristics of the PROMs' associated MCID. Observations In this narrative review, a literature search in Scopus and Web of Science was conducted on June 29, 2022, using keywords related to PROM development and validation studies in otolaryngology and reference lists. Studies that met the definition of a PROM and assessed an otolaryngologic disorder or study population were included for full-text review. After full-text review of 188 articles, the top 100 most-cited PROM development and validation publications, resulting in 106 total PROMs, were chosen for review. A total of 39 (37%) of the identified PROMs had an associated MCID. Of those reporting an MCID, 14 (35.9%) used an anchor-based method, 12 (30.8%) used a distribution-based method, 10 (25.6%) used both, and 3 (7.7%) did not specify or used neither method. Rhinology had the greatest number of PROMs with an associated MCID (16 of 24, 66%), and pediatrics had the fewest (1 of 13, 7.7%). The median number of citations of PROMs with an MCID was higher than those without an MCID. Conclusions and Relevance The majority of the most-cited PROMs in otolaryngology lack an associated MCID. These data indicated that there are a multitude of PROMs that have been cited hundreds of times and used for decades without the ability to identify whether a particular change in score on the instrument is clinically meaningful. There is a need to determine and validate MCIDs for commonly used PROMs to aid clinical research and trial interpretation.
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Affiliation(s)
- Andrew M. Peterson
- Clinical Outcomes Research Office, Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Brevin Miller
- Clinical Outcomes Research Office, Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
- University of Missouri Kansas City School of Medicine, Kansas City, Missouri
| | - Patrick Ioerger
- Clinical Outcomes Research Office, Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
- University of Kansas Medical Center, Kansas City, Kansas
| | - Firas Hentati
- Clinical Outcomes Research Office, Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
- Case Western Reserve University, Cleveland, Ohio
| | - Michelle M. Doering
- Becker Medical Library, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Dorina Kallogjeri
- Clinical Outcomes Research Office, Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Jay F. Piccirillo
- Clinical Outcomes Research Office, Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
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Andorfer KEC, Zeman F, Koller M, Zeller J, Fischer R, Seebauer CT, Vielsmeier V, Bohr C, Kühnel TS. TIMolol Nasal Spray as a Treatment for Epistaxis in Hereditary Hemorrhagic Telangiectasia (TIM-HHT)—A Prospective, Randomized, Double-Blind, Controlled, Cross-Over Trial. Pharmaceutics 2022; 14:pharmaceutics14112335. [PMID: 36365152 PMCID: PMC9692661 DOI: 10.3390/pharmaceutics14112335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 10/25/2022] [Accepted: 10/27/2022] [Indexed: 12/03/2022] Open
Abstract
To date, there is no approved local therapeutic agent for the treatment of epistaxis due to hereditary hemorrhagic telangiectasia (HHT). Several case reports suggest the topical use of timolol. This monocentric, prospective, randomized, placebo-controlled, double-blinded, cross-over study investigated whether the effectiveness of the standard treatment with a pulsed diode laser can be increased by also using timolol nasal spray. The primary outcome was severity of epistaxis after three months, while the main secondary outcome was severity of epistaxis and subjective satisfaction after one month. Twenty patients were allocated and treated, of which 18 patients completed both 3-month treatment sequences. Timolol was well tolerated by all patients. Epistaxis Severity Score after three months, the primary outcome measure, showed a beneficial, but statistically nonsignificant (p = 0.084), effect of additional timolol application. Epistaxis Severity Score (p = 0.010) and patients’ satisfaction with their nosebleeds after one month (p = 0.050) showed statistically significant benefits. This placebo-controlled, randomized trial provides some evidence that timolol nasal spray positively impacts epistaxis severity and subjective satisfaction in HHT patients when additively applied to standard laser therapy after one month. However, the effect of timolol was observed to diminish over time. Trials with larger sample sizes are warranted to confirm these findings.
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Affiliation(s)
- Kornelia E. C. Andorfer
- Department of Otorhinolaryngology, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, D-93053 Regensburg, Germany
- Correspondence: ; Tel.: +49-941-944-9410
| | - Florian Zeman
- Center for Clinical Studies, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, D-93053 Regensburg, Germany
| | - Michael Koller
- Center for Clinical Studies, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, D-93053 Regensburg, Germany
| | - Judith Zeller
- Department of Internal Medicine II, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, D-93053 Regensburg, Germany
| | - René Fischer
- Department of Otorhinolaryngology, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, D-93053 Regensburg, Germany
| | - Caroline T. Seebauer
- Department of Otorhinolaryngology, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, D-93053 Regensburg, Germany
| | - Veronika Vielsmeier
- Department of Otorhinolaryngology, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, D-93053 Regensburg, Germany
| | - Christopher Bohr
- Department of Otorhinolaryngology, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, D-93053 Regensburg, Germany
| | - Thomas S. Kühnel
- Department of Otorhinolaryngology, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, D-93053 Regensburg, Germany
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Al-Samkari H, Eng W. A precision medicine approach to hereditary hemorrhagic telangiectasia and complex vascular anomalies. J Thromb Haemost 2022; 20:1077-1088. [PMID: 35343049 PMCID: PMC10044495 DOI: 10.1111/jth.15715] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 03/24/2022] [Accepted: 03/25/2022] [Indexed: 11/29/2022]
Abstract
Vascular anomalies represent a diverse group of disorders classified broadly as malformations or tumors and include the second most common hereditary bleeding disorder worldwide, hereditary hemorrhagic telangiectasia (HHT). Patients with HHT and other vascular anomalies suffer morbid consequences of these diseases, including bleeding, thrombosis, anemia, localized intravascular coagulation, tissue overgrowth, infections, and other complications. The International Society for the Study of Vascular Anomalies (ISSVA) has developed a standard classification of these disorders, creating a uniform approach to their diagnosis, and the treatments for vascular anomalies are rapidly evolving. Recent discoveries have elucidated the molecular basis of a number of common and uncommon vascular anomalies. HHT occurs due to mutations in the transforming growth factor beta (TGF-β) pathway, resulting in vascular endothelial growth factor excess. Complex vascular anomalies including Klippel-Trénaunay syndrome (KTS) and arteriovenous malformation (AVM) may occur due to mutations in the PI3K/AKT/mTOR and RAS/MAPK/MEK pathways. The discovery of the pathophysiologic mechanisms driving these diseases has led to improved phenotype-genotype correlation and the opportunity to target molecular pathways with medical therapies. Therefore, targeted agents have quickly become a standard of care in the treatment of vascular disorders (particularly HHT). Herein, we provide a case-based approach to the use of antiangiogenic therapies including bevacizumab and pazopanib for the treatment of bleeding in HHT and the use of mammalian target of rapamycin (sirolimus), PIK3CA (alpelisib), and MEK (trametinib) inhibitors in the treatment of complex vascular anomalies.
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Affiliation(s)
- Hanny Al-Samkari
- Division of Hematology Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Whitney Eng
- Harvard Medical School, Boston, Massachusetts, USA
- Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Boston, Massachusetts, USA
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Al-Samkari H. Systemic Antiangiogenic Therapies for Bleeding in Hereditary Hemorrhagic Telangiectasia: A Practical, Evidence-Based Guide for Clinicians. Semin Thromb Hemost 2022; 48:514-528. [PMID: 35226946 DOI: 10.1055/s-0042-1743467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Management of bleeding in hereditary hemorrhagic telangiectasia (HHT), the second most common hereditary bleeding disorder in the world, is currently undergoing a paradigm shift. Disease-modifying antiangiogenic therapies capable of achieving durable hemostasis via inducing telangiectasia regression have emerged as a highly effective and safe modality to treat epistaxis and gastrointestinal bleeding in HHT. While evidence to date is incomplete and additional studies are ongoing, patients presently in need are being treated with antiangiogenic agents off-label. Intravenous bevacizumab, oral pazopanib, and oral thalidomide are the three targeted primary angiogenesis inhibitors, with multiple studies describing both reassuring safety and impressive effectiveness in the treatment of moderate-to-severe HHT-associated bleeding. However, at present there is a paucity of guidance in the literature, including the published HHT guidelines, addressing the practical aspects of antiangiogenic therapy for HHT in clinical practice. This review article and practical evidence-based guide aims to fill this unaddressed need, synthesizing published data on the use of antiangiogenic agents in HHT, relevant data for their use outside of HHT, and expert guidance where evidence is lacking. After a brief review of principles of bleeding therapy in HHT, guidance on hematologic support with iron and blood products, and alternatives to antiangiogenic therapy, this article examines each of the aforementioned antiangiogenic agents in detail, including patient selection, initiation, monitoring, toxicity management, and discontinuation. With proper, educated use of antiangiogenic therapies in HHT, patients with even the most severe bleeding manifestations can achieve durable hemostasis with minimal side-effects, dramatically improving health-related quality of life and potentially altering the disease course.
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Affiliation(s)
- Hanny Al-Samkari
- Division of Hematology Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Khanwalkar AR, Rathor A, Read AK, Ma Y, Hwang PH. Randomized controlled double-blinded clinical trial of the effect of bevacizumab injection in the management of epistaxis in HHT patients undergoing surgical cauterization. Int Forum Allergy Rhinol 2022; 12:1034-1042. [PMID: 34989143 DOI: 10.1002/alr.22961] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 12/09/2021] [Accepted: 12/27/2021] [Indexed: 11/10/2022]
Abstract
INTRODUCTION Given its role in the disease pathophysiology, inhibition of VEGF-mediated angiogenesis has received attention as a potential strategy to reduce epistaxis associated with hereditary hemorrhagic telangiectasia (HHT). This study evaluates the efficacy of a submucosal injection of bevacizumab, a VEGF-inhibitor, in reducing the severity of epistaxis and improving quality of life when given at the time of operative electrocautery. METHODS This randomized, double-blinded placebo-controlled trial was conducted at a single institution from 2014 to 2019. Patients scheduled to undergo operative bipolar electrocautery of nasal telangiectasias were randomized to receive a submucosal injection of saline or bevacizumab at time of surgery. Surveys to assess epistaxis severity and quality-of-life (QOL), including the Epistaxis Severity Score (ESS) and Short Form 12 (SF-12), were administered preoperatively and at 1, 2, 4, and 6 months postoperatively. The minimal clinically important difference (MCID) of the ESS instrument is reported to be 0.71. RESULTS Of 39 patients enrolled, 37 (94.9%) completed the study. The saline group demonstrated reduced ESS versus baseline at 1 (-1.2, p = 0.01) and 4 (-1.2, p = 0.05) months post-procedure. The bevacizumab group demonstrated reduced ESS versus baseline at 1 (-2.3, p<0.001), 2 (-2.3, p<0.001), 4 (-2.0, p = 0.003), and 6 (-1.3, p = 0.05) months post-procedure. The additive benefit of bevacizumab over saline exceeded the MCID at 1, 2, and 4 months but the difference was not statistically significant. CONCLUSION The addition of a single treatment of submucosal bevacizumab may be associated with additional clinically meaningful benefit for up to 4 months when compared to electrocautery alone. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Ashoke R Khanwalkar
- Department of Otolaryngology - Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Aakanksha Rathor
- Department of Otolaryngology - Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Amelia K Read
- Department of Otolaryngology - Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Yifei Ma
- Department of Otolaryngology - Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Peter H Hwang
- Department of Otolaryngology - Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, CA, USA
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Andorfer KEC, Seebauer CT, Koller M, Zeman F, Berneburg M, Fischer R, Vielsmeier V, Bohr C, Kühnel TS. TIMolol nasal spray as a treatment for epistaxis in hereditary hemorrhagic telangiectasia (HHT) - study protocol of the prospective, randomized, double-blind, controlled cross-over TIM-HHT trial. Clin Hemorheol Microcirc 2021; 80:307-315. [PMID: 34864649 DOI: 10.3233/ch-211253] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Hereditary hemorrhagic telangiectasia (HHT) is an inherited orphan disease, in which the absence of capillary beds between arterioles and venules lead to arteriovenous shunts. Epistaxis is the core symptom. Several case reports have described the nonselective beta-adrenergic receptor antagonist timolol as a successful treatment method of nosebleeds due in HHT patients. OBJECTIVE TIM-HHT is a single-site, prospective, randomized, placebo-controlled, double-blind, cross-over study to investigate whether the efficacy of standard laser treatment of epistaxis in HHT patients can be increased by the additional use of timolol nasal spray (1 mg/d). METHODS Twenty patients will be randomly allocated to one of two treatment sequences. Primary outcome is the severity of epistaxis determined by the Epistaxis Severity Score (ESS). Secondary outcomes are subjective satisfaction, quality of life, as well as the hemoglobin, ferritin, and transferrin levels of the participating patients. Safety outcome is assessed by means of pulse, blood pressure, and adverse events. CONCLUSION TIM-HHT will evaluate the efficacy and safety of timolol as an additional treatment of epistaxis in HHT patients in a three-month trial period. Benzalkonium chloride is used as a placebo, which has no documented positive effect on the nasal mucosa and hence on epistaxis in HHT patients (in contrast to saline). TRIAL REGISTRATION German Clinical Trials Register (DRKS), DRKS00020994. Registered on 10 March 2020.
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Affiliation(s)
- Kornelia E C Andorfer
- Department of Otorhinolaryngology, University Hospital Regensburg, Regensburg, Germany
| | - Caroline T Seebauer
- Department of Otorhinolaryngology, University Hospital Regensburg, Regensburg, Germany
| | - Michael Koller
- Center for Clinical studies, University Hospital Regensburg, Regensburg, Germany
| | - Florian Zeman
- Center for Clinical studies, University Hospital Regensburg, Regensburg, Germany
| | - Mark Berneburg
- Department of Dermatology and Center for Orphan Diseases, University Hospital Regensburg, Regensburg, Germany
| | - René Fischer
- Department of Otorhinolaryngology, University Hospital Regensburg, Regensburg, Germany
| | - Veronika Vielsmeier
- Department of Otorhinolaryngology, University Hospital Regensburg, Regensburg, Germany
| | - Christopher Bohr
- Department of Otorhinolaryngology, University Hospital Regensburg, Regensburg, Germany
| | - Thomas S Kühnel
- Department of Otorhinolaryngology, University Hospital Regensburg, Regensburg, Germany
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11
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Hayama M, Maeda Y, Shikina T, Tatehara S, Inokuchi G, Hoag JB, Sato T, Obata S, Nakatani A, Amano Y, Hida E, Nibu KI, Inohara H. Validation of epistaxis severity score for hereditary hemorrhagic telangiectasia in Japan. Auris Nasus Larynx 2021; 49:415-420. [PMID: 34857410 DOI: 10.1016/j.anl.2021.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 10/21/2021] [Accepted: 11/10/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVE This study aimed to assess the health-related QoL (HR-QoL) of patients with hereditary hemorrhagic telangiectasia (HHT), with emphasis on the role/social aspects, and validate the Japanese version of the epistaxis severity score (ESS) in these patients. METHODS The Japanese version of the ESS was created through forward and reverse translation, and consultation with the original author. A validation analysis was performed by comparing ESS severity with the invasiveness of previous treatments for epistaxis and assessing the correlation between the ESS and HR-QoL. Medical history forms, ESS questionnaires, and the Medical Outcomes Study Short Form 36 (SF-36) were distributed to participants with HHT in August 2020. The relation between the ESS and summary scores of SF-36 was assessed by performing analysis of variance and Spearman's correlation. RESULTS In total, 73 participants were included in this study. The average ESS was 5.02; there were mild (32.9%), moderate (45.2%), and severe (21.9%) epistaxis groups. Patients with higher ESS received a significantly more invasive treatment (Fisher's exact test, p < 0.05). The ESS was also negatively correlated with the physical component score (PCS) (r = -0.489, p < 0.001). Comorbid liver and gastrointestinal arteriovenous malformations significantly reduced the PCS (p < 0.05). Multiple regression analysis revealed that the ESS was a significant variable (p < 0.01). The role/social component score was significantly lower in the severe ESS group than in the mild or moderate group. CONCLUSION The Japanese version of the ESS was considered valid and may be useful as an outcome measure of future HHT-associated epistaxis trials in Japan.
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Affiliation(s)
- Masaki Hayama
- Department of Otorhinolaryngology-Head and Neck Surgery, Osaka University Graduate School of Medicine, Suita city, Osaka, Japan.
| | - Yohei Maeda
- Department of Otorhinolaryngology-Head and Neck Surgery, Osaka University Graduate School of Medicine, Suita city, Osaka, Japan
| | | | - Shun Tatehara
- Department of Otolaryngology - Head and Neck Surgery, Kobe University Graduate School of Medicine, Kobe city, Hyogo, Japan
| | - Go Inokuchi
- Department of Otolaryngology - Head and Neck Surgery, Kobe University Graduate School of Medicine, Kobe city, Hyogo, Japan
| | - Jeffrey B Hoag
- Department of Pulmonary, Allergy and Critical Care Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, U.S.A
| | - Tomoharu Sato
- Department of Biostatistics and Data Science, Osaka University Graduate School of Medicine, Suita city, Osaka, Japan
| | - Sho Obata
- Department of Otorhinolaryngology-Head and Neck Surgery, Osaka University Graduate School of Medicine, Suita city, Osaka, Japan
| | - Ayaka Nakatani
- Department of Otorhinolaryngology-Head and Neck Surgery, Osaka University Graduate School of Medicine, Suita city, Osaka, Japan
| | - Yuta Amano
- Department of Otorhinolaryngology-Head and Neck Surgery, Osaka University Graduate School of Medicine, Suita city, Osaka, Japan
| | - Eisuke Hida
- Department of Biostatistics and Data Science, Osaka University Graduate School of Medicine, Suita city, Osaka, Japan
| | - Ken-Ichi Nibu
- Department of Otolaryngology - Head and Neck Surgery, Kobe University Graduate School of Medicine, Kobe city, Hyogo, Japan
| | - Hidenori Inohara
- Department of Otorhinolaryngology-Head and Neck Surgery, Osaka University Graduate School of Medicine, Suita city, Osaka, Japan
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12
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Marcos S, Botella LM, Albiñana V, Arbia A, de Rosales AM. Sclerotherapy on Demand with Polidocanol to Treat HHT Nosebleeds. J Clin Med 2021; 10:jcm10173845. [PMID: 34501293 PMCID: PMC8432129 DOI: 10.3390/jcm10173845] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 08/12/2021] [Accepted: 08/24/2021] [Indexed: 01/22/2023] Open
Abstract
Epistaxis is the most prevalent clinical symptom in Hereditary Haemorrhagic Telangiectasia (HHT), causing anaemia and decreasing the quality of life (QOL). Since 2013, in Hospital Universitario Fundación Alcorcón, more than 150 HHT patients have been treated by nose sclerotherapy on demand. This study shows the results of 105 patients treated with sclerotherapy between 2017 and 2019. HHT-ESS (epistaxis severity score) was used to measure the severity and frequency of epistaxis. QOL was determined before and after treatment by EuroQol-5D (EQ-5D) and the visual analogue scale (VAS) on the health condition. According to HHT-ESS before treatment, 22 patients presented mild, 35 moderate, and 47 severe epistaxes. Sclerotherapy significantly decreased the frequency and severity of epistaxis, with a significant drop of HHT-ESS in 4.6 points, from 6.23 ± 2.3 to 1.64 ± 1.6. Furthermore, the QOL significantly improved, the EQ-5D scale raised from 0.7 ± 0.26 pre- to 0.92 ± 0.16 post-treatment (p < 0.05). Additionally, VAS mean value showed a significant increase from 4.38 ± 2.4 to 8.35 ± 1.2. The QOL improvement was correlated with the ESS decrease. In conclusion, this study shows that on-demand sclerotherapy at the office significantly reduces HHT epistaxis as well as improved the patients' QOL.
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Affiliation(s)
- Sol Marcos
- Otorrhinolaringology Department, Hospital Universitario Fundación Alcorcón, 28922 Madrid, Spain;
- Correspondence:
| | - Luisa María Botella
- CIBER Rare Diseases Unit 707, Centro de Investigaciones Biológicas Margarita Salas, CSIC, 28040 Madrid, Spain; (L.M.B.); (V.A.)
| | - Virginia Albiñana
- CIBER Rare Diseases Unit 707, Centro de Investigaciones Biológicas Margarita Salas, CSIC, 28040 Madrid, Spain; (L.M.B.); (V.A.)
| | - Agustina Arbia
- Otorrhinolaringology Department, Hospital Universitario Fundación Alcorcón, 28922 Madrid, Spain;
| | - Anna María de Rosales
- Pharmaceutical Department, Hospital Universitario Fundación Alcorcón, 28922 Madrid, Spain;
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13
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Al-Samkari H, Kasthuri RS, Parambil JG, Albitar HA, Almodallal YA, Vázquez C, Serra MM, Dupuis-Girod S, Wilsen CB, McWilliams JP, Fountain EH, Gossage JR, Weiss CR, Latif MA, Issachar A, Mei-Zahav M, Meek ME, Conrad M, Rodriguez-Lopez J, Kuter DJ, Iyer VN. An international, multicenter study of intravenous bevacizumab for bleeding in hereditary hemorrhagic telangiectasia: the InHIBIT-Bleed study. Haematologica 2021; 106:2161-2169. [PMID: 32675221 PMCID: PMC8327711 DOI: 10.3324/haematol.2020.261859] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Indexed: 12/13/2022] Open
Abstract
Hereditary hemorrhagic telangiectasia (HHT, Osler-Weber-Rendu disease) is a rare multisystem vascular disorder that causes chronic gastrointestinal bleeding, epistaxis, and severe anemia. Bevacizumab, an anti-vascular endothelial growth factor antibody, may be effective to treat bleeding in HHT. This international, multicenter, retrospective study evaluated the use of systemic bevacizumab to treat HHTassociated bleeding and anemia at 12 HHT treatment centers. Hemoglobin, Epistaxis Severity Score (ESS), red cell units transfused, and intravenous iron infusions before and after treatment were evaluated using paired means testing and mixed-effects linear models. Bevacizumab was given to 238 HHT patients for a median of 12 (range, 1-96) months. Compared with pretreatment, bevacizumab increased mean hemoglobin by 3.2 g/dL (95% confidence interval: 2.9-3.5 g/dL); i.e., from a mean hemoglobin of 8.6 (8.5-8.8) g/dL to 11.8 (11.5-12.1) g/dL; P<0.0001) and decreased the ESS by 3.4 (3.2-3.7) points (mean ESS 6.8 [6.6-7.1] versus 3.4 [3.2-3.7]; P<0.0001) during the first year of treatment. Compared with 6 months before treatment, the number of red blood cell units transfused decreased by 82% (median of 6.0 [interquartile range, 0.0-13.0] units versus 0 [0.0-1.0] units; P<0.0001) and iron infusions decreased by 70% (median of 6.0 [1.0-18.0] infusions versus 1.0 [0.0-4.0] infusions, P<0.0001) during the first 6 months of bevacizumab treatment. Outcomes were similar regardless of the underlying pathogenic mutation. Following initial induction infusions, continuous/scheduled bevacizumab maintenance achieved higher hemoglobin and lower ESS than intermittent/as-needed maintenance but with more drug exposure. Bevacizumab was well tolerated: hypertension, fatigue, and proteinuria were the most common adverse events. Venous thromboembolism occurred in 2% of patients. In conclusion, systemic bevacizumab was safe and effective for managing chronic bleeding and anemia in HHT.
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Affiliation(s)
- Hanny Al-Samkari
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Raj S Kasthuri
- Division of Hematology/Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - Hasan A Albitar
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Carolina Vázquez
- Department of Internal Medicine, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Marcelo M Serra
- Department of Internal Medicine, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Sophie Dupuis-Girod
- Centre de Reference pour la maladie de Rendu-Osler, Hospices Civils de Lyon, Lyon, France
| | - Craig B Wilsen
- Department of Radiology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Justin P McWilliams
- Department of Radiology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Evan H Fountain
- Division of Pulmonary, Critical Care, and Sleep Medicine, Augusta University, Augusta, GA, USA
| | - James R Gossage
- Division of Pulmonary, Critical Care, and Sleep Medicine, Augusta University, Augusta, GA, USA
| | - Clifford R Weiss
- Div. of Interventional Radiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Muhammad A Latif
- Div. of Interventional Radiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Assaf Issachar
- Schneider Children's Medical Center of Israel, Tel Aviv University, Israel
| | - Meir Mei-Zahav
- Schneider Children's Medical Center of Israel, Tel Aviv University, Israel
| | - Mary E Meek
- Department of Radiology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Miles Conrad
- Dept. of Radiology, University of California San Francisco Medical Center, San Francisco, CA, USA
| | - Josanna Rodriguez-Lopez
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - David J Kuter
- Division of Hematology, Massachusetts General Hospital, Boston, MA, USA
| | - Vivek N Iyer
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
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14
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Parambil JG, Gossage JR, McCrae KR, Woodard TD, Menon KVN, Timmerman KL, Pederson DP, Sprecher DL, Al-Samkari H. Pazopanib for severe bleeding and transfusion-dependent anemia in hereditary hemorrhagic telangiectasia. Angiogenesis 2021; 25:87-97. [PMID: 34292451 PMCID: PMC8295629 DOI: 10.1007/s10456-021-09807-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 07/07/2021] [Indexed: 11/29/2022]
Abstract
Hereditary hemorrhagic telangiectasia (HHT) is a rare angiogenic disorder causing chronic gastrointestinal bleeding, epistaxis, and severe anemia. Pazopanib is an oral multi-kinase angiogenesis inhibitor with promise to treat bleeding in HHT. We analyzed outcomes of HHT patients with the most severe bleeding causing RBC transfusion dependence treated on a predefined institutional pazopanib treatment pathway (with data collected retrospectively). The primary endpoint was achievement of transfusion independence. Secondary endpoints included hemoglobin, epistaxis severity score, RBC transfusion and iron infusion requirements, number of local hemostatic procedures, ferritin and transferrin saturation, compared using paired and repeated measures mean tests. Thirteen transfusion-dependent HHT patients received pazopanib [median (range) dose 150 (25–300) mg daily)] for a median of 22 months. All patients achieved transfusion independence. Compared with pretreatment, pazopanib increased mean hemoglobin by 4.8 (95% CI, 3.6–5.9) g/dL (7.8 vs. 12.7 g/dL, P < 0.0001) and decreased mean epistaxis severity score by 4.77 (3.11–6.44) points (7.20 vs. 2.43 points, P < 0.0001) after 12 months of treatment. Compared with 3 months of pretreatment, RBC transfusions decreased by 93% (median of 16.0 vs. 0.0 units, P < 0.0001) and elemental iron infusion decreased by 92% (median of 4500 vs. 0 mg, P = 0.005) during the first 3 months of treatment; improvements were maintained over time. Pazopanib was well-tolerated: hypertension, lymphocytopenia, and fatigue were the most common TEAEs. In conclusion, pazopanib was safe and effective to manage severe bleeding in HHT, liberating all patients from transfusion dependence and normalizing hematologic parameters at doses lower than used to treat malignancies. These findings require confirmation in a randomized trial.
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Affiliation(s)
- Joseph G Parambil
- Cleveland Clinic, Respiratory Institute, 9500 Euclid Avenue A-90, Cleveland, OH, 44195, USA.
| | - James R Gossage
- Division of Pulmonary, Critical Care and Sleep Medicine, Augusta University, Augusta, GA, USA
| | - Keith R McCrae
- Cleveland Clinic, Taussig Cancer Institute, Cleveland, OH, USA
| | - Troy D Woodard
- Cleveland Clinic, Head and Neck Institute, Cleveland, OH, USA
| | | | - Kasi L Timmerman
- Cleveland Clinic, Respiratory Institute, 9500 Euclid Avenue A-90, Cleveland, OH, 44195, USA
| | - Douglas P Pederson
- Cleveland Clinic, Respiratory Institute, 9500 Euclid Avenue A-90, Cleveland, OH, 44195, USA
| | | | - Hanny Al-Samkari
- Division of Hematology, Massachusetts General Hospital, Zero Emerson Pl Suite 118, Office 112, Boston, MA, 02114, USA.
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15
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Hereditary hemorrhagic telangiectasia: systemic therapies, guidelines, and an evolving standard of care. Blood 2021; 137:888-895. [PMID: 33171488 DOI: 10.1182/blood.2020008739] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 11/03/2020] [Indexed: 12/13/2022] Open
Abstract
Hereditary hemorrhagic telangiectasia (HHT) management is evolving because of the emergence and development of antiangiogenic therapies to eliminate bleeding telangiectasias and achieve hemostasis. This progress is reflected in recent clinical recommendations published in the Second International Guidelines for the Diagnosis and Treatment of HHT, in which systemic therapies including antiangiogenics and antifibrinolytics are now recommended as standard treatment options for bleeding. This review highlights the new recommendations especially relevant to hematologists in managing bleeding, anticoagulation, and anemia in patients with HHT.
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16
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Wu V, Lee JM, Vozoris NT, Faughnan ME. Weekly epistaxis duration as an indicator of epistaxis severity in hereditary hemorrhagic telangiectasia-Preliminary results from a randomized controlled trial. Laryngoscope Investig Otolaryngol 2021; 6:370-375. [PMID: 34195356 PMCID: PMC8223446 DOI: 10.1002/lio2.561] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 03/04/2021] [Accepted: 03/29/2021] [Indexed: 01/15/2023] Open
Abstract
OBJECTIVES There is great interest in developing and studying novel therapies for epistaxis in hereditary hemorrhagic telangiectasia (HHT) given its associated morbidity and impact on patients' quality of life. Several recent randomized controlled trials (RCTs) have been negative, likely attributed to poorly characterized outcome measures. This study reported on and evaluated an epistaxis outcome measure, weekly epistaxis duration (WED) in an ongoing RCT, with the aim of better characterizing the measurement of epistaxis for clinical trials. MATERIALS AND METHODS Patients were recruited to an ongoing phase II, double-blind, cross-over RCTs of oral doxycycline for HHT-associated epistaxis. Patients were included for the epistaxis measures analysis if they had already completed the initial 3-month run-in period, and had received treatment of either study drug doxycycline or placebo for a minimum of 6 months. The primary measure of interest was patient-reported outcome (PRO)-WED, captured from prospective daily diaries. Epistaxis severity score (ESS) was collected as a secondary outcome. RESULTS Seven patients were included for analysis, with 98% completion of the daily diary. The average PRO-WED across all patients was 85.0 minutes, SD 93.2 at baseline, and 65.6 minutes, SD 59.5 during treatment/placebo. Coefficient of variance for PRO-WED at baseline and during treatment/placebo was 0.49, SD 0.1 and 0.58, SD 0.2, respectively. Statistically significant changes in the mean PRO-WED from baseline to treatment/placebo was noted in six patients (86%). Only two patients (29%) had a significant change in ESS, with both reporting decreased (improved) scores after treatment/placebo as compared to baseline. CONCLUSIONS PRO-WED was a feasible clinical trials measure, was reasonably stable during baseline measurement, and appeared to be variable with treatment state, suggesting it may provide a sensitive clinical trials PRO in HHT.
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Affiliation(s)
- Vincent Wu
- Department of Otolaryngology – Head and Neck SurgerySt. Michael's Hospital, University of TorontoTorontoCanada
| | - John M. Lee
- Department of Otolaryngology – Head and Neck SurgerySt. Michael's Hospital, University of TorontoTorontoCanada
- Li Ka Shing Knowledge InstituteSt. Michael's HospitalTorontoCanada
| | - Nicholas T. Vozoris
- Division of Respirology, Department of MedicineSt. Michael's Hospital, University of TorontoTorontoCanada
| | - Marie E. Faughnan
- Division of Respirology, Department of MedicineSt. Michael's Hospital, University of TorontoTorontoCanada
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17
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Peterson AM, Lee JJ, Kallogjeri D, Schneider JS, Chakinala MM, Piccirillo JF. Efficacy of Timolol in a Novel Intranasal Thermosensitive Gel for Hereditary Hemorrhagic Telangiectasia-Associated Epistaxis: A Randomized Clinical Trial. JAMA Otolaryngol Head Neck Surg 2021; 146:1006-1014. [PMID: 32940653 DOI: 10.1001/jamaoto.2020.3025] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Other than nasal moisturizers, no standard-of-care medical therapy exists for epistaxis in hereditary hemorrhagic telangiectasia (HHT). With epistaxis as the greatest cause of morbidity in patients with HHT, there is a need to identify effective topical therapies. Objective To determine the efficacy and safety of an intranasal timolol thermosensitive gel vs placebo thermosensitive gel in treating HHT-associated epistaxis. Design, Setting, and Participants This double-blind, placebo-controlled randomized clinical trial was conducted from October 29, 2019, to May 20, 2020, at a tertiary care center. A total of 27 patients with HHT and moderate-to-severe epistaxis were recruited and included in this prespecified analysis: 14 in the timolol group and 13 in the placebo group. Inclusion criteria included (1) age 18 years or older, (2) clinical or genetic diagnosis of HHT, (3) screening Epistaxis Severity Score (ESS) of 4 or greater and 2 or more nosebleeds cumulatively lasting at least 5 minutes per week, (4) stable epistaxis pattern over the preceding 3 months, and (5) no change in epistaxis treatment or nasal hygiene regimen in the preceding month. Exclusion criteria included (1) contraindications to systemic β-blocker administration, (2) use of medications interacting with timolol, (3) use of antiangiogenic medications in the last month before recruitment, and (4) use of anticoagulants, antiplatelets, or fibrinolytic therapies within the last month. Interventions Novel thermosensitive intranasal timolol (0.1%) gel vs placebo thermosensitive gel applied twice daily to each nostril for 8 weeks. Main Outcomes and Measures The primary outcome was the median change in ESS and percentage of participants reaching the minimal clinically important difference in ESS. Secondary outcomes were changes in Clinical Global Impression-Severity and Clinical Global Impression-Improvement scores, Nasal Outcome Score for Epistaxis in Hereditary Hemorrhagic Telangiectasia, and hemoglobin level. Results Of 27 participants randomized (median [range] age, 55 [20-76] years; 14 women [52%]; 25 White [93%]), a total of 23 patients with HHT completed the primary outcome measure. Within the timolol gel and placebo gel groups, respectively, the median change (range) in ESS was 2.32 (0.22 to 5.97) vs 1.96 (-0.91 to 5.98), and 9 of 11 (82%) vs 9 of 12 (75%) participants experienced a clinically meaningful improvement in ESS. Twenty-two of the 23 participants (96%) reported improvement via the Clinical Global Impression-Improvement score, with 81% vs 58% of participants reporting reduced severity of epistaxis in the timolol vs placebo group, respectively. Of participants completing the Nasal Outcome Score for Epistaxis in HHT at follow-up visit, 7 of 10 (70%) in the timolol group achieved a clinically important difference vs 5 of 10 (50%) in the placebo group. There was no change in hemoglobin level between or within groups. Zero participants in the placebo group and 2 of 13 (15%) in the timolol group withdrew because of adverse events. Conclusions and Relevance Thermosensitive gel, alone or in combination with timolol, was highly effective in reducing HHT-associated epistaxis. The timolol group had greater improvement in epistaxis and quality of life than the placebo group, but effect estimates were imprecise, and no definitive conclusions on the superiority of timolol can be drawn. Physicians treating patients with HHT-associated epistaxis should consider a thermosensitive gel (with or without timolol) for their patients. Trial Registration ClinicalTrials.gov Identifier: NCT04139018.
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Affiliation(s)
- Andrew M Peterson
- Clinical Outcomes Research Office, Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri.,University of Missouri-Kansas City School of Medicine, Kansas City
| | - Jake J Lee
- Clinical Outcomes Research Office, Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Dorina Kallogjeri
- Clinical Outcomes Research Office, Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - John S Schneider
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Murali M Chakinala
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, Washington University School of Medicine in St Louis, St Louis, Missouri.,Washington University Hereditary Hemorrhagic Telangiectasia Center of Excellence, St Louis, Missouri
| | - Jay F Piccirillo
- Clinical Outcomes Research Office, Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri
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18
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Peterson AM, Kallogjeri D, Spitznagel E, Chakinala MM, Schneider JS, Piccirillo JF. Development and Validation of the Nasal Outcome Score for Epistaxis in Hereditary Hemorrhagic Telangiectasia (NOSE HHT). JAMA Otolaryngol Head Neck Surg 2021; 146:999-1005. [PMID: 33022056 DOI: 10.1001/jamaoto.2020.3040] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Epistaxis is the greatest cause of morbidity in patients with hereditary hemorrhagic telangiectasia (HHT); because of this, a validated epistaxis-specific quality-of-life instrument for HHT should be made available. Objective To develop and validate an epistaxis-specific quality-of-life patient-reported outcome measure for HHT. Design, Setting, and Participants This survey study focused on the development and validation of the Nasal Outcome Score for Epistaxis (NOSE) in HTT (NOSE HHT) outcome measure with data prospectively collected from December 10, 2019, to March 15, 2020. A total of 401 patients were recruited from within the Cure Hemorrhagic Telangiectasia online patient advocacy social media network, the Washington University HHT Center of Excellence, and a randomized clinical trial investigating an intranasal timolol gel for HHT-associated epistaxis. Main Outcomes and Measures Face and content validity, factor analysis, internal consistency as measured through Cronbach α, construct validity, responsiveness to change, and minimal clinically important difference. Results The NOSE HHT was developed and validated with a possible score ranging discretely from 0 to 4 for each of the 29 items and a total score ranging continuously from 0 to 4 after dividing by the total number of items answered. A total of 401 participants completed the NOSE HHT. Factor analysis identified 3 factors that matched the a priori specified subgroups of particular aspects of life affected by HHT-associated epistaxis: physical problems (mean [SD] magnitude, 1.59 [0.83]), functional limitations (mean [SD] magnitude, 1.28 [0.84]), and emotional consequences (mean [SD] magnitude, 1.95 [1.02]). The instrument had high internal consistency with an overall Cronbach α of 0.960. Convergent validity determined the total NOSE HHT score to be a strong predictor of disease severity; total NOSE HHT score can be split up into the following epistaxis severity categories: mild (0-1), moderate (1.01-2), and severe (>2). The instrument was found to be sensitive to change, and the minimal clinically important difference for the total NOSE HHT score was 0.46. Conclusions and Relevance Evaluation of the consistency, reliability, and responsiveness of the NOSE HHT survey found it to be a valid instrument to assess severity and change in epistaxis. Study results suggest that the NOSE HHT survey is clinically applicable and useful as an outcome measure of future HHT-associated epistaxis trials.
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Affiliation(s)
- Andrew M Peterson
- Clinical Outcomes Research Office, Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri.,University of Missouri-Kansas City School of Medicine, Kansas City
| | - Dorina Kallogjeri
- Clinical Outcomes Research Office, Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Edward Spitznagel
- Department of Mathematics, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Murali M Chakinala
- Department of Medicine, Washington University in St Louis, St Louis, Missouri
| | - John S Schneider
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Jay F Piccirillo
- Clinical Outcomes Research Office, Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri
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19
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Jorgensen OJ, Steineger J, Bachmann-Harildstad G, Dheyauldeen S. A comparative study of two grading systems for epistaxis in hereditary haemorrhagic telangiectasia. Rhinology 2021; 59:212-218. [PMID: 33821857 DOI: 10.4193/rhin20.540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Different institutions use different grading systems for hereditary haemorrhagic telangiectasia (HHT)-associated epistaxis. It is important to have a universal, standardized grading system to compare and evaluate the effectiveness of different treatment options. We introduced the "Intensity, Frequency and need for Blood Transfusion" (IFT) grading system for HHT-associated epistaxis in 2008. Hoag et al. proposed the "Epistaxis Severity Score" (ESS) for the International HHT foundation in 2010. This study aimed to evaluate the potential correlation between the ESS and IFT grading systems. METHODS The study included 354 simultaneous reports using the IFT and ESS from 106 patients. The correlation between the ESS, IFT and haemoglobin levels was measured using Pearson's correlation coefficient. The ESS and IFT were scored simultaneously by the patient and doctor in 48 cases to evaluate if there was a discrepancy in the scoring applied by either set of responders. RESULTS The measured correlation between the two grading systems was good (0.75). The grade of epistaxis reported by patients and doctors respectively showed no significant difference. Both the IFT and ESS grading systems correlate significantly to the haemoglobin level. CONCLUSIONS Both the IFT and ESS scores correlate to each other, and their results are comparable. Whether the IFT or ESS scoring was performed by the patient or doctor had no significant impact.
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Affiliation(s)
- O J Jorgensen
- Department of Otorhinolaryngology and Head and Neck Surgery, Oslo University Hospital, Medical Faculty, University of Oslo, Oslo, Norway
| | - J Steineger
- Department of Otorhinolaryngology and Head and Neck Surgery, Oslo University Hospital, Medical Faculty, University of Oslo, Oslo, Norway
| | - G Bachmann-Harildstad
- Department of Otorhinolaryngology, Akershus University Hospital and Institute of Clinical Medicine, Akershus University Hospital, Oslo University, Lorenskog, Norway
| | - S Dheyauldeen
- Department of Otorhinolaryngology and Head and Neck Surgery, Oslo University Hospital, Medical Faculty, University of Oslo, Oslo, Norway
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20
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Mei-Zahav M, Gendler Y, Bruckheimer E, Prais D, Birk E, Watad M, Goldschmidt N, Soudry E. Topical Propranolol Improves Epistaxis Control in Hereditary Hemorrhagic Telangiectasia (HHT): A Randomized Double-Blind Placebo-Controlled Trial. J Clin Med 2020; 9:jcm9103130. [PMID: 32998220 PMCID: PMC7601781 DOI: 10.3390/jcm9103130] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 09/18/2020] [Accepted: 09/26/2020] [Indexed: 02/07/2023] Open
Abstract
Epistaxis is a common debilitating manifestation in hereditary hemorrhagic telangiectasia (HHT), due to mucocutaneous telangiectases. The epistaxis can be difficult to control despite available treatments. Dysregulated angiogenesis has been shown to be associated with telangiectases formation. Topical propranolol has demonstrated antiangiogenic properties. We performed a two-phase study, i.e., a double-blind placebo-controlled phase, followed by an open-label phase. The aim of the study was assessment of safety and efficacy of nasal propranolol gel in HHT-related epistaxis. Twenty participants with moderate-severe HHT-related epistaxis were randomized to eight weeks of propranolol gel 1.5%, or placebo 0.5 cc, applied to each nostril twice daily; and continued propranolol for eight weeks in an open-label study. For the propranolol group, the epistaxis severity score (ESS) improved significantly (-2.03 ± 1.7 as compared with -0.35 ± 0.68 for the placebo group, p = 0.009); hemoglobin levels improved significantly (10.5 ± 2.6 to 11.4 ± 2.02 g/dL, p = 0.009); and intravenous iron and blood transfusion requirement decreased. The change in nasal endoscopy findings was not significant. During the open-label period, the ESS score improved significantly in the former placebo group (-1.99 ± 1.41, p = 0.005). The most common adverse event was nasal mucosa burning sensation. No cardiovascular events were reported. Our results suggest that topical propranolol gel is safe and effective in HHT-related epistaxis.
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Affiliation(s)
- Meir Mei-Zahav
- Pulmonary Institute, Schneider Children’s Medical Center of Israel, Petah Tikva 49202, Israel; (Y.G.); (D.P.)
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 69978, Israel; (E.B.); (E.B.); (M.W.); (E.S.)
- The National HHT Center, Pulmonary Institute, Schneider CMCI, 14 Kaplan St., Petach Tikva 49202, Israel
- Correspondence:
| | - Yulia Gendler
- Pulmonary Institute, Schneider Children’s Medical Center of Israel, Petah Tikva 49202, Israel; (Y.G.); (D.P.)
- The Department of Nursing, Ariel University, Ariel 40700, Israel
| | - Elchanan Bruckheimer
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 69978, Israel; (E.B.); (E.B.); (M.W.); (E.S.)
- Cardiology Department, Schneider Children’s Medical Center of Israel, Petah Tikva 49202, Israel
| | - Dario Prais
- Pulmonary Institute, Schneider Children’s Medical Center of Israel, Petah Tikva 49202, Israel; (Y.G.); (D.P.)
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 69978, Israel; (E.B.); (E.B.); (M.W.); (E.S.)
- The National HHT Center, Pulmonary Institute, Schneider CMCI, 14 Kaplan St., Petach Tikva 49202, Israel
| | - Einat Birk
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 69978, Israel; (E.B.); (E.B.); (M.W.); (E.S.)
- Cardiology Department, Schneider Children’s Medical Center of Israel, Petah Tikva 49202, Israel
| | - Muhamad Watad
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 69978, Israel; (E.B.); (E.B.); (M.W.); (E.S.)
| | - Neta Goldschmidt
- Department of Hematology, Hadassah-Hebrew University Medical Center, Jerusalem 91120, Israel;
| | - Ethan Soudry
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 69978, Israel; (E.B.); (E.B.); (M.W.); (E.S.)
- Department of Otolaryngology Head and Neck Surgery, Rabin Medical Center, Petah Tikva 49202, Israel
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21
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Beckman JD, Li Q, Hester ST, Leitner O, Smith KL, Kasthuri RS. Integration of clinical parameters, genotype and epistaxis severity score to guide treatment for hereditary hemorrhagic telangiectasia associated bleeding. Orphanet J Rare Dis 2020; 15:185. [PMID: 32660636 PMCID: PMC7359017 DOI: 10.1186/s13023-020-01453-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 06/29/2020] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Hereditary Hemorrhagic Telangiectasia (HHT) is a rare inherited disorder characterized by development of mucocutaneous telangiectases and visceral organ arteriovenous malformations, which can lead to recurrent, spontaneous bleeding and development of iron deficiency anemia. The primary objective of this study was to ascertain the relationship between epistaxis severity scores (ESS), laboratory values, genotype, and phenotype in HHT. Our secondary objective was to assess efficacy of systemic antifibrinolytic therapy in reducing ESS in HHT. METHODOLOGY We conducted a retrospective review of patients seen at the UNC HHT Center from January 1, 2009 to February 28, 2015. ESS, demographics, and results of genetic testing were abstracted from the medical record. Response to antifibrinolytic therapy was evaluated by comparing pre-post ESS. RESULTS One hundred and forty nine patients were eligible with 116 having genetic testing and 33 without. Age, hemoglobin and ferritin levels were predictive of ESS. Of the 116 patients that underwent genetic testing: 63 had an ACVRL1 mutation, 40 had an ENG mutation, 2 had a SMAD4 mutation, and 11 patients had no pathologic HHT genetic variation detected. Compared to patients without a detectable HHT-associated genetic variation, patients with a HHT-associated genetic variation had higher ESS scores (p < 0.05). Neither ESS nor genotype was predictive of pulmonary or brain AVMs. Twenty-four HHT patients with ESS > 4 were started on antifibrinolytic therapy (tranexamic acid or aminocaproic acid) and had a post-treatment ESS recorded. All patients had a decrease in ESS of > 0.71 (minimal meaningful difference), but patients taking antifibrinolytics displayed larger decreases. No patients on antifibrinolytics experienced a VTE with median follow up of 13 months. CONCLUSIONS We demonstrate that the ESS correlates with age, hemoglobin and ferritin. Additionally, we demonstrate that HHT patients with genetic mutations have higher ESS scores. Our data demonstrate that antifibrinolytics are effective in decreasing epistaxis severity and safe with long-term use in HHT patients.
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Affiliation(s)
- Joan D Beckman
- Department of Medicine, Division of Hematology, Oncology, and Transplantation, University of Minnesota, Minneapolis, MN, 55455, USA
| | - Quefeng Li
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Samuel T Hester
- Department of Internal Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Ofri Leitner
- Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Karen L Smith
- Department of Medicine, Division of Hematology/Oncology, University of North Carolina at Chapel Hill, CB#7035, 8206B Mary Ellen Jones Bldg, 116 Manning Drive, Chapel Hill, NC, 27599, USA
| | - Raj S Kasthuri
- Department of Medicine, Division of Hematology/Oncology, University of North Carolina at Chapel Hill, CB#7035, 8206B Mary Ellen Jones Bldg, 116 Manning Drive, Chapel Hill, NC, 27599, USA.
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22
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Wu V, Kell E, Faughnan ME, Lee JM. In-Office KTP Laser for Treating Hereditary Hemorrhagic Telangiectasia-Associated Epistaxis. Laryngoscope 2020; 131:E689-E693. [PMID: 32557619 DOI: 10.1002/lary.28824] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 05/01/2020] [Accepted: 05/18/2020] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To evaluated the efficacy and safety of in-office potassium titanyl phosphate (KTP) laser treatment for the management of epistaxis in hereditary hemorrhagic telangiectasia (HHT) patients. METHODS A retrospective case series of all HHT patients over age of 18 who underwent in-office KTP laser treatment from July 1, 2017 to December 31, 2019 was performed. The primary outcome measure was the epistaxis severity score (ESS) pre- and post-procedure. Secondary outcome measures included patient reported pain (on a 10-point Likert-type scale), and procedural adverse events and complications. RESULTS A total of 16 patients underwent KTP in-office laser treatment during the review period. There was both a clinically and statistically significant decrease in the ESS after in-office laser treatment, baseline ESS -7.24, SD 1.71, follow up ESS -4.92, SD 1.83 (mean difference 2.94, 95% confidence interval, 1.83-4.04, P < .0001). There were no reported adverse events or complications associated with the procedure. The mean pain score reported was 0.19, SD 0.75. The average blood loss was 10.8 mL, SD 37.3. The majority of patients (62.5%, 10/16) had no blood loss during the procedure. CONCLUSION Clinically and statistically significant decreases were noted in the ESS of HHT patients after in-office KTP laser photocoagulation. The procedure was well tolerated by patients, without any adverse events or complications. LEVEL OF EVIDENCE 4 Laryngoscope, 131:E689-E693, 2021.
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Affiliation(s)
- Vincent Wu
- Division of Rhinology, Department of Otolaryngology-Head and Neck Surgery, St. Michael's Hospital, Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada
| | - Erika Kell
- Division of Rhinology, Department of Otolaryngology-Head and Neck Surgery, St. Michael's Hospital, Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada
| | - Marie E Faughnan
- Toronto HHT Centre, Division of Respirology, Department of Medicine, St. Michael's Hospital, Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada.,Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - John M Lee
- Division of Rhinology, Department of Otolaryngology-Head and Neck Surgery, St. Michael's Hospital, Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada.,Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
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23
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Efficacy and Safety of a 0.1% Tacrolimus Nasal Ointment as a Treatment for Epistaxis in Hereditary Hemorrhagic Telangiectasia: A Double-Blind, Randomized, Placebo-Controlled, Multicenter Trial. J Clin Med 2020; 9:jcm9051262. [PMID: 32357559 PMCID: PMC7287684 DOI: 10.3390/jcm9051262] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 04/17/2020] [Accepted: 04/20/2020] [Indexed: 01/10/2023] Open
Abstract
Hereditary hemorrhagic telangiectasia is a rare but ubiquitous genetic disease. Epistaxis is the most frequent and life-threatening manifestation and tacrolimus, an immunosuppressive agent, appears to be an interesting new treatment option because of its anti-angiogenic properties. Our objective was to evaluate, six weeks after the end of the treatment, the efficacy on the duration of nosebleeds of tacrolimus nasal ointment, administered for six weeks to patients with hereditary hemorrhagic telangiectasia complicated by nosebleeds, and we performed a prospective, multicenter, randomized, placebo-controlled, double-blinded, ratio 1:1 phase II study. Patients were recruited from three French Hereditary Hemorrhagic Telangiectasia (HHT) centers between May 2017 and August 2018, with a six-week follow-up, and we included people aged over 18 years, diagnosed with hereditary hemorrhagic telangiectasia and epistaxis (total duration > 30 min/6 weeks prior to inclusion). Tacrolimus ointment 0.1% was self-administered by the patients twice daily. About 0.1 g of product was to be administered in each nostril with a cotton swab. A total of 50 patients was randomized and treated. Mean epistaxis duration before and after treatment in the tacrolimus group were 324.64 and 249.14 min, respectively, and in the placebo group 224.69 and 188.14 min, respectively. Epistaxis duration improved in both groups, with no significant difference in our main objective comparing epistaxis before and after treatment (p = 0.77); however, there was a significant difference in evolution when comparing epistaxis before and during treatment (p = 0.04). Toxicity was low and no severe adverse events were reported. In conclusion, tacrolimus nasal ointment, administered for six weeks, did not improve epistaxis in HHT patients after the end of the treatment. However, the good tolerance, associated with a significant improvement in epistaxis duration during treatment, encouraged us to perform a phase 3 trial on a larger patient population with a main outcome of epistaxis duration during treatment and a longer treatment time.
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24
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Khoueir N, Borsik M, Camous D, Herman P, Verillaud B. Injection of bevacizumab and cyanoacrylate glue for hereditary hemorrhagic telangiectasia. Laryngoscope 2019; 129:2210-2215. [PMID: 31566760 DOI: 10.1002/lary.27889] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 11/27/2018] [Accepted: 12/03/2018] [Indexed: 11/12/2022]
Abstract
OBJECTIVES/HYPOTHESIS The objective of this study was to report for the first time on the results of submucosal injections of bevacizumab used in conjunction with cyanoacrylate glue sclerotherapy in hereditary hemorrhagic telangiectasia (HHT). STUDY DESIGN Retrospective analytic chart review. METHODS We performed a chart review that included all patients with HHT treated with intranasal bevacizumab and cyanoacrylate glue for refractory epistaxis at Lariboisiere University Hospital from 2013 with a minimum follow-up of 6 months. We injected 100 mg (25 mg/mL) of bevacizumab diluted in 2 mL of serum at the base of the telangiectasias, and sclerotherapy with an injection of cyanoacrylate glue was used adjunctively. Treatment efficacy was based on changes in Epistaxis Severity Scores (ESS) and the Bergler-Sadick Scale. Quality of life and patient satisfaction were evaluated using the Cantril Self-Anchoring Ladder (CL) and Likert scale, respectively. RESULTS Thirty-one patients were included, with a mean follow-up of 26.6 months. The average ESS score significantly decreased from 7.82 to 3.89 (P < .05). The Bergler-Sadick score significantly improved (P < .05) following the treatment, including the frequency (from 2.74 to 1.64) and the quantity (from 2.54 to 1.51) scales. Quality of life was significantly improved (P < .05) using the CL score (from 4.16 to 7.22). The Likert satisfaction scale related to the treatment efficacy was high, with an average of 7.03 out of 10. No complications were noted. CONCLUSIONS Submucosal injections of bevacizumab in conjunction with cyanoacrylate glue sclerotherapy significantly reduced epistaxis and improved the quality of life in HHT. Prospective comparative studies are needed to further evaluate the significance of this treatment modality. LEVEL OF EVIDENCE 3b Laryngoscope, 129:2210-2215, 2019.
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Affiliation(s)
- Nadim Khoueir
- Department of Otolaryngology-Head and Neck Surgery/Skull Base Surgery, Hospital Groups Saint Louis, Lariboisière, Fernand-Widal, Public Assistance Paris Hospitals, Paris-Diderot University, Paris, France.,Department of Otolaryngology-Head and Neck Surgery, Hotel Dieu de France University Hospital, Saint Joseph University, Faculty of Medicine, Beirut, Lebanon
| | - Michel Borsik
- Department of Otolaryngology-Head and Neck Surgery/Skull Base Surgery, Hospital Groups Saint Louis, Lariboisière, Fernand-Widal, Public Assistance Paris Hospitals, Paris-Diderot University, Paris, France
| | - Domitille Camous
- Department of Otolaryngology-Head and Neck Surgery/Skull Base Surgery, Hospital Groups Saint Louis, Lariboisière, Fernand-Widal, Public Assistance Paris Hospitals, Paris-Diderot University, Paris, France
| | - Philippe Herman
- Department of Otolaryngology-Head and Neck Surgery/Skull Base Surgery, Hospital Groups Saint Louis, Lariboisière, Fernand-Widal, Public Assistance Paris Hospitals, Paris-Diderot University, Paris, France
| | - Benjamin Verillaud
- Department of Otolaryngology-Head and Neck Surgery/Skull Base Surgery, Hospital Groups Saint Louis, Lariboisière, Fernand-Widal, Public Assistance Paris Hospitals, Paris-Diderot University, Paris, France
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25
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Hochet B, Achard S, Maillard H, Mortuaire G. Retrospective analysis of submucosal radiofrequency procedure for the treatment of nasal bleeding in 44 patients with hereditary haemorrhagic telangiectasia. Clin Otolaryngol 2019; 44:1138-1141. [PMID: 31433905 DOI: 10.1111/coa.13418] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 06/07/2019] [Accepted: 08/18/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Baptiste Hochet
- Otorhinolaryngology - Head and Neck Surgery Department, University Hospital, Lille, France
| | - Sophie Achard
- Otorhinolaryngology - Head and Neck Surgery Department, University Hospital, Lille, France
| | - Helene Maillard
- Department of Internal Medicine, Huriez Hospital, University of Lille, Lille, France
| | - Geoffrey Mortuaire
- Otorhinolaryngology - Head and Neck Surgery Department, University Hospital, Lille, France.,Lille Inflammation Research International Center - Inserm U995, Université de Lille, Lille, France
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26
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Steineger J, Geirdal AØ, Osnes T, Heimdal KR, Dheyauldeen S. Intranasal bevacizumab injections improve quality of life in HHT patients. Laryngoscope 2019; 130:E284-E288. [DOI: 10.1002/lary.28179] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 05/15/2019] [Accepted: 06/19/2019] [Indexed: 01/31/2023]
Affiliation(s)
- Johan Steineger
- Division of Head and Neck and Reconstructive Surgery, Department of Otorhinolaryngology, Head and Neck SurgeryOslo University Hospital Rikshospitalet Oslo Norway
- Institute of Clinical MedicineUniversity of Oslo Norway
| | | | - Terje Osnes
- Division of Head and Neck and Reconstructive Surgery, Department of Otorhinolaryngology, Head and Neck SurgeryOslo University Hospital Rikshospitalet Oslo Norway
- Institute of Clinical MedicineUniversity of Oslo Norway
| | | | - Sinan Dheyauldeen
- Division of Head and Neck and Reconstructive Surgery, Department of Otorhinolaryngology, Head and Neck SurgeryOslo University Hospital Rikshospitalet Oslo Norway
- Institute of Clinical MedicineUniversity of Oslo Norway
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27
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Esteban-Casado S, Martín de Rosales Cabrera AM, Usarralde Pérez A, Martínez Simón JJ, Zhan Zhou E, Marcos Salazar MS, Pérez Encinas M, Botella Cubells L. Sclerotherapy and Topical Nasal Propranolol: An Effective and Safe Therapy for HHT-Epistaxis. Laryngoscope 2019; 129:2216-2223. [PMID: 30908653 DOI: 10.1002/lary.27930] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 01/30/2019] [Accepted: 02/22/2019] [Indexed: 12/28/2022]
Abstract
OBJECTIVES Epistaxis is the most frequent clinical manifestation of hereditary hemorrhagic telangiectasia (HHT). Several topical, systemic, and surgical treatments have been tried, but none have been completely effective. The aim of the present study is to evaluate whether a combined treatment sclerotherapy and topical therapy with propranolol 0.5% nasal formulation would reduce the epistaxis due to HHT and improve patient's quality of life. METHODS An observational cross-sectional study was carried out. The primary outcome measure was frequency and severity of epistaxis as measured by the epistaxis severity score (ESS) at baseline (4 weeks before therapy) and at least 4 weeks after the treatment was implemented. Quality of life was analyzed using EuroQol-5D (EQ-5D) scale and visual analogue (VAS) scale before and after treatment. RESULTS A total of 38 consecutive patients subjected to the combined treatment were evaluated (mean age: 57.2 years, standard deviation [SD] = 13.9; 60.5% women). The mean time of treatment was 37.1 weeks (SD = 14.9). Combined therapy significantly reduces frequency and severity of epistaxis, with an ESS improvement of 5 points from 6.9 ± 2.6 to 1.9 ± 1.3 (P < 0.05); however, the EQ-5D scale increased from 0.66 ± 0.27 to 0.93 ± 0.12 (P < 0.05). The difference in VAS means showed an increase from 44.6 ± 28.3 to 82.5 ± 12.5 (P < 0.05). The increases in quality of life are in line with the drop in ESS. CONCLUSION The study demonstrated that combined therapy (sclerotherapy and topical nasal propranolol) significantly reduced the epistaxis due to HHT and increased patients' quality of life. LEVEL OF EVIDENCE 2c Laryngoscope, 129:2216-2223, 2019.
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Affiliation(s)
| | | | | | | | - Estefanía Zhan Zhou
- Pharmacy Department, University Hospital Alcorcón Foundation, Alcorcón, Madrid
| | - M Sol Marcos Salazar
- Otorhinolaryngology Department, University Hospital Alcorcón Foundation, Alcorcón, Madrid
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28
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Iyer VN, Apala DR, Pannu BS, Kotecha A, Brinjikji W, Leise MD, Kamath PS, Misra S, Begna KH, Cartin-Ceba R, DuBrock HM, Krowka MJ, O'Brien EK, Pruthi RK, Schroeder DR, Swanson KL. Intravenous Bevacizumab for Refractory Hereditary Hemorrhagic Telangiectasia-Related Epistaxis and Gastrointestinal Bleeding. Mayo Clin Proc 2018; 93:155-166. [PMID: 29395350 DOI: 10.1016/j.mayocp.2017.11.013] [Citation(s) in RCA: 77] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Revised: 11/02/2017] [Accepted: 11/20/2017] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To present a multiyear clinical experience with intravenous bevacizumab for the management of severe gastrointestinal bleeding and/or epistaxis in patients with hereditary hemorrhagic telangiectasia (HHT). PATIENTS AND METHODS All patients treated with intravenous bevacizumab for severe hereditary hemorrhagic telangiectasia-related bleeding from June 1, 2013, through January 31, 2017, were included in this report. Severity of epistaxis (determined using the Epistaxis Severity Score questionnaire); hemoglobin, iron, and ferritin levels; and quality of life data were collected serially in all patients. RESULTS Intravenous bevacizumab was administered to 34 patients using a standardized treatment protocol. Anemia was primarily related to severe epistaxis (n=15, 44%), severe gastrointestinal bleeding (n=4, 12%), or both (n=15, 44%), with a median baseline hemoglobin level of 9.1 g/dL (range, 8.3-10.5 gm/dL; to convert to mmol/L, multiply by 0.62). Red blood cell (RBC) transfusions had been administered to 28 patients (82%). Of these, 16 patients (47%) were RBC transfusion dependent and had received a median of 75 RBC transfusions (range, 4->500 RBC units) before bevacizumab initiation. The median length of follow-up was 17.6 months from the beginning of bevacizumab treatment (range, 3-42.5 months). There was a significant reduction in epistaxis severity scores (P<.001) and RBC transfusion requirements (P=.007) after completion of the initial bevacizumab treatment cycle. New-onset or worsened hypertension was noted in 4 patients, with 1 patient experiencing hypertensive urgency with a temporary decline in renal function. CONCLUSION Intravenous bevacizumab is an effective treatment option for patients with severe anemia related to epistaxis and/or gastrointestinal bleeding. Further studies are needed to establish a dose-response relationship as well as clinical, genetic, and biomarker predictors of response.
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Affiliation(s)
- Vivek N Iyer
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN.
| | - Dinesh R Apala
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Bibek S Pannu
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Aditya Kotecha
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | | | - Michael D Leise
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Sanjay Misra
- Department of Radiology, Mayo Clinic, Rochester, MN
| | | | | | - Hilary M DuBrock
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Michael J Krowka
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Erin K O'Brien
- Division of Otorhinolaryngology, Mayo Clinic, Rochester, MN
| | | | - Darrell R Schroeder
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
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29
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Mei-Zahav M, Blau H, Bruckheimer E, Zur E, Goldschmidt N. Topical propranolol improves epistaxis in patients with hereditary hemorrhagic telangiectasia - a preliminary report. J Otolaryngol Head Neck Surg 2017; 46:58. [PMID: 28978360 PMCID: PMC5628419 DOI: 10.1186/s40463-017-0235-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Accepted: 09/26/2017] [Indexed: 11/17/2022] Open
Abstract
Background Severe epistaxis is often difficult to control in patients with hereditary hemorrhagic telangiectasia (HHT). Propranolol has been shown to have antiangiogenic properties in vitro and in vivo and is commonly used to treat hemangiomas. We present our experience with topical nasal propranolol for the treatment of moderate to severe epistaxis in patients with HHT. Methods Retrospective case series. Six patients with HHT were treated with 0.5 cm3 of 1.5% propranolol gel, applied to each nostril twice daily for at least 12 weeks. Outcome measures were epistaxis severity score (ESS), hemoglobin level, and number of blood transfusions prior to and while on treatment. Local and systemic side effects were recorded. Results The mean duration of treatment was 30 ± 5.6 weeks. A significant improvement in the ESS was found in all patients, with a mean decrease from 6.4 ± 2.1 at treatment onset to 3.5 ± 1.7 at 12 weeks (p = 0.028). Hemoglobin level increased significantly from 8.4 ± 3.1 to 11.0 ± 1.8 g/dL at 12 weeks (p = 0.043). The mean number of blood transfusions decreased from 4.5 ± 4.9 before treatment to 2.5 ± 2.9 at 12 weeks and 0.3 ± 0.8 at 24 weeks, but the difference did not reach statistical significance (p = 0.109 for both). No significant side effects of treatment were recorded. Conclusions These preliminary results suggest that topical propranolol may be effective for the treatment of epistaxis in patients with HHT. A prospective controlled trial is required to confirm our findings.
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Affiliation(s)
- Meir Mei-Zahav
- The National HHT Center, Pulmonary Institute, Schneider Children's Medical Center of Israel, 49202, Petach Tikva, Israel. .,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Hannah Blau
- The National HHT Center, Pulmonary Institute, Schneider Children's Medical Center of Israel, 49202, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Elchanan Bruckheimer
- Cardiology Institutes, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eyal Zur
- Super-Pharm Professional - Central Compounding Pharmacy, Petach Tikva, Israel
| | - Neta Goldschmidt
- Department of Hematology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
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30
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Shovlin CL, Gilson C, Busbridge M, Patel D, Shi C, Dina R, Abdulla FN, Awan I. Can Iron Treatments Aggravate Epistaxis in Some Patients With Hereditary Hemorrhagic Telangiectasia? Laryngoscope 2016; 126:2468-2474. [PMID: 27107394 PMCID: PMC5095791 DOI: 10.1002/lary.25959] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Revised: 01/31/2016] [Accepted: 02/10/2016] [Indexed: 01/04/2023]
Abstract
OBJECTIVES/HYPOTHESIS To examine whether there is a rationale for iron treatments precipitating nosebleeds (epistaxis) in a subgroup of patients with hereditary hemorrhagic telangiectasia (HHT). STUDY DESIGN Survey evaluation of HHT patients, and a randomized control trial in healthy volunteers. METHODS Nosebleed severity in response to iron treatments and standard investigations were evaluated by unbiased surveys in patients with HHT. Serial blood samples from a randomized controlled trial of 18 healthy volunteers were used to examine responses to a single iron tablet (ferrous sulfate, 200 mg). RESULTS Iron tablet users were more likely to have daily nosebleeds than non-iron-users as adults, but there was no difference in the proportions reporting childhood or trauma-induced nosebleeds. Although iron and blood transfusions were commonly reported to improve nosebleeds, 35 of 732 (4.8%) iron tablet users, in addition to 17 of 261 (6.5%) iron infusion users, reported that their nosebleeds were exacerbated by the respective treatments. These rates were significantly higher than those reported for control investigations. Serum iron rose sharply in four of the volunteers ingesting ferrous sulfate (by 19.3-33.1 μmol/L in 2 hours), but not in 12 dietary controls (2-hour iron increment ranged from -2.2 to +5.0 μmol/L). High iron absorbers demonstrated greater increments in serum ferritin at 48 hours, but transient rises in circulating endothelial cells, an accepted marker of endothelial damage. CONCLUSIONS Iron supplementation is essential to treat or prevent iron deficiency, particularly in patients with pathological hemorrhagic iron losses. However, in a small subgroup of individuals, rapid changes in serum iron may provoke endothelial changes and hemorrhage. LEVEL OF EVIDENCE 4. Laryngoscope, 126:2468-2474, 2016.
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Affiliation(s)
- Claire L Shovlin
- Cardiovascular Sciences, National Heart and Lung Institute, Imperial College London, London, United Kingdom.
- Respiratory Medicine, Imperial College Healthcare National Health Service Trust, London, United Kingdom.
| | - Clare Gilson
- Respiratory Medicine, Imperial College Healthcare National Health Service Trust, London, United Kingdom
| | - Mark Busbridge
- Clinical Chemistry, Imperial College Healthcare National Health Service Trust, London, United Kingdom
| | - Dilip Patel
- Cardiovascular Sciences, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Chenyang Shi
- Cardiovascular Sciences, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Roberto Dina
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - F Naziya Abdulla
- Cardiovascular Sciences, National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Imperial College London School of Medicine, London, United Kingdom
| | - Iman Awan
- Cardiovascular Sciences, National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Imperial College London School of Medicine, London, United Kingdom
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31
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Chamali B, Finnamore H, Manning R, Laffan MA, Hickson M, Whelan K, Shovlin CL. Dietary supplement use and nosebleeds in hereditary haemorrhagic telangiectasia - an observational study. Intractable Rare Dis Res 2016; 5:109-13. [PMID: 27195194 PMCID: PMC4869576 DOI: 10.5582/irdr.2016.01019] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 04/05/2016] [Accepted: 04/07/2016] [Indexed: 12/18/2022] Open
Abstract
Understanding potential provocations of haemorrhage is important in a range of clinical settings, and particularly for people with abnormal vasculature. Patients with hereditary haemorrhagic telangiectasia (HHT) can report haemorrhage from nasal telangiectasia in real time, and suggested dietary factors may precipitate nosebleeds. To examine further, nosebleed severity, dietary supplement use, and blood indices were evaluated in an unselected group of 50 HHT patients recruited from a specialist UK service. Using the validated Epistaxis Severity Score, nosebleed severity ranged from 0 to 9.1 out of 10 (median 3.9). Using a Food Frequency Questionnaire, 24/50 (48%) participants reported use of dietary supplements in the previous year. A third (18/50; 36%) had used self prescribed, non-iron containing dietary supplements, ingesting between 1 and 3 different supplements each day. Eight (16%) used fish oils. Despite having more severe epistaxis (p = 0.012), the 12 iron supplement users had higher serum iron concentrations, and were able to maintain their red blood cell indices. In contrast, there was no evident benefit for the participants using non iron supplements. Furthermore, platelet counts and serum fibrinogen tended to be lower in fish oil/supplement users, and one fish oil user demonstrated reduced in vitro platelet aggregation. In conclusion, in this small study, a third of HHT patients used non-iron dietary supplements, and one in six ingested fish oils, unaware of their known anti-platelet activity. The scale of use, and potential of these "natural health supplements" to exacerbate nosebleeds has not been appreciated previously in HHT.
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Affiliation(s)
- Basel Chamali
- National Heart and Lung Institute Cardiovascular Sciences, Imperial College London, UK
- Imperial College School of Medicine, Imperial College London, UK
| | - Helen Finnamore
- National Heart and Lung Institute Cardiovascular Sciences, Imperial College London, UK
- Diabetes and Nutritional Sciences Division, King's College London, UK
| | - Richard Manning
- Haematology Department, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Michael A Laffan
- Haematology Department, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
- Centre for Haematology, Imperial College London, UK
| | - Mary Hickson
- Nutrition and Dietetics, Imperial College Healthcare NHS Trust, London, UK (Current address: School of Health Professions, Plymouth University, Plymouth, UK)
| | - Kevin Whelan
- Diabetes and Nutritional Sciences Division, King's College London, UK
| | - Claire L Shovlin
- National Heart and Lung Institute Cardiovascular Sciences, Imperial College London, UK
- HHTIC London, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
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