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Lopalco G, Rigante D, Lopalco A, Emmi G, Venerito V, Vitale A, Capozio G, Denora N, Cantarini L, Iannone F. Safety of systemic treatments for Behçet's syndrome. Expert Opin Drug Saf 2020; 19:1269-1301. [PMID: 32883123 DOI: 10.1080/14740338.2020.1817379] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Treatment of Behçet's syndrome (BS) is aimed at controlling all symptoms of such a complex disorder, ensuring a good quality of life and preventing life-threatening complications. A better understanding of the pathogenic role of different chemokines has improved our knowledge of BS and elicited a more specific use of therapies currently available, minimizing the burden of potential side-effects related to treatment. AREAS COVERED This work aims to provide a detailed overview of the safety profile for current therapies available in the treatment of BS, focusing on the main side-effects, toxicity and contraindications. EXPERT OPINION The greatest experience in the management of BS has been achieved with the employment of monoclonal anti-tumor necrosis factor antibodies which have been advocated for BS refractory manifestations. Moreover, interleukin-1 inhibitors have proven to be effective as well as safe, despite escalation of their dosage, especially to manage the most severe and difficult-to-treat ocular manifestations. However, general treatment of BS patients remains awkward as protean clinical features may respond differently to the same treatment or even worsen. Therefore, patients' safety for therapies used in BS promotes the implementation of precision medicine, which could help targeting accurately the pathogenetic mechanisms concealed behind specific clinical phenotypes.
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Affiliation(s)
- Giuseppe Lopalco
- Department of Emergency and Organ Transplantation, Rheumatology Unit, University of Bari , Bari, Italy
| | - Donato Rigante
- Department of Life Sciences and Public Health, Fondazione Policlinico Universitario "A. Gemelli" IRCCS , Rome, Italy.,Università Cattolica Sacro Cuore , Rome, Italy
| | - Antonio Lopalco
- Department of Pharmacy - Drug Sciences, University of Bari , Bari, Italy
| | - Giacomo Emmi
- Department of Experimental and Clinical Medicine, University of Florence , Florence, Italy
| | - Vincenzo Venerito
- Department of Emergency and Organ Transplantation, Rheumatology Unit, University of Bari , Bari, Italy
| | - Antonio Vitale
- Research Centre of Systemic Autoinflammatory Diseases, Behçet's Disease Clinic and Rheumatology-Ophthalmology Collaborative Uveitis Centre, Department of Medical Sciences, Surgery and Neurosciences, University of Siena , Siena, Italy
| | - Giovanna Capozio
- Department of Life Sciences and Public Health, Fondazione Policlinico Universitario "A. Gemelli" IRCCS , Rome, Italy
| | - Nunzio Denora
- Department of Pharmacy - Drug Sciences, University of Bari , Bari, Italy
| | - Luca Cantarini
- Research Centre of Systemic Autoinflammatory Diseases, Behçet's Disease Clinic and Rheumatology-Ophthalmology Collaborative Uveitis Centre, Department of Medical Sciences, Surgery and Neurosciences, University of Siena , Siena, Italy
| | - Florenzo Iannone
- Department of Emergency and Organ Transplantation, Rheumatology Unit, University of Bari , Bari, Italy
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2
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Mladěnka P, Applová L, Patočka J, Costa VM, Remiao F, Pourová J, Mladěnka A, Karlíčková J, Jahodář L, Vopršalová M, Varner KJ, Štěrba M. Comprehensive review of cardiovascular toxicity of drugs and related agents. Med Res Rev 2018; 38:1332-1403. [PMID: 29315692 PMCID: PMC6033155 DOI: 10.1002/med.21476] [Citation(s) in RCA: 134] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 10/20/2017] [Accepted: 11/16/2017] [Indexed: 12/12/2022]
Abstract
Cardiovascular diseases are a leading cause of morbidity and mortality in most developed countries of the world. Pharmaceuticals, illicit drugs, and toxins can significantly contribute to the overall cardiovascular burden and thus deserve attention. The present article is a systematic overview of drugs that may induce distinct cardiovascular toxicity. The compounds are classified into agents that have significant effects on the heart, blood vessels, or both. The mechanism(s) of toxic action are discussed and treatment modalities are briefly mentioned in relevant cases. Due to the large number of clinically relevant compounds discussed, this article could be of interest to a broad audience including pharmacologists and toxicologists, pharmacists, physicians, and medicinal chemists. Particular emphasis is given to clinically relevant topics including the cardiovascular toxicity of illicit sympathomimetic drugs (e.g., cocaine, amphetamines, cathinones), drugs that prolong the QT interval, antidysrhythmic drugs, digoxin and other cardioactive steroids, beta-blockers, calcium channel blockers, female hormones, nonsteroidal anti-inflammatory, and anticancer compounds encompassing anthracyclines and novel targeted therapy interfering with the HER2 or the vascular endothelial growth factor pathway.
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Affiliation(s)
- Přemysl Mladěnka
- Department of Pharmacology and Toxicology, Faculty of Pharmacy in Hradec KrálovéCharles UniversityHradec KrálovéCzech Republic
| | - Lenka Applová
- Department of Pharmacology and Toxicology, Faculty of Pharmacy in Hradec KrálovéCharles UniversityHradec KrálovéCzech Republic
| | - Jiří Patočka
- Department of Radiology and Toxicology, Faculty of Health and Social StudiesUniversity of South BohemiaČeské BudějoviceCzech Republic
- Biomedical Research CentreUniversity HospitalHradec KraloveCzech Republic
| | - Vera Marisa Costa
- UCIBIO, REQUIMTE, Laboratory of Toxicology, Department of Biological Sciences, Faculty of PharmacyUniversity of PortoPortoPortugal
| | - Fernando Remiao
- UCIBIO, REQUIMTE, Laboratory of Toxicology, Department of Biological Sciences, Faculty of PharmacyUniversity of PortoPortoPortugal
| | - Jana Pourová
- Department of Pharmacology and Toxicology, Faculty of Pharmacy in Hradec KrálovéCharles UniversityHradec KrálovéCzech Republic
| | - Aleš Mladěnka
- Oncogynaecologic Center, Department of Gynecology and ObstetricsUniversity HospitalOstravaCzech Republic
| | - Jana Karlíčková
- Department of Pharmaceutical Botany and Ecology, Faculty of Pharmacy in Hradec KrálovéCharles UniversityHradec KrálovéCzech Republic
| | - Luděk Jahodář
- Department of Pharmaceutical Botany and Ecology, Faculty of Pharmacy in Hradec KrálovéCharles UniversityHradec KrálovéCzech Republic
| | - Marie Vopršalová
- Department of Pharmacology and Toxicology, Faculty of Pharmacy in Hradec KrálovéCharles UniversityHradec KrálovéCzech Republic
| | - Kurt J. Varner
- Department of PharmacologyLouisiana State University Health Sciences CenterNew OrleansLAUSA
| | - Martin Štěrba
- Department of Pharmacology, Faculty of Medicine in Hradec KrálovéCharles UniversityHradec KrálovéCzech Republic
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3
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Qiao J, Wu Y, Wu X, Liu Y, Li X, Ju W, Qi K, Li D, Gardiner EE, Andrews RK, Zeng L, Xu K. An absence of platelet activation following thalidomide treatment in vitro or in vivo. Oncotarget 2018; 8:35776-35782. [PMID: 28415757 PMCID: PMC5482616 DOI: 10.18632/oncotarget.16205] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Accepted: 03/01/2017] [Indexed: 12/18/2022] Open
Abstract
Increased risk of thromboembolism and platelet hyperreactivity has been reported in patients receiving thalidomide therapy. Whether thalidomide induces platelet activation directly or through other factors remains unclear. The aim of this study was to evaluate the effect of thalidomide on platelet activation under resting conditions in vitro and in vivo. Isolated human or mouse platelets were treated with different concentrations of thalidomide (10, 50 and 100 μg/ml) for 60 min at 37°C followed by analysis of platelet surface expression of platelet receptors GPIbα, GPVI, αIIbβ3 and P-selectin, and PAC-1 or fibrinogen binding, by flow cytometry and collagen- or ADP-induced platelet aggregation. In addition, thalidomide (200 mg/kg) was intraperitoneally injected into mice for analysis of the effect of thalidomide on platelet activation in vivo. No increased expression of P-selectin, PAC-1 or fibrinogen binding was observed in either human and mouse platelets after thalidomide treatment in vitro for 60 min at 37°C. Thalidomide treatment also did not affect expression of GPIbα, GPVI or αIIbβ3, nor did it affect collagen- or ADP-induced platelet aggregation at threshold concentrations. However, while mice injected with thalidomide displayed no increased surface expression of platelet P-selectin or αIIbβ3, there was a significantly shortened tail bleeding time, thrombin time, prothrombin time together with higher levels of Factor IX and fibrinogen. In conclusion, thalidomide at therapeutic doses does not directly induce platelet activation under resting conditions in vitro or in vivo, but results in increased procoagulant activity, which could explain the thalidomide-dependent prothrombotic tendency in patients.
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Affiliation(s)
- Jianlin Qiao
- Blood Diseases Institute, Xuzhou Medical University, Xuzhou, China.,Department of Hematology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China.,Key Laboratory of Bone Marrow Stem Cell, Jiangsu Province, Xuzhou, China
| | - Yulu Wu
- Blood Diseases Institute, Xuzhou Medical University, Xuzhou, China
| | - Xiaoqing Wu
- Blood Diseases Institute, Xuzhou Medical University, Xuzhou, China
| | - Yun Liu
- Blood Diseases Institute, Xuzhou Medical University, Xuzhou, China
| | - Xiaoqian Li
- Department of Hematology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Wen Ju
- Blood Diseases Institute, Xuzhou Medical University, Xuzhou, China.,Department of Hematology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China.,Key Laboratory of Bone Marrow Stem Cell, Jiangsu Province, Xuzhou, China
| | - Kunming Qi
- Department of Hematology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Depeng Li
- Department of Hematology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Elizabeth E Gardiner
- Department of Cancer Biology and Therapeutics, John Curtin School of Medical Research, Australian National University, Canberra, Australia
| | - Robert K Andrews
- Australian Centre for Blood Diseases, Monash University, Melbourne, Australia
| | - Lingyu Zeng
- Blood Diseases Institute, Xuzhou Medical University, Xuzhou, China.,Key Laboratory of Bone Marrow Stem Cell, Jiangsu Province, Xuzhou, China
| | - Kailin Xu
- Blood Diseases Institute, Xuzhou Medical University, Xuzhou, China.,Department of Hematology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China.,Key Laboratory of Bone Marrow Stem Cell, Jiangsu Province, Xuzhou, China
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4
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Chang Y, Dabiri G, Damstetter E, Baiyee Ebot E, Powers JG, Phillips T. Coagulation disorders and their cutaneous presentations: Pathophysiology. J Am Acad Dermatol 2016; 74:783-92; quiz 793-4. [PMID: 27085225 DOI: 10.1016/j.jaad.2015.08.072] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2015] [Revised: 08/19/2015] [Accepted: 08/20/2015] [Indexed: 12/21/2022]
Abstract
Hypercoagulable states are inherited or acquired predispositions to venous or arterial thromboses that are best understood in the context of the coagulation cascade. Dermatologists can play a critical role in diagnosing and treating patients with hypercoagulable states because cutaneous symptoms may be a presenting manifestation, thereby reducing morbidity and mortality related to these conditions. This review focuses on the epidemiology and pathophysiology of hypercoagulable states, while the accompanying article iterates the basic clinical features, diagnostic testing, and management of patients who have these conditions.
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Affiliation(s)
- Yunyoung Chang
- Department of Dermatology, Boston University School of Medicine, Boston, Massachusetts
| | - Ganary Dabiri
- Department of Dermatology and Skin Surgery, Roger Williams Medical Center/Boston University School of Medicine, Providence, Rhode Island
| | - Elizabeth Damstetter
- Department of Dermatology, Boston University School of Medicine, Boston, Massachusetts
| | - Emily Baiyee Ebot
- Department of Hematology and Oncology, University Medical Group, Providence, Rhode Island
| | | | - Tania Phillips
- Department of Dermatology, Boston University School of Medicine, Boston, Massachusetts.
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5
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Castelli R, Orofino N, Losurdo A, Gualtierotti R, Cugno M. Choosing treatment options for patients with relapsed/refractory multiple myeloma. Expert Rev Anticancer Ther 2013; 14:199-215. [PMID: 24329153 DOI: 10.1586/14737140.2014.863153] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Multiple myeloma (MM) is a clonal plasma cell disorder that is still incurable using conventional treatments. Over the last decade, advances in front-line therapy have led to an increase in survival, but there are still some doubts in the case of relapsed/refractory disease. We searched the PubMed database for articles on treatment options for patients with relapsed/refractory MM published between 1996 and 2013. These treatments included hematopoietic cell transplantation (HCT), rechallenges using previous chemotherapy regimens, and trials of new regimens. The introduction of new agents such as the immunomodulatory drugs (IMIDs) thalidomide and lenalidomide, and the first-in-its-class proteasome inhibitor bortezomib, has greatly improved clinical outcomes in patients with relapsed/refractory MM, but not all patients respond and those that do may eventually relapse or become refractory to treatment. The challenge is therefore to select the optimal treatment for each patient by balancing efficacy and toxicity. To do this, it is necessary to consider disease-related factors, such as the quality and duration of responses to previous therapies, and the aggressiveness of the relapse, and patient-related factors such as age, comorbidities, performance status, pre-existing toxicities and cytogenetic patterns. The message from the trials reviewed in this article is that the new agents may be used to re-treat relapsed/refractory disease, and that the sequencing of their administration should be modulated on the basis of the various disease and patient-related factors. Moreover, our understanding of the pharmacology and molecular action of the new drugs will contribute to the possibility of developing tailored treatment.
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Affiliation(s)
- Roberto Castelli
- Department of Pathophysiology and Transplantation, Internal Medicine, University of Milan, Milan, Italy
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6
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Castelli R, Gualtierotti R, Orofino N, Losurdo A, Gandolfi S, Cugno M. Current and emerging treatment options for patients with relapsed myeloma. Clin Med Insights Oncol 2013; 7:209-19. [PMID: 24179412 PMCID: PMC3813615 DOI: 10.4137/cmo.s8014] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Multiple myeloma (MM) is a neoplastic disorder. It results from proliferation of clonal plasma cells in bone marrow with production of monoclonal proteins, which are detectable in serum or urine. MM is clinically characterized by destructive bone lesions, anemia, hypercalcemia and renal insufficiency. Its prognosis is severe, with a median survival after diagnosis of approximately 3 years due to frequent relapses. Treatments for patients with relapsed/refractory MM include hematopoietic cell transplantation, a rechallenge using a previous chemotherapy regimen or a trial of a new regimen. The introduction of new drugs such as thalidomide, lenalidomide and bortezomib has markedly improved MM outcomes. When relapse occurs, the clinician's challenge is to select the optimal treatment for each patient while balancing efficacy and toxicity. Patients with indolent relapse can be first treated with a 2-drug or a 3-drug combination. Patients with more aggressive relapse often require therapy with a combination of multiple active agents. Autologous stem cell transplantation should be considered as salvage therapy at first relapse for patients who have cryopreserved stem cells early in the disease course. The aim of this review is to provide an overview on the pharmacological and molecular action of treatments used for patients with relapsed/refractory multiple myeloma.
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Affiliation(s)
- Roberto Castelli
- Internal Medicine, Department of Pathophysiology and Transplantation, University of Milan, and Department of Medicine, IRCCS Fondazione Ca’ Granda Policlinico, Milan, Italy
| | - Roberta Gualtierotti
- Internal Medicine, Department of Pathophysiology and Transplantation, University of Milan, and Department of Medicine, IRCCS Fondazione Ca’ Granda Policlinico, Milan, Italy
| | - Nicola Orofino
- Internal Medicine, Department of Pathophysiology and Transplantation, University of Milan, and Department of Medicine, IRCCS Fondazione Ca’ Granda Policlinico, Milan, Italy
| | - Agnese Losurdo
- Internal Medicine, Department of Pathophysiology and Transplantation, University of Milan, and Department of Medicine, IRCCS Fondazione Ca’ Granda Policlinico, Milan, Italy
| | - Sara Gandolfi
- Internal Medicine, Department of Pathophysiology and Transplantation, University of Milan, and Department of Medicine, IRCCS Fondazione Ca’ Granda Policlinico, Milan, Italy
| | - Massimo Cugno
- Internal Medicine, Department of Pathophysiology and Transplantation, University of Milan, and Department of Medicine, IRCCS Fondazione Ca’ Granda Policlinico, Milan, Italy
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7
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Castelli R, Cassin R, Cannavò A, Cugno M. Immunomodulatory Drugs: New Options for the Treatment of Myelodysplastic Syndromes. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2013; 13:1-7. [DOI: 10.1016/j.clml.2012.09.016] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/03/2012] [Revised: 09/24/2012] [Accepted: 09/26/2012] [Indexed: 10/27/2022]
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8
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Castelli R, Cannavò A, Conforti F, Grava G, Cortelezzi A. Immunomodulatory drugs in multiple myeloma: from molecular mechanisms of action to clinical practice. Immunopharmacol Immunotoxicol 2012; 34:740-53. [DOI: 10.3109/08923973.2012.658921] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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9
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Donati MB, Lorenzet R. Thrombosis and cancer: 40years of research. Thromb Res 2012; 129:348-52. [DOI: 10.1016/j.thromres.2011.12.022] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2011] [Revised: 12/15/2011] [Accepted: 12/19/2011] [Indexed: 10/14/2022]
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Abstract
In this introductory chapter a story has been reviewed concerning the evolution of the concept of "cancer and thrombosis", since its first description by Armand Trousseau in 1865. From scattered reports on experimental material (tumor extracts) or on animal models of tumor/metastasis growth, through the progress of cell biology and experimental pharmacology, during the last 20 years interest has moved to clinical questions, such as: how to prevent and treat thrombosis, a frequent complication of both solid and hematologic malignancies? Has an occult cancer to be suspected in the majority of cases of idiopathic deep vein thrombosis? Do we need to prevent pharmacologically the occurrence of chemotherapy-associated thrombosis? Do anticoagulants have an impact on the natural history of some tumors? Why antiangiogenetic agents may be associated to a thrombotic risk? Presently, a continuous cross-talk between clinical results and experimental data is required to provide answers to these questions, taking advantage of a multidisciplinary approach to this old but still partially mysterious issue.
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Affiliation(s)
- Maria Benedetta Donati
- "RE ARTU" Research Laboratories, Centre for High Technology and Education in Biomedical Sciences, Catholic University, L. Agostino Gemelli, 1, 86100 Campobasso, Italy
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11
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Ortín X, Rodríguez-Luaces M, Calabuig M, Font L. Stroke in a multiple myeloma patient treated with thalidomide. J Stroke Cerebrovasc Dis 2008; 15:283-5. [PMID: 17904089 DOI: 10.1016/j.jstrokecerebrovasdis.2006.06.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2006] [Accepted: 06/26/2006] [Indexed: 11/22/2022] Open
Abstract
The antiangiogenic and immunomodulatory properties of thalidomide have led to its use and evaluation in refractory or relapsed multiple myeloma (MM). However, thalidomide use is associated with several side effects, although deep vein thrombosis and peripheral neuropathy are the most serious. The incidence of thrombosis after treatment with thalidomide ranges from 2% to 23%, but is higher among patients who also receive chemotherapy. Thromboembolic episodes are usually venous and may cause pulmonary embolism or even myocardial infarction and cerebral venous thrombosis. Arterial occlusion is rare, and the association between arterial thrombotic events and thalidomide is infrequent with only a few patients reported who developed arterial strokes on thalidomide. We describe a case of nonfatal thrombotic stroke occurring in a patient with relapsed MM treated with thalidomide.
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Affiliation(s)
- Xavier Ortín
- Servicio de Hematología, Hospital de Tortosa Verge de la Cinta, Tortosa, Spain
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12
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Altintas A, Ayyildiz O, Atay A, Cil T, Isikdogan A, Muftuoglu E. Thalidomide-associated Arterial Thrombosis: Two Case Reports. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2007. [DOI: 10.47102/annals-acadmedsg.v36n4p304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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13
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Abstract
Significant progress in the treatment of multiple myeloma has resulted in improvement of disease control with a trend toward overall and progression-free survival benefit. With the availability of several new therapeutic agents and combinations, a careful emphasis should be placed in the management of disease- and therapy-associated complications. Aggressive management of these complications can impact patients' quality of life as well as treatment outcome. This review highlights some of the critical supportive care measures integral to the optimal care of patients with multiple myeloma.
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Abstract
AbstractThe rate of venous thromboembolism (VTE) in patients with acute leukemia or lymphomas is comparable with that of other “high-risk” cancer types. Chemotherapy and anti-angiogenic drugs increase the thrombotic risk in patients with lymphomas, acute leukemias and multiple myeloma (MM). Patients with hematologic malignancies often present with a hypercoagulable state or chronic disseminated intravascular coagulation (DIC) in the absence of active thrombosis and/or bleeding. Malignant cell procoagulant properties, cytotoxic therapies, and concomitant infections are major determinants for clotting activation in hematologic malignancies. In acute leukemia, clinical manifestations range from localized venous or arterial thrombosis to a diffuse, life-threatening thrombohemorrhagic syndrome (THS). All-trans retinoic acid (ATRA) has greatly improved the management of acute promyelocytic leukemia (APL), but has not significantly changed the rate of early hemorrhagic deaths and may actually promote thrombosis. Randomized, controlled trials (RCTs) of different prophylactic regimens to prevent VTE or THS in hematologic malignancies are urgently needed, particularly in patients with lymphoma or MM during chemotherapy and in patients with APL. Anticoagulant therapy is a particular challenge in patients with hematologic malignancies, since these patients are at very high risk for hemorrhage. No guidelines are available for the prophylaxis or treatment of VTE; extrapolations can be made from existing guidelines for management of patients with other malignancies; prolonged periods of treatment-induced thrombocytopenia in patients with hematologic malignancies, however, require a more judicious application of standard anticoagulant approaches. Use of the newer anticoagulants will require careful assessment of hemorrhagic risk in this group of high-risk patients but may be justified under special circumstances.
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15
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Castelli R, Porro F, Tarsia P. The heparins and cancer: review of clinical trials and biological properties. Vasc Med 2006; 9:205-13. [PMID: 15675186 DOI: 10.1191/1358863x04vm566ra] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The association between cancer and thromboembolic disease is a well-known phenomenon and can contribute significantly to the morbidity and mortality of cancer patients. The spectrum of thromboembolic manifestations in cancer patients includes deep vein thrombosis, pulmonary embolism, but also intravascular disseminated coagulation and abnormalities in the clotting system in the absence of clinical manifestations. Unfractionated heparin (UFH) and particularly low molecular weight heparins (LMWH-s) are widely used for the prevention and treatment of thromboembolic manifestations that commonly accompany malignancies. Malignant growth has also been linked to the activity of heparin-like glycosaminoglycans, to neoangiogenesis, to protease activity, to immune function and gene expression. All these factors contribute in the proliferation and dissemination of malignancies. Heparins may play a role in tumour cell growth and in cancer dissemination. The aims of the study are to review the efficiency of heparins in the prevention and treatment of cancer-related thromboembolic complications, and review the biological effects of heparins. Heparins are effective in reducing the frequency of thromboembolic complications in cancer patients. Meta-analyses comparing unfractionated heparins and LMWH-s for the treatment of deep vein thrombosis have shown better outcome with a reduction of major bleeding complications in patients treated with LMWH-s. LMWH have antitumour effects in animal models of malignancy: heparin oligosaccharides containing less than 10 saccharide residues have been found to inhibit the biological activity of basic fibroblast growth factor (bFGF), whereas heparin fragments with less than 18 saccharide residues have been reported to inhibit the binding of vascular endothelial growth factor (VEGF) to its receptors on endothelial cells. It has been shown that LMWH, in contrast with UFH, can hinder the binding of growth factors to their high-affinity receptors as a result of its smaller size. In vitro heparin fragments of less than 18 saccharide residues reduce the activity of VEGF, and fragments of less than 10 saccharide residues inhibit the activity of bFGF. Small molecular heparin fractions have also been shown to inhibit VEGF- and bFGF-mediated angiogenesis in vivo, in contrast with UFH. Moreover, heparin may influence malignant cell growth through other different interrelated mechanisms: inhibition of (1) heparin-binding growth factors that drive malignant cell growth; (2) tumour cell heparinases that mediate tumour cell invasion and metastasis; (3) cell surface selectin-mediated tumour cell metastasis and blood coagulation. The above evidence, together with favourable pharmaco-properties and with a reduction in major bleeding complications, suggests an important role for LMWH-s in thromboprophylaxis and in the therapy of venous thromboembolism in cancer patients. There is sufficient experimental data to suggest that heparins may interfere with various aspects of cancer proliferation, angiogenesis, and metastasis formation. Large-scale clinical trials are required to determine the clinical impact of the above activities on the natural history of the disease.
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Affiliation(s)
- Roberto Castelli
- Emergency Medicine Department, IRCCS Ospedale Maggiore di Milano, Milano, Italy.
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Rus C, Bazzan M, Palumbo A, Bringhen S, Boccadoro M. Thalidomide in front line treatment in multiple myeloma: serious risk of venous thromboembolism and evidence for thromboprophylaxis. J Thromb Haemost 2004; 2:2063-5. [PMID: 15550053 DOI: 10.1111/j.1538-7836.2004.00931.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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17
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Silingardi M, Iotti M, Trenti C, Salvarani C, Iori I. Thalidomide, deep venous thrombosis and vasculitis. J Thromb Haemost 2004; 2:2062-3. [PMID: 15550052 DOI: 10.1111/j.1538-7836.2004.00952.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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18
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Kettner SC, Pollak A, Zimpfer M, Seybold T, Prusa AR, Herkner K, Kuhle S. Heparinase-Modified Thrombelastography in Term and Preterm Neonates. Anesth Analg 2004; 98:1650-1652. [PMID: 15155319 DOI: 10.1213/01.ane.0000115149.25496.dd] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
UNLABELLED Thrombelastography (TEG) appears to be a promising test to assess coagulation in infants and children. TEG enables a rapid assessment of hemostatic function with only 300 microL of whole blood and provides information about plasmatic coagulation, platelet function, and fibrinolysis. In this study, we used TEG to assess the coagulation system of preterm and term neonates to determine the effects of their deficient coagulation factor levels on global hemostatic function. Heparinase-modified TEG, platelet and red blood cell count, plasma fibrinogen, and prothrombin time were assessed in four groups of clinically stable infants: severely preterm (gestational age [GA], 27-31 wk), moderately preterm (GA, 32-36 wk), term (GA, 36-40 wk), and former preterm (corrected GA, 34-40 wk). Healthy adult volunteers served as a control group. When compared with the adult group, thromboelastography revealed no defects in coagulation from groups of clinically stable infants, documenting the functional integrity of coagulation despite, in part, decreased conventional coagulation variables. Because clinically stable preterm and term infants show a relatively small incidence of bleeding, despite prolonged conventional coagulation tests, TEG may better reflect the hemostatic potential of these patients compared with conventional coagulation tests. IMPLICATIONS This study assessed the coagulation of preterm and term infants by thrombelastography and found functional integrity of coagulation despite, in part, decreased conventional coagulation variables.
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Affiliation(s)
- Stephan C Kettner
- *Department of Anesthesiology and General Intensive Care, University of Vienna; †Ludwig Boltzmann Institute of Clinical Anesthesiology and Intensive Care; ‡Department of Neonatology and Intensive Care, University of Vienna; and §Ludwig Boltzmann Institute of Pediatric Endocrinology and Immunology, University of Vienna, Vienna, Austria
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Arkel YS, Ku DHW, Thurston AL. The effect of thalidomide on tissue factor activity in Mono Mac 6 cells and the relationship to tumor necrosis factor (TNF)-alpha-stimulated cells. J Thromb Haemost 2003; 1:2691-2. [PMID: 14675113 DOI: 10.1111/j.1538-7836.2003.0543i.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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