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Tariq Z, Qadeer MI, Anjum I, Hano C, Anjum S. Thalassemia and Nanotheragnostics: Advanced Approaches for Diagnosis and Treatment. BIOSENSORS 2023; 13:bios13040450. [PMID: 37185525 PMCID: PMC10136341 DOI: 10.3390/bios13040450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 03/20/2023] [Accepted: 03/27/2023] [Indexed: 05/17/2023]
Abstract
Thalassemia is a monogenic autosomal recessive disorder caused by mutations, which lead to abnormal or reduced production of hemoglobin. Ineffective erythropoiesis, hemolysis, hepcidin suppression, and iron overload are common manifestations that vary according to genotypes and dictate, which diagnosis and therapeutic modalities, including transfusion therapy, iron chelation therapy, HbF induction, gene therapy, and editing, are performed. These conventional therapeutic methods have proven to be effective, yet have several disadvantages, specifically iron toxicity, associated with them; therefore, there are demands for advanced therapeutic methods. Nanotechnology-based applications, such as the use of nanoparticles and nanomedicines for theragnostic purposes have emerged that are simple, convenient, and cost-effective methods. The therapeutic potential of various nanoparticles has been explored by developing artificial hemoglobin, nano-based iron chelating agents, and nanocarriers for globin gene editing by CRISPR/Cas9. Au, Ag, carbon, graphene, silicon, porous nanoparticles, dendrimers, hydrogels, quantum dots, etc., have been used in electrochemical biosensors development for diagnosis of thalassemia, quantification of hemoglobin in these patients, and analysis of conventional iron chelating agents. This review summarizes the potential of nanotechnology in the development of various theragnostic approaches to determine thalassemia-causing gene mutations using various nano-based biosensors along with the employment of efficacious nano-based therapeutic procedures, in contrast to conventional therapies.
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Affiliation(s)
- Zahra Tariq
- Department of Biotechnology, Kinnaird College for Women, 92-Jail Road, Lahore 54000, Pakistan
| | | | - Iram Anjum
- Department of Biotechnology, Kinnaird College for Women, 92-Jail Road, Lahore 54000, Pakistan
| | - Christophe Hano
- Department of Chemical Biology, Eure & Loir Campus, University of Orleans, 28000 Chartres, France
| | - Sumaira Anjum
- Department of Biotechnology, Kinnaird College for Women, 92-Jail Road, Lahore 54000, Pakistan
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Glucose Homeostasis and Assessment of β-Cell Function by 3-hour Oral Glucose Tolerance (OGTT) in Patients with β-Thalassemia Major with Serum Ferritin below 1,000 ng/dL: Results from a Single ICET-A Centre. Mediterr J Hematol Infect Dis 2023; 15:e2023006. [PMID: 36660350 PMCID: PMC9833310 DOI: 10.4084/mjhid.2023.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 12/19/2022] [Indexed: 01/03/2023] Open
Abstract
Aims The primary aim of this study was to evaluate retrospectively the glucose homeostasis and surrogate indices of insulin sensitivity and resistance, during a 3-hour oral glucose tolerance test (OGTT), in β-thalassemia major patients (β-TM) with serum ferritin (SF) below 1,000 ng/mL. Patients and methods The retrospective cohort study evaluated the medical records of 24 β-TM patients from 2010 to 2022. At the year of study the mean age of patients was 31.0 ± 4.1 (20-37.11) years; 13 (54.1%) were females. The most commonly used iron chelator was deferoxamine (DFO: 75%), followed by deferiprone (DFP:12.5%) and deferasirox (DFX: 12.5%). Insulin sensitivity and resistance indices were derived from OGTT. A liver iron concentration (LIC) < 3 mg/g d.w. and a global heart T2* value > 20 ms were considered as conservative cut-off values for insignificant iron overload (IOL). Results The mean SF levels in the whole study cohort population at the age of evaluation was 549.6 ± 232.3 ng/mL. Based on the SF levels, two groups were identified: Group A (N = 14) < 500 ng/mL and Group B (N=10) 500-1,000 ng/mL. Normal glucose tolerance (NGT) during OGTT was observed in 4 patients of Group A (28.5 %) and in 5 patients of Group B (50%) (P: 0.29). The remaining 15/24 patients (62.5%) had glucose dysregulation (GD). The mean age at starting iron chelation therapy (ICT) and the mean SF peak in Group A versus Group B were significantly higher in group A. The GD was associated with significantly attenuated IGI (first phase of insulin response) and impaired oral disposition index (oDI). Hypogonadotropic hypogonadism (HH) was the most common associated endocrine complication in both groups of patients. Conclusions This study showed that efficient iron chelation monotherapy in patients with β-TM and SF < 1,000 ng/ml did not entirely prevent glucose metabolism disorders, abnormalities of insulin secretion and sensitivity, and development of acquired hypogonadism.
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Rostoker G, Senet P, Lepeytre F, Griuncelli M, Loridon C, Rabaté C, Cohen Y. Analysis of liver iron concentration in an elderly female undergoing hemodialysis with calcific uremic arteriolopathy does not support the role of iron overload in calciphylaxis: lesson for the clinical nephrologist. J Nephrol 2021; 34:1547-1551. [PMID: 33484427 PMCID: PMC8494698 DOI: 10.1007/s40620-020-00904-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 11/04/2020] [Indexed: 11/25/2022]
Affiliation(s)
- Guy Rostoker
- Division of Nephrology and Dialysis, Ramsay Santé, Hôpital Privé Claude Galien, 20 Route de Boussy-Saint-Antoine, 91480, Quincy-Sous-Sénart, France.
- Collège de Médecine des Hôpitaux de Paris, 10 Rue des Fossés Saint-Marcel, 75005, Paris, France.
- Service de Néphrologie et de Dialyse, Ramsay Santé, HP Claude Galien, 20 Route de Boussy-Saint-Antoine, 91480, Quincy-Sous-Sénart, France.
| | - Patricia Senet
- Division of Dermatology and Allergology, Assistance Publique Hôpitaux de Paris, Hôpital Tenon, Sorbonne Université, 4 Rue de la Chine, 75020, Paris, France
| | - Fanny Lepeytre
- Division of Nephrology and Dialysis, Ramsay Santé, Hôpital Privé Claude Galien, 20 Route de Boussy-Saint-Antoine, 91480, Quincy-Sous-Sénart, France
| | - Mireille Griuncelli
- Division of Nephrology and Dialysis, Ramsay Santé, Hôpital Privé Claude Galien, 20 Route de Boussy-Saint-Antoine, 91480, Quincy-Sous-Sénart, France
| | - Christelle Loridon
- Division of Nephrology and Dialysis, Ramsay Santé, Hôpital Privé Claude Galien, 20 Route de Boussy-Saint-Antoine, 91480, Quincy-Sous-Sénart, France
| | - Clémentine Rabaté
- Division of Nephrology and Dialysis, Ramsay Santé, Hôpital Privé Claude Galien, 20 Route de Boussy-Saint-Antoine, 91480, Quincy-Sous-Sénart, France
| | - Yves Cohen
- Division of Radiology, Ramsay Santé, Hôpital Privé Claude Galien, 20 Route de Boussy-Saint-Antoine, 91480, Quincy-Sous-Sénart, France
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Combined chelation with high-dose deferiprone and deferoxamine to improve survival and restore cardiac function effectively in patients with transfusion-dependent thalassemia presenting severe cardiac complications. Ann Hematol 2020; 99:2289-2294. [DOI: 10.1007/s00277-020-04196-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Accepted: 07/20/2020] [Indexed: 01/19/2023]
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Marsella M, Ricchi P. Thalassemia and hepatocellular carcinoma: links and risks. J Blood Med 2019; 10:323-334. [PMID: 31572038 PMCID: PMC6756274 DOI: 10.2147/jbm.s186362] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Accepted: 08/22/2019] [Indexed: 01/19/2023] Open
Abstract
The increased survival and lifespan of thalassemia patients, in the setting of better iron overload monitoring and chelation, have also however increased the incidence of diseases and complications, which were less likely to develop. Among these, one of the most worrying in recent years is hepatocellular carcinoma (HCC). Due to blood transfusions, many patients with thalassemia are or have been infected with hepatitis C virus (HCV) or hepatitis B virus (HBV), especially those born before the 1990s or in countries in which universal HBV vaccination and safe blood programs are still not completely implemented. However, HCC has also been described in nontransfused patients and in those who are HCV- and HBV-negative. Therefore, other risk factors are involved in hepatocarcinogenesis in thalassemia. The following review analyzes recent literature on the role of different risk factors in the progression of liver disease in thalassemia as well as the importance of surveillance. Treatment of HCC in thalassemia is still highly debated and requires further studies.
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Affiliation(s)
- Maria Marsella
- Department of Woman and Child, Pediatric Unit, San Giuseppe Moscati Hospital, Avellino, Italy
| | - Paolo Ricchi
- Unità Operativa Semplice Dipartimentale (UOSD) Malattie Rare Del Globulo Rosso, Dipartimento di oncoematologia, Azienda Ospedaliera Di Rilievo Nazionale "A. Cardarelli", Napoli, Italy
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Rostoker G, Vaziri ND. Risk of iron overload with chronic indiscriminate use of intravenous iron products in ESRD and IBD populations. Heliyon 2019; 5:e02045. [PMID: 31338466 PMCID: PMC6627982 DOI: 10.1016/j.heliyon.2019.e02045] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Revised: 03/14/2019] [Accepted: 07/03/2019] [Indexed: 01/19/2023] Open
Abstract
The routine use of recombinant erythropoiesis-stimulating agents (ESA) over the past three decades has enabled the partial correction of anaemia in most patients with end-stage renal disease (ESRD). Since ESA use frequently leads to iron deficiency, almost all ESA-treated haemodialysis patients worldwide receive intravenous iron (IV) to ensure sufficient available iron during ESA therapy. Patients with inflammatory bowel disease (IBD) are also often treated with IV iron preparations, as anaemia is common in IBD. Over the past few years, liver magnetic resonance imaging (MRI) has become the gold standard method for non-invasive diagnosis and follow-up of iron overload diseases. Studies using MRI to quantify liver iron concentration in ESRD have shown a link between high infused iron dose and risk of haemosiderosis in dialysis patients. In September 2017, the Pharmacovigilance Committee (PRAC) of the European Medicines Agency (EMA) considered convergent publications over the last few years on iatrogenic haemosiderosis in dialysis patients and requested that companies holding marketing authorization for iron products should investigate the risk of iron overload, particularly in patients with end-stage renal disease on dialysis and, by analogy, patients with IBD. We present a narrative review of data supporting the views and decision of the EMA, and then give our expert opinion on this controversial field of anaemia therapeutics.
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Affiliation(s)
- Guy Rostoker
- Division of Nephrology and Dialysis, Hôpital Privé Claude Galien, Ramsay-Générale de Santé, Quincy-sous-Sénart, France
| | - Nosratola D Vaziri
- Division of Nephrology and Hypertension, University of California, Irvine, USA
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Olivieri NF, Sabouhanian A, Gallie BL. Single-center retrospective study of the effectiveness and toxicity of the oral iron chelating drugs deferiprone and deferasirox. PLoS One 2019; 14:e0211942. [PMID: 30811439 PMCID: PMC6392256 DOI: 10.1371/journal.pone.0211942] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2018] [Accepted: 01/25/2019] [Indexed: 01/19/2023] Open
Abstract
Background Iron overload, resulting from blood transfusions in patients with chronic anemias, has historically been controlled with regular deferoxamine, but its parenteral requirement encouraged studies of orally-active agents, including deferasirox and deferiprone. Deferasirox, licensed by the US Food and Drug Administration in 2005 based upon the results of randomized controlled trials, is now first-line therapy worldwide. In contrast, early investigator-initiated trials of deferiprone were prematurely terminated after investigators raised safety concerns. The FDA declined market approval of deferiprone; years later, it licensed the drug as “last resort” therapy, to be prescribed only if first-line drugs had failed. We undertook to evaluate the long-term effectiveness and toxicities of deferiprone and deferasirox in one transfusion clinic. Methods and findings Under an IRB-approved study, we retrospectively inspected the electronic medical records of consented iron-loaded patients managed between 2009 and 2015 at The University Health Network (UHN), Toronto. We compared changes in liver and heart iron, adverse effects and other outcomes, in patients treated with deferiprone or deferasirox. Results Although deferiprone was unlicensed in Canada, one-third (n = 41) of locally-transfused patients had been switched from first-line, licensed therapies (deferoxamine or deferasirox) to regimens of unlicensed deferiprone. The primary endpoint of monitoring in iron overload, hepatic iron concentration (HIC), increased (worsened) during deferiprone monotherapy (mean 10±2–18±2 mg/g; p < 0.0003), exceeding the threshold for life-threatening complications (15 mg iron/g liver) in 50% patients. During deferasirox monotherapy, mean HIC decreased (improved) (11±1–6±1 mg/g; p < 0.0001). Follow-up HICs were significantly different following deferiprone and deferasirox monotherapies (p < 0.0000002). Addition of low-dose deferoxamine (<40 mg/kg/day) to deferiprone did not result in reductions of HIC to <15 mg/g (baseline 20±4 mg/g; follow-up, 18±4 mg/g; p < 0.2) or in reduction in the proportion of patients with HIC exceeding 15 mg/g (p < 0.2). During deferiprone exposure, new diabetes mellitus, a recognized consequence of inadequate iron control, was diagnosed in 17% patients, most of whom had sustained HICs exceeding 15 mg/g for years; one woman died after 13 months of a regimen of deferiprone and low-dose deferasirox. During deferiprone exposure, serum ALT increased over baseline in 65% patients. Mean serum ALT increased 6.6-fold (p < 0.001) often persisting for years. During deferasirox exposure, mean ALT was unchanged (p < 0.84). No significant differences between treatment groups were observed in the proportions of patients estimated to have elevated cardiac iron. Conclusions Deferiprone showed ineffectiveness and significant toxicity in most patients. Combination with low doses of first-line therapies did not improve the effectiveness of deferiprone. Exposure to deferiprone, over six years while the drug was unlicensed, in the face of ineffectiveness and serious toxicities, demands review of the standards of local medical practice. The limited scope of regulatory approval of deferiprone, worldwide, should restrict its exposure to the few patients genuinely unable to tolerate the two effective, first-line therapies.
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Affiliation(s)
- Nancy F. Olivieri
- Medicine and Public Health Sciences, University of Toronto, Toronto, Ontario, Canada
- Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
- * E-mail:
| | - Amir Sabouhanian
- Medicine and Public Health Sciences, University of Toronto, Toronto, Ontario, Canada
- Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Brenda L. Gallie
- Department of Ophthalmology and Vision Science, Hospital for Sick Children, Toronto, Ontario, Canada
- Departments of Ophthalmology and Vision Science, Medical Biophysics and Molecular Genetics, University of Toronto, Toronto, Ontario, Canada
- Techna Institute and Krembil Research Institute, University Health Network, Toronto, Ontario, Canada
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Coates TD, Carson S, Wood JC, Berdoukas V. Management of iron overload in hemoglobinopathies: what is the appropriate target iron level? Ann N Y Acad Sci 2017; 1368:95-106. [PMID: 27186942 DOI: 10.1111/nyas.13060] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Revised: 03/04/2016] [Accepted: 03/09/2016] [Indexed: 01/19/2023]
Abstract
Patients with thalassemia become iron overloaded from increased absorption of iron, ineffective erythropoiesis, and chronic transfusion. Before effective iron chelation became available, thalassemia major patients died of iron-related cardiac failure in the second decade of life. Initial treatment goals for chelation therapy were aimed at levels of ferritin and liver iron concentrations associated with prevention of adverse cardiac outcomes and avoidance of chelator toxicity. Cardiac deaths were greatly reduced and survival was much longer. Epidemiological data from the general population draw clear associations between increased transferrin saturation (and, by inference, labile iron) and early death, diabetes, and malignant transformation. The rate of cancers now seems to be significantly higher in thalassemia than in the general population. Reduction in iron can reverse many of these complications and reduce the risk of malignancy. As toxicity can result from prolonged exposure to even low levels of excess iron, and survival in thalassemia patients is now many decades, it would seem prudent to refocus attention on prevention of long-term complications of iron overload and to maintain labile iron and total body iron levels within a normal range, if expertise and resources are available to avoid complications of overtreatment.
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Affiliation(s)
- Thomas D Coates
- Section of Hematology, Children's Center for Cancer, Blood Diseases and Bone Marrow Transplantation
| | - Susan Carson
- Section of Hematology, Children's Center for Cancer, Blood Diseases and Bone Marrow Transplantation
| | - John C Wood
- Division of Cardiology, Children's Hospital Los Angeles, University of Southern California, Keck School of Medicine, Los Angeles, California
| | - Vasilios Berdoukas
- Section of Hematology, Children's Center for Cancer, Blood Diseases and Bone Marrow Transplantation
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Yadav A, Flora SJS. Nano drug delivery systems: a new paradigm for treating metal toxicity. Expert Opin Drug Deliv 2016; 13:831-41. [PMID: 27030893 DOI: 10.1517/17425247.2016.1160890] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
INTRODUCTION The standard medical treatment for metal toxicity is chelation therapy. Chelating agents work by forming less toxic complexes with the toxic metal ions which are readily excreted from the body. These compounds, based on their hydrophilic/lipophilic property, can either remove toxic metal ions from extracellular sites or can penetrate the intracellular compartments to facilitate the removal of toxic metal ions. However, there are various disadvantages associated with this kind of therapy, notably, selectivity. Other problems and challenges are that the therapy regime is expensive, time consuming and has poor patient compliance. Two chelating agents, dimercaptosuccinic acid (DMSA) and dimercaptopropionicsulfonate (DMPS) have gained increased acceptance among clinicians, undoubtedly improving the management of metal intoxications. AREAS COVERED The present review provides an insight into the conventional chelating agents, new chelators under development, and the new opportunities presented by the use of nanotherapy for the treatment of metal poisoning cases. EXPERT OPINION Today's research should not only focus towards development of alternate chelators but also targeted therapy such as the nanotherapy.
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Affiliation(s)
- Abhishek Yadav
- a Directorate of Planning & Coordination , Defence Research and Development Organisation, Ministry of Defence, Govt. of India , Delhi , India
| | - Swaran Jeet Singh Flora
- b Division of Regulatory Toxicology , Defence Research and Development Establishment , Gwalior , Madhya Pradesh , India
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Abstract
As an essential element, iron plays a central role in many physiological processes, including redox balance, inflammation, energy metabolism, and environment sensing. Perturbations in iron homeostasis are associated with several conditions, including hyperglycemia and diabetes, both of which have been studied in patients and animal models. To clarify the pleiotropic role of iron homeostasis in diabetes development, the early studies on diseases with iron-overload, studies on clinical iron depletion therapies, associations between iron-related genetic polymorphisms and diabetes, and etiological mechanisms underlying iron perturbations-impaired insulin secretion and insulin sensitivity were carefully reviewed and discussed. Hereditary hemochromatosis, transfusion-dependent thalassemia, and excess heme iron intake can increase the risk of developing diabetes. Genetically modified mice and mice fed a high-iron diet present with discrepant phenotypes due to differences in tissue iron distribution. Moreover, several genetic polymorphisms related to iron homeostasis have been associated with the risk of developing diabetes. Tightly controlled iron metabolism is essential for insulin secretion and insulin sensitivity, and iron overload in pancreatic islets alters reactive oxygen species (ROS) generation, as well as hypoxia-inducible factor-1α (HIF-1α) stability and adenosine triphosphate (ATP) synthesis, thereby impairing the function and viability of β-cells. Decreased levels of adiponectin, macrophage-mediated inflammation, and ROS-mediated liver kinase B1 (LKB1)/adenosine monophosphate-activated protein kinase (AMPK) activation can contribute to iron overload-induced insulin resistance, whereas iron deficiency could also participate in obesity-related inflammation, hypoxia, and insulin resistance. Because iron homeostasis is closely correlated with many metabolic processes, future studies are needed in order to elucidate the finely tuned network among iron homeostasis, carbohydrate and lipid metabolism, inflammation, and hypoxia.
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Affiliation(s)
- Xinhui Wang
- Department of Nutrition, Research Center for Nutrition and Health, Institute of Nutrition and Food Safety, School of Public Health, School of Medicine, Zhejiang University, 866 Yuhangtang Road, Hangzhou, Zhejiang, 310058, China
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Songdej D, Sirachainan N, Wongwerawattanakoon P, Sasanakul W, Kadegasem P, Sungkarat W, Chuansumrit A. Combined chelation therapy with daily oral deferiprone and twice-weekly subcutaneous infusion of desferrioxamine in children with β-thalassemia: 3-year experience. Acta Haematol 2014; 133:226-36. [PMID: 25376266 DOI: 10.1159/000363210] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2013] [Accepted: 04/24/2014] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To study the efficacy of combined treatment with oral and subcutaneous iron chelators. MATERIAL AND METHODS 50-100 mg/kg/day of oral deferiprone (DFP) combined with 40 mg/kg/dose s.c. desferrioxamine (DFO) twice weekly were given to transfusion-dependent β-thalassemia children. RESULTS Enrolled patients (9 with β-thalassemia major and 33 with β-thalassemia hemoglobin E), ranging from 3 to 18 years in age, were divided into 3 groups; group 1 ferritin ≥1,000-2,500 ng/ml (n = 10), group 2 ferritin >2,500-4,000 ng/ml (n = 23) and group 3 ferritin >4,000 ng/ml (n = 9). Of the 42 patients, 28 reached the 36-month follow-up. Ten patients whose ferritin declined <15% while receiving 100 mg/kg/day of DFP were considered nonresponders. The median age and previous transfusion duration before enrollment were significantly higher in nonresponders than responders (p = 0.04 and 0.003, respectively). The responders exhibited a significant fall in median ferritin levels from 2,954.6 to 936.6 ng/ml (p < 0.001). Time to a significant decrease in serum ferritin among responders was 6 months. In 13 patients, 16 episodes of adverse events occurred: hemophagocytosis with cytopenia (n = 1), neutropenia (n = 2), thrombocytopenia (n = 2), elevated alanine aminotransferase (n = 5), elevated serum creatinine (n = 1), proteinuria (n = 1) and gastrointestinal discomfort (n = 4). CONCLUSION Combination therapy with daily oral DFP and subcutaneous DFO twice weekly is a safe and effective alternative to chelation monotherapy in β-thalassemia children.
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Affiliation(s)
- Duantida Songdej
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Coates TD. Physiology and pathophysiology of iron in hemoglobin-associated diseases. Free Radic Biol Med 2014; 72:23-40. [PMID: 24726864 PMCID: PMC4940047 DOI: 10.1016/j.freeradbiomed.2014.03.039] [Citation(s) in RCA: 101] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Revised: 03/26/2014] [Accepted: 03/27/2014] [Indexed: 01/19/2023]
Abstract
Iron overload and iron toxicity, whether because of increased absorption or iron loading from repeated transfusions, can be major causes of morbidity and mortality in a number of chronic anemias. Significant advances have been made in our understanding of iron homeostasis over the past decade. At the same time, advances in magnetic resonance imaging have allowed clinicians to monitor and quantify iron concentrations noninvasively in specific organs. Furthermore, effective iron chelators are now available, including preparations that can be taken orally. This has resulted in substantial improvement in mortality and morbidity for patients with severe chronic iron overload. This paper reviews the key points of iron homeostasis and attempts to place clinical observations in patients with transfusional iron overload in context with the current understanding of iron homeostasis in humans.
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Affiliation(s)
- Thomas D Coates
- Children׳s Center for Cancer and Blood Diseases, Children׳s Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA 90027, USA.
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Lee TA, von Riedemann S, Tricta F. Cost-utility of chelators in transfusion-dependent β-thalassemia major patients: a review of the pharmacoeconomic literature. Expert Rev Pharmacoecon Outcomes Res 2014; 14:651-60. [PMID: 24918168 DOI: 10.1586/14737167.2014.927314] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
In the inherited hematologic disorder β-thalassemia major, patients receive regular, lifelong blood transfusions, which carry excess iron that the body is unable to eliminate. Chelation therapy (deferoxamine, deferiprone, deferasirox or deferoxamine-deferiprone combination) is required to reduce iron accumulation in target organs and the associated morbidity and mortality. Each chelation regimen has a distinct safety/efficacy profile and particular costs associated with its use. This review aims to provide an overview of published cost-utility analyses of currently used chelation regimens, and to comment on the potential relevance of their findings in the USA market, where deferiprone has recently been introduced.
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Affiliation(s)
- Todd A Lee
- University of Illinois at Chicago, 833 South Wood Street, RM164 MC886, Chicago, IL 60612, USA
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Cabantchik ZI, Munnich A, Youdim MB, Devos D. Regional siderosis: a new challenge for iron chelation therapy. Front Pharmacol 2013; 4:167. [PMID: 24427136 PMCID: PMC3875873 DOI: 10.3389/fphar.2013.00167] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2013] [Accepted: 12/15/2013] [Indexed: 01/01/2023] Open
Abstract
The traditional role of iron chelation therapy has been to reduce body iron burden via chelation of excess metal from organs and fluids and its excretion via biliary-fecal and/or urinary routes. In their present use for hemosiderosis, chelation regimens might not be suitable for treating disorders of iron maldistribution, as those are characterized by toxic islands of siderosis appearing in a background of normal or subnormal iron levels (e.g., sideroblastic anemias, neuro- and cardio-siderosis in Friedreich ataxia- and neurosiderosis in Parkinson's disease). We aimed at clearing local siderosis from aberrant labile metal that promotes oxidative damage, without interfering with essential local functions or with hematological iron-associated properties. For this purpose we introduced a conservative mode of iron chelation of dual activity, one based on scavenging labile metal but also redeploying it to cell acceptors or to physiological transferrin. The “scavenging and redeployment” mode of action was designed both for correcting aberrant iron distribution and also for minimizing/preventing systemic loss of chelated metal. We first examine cell models that recapitulate iron maldistribution and associated dysfunctions identified with Friedreich ataxia and Parkinson's disease and use them to explore the ability of the double-acting agent deferiprone, an orally active chelator, to mediate iron scavenging and redeployment and thereby causing functional improvement. We subsequently evaluate the concept in translational models of disease and finally assess its therapeutic potential in prospective double-blind pilot clinical trials. We claim that any chelator applied to diseases of regional siderosis, cardiac, neuronal or endocrine ought to preserve both systemic and regional iron levels. The proposed deferiprone-based therapy has provided a paradigm for treating regional types of siderosis without affecting hematological parameters and systemic functions.
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Affiliation(s)
- Zvi Ioav Cabantchik
- Department of Biological Chemistry, Adelina and Massimo Della Pergola Chair, Alexander Silberman Institute of Life Sciences, Hebrew University of Jerusalem Givat Ram, Jerusalem, Israel
| | - Arnold Munnich
- Clinical Research Unit, Medical Genetic Clinic and Research Unit INSERM 781, Hôpital Necker-Enfants Malades and Université Paris V René Descartes Paris, France
| | - Moussa B Youdim
- Technion-Rappaport Family Faculty of Medicine, Eve Topf Center of Excellence Haifa, Israel
| | - David Devos
- Department of Medical Pharmacology, EA1046, Faculty of Medicine, Lille Nord de France University and Lille University Medical Center Lille, France
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15
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Ghahramanlu E, Banihashem A, Mirhossini NZ, Hosseini G, Mostafavi-Toroghi H, Tavallaie S, Meshkat M, Ghayour-Mobarhan M, Ferns G. Effect of zinc supplementation on serum antibody titers to heat shock protein 27 in patients with thalassemia major. Hematology 2013; 19:113-9. [DOI: 10.1179/1607845413y.0000000099] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Affiliation(s)
- Elham Ghahramanlu
- Blood Transfusion Research CenterHigh Institute for Research and Education in Transfusion Medicine, North Khorasan, Iran
| | - Abdollah Banihashem
- Hematology DepartmentSheikh Hospital, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Naghme-Zahra Mirhossini
- Biochemistry of Nutrition Research Center and Cardiovascular Research Center Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Golkoo Hosseini
- Biochemistry of Nutrition Research Center and Cardiovascular Research Center Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Hesam Mostafavi-Toroghi
- Biochemistry of Nutrition Research Center and Cardiovascular Research Center Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Shima Tavallaie
- Biochemistry of Nutrition Research Center and Cardiovascular Research Center Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mojtaba Meshkat
- Department of BiostatisticsIslamic Azad University, Mashhad Branch, Mashhad, Iran
| | - Majid Ghayour-Mobarhan
- Biochemistry of Nutrition Research Center and Cardiovascular Research Center Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Gordon Ferns
- Institute for Science & Technology in Medicine, Faculty of Health, University of Keele, Staffordshire ST4 7QB, UK
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16
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Berdoukas V, Nord A, Carson S, Puliyel M, Hofstra T, Wood J, Coates TD. Tissue iron evaluation in chronically transfused children shows significant levels of iron loading at a very young age. Am J Hematol 2013; 88:E283-5. [PMID: 23861216 DOI: 10.1002/ajh.23543] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2013] [Revised: 06/28/2013] [Accepted: 07/09/2013] [Indexed: 01/17/2023]
Abstract
Chronic blood transfusions start at a very young age in subjects with transfusion-dependent anemias, the majority of whom have hereditary anemias. To understand how rapidly iron overload develops, we retrospectively reviewed 308 MRIs for evaluation of liver, pancreatic, or cardiac iron in 125 subjects less than 10 years old. Median age at first MRI evaluation was 6.0 years. Median liver iron concentrations in patients less than 3.5 years old were 14 and 13 mg/g dry weight in thalassemia major (TM) and Diamond-Blackfan anemia (DBA) patients, respectively. At time of first MRI, pancreatic iron was markedly elevated (> 100 Hz) in DBA patients, and cardiac iron ( R₂* >50 Hz) was present in 5/112 subjects (4.5%), including a 2.5 years old subject with DBA. Five of 14 patients (38%) with congenital dyserythropoietic anemia (CDA) developed excess cardiac iron before their 10th birthday. Thus, clinically significant hepatic and cardiac iron accumulation occurs at an early age in patients on chronic transfusions, particularly in those with ineffective or absent erythropoiesis, such as DBA, CDA, and TM, who are at higher risk for iron cardiomyopathy. Performing MRI for iron evaluation in the liver, heart, and pancreas as early as feasible, particularly in those conditions in which there is suppressed bone marrow activity is very important in the management of iron loaded children in order to prescribe appropriate chelation to prevent long-term sequelae. .
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Affiliation(s)
- Vasilios Berdoukas
- Division of Hematology/Oncology, Department of Pediatrics, Keck School of Medicine, Children's Hospital Los Angeles; University of Southern California; Los Angeles California
| | - Anne Nord
- Division of Hematology/Oncology, Department of Pediatrics, Keck School of Medicine, Children's Hospital Los Angeles; University of Southern California; Los Angeles California
| | - Susan Carson
- Division of Hematology/Oncology, Department of Pediatrics, Keck School of Medicine, Children's Hospital Los Angeles; University of Southern California; Los Angeles California
| | - Mammen Puliyel
- Division of Hematology/Oncology, Department of Pediatrics, Keck School of Medicine, Children's Hospital Los Angeles; University of Southern California; Los Angeles California
| | - Thomas Hofstra
- Division of Hematology/Oncology, Department of Pediatrics, Keck School of Medicine, Children's Hospital Los Angeles; University of Southern California; Los Angeles California
| | - John Wood
- Division of Cardiology, Department of Pediatrics, Keck School of Medicine, Children's Hospital Los Angeles; University of Southern California; Los Angeles California
| | - Thomas D. Coates
- Division of Hematology/Oncology, Department of Pediatrics, Keck School of Medicine, Children's Hospital Los Angeles; University of Southern California; Los Angeles California
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17
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Viprakasit V, Nuchprayoon I, Chuansumrit A, Torcharus K, Pongtanakul B, Laothamatas J, Srichairatanakool S, Pooliam J, Supajitkasem S, Suriyaphol P, Tanphaichitr VS, Tuchinda S. Deferiprone (GPO-L-ONE(®) ) monotherapy reduces iron overload in transfusion-dependent thalassemias: 1-year results from a multicenter prospective, single arm, open label, dose escalating phase III pediatric study (GPO-L-ONE; A001) from Thailand. Am J Hematol 2013; 88:251-60. [PMID: 23460233 DOI: 10.1002/ajh.23386] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2012] [Revised: 12/19/2012] [Accepted: 12/24/2012] [Indexed: 01/19/2023]
Abstract
Accessibility to iron chelators including deferoxamine and deferasirox remains obscured in many developing countries. To provide an alternative, the government pharmaceutical organization of Thailand (GPO) manufactured deferiprone which has similar bioequivalent to the standard product. Seventy-three pediatric patients with severe β thalassemias, age range 3.2-19 years, were recruited to a 1-year multicenter prospective, single arm, open label, dose escalating Phase III study of deferiprone to determine its clinical efficacy and safety. Sixty-four patients (87.6%) completed the study with good compliance (>94%). Average deferiprone dose was 79.1±4.3 mg/kg/day. Overall, mean serum ferritin (SF) levels at 1 year were not significantly changed from baseline. However, 45% of patients (response group) had SF reduced >15% from baseline at 1 year with a median reduction of 1,065 ng ml(-1) . Baseline SF was the major factor that predicts clinical efficacy; patients with baseline SF>3,500 ng ml(-1) had the most significant fall of SF at 1 year. A subgroup analysis by MRI-T2* confirmed that the response group had higher baseline liver iron and deferiprone could significantly reduce liver iron overload and normalize levels of ALT at 1 year. Although, gastrointestinal irritation (20.5%) was the most common drug-related adverse events (AEs) followed by transaminitis (16.4%) and neutropenia (6.8%), all patients were well tolerated. There was no mortality and agranulocytosis found in this trial. Monotherapy of deferiprone with appropriate dose adjustment and monitoring for adverse events appeared to be an effective chelation therapy in some patients with good compliance and acceptable safety profiles.
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Affiliation(s)
- Vip Viprakasit
- Hematology/Oncology Division, Department of Pediatrics and Thalassemia Center; Faculty of Medicine Siriraj Hospital, Mahidol University; Bangkok Thailand
| | - Issarang Nuchprayoon
- Department of Pediatrics; King Chulalongkorn Memorial Hospital, Chulalongkorn University; Bangkok Thailand
| | - Ampaiwan Chuansumrit
- Department of Pediatrics; Ramathibodi Hospital, Mahidol University; Bangkok Thailand
| | - Kitti Torcharus
- Department of Pediatrics; Phramongkutklao College of Medicine; Bangkok Thailand
| | - Bunchoo Pongtanakul
- Hematology/Oncology Division, Department of Pediatrics and Thalassemia Center; Faculty of Medicine Siriraj Hospital, Mahidol University; Bangkok Thailand
| | - Jiraporn Laothamatas
- Department of Radiology; Ramathibodi Hospital, Mahidol University; Bangkok Thailand
| | - Somdet Srichairatanakool
- Department of Biochemistry; Faculty of Medicine; Chiang Mai University; Chiang Mai, Bangkok Thailand
| | - Julaporn Pooliam
- Clinical Epidemiology Unit, Office for Research and Development, Faculty of Medicine Siriraj Hospital; Mahidol University; Bangkok Thailand
| | - Siriwat Supajitkasem
- Bioinformatics and Data Management for Research Unit; Office for Research and Development, Faculty of Medicine Siriraj Hospital, Mahidol University; Bangkok Thailand
| | - Prapat Suriyaphol
- Bioinformatics and Data Management for Research Unit; Office for Research and Development, Faculty of Medicine Siriraj Hospital, Mahidol University; Bangkok Thailand
| | - Voravarn S. Tanphaichitr
- Hematology/Oncology Division, Department of Pediatrics and Thalassemia Center; Faculty of Medicine Siriraj Hospital, Mahidol University; Bangkok Thailand
- Thalassemia Foundation of Thailand (TFT); Bangkok Thailand
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18
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Kountouras D, Tsagarakis NJ, Fatourou E, Dalagiorgos E, Chrysanthos N, Berdoussi H, Vgontza N, Karagiorga M, Lagiandreou A, Kaligeros K, Voskaridou E, Roussou P, Diamanti-Kandarakis E, Koskinas J. Liver disease in adult transfusion-dependent beta-thalassaemic patients: investigating the role of iron overload and chronic HCV infection. Liver Int 2013; 33:420-7. [PMID: 23402611 DOI: 10.1111/liv.12095] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2012] [Accepted: 12/10/2012] [Indexed: 12/28/2022]
Abstract
BACKGROUND Iron overload and hepatitis-C virus (HCV) infection, have been implicated in the evolution of liver disease, in patients with transfusion-dependent beta-thalassaemia major (BTM). However, the impact of these factors in late stages of liver disease in adults with BTM, has not been extensively studied. AIMS To investigate serum indices of iron overload, HCV infection and liver disease, in a cohort of 211 adult Greek patients with BTM, in relation with the findings from liver biopsies. METHODS In this cross-sectional study, 211 patients with BTM were enrolled and studied, in relation with HCV infection, ferritin, transaminases, chelation treatment and antiviral treatment. Based on 109 patients biopsied, we correlated liver fibrosis, haemosiderosis and inflammation, with serum indices and HCV status RESULTS Among all patients, 74.4% were anti-HCV positive (HCV+). Ferritin was positively correlated with transaminases and negatively correlated with age, while it was not significantly different among HCV+ and HCV- patients. Among the HCV+ patients, 55.4% reported antiviral treatment, while genotype 1 predominated. In a subfraction of 109 patients, in which liver biopsy was performed, 89% were HCV+ and 11% HCV-. Fibrosis was significantly correlated with age (P = 0.046), AST (P = 0.004), ALT (P = 0.044) and inflammation (P < 0.001). Advanced fibrosis was present with even minimal haemosiderosis, independently of ferritin values or HCV history. CONCLUSIONS These data suggest that in the late stages of liver disease in BTM patients, iron overload may be the critical determinant, since fibrosis is related to the minimal haemosiderosis, independently of HCV history.
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Affiliation(s)
- Dimitrios Kountouras
- 2nd Department of Internal Medicine, Hippokration General Hospital, Medical School, University of Athens, Athens, Greece.
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19
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Haghpanah S, Nasirabadi S, Ghaffarpasand F, Karami R, Mahmoodi M, Parand S, Karimi M. Quality of life among Iranian patients with beta-thalassemia major using the SF-36 questionnaire. SAO PAULO MED J 2013; 131:166-72. [PMID: 23903265 PMCID: PMC10852107 DOI: 10.1590/1516-3180.2013.1313470] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2012] [Revised: 02/13/2012] [Accepted: 09/12/2012] [Indexed: 01/19/2023] Open
Abstract
CONTEXT AND OBJECTIVE Patients with beta-thalassemia major (β-TM) experience physical, psychological and social problems that lead to decreased quality of life (QoL). The aim here was to measure health-related QoL and its determinants among patients with β-TM, using the Short Form-36 (SF-36) questionnaire. DESIGN AND SETTING Cross-sectional study at the Hematology Research Center of Shiraz University of Medical Sciences, in southern Iran. METHODS One hundred and one patients with β-TM were randomly selected. After the participants' demographics and disease characteristics had been recorded, they were asked to fill out the SF-36 questionnaire. The correlations of clinical and demographic factors with the QoL score were evaluated. RESULTS There were 44 men and 57 women of mean age 19.52 ± 4.3 years (range 12-38). On two scales, pain (P = 0.041) and emotional role (P = 0.009), the women showed significantly lower scores than the men. Lower income, poor compliance with iron-chelating therapy and presence of comorbidities were significantly correlated with lower SF-36 scores. These factors were also found to be determinants of worse SF-36 scores in multivariate analysis. CONCLUSIONS We showed that the presence of disease complications, poor compliance with iron-chelating therapy and poor economic status were predictors of worse QoL among patients with β-TM. Prevention and proper management of disease-related complications, increased knowledge among patients regarding the importance of managing comorbidities and greater compliance with iron-chelating therapy, along with psychosocial and financial support, could help these patients to cope better with this chronic disease state.
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Affiliation(s)
- Sezaneh Haghpanah
- MD, MPH. Assistant Professor and Internal Manager, Hematology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.
| | - Shiva Nasirabadi
- BSc. Master’s Student and Genetics Specialist, Hematology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.
| | - Fariborz Ghaffarpasand
- MD. Physician, Health Policy Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.
| | - Rahmatollah Karami
- MD. Physician, Health Policy Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.
| | - Mojtaba Mahmoodi
- MD. Physician, Health Policy Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.
| | - Shirin Parand
- MA. Assistant Editor, Hematology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.
| | - Mehran Karimi
- MD. Professor of Pediatric Hematology and Oncology, Hematology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.
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20
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An update on iron chelation therapy. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2012; 10:411-22. [PMID: 22790257 DOI: 10.2450/2012.0008-12] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 01/19/2012] [Accepted: 02/21/2012] [Indexed: 02/07/2023]
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21
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Farmaki K, Tzoumari I, Pappa C. Oral chelators in transfusion-dependent thalassemia major patients may prevent or reverse iron overload complications. Blood Cells Mol Dis 2011; 47:33-40. [PMID: 21531154 DOI: 10.1016/j.bcmd.2011.03.007] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2011] [Revised: 03/19/2011] [Accepted: 03/21/2011] [Indexed: 01/22/2023]
Abstract
Combined chelation treatment may be a better approach for transfusion-dependent thalassemia major patients with iron overload complications because of increased efficacy. Combination therapy with desferrioxamine and deferiprone has already been reported to improve survival dramatically by reversing cardiac dysfunction and other endocrine complications. Some patients have intolerance or inconvenience to parenteral desferrioxamine. The hypothesis of this study was that combining two oral chelators, deferiprone and deferasirox, might lead to similar results. Following approval by the hospital ethical committee and a written informed consent from each patient, 16 patients who fulfilled the criteria participated in a study protocol for a period of up to 2 years. Efficacy measures analysis demonstrated a statistically significant decrease of total body iron load as estimated by serum ferritin, LIC and MRI T2* indices. Regarding the safety assessment, the incidence of adverse events was minor compared to the associated toxicity of monotherapy of each drug. No new onset of iron overload-related complications was demonstrated. A reversal of cardiac dysfunction was observed in 2/4 patients, while the mean LVEF increased significantly. Regarding endocrine assessment, in 2/8 patients with impaired glucose tolerance, we noted a significant decrease in the mean 2h glucose in OGTT. Additionally an improvement in gonadal function was observed and one male and one female gave birth to two healthy children without hormonal stimulation. Combined oral chelation in thalassemia offers the promise of easier administration, better compliance and may lead to an improvement of patient quality of life by preventing or even reversing iron overload complications.
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Affiliation(s)
- Kallistheni Farmaki
- Thalassemia Unit, General Hospital of Corinth, 1 Dervenakion, Corinth, Greece.
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22
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Kwiatkowski JL. Real-world use of iron chelators. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2011; 2011:451-458. [PMID: 22160073 DOI: 10.1182/asheducation-2011.1.451] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Whereas RBC transfusion therapy is lifesaving in thalassemia, obligatory iron loading accompanies such treatment and chelation therapy to remove and detoxify iron resulting from these chronic transfusions must therefore be administered. Morbidity and mortality in thalassemia is linked closely to the adequacy of chelation. Three chelators are currently available worldwide-deferoxamine, deferasirox, and deferiprone, although the latter is available in North America only in research protocols and compassionate use programs. These chelators can be used as monotherapy or in combination, although only the combination of deferiprone and deferoxamine has been extensively studied to date. Several factors, including chelator availability and its properties, drug tolerability, degree of organ-specific iron loading, ongoing transfusional iron burden, and patient preference, must be considered in the design of optimal, individualized chelation regimens, and these factors must periodically be reviewed and chelation adjusted accordingly. Ultimately, comparative effectiveness trials may help to determine the ideal strategy (eg, intensification of monotherapy or combined therapy including agents and doses) for treating various scenarios of organ-specific iron loading.
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Affiliation(s)
- Janet L Kwiatkowski
- Children's Hospital of Philadelphia and University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA.
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