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Taneera J, Mahgoub E, Qannita R, Alalami A, Shehadat OA, Youssef M, Dib A, Hajji AA, Hajji AA, Al-Khaja F, Dewedar H, Hamad M. β-Thalassemia and Diabetes Mellitus: Current State and Future Directions. Horm Metab Res 2024; 56:272-278. [PMID: 37871612 DOI: 10.1055/a-2185-5073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
β-Thalassemia major is a congenital hemoglobin disorder that requires regular blood transfusion. The disease is often associated with iron overload and diabetes mellitus, among other complications. Pancreatic iron overload in β-thalassemia patients disrupts β-cell function and insulin secretion and induces insulin resistance. Several risk factors, including family history of diabetes, sedentary lifestyle, obesity, gender, and advanced age increase the risk of diabetes in β-thalassemia patients. Precautionary measures such as blood glucose monitoring, anti-diabetic medications, and healthy living in β-thalassemia patients notwithstanding, the prevalence of diabetes in β-thalassemia patients continues to rise. This review aims to address the relationship between β-thalassemia and diabetes in an attempt to understand how the pathology and management of β-thalassemia precipitate diabetes mellitus. The possible employment of surrogate biomarkers for early prediction and intervention is discussed. More work is still needed to better understand the molecular mechanism(s) underlying the link between β-thalassemia and diabetes and to identify novel prognostic and therapeutic targets.
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Affiliation(s)
- Jalal Taneera
- Sharjah Institute for Medical Research, University of Sharjah, Sharjah, United Arab Emirates
| | - Eglal Mahgoub
- Sharjah Institute for Medical Research, University of Sharjah, Sharjah, United Arab Emirates
| | - Reem Qannita
- Sharjah Institute for Medical Research, University of Sharjah, Sharjah, United Arab Emirates
| | - Ayah Alalami
- Sharjah Institute for Medical Research, University of Sharjah, Sharjah, United Arab Emirates
| | - Ola Al Shehadat
- Sharjah Institute for Medical Research, University of Sharjah, Sharjah, United Arab Emirates
| | - Mona Youssef
- Sharjah Institute for Medical Research, University of Sharjah, Sharjah, United Arab Emirates
| | - Ayah Dib
- Sharjah Institute for Medical Research, University of Sharjah, Sharjah, United Arab Emirates
| | - Alaa Al Hajji
- Sharjah Institute for Medical Research, University of Sharjah, Sharjah, United Arab Emirates
| | - Amani Al Hajji
- Sharjah Institute for Medical Research, University of Sharjah, Sharjah, United Arab Emirates
| | | | - Hany Dewedar
- Dubai Thalassemia Center, Dubai, United Arab Emirates
| | - Mawieh Hamad
- University of Sharjah College of Health Sciences, Sharjah, United Arab Emirates
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Kontoghiorghes GJ. Drug Selection and Posology, Optimal Therapies and Risk/Benefit Assessment in Medicine: The Paradigm of Iron-Chelating Drugs. Int J Mol Sci 2023; 24:16749. [PMID: 38069073 PMCID: PMC10706143 DOI: 10.3390/ijms242316749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 11/19/2023] [Accepted: 11/22/2023] [Indexed: 12/18/2023] Open
Abstract
The design of clinical protocols and the selection of drugs with appropriate posology are critical parameters for therapeutic outcomes. Optimal therapeutic protocols could ideally be designed in all diseases including for millions of patients affected by excess iron deposition (EID) toxicity based on personalised medicine parameters, as well as many variations and limitations. EID is an adverse prognostic factor for all diseases and especially for millions of chronically red-blood-cell-transfused patients. Differences in iron chelation therapy posology cause disappointing results in neurodegenerative diseases at low doses, but lifesaving outcomes in thalassemia major (TM) when using higher doses. In particular, the transformation of TM from a fatal to a chronic disease has been achieved using effective doses of oral deferiprone (L1), which improved compliance and cleared excess toxic iron from the heart associated with increased mortality in TM. Furthermore, effective L1 and L1/deferoxamine combination posology resulted in the complete elimination of EID and the maintenance of normal iron store levels in TM. The selection of effective chelation protocols has been monitored by MRI T2* diagnosis for EID levels in different organs. Millions of other iron-loaded patients with sickle cell anemia, myelodysplasia and haemopoietic stem cell transplantation, or non-iron-loaded categories with EID in different organs could also benefit from such chelation therapy advances. Drawbacks of chelation therapy include drug toxicity in some patients and also the wide use of suboptimal chelation protocols, resulting in ineffective therapies. Drug metabolic effects, and interactions with other metals, drugs and dietary molecules also affected iron chelation therapy. Drug selection and the identification of effective or optimal dose protocols are essential for positive therapeutic outcomes in the use of chelating drugs in TM and other iron-loaded and non-iron-loaded conditions, as well as general iron toxicity.
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Affiliation(s)
- George J Kontoghiorghes
- Postgraduate Research Institute of Science, Technology, Environment and Medicine, Limassol 3021, Cyprus
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Kontoghiorghes GJ. The Vital Role Played by Deferiprone in the Transition of Thalassaemia from a Fatal to a Chronic Disease and Challenges in Its Repurposing for Use in Non-Iron-Loaded Diseases. Pharmaceuticals (Basel) 2023; 16:1016. [PMID: 37513928 PMCID: PMC10384919 DOI: 10.3390/ph16071016] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 07/13/2023] [Accepted: 07/15/2023] [Indexed: 07/30/2023] Open
Abstract
The iron chelating orphan drug deferiprone (L1), discovered over 40 years ago, has been used daily by patients across the world at high doses (75-100 mg/kg) for more than 30 years with no serious toxicity. The level of safety and the simple, inexpensive synthesis are some of the many unique properties of L1, which played a major role in the contribution of the drug in the transition of thalassaemia from a fatal to a chronic disease. Other unique and valuable clinical properties of L1 in relation to pharmacology and metabolism include: oral effectiveness, which improved compliance compared to the prototype therapy with subcutaneous deferoxamine; highly effective iron removal from all iron-loaded organs, particularly the heart, which is the major target organ of iron toxicity and the cause of mortality in thalassaemic patients; an ability to achieve negative iron balance, completely remove all excess iron, and maintain normal iron stores in thalassaemic patients; rapid absorption from the stomach and rapid clearance from the body, allowing a greater frequency of repeated administration and overall increased efficacy of iron excretion, which is dependent on the dose used and also the concentration achieved at the site of drug action; and its ability to cross the blood-brain barrier and treat malignant, neurological, and microbial diseases affecting the brain. Some differential pharmacological activity by L1 among patients has been generally shown in relation to the absorption, distribution, metabolism, elimination, and toxicity (ADMET) of the drug. Unique properties exhibited by L1 in comparison to other drugs include specific protein interactions and antioxidant effects, such as iron removal from transferrin and lactoferrin; inhibition of iron and copper catalytic production of free radicals, ferroptosis, and cuproptosis; and inhibition of iron-containing proteins associated with different pathological conditions. The unique properties of L1 have attracted the interest of many investigators for drug repurposing and use in many pathological conditions, including cancer, neurodegenerative conditions, microbial conditions, renal conditions, free radical pathology, metal intoxication in relation to Fe, Cu, Al, Zn, Ga, In, U, and Pu, and other diseases. Similarly, the properties of L1 increase the prospects of its wider use in optimizing therapeutic efforts in many other fields of medicine, including synergies with other drugs.
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Affiliation(s)
- George J Kontoghiorghes
- Postgraduate Research Institute of Science, Technology, Environment and Medicine, Limassol 3021, Cyprus
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Kontoghiorghes GJ. Deferiprone and Iron-Maltol: Forty Years since Their Discovery and Insights into Their Drug Design, Development, Clinical Use and Future Prospects. Int J Mol Sci 2023; 24:ijms24054970. [PMID: 36902402 PMCID: PMC10002863 DOI: 10.3390/ijms24054970] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 02/24/2023] [Accepted: 03/02/2023] [Indexed: 03/08/2023] Open
Abstract
The historical insights and background of the discovery, development and clinical use of deferiprone (L1) and the maltol-iron complex, which were discovered over 40 years ago, highlight the difficulties, complexities and efforts in general orphan drug development programs originating from academic centers. Deferiprone is widely used for the removal of excess iron in the treatment of iron overload diseases, but also in many other diseases associated with iron toxicity, as well as the modulation of iron metabolism pathways. The maltol-iron complex is a recently approved drug used for increasing iron intake in the treatment of iron deficiency anemia, a condition affecting one-third to one-quarter of the world's population. Detailed insights into different aspects of drug development associated with L1 and the maltol-iron complex are revealed, including theoretical concepts of invention; drug discovery; new chemical synthesis; in vitro, in vivo and clinical screening; toxicology; pharmacology; and the optimization of dose protocols. The prospects of the application of these two drugs in many other diseases are discussed under the light of competing drugs from other academic and commercial centers and also different regulatory authorities. The underlying scientific and other strategies, as well as the many limitations in the present global scene of pharmaceuticals, are also highlighted, with an emphasis on the priorities for orphan drug and emergency medicine development, including the roles of the academic scientific community, pharmaceutical companies and patient organizations.
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Affiliation(s)
- George J Kontoghiorghes
- Postgraduate Research Institute of Science, Technology, Environment and Medicine, Limassol 3021, Cyprus
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Origa R, Gianesin B, Longo F, Di Maggio R, Cassinerio E, Gamberini MR, Pinto VM, Quarta A, Casale M, La Nasa G, Caocci G, Piroddi A, Piolatto A, Di Mauro A, Romano C, Gigante A, Barella S, Maggio A, Graziadei G, Perrotta S, Forni GL. Incidence of cancer and related deaths in hemoglobinopathies: A follow-up of 4631 patients between 1970 and 2021. Cancer 2023; 129:107-117. [PMID: 36321594 PMCID: PMC10092274 DOI: 10.1002/cncr.34509] [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: 07/14/2022] [Revised: 08/06/2022] [Accepted: 08/22/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND The correlation between thalassemia and malignancies other than hepatocellular carcinoma (HCC) and the possible relationship between other hemoglobinopathies and tumor risk have been poorly evaluated. METHODS Eight Italian specialized centers evaluated the incidence of malignant neoplasms in hemoglobinopathies as well as their sites and features. The study cohort included 4631 patients followed between 1970 and 2021 (transfusion-dependent β-thalassemia, 55.6%; non-transfusion-dependent thalassemia, 17.7%; sickle cell disease, 17.6%; hemoglobin H disease, 8.3%). RESULTS A total of 197 diagnoses of cancer were reported (incidence rate, 442 cases per 100,000 person-years). The liver was the most frequent site of tumors in both sexes, with a higher incidence (190 cases per 100,000 person-years) in comparison with the general population found in all types of hemoglobinopathies (except hemoglobin H disease). In recent years, tumors have become the second cause of death in patients with transfusion-dependent thalassemia. A lower risk of breast and prostate cancer was observed in the whole group of patients with hemoglobinopathies. The first cancer diagnoses dated back to the 1980s, and the incidence rate sharply increased after the 2000s. However, although the incidence rate of cancers of all sites but the liver continued to show an increasing trend, the incidence of HCC showed stability. CONCLUSIONS These findings provide novel insights into the relationship between cancer and hemoglobinopathies and suggest that the overall risk is not increased in these patients. HCC has been confirmed as the most frequent tumor, but advances in chelation and the drugs that have led to the eradication of hepatitis C may explain the recent steadiness in the number of diagnoses that is reported here.
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Affiliation(s)
- Raffaella Origa
- Università di Cagliari, SSD Talassemia, Ospedale Microcitemico 'A. Cao,' ASL8 Cagliari, Cagliari, Italy
| | | | - Filomena Longo
- Centro Microcitemie-Pediatria Azienda Ospedaliero Universitaria San Luigi Gonzaga, Turin, Italy
| | - Rosario Di Maggio
- Unità Operativa Complessa Ematologia per le Malattie Rare del Sangue e degli Organi Ematopoietici, Azienda Ospedaliera Ospedali Riuniti Villa Sofia-V. Cervello, Palermo, Italy
| | - Elena Cassinerio
- Attività Diurne Malattie Rare Internistiche-Medicina Generale, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Maria Rita Gamberini
- Day Hospital della Talassemia e delle Emoglobinopatie, Azienda Ospedaliero-Universitaria S. Anna, Ferrara, Italy
| | - Valeria Maria Pinto
- Struttura Semplice Dipartimentale Centro della Microcitemia, delle Anemie Congenite e dei Disordini del Metabolismo del Ferro, Ente Ospedaliero Ospedali Galliera, Genoa, Italy
| | - Antonella Quarta
- Unità Operativa Semplice Centro Microcitemia, Unità Operativa Complessa Ematologia e Trapianto di Cellule Staminali Emopoietiche, Ospedale 'A. Perrino', Brindisi, Italy
| | - Maddalena Casale
- Dipartimento della Donna, del Bambino e di Chirurgia Generale e Specialistica, Università̀ della Campania 'Luigi Vanvitelli,', Naples, Italy
| | - Giorgio La Nasa
- Università di Cagliari, Struttura Complessa Ematologia e Centro Trapianto di Midollo Osseo, Ospedale Businco, Cagliari, Italy
| | - Giovanni Caocci
- Università di Cagliari, Struttura Complessa Ematologia e Centro Trapianto di Midollo Osseo, Ospedale Businco, Cagliari, Italy
| | - Antonio Piroddi
- Centro Trapianti Cellule Staminali, Ospedale Microcitemico 'A. Cao', ASL8 Cagliari, Cagliari, Italy
| | - Andrea Piolatto
- Centro Microcitemie-Pediatria Azienda Ospedaliero Universitaria San Luigi Gonzaga, Turin, Italy
| | - Alessandra Di Mauro
- Attività Diurne Malattie Rare Internistiche-Medicina Generale, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Claudia Romano
- Unità Operativa Semplice Centro Microcitemia, Unità Operativa Complessa Ematologia e Trapianto di Cellule Staminali Emopoietiche, Ospedale 'A. Perrino', Brindisi, Italy
| | | | - Susanna Barella
- Struttura Semplice Dipartimentale Talassemia, Ospedale Microcitemico 'A. Cao,' ASL8 Cagliari, Cagliari, Italy
| | - Aurelio Maggio
- Unità Operativa Complessa Ematologia per le Malattie Rare del Sangue e degli Organi Ematopoietici, Azienda Ospedaliera Ospedali Riuniti Villa Sofia-V. Cervello, Palermo, Italy
| | - Giovanna Graziadei
- Attività Diurne Malattie Rare Internistiche-Medicina Generale, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Silverio Perrotta
- Dipartimento della Donna, del Bambino e di Chirurgia Generale e Specialistica, Università̀ della Campania 'Luigi Vanvitelli,', Naples, Italy
| | - Gian Luca Forni
- Struttura Semplice Dipartimentale Centro della Microcitemia, delle Anemie Congenite e dei Disordini del Metabolismo del Ferro, Ente Ospedaliero Ospedali Galliera, Genoa, Italy
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The Outcomes of Patients with Haemoglobin Disorders in Cyprus: A Joined Report of the Thalassaemia International Federation and the Nicosia and Paphos Thalassaemia Centres (State Health Services Organisation). THALASSEMIA REPORTS 2022. [DOI: 10.3390/thalassrep12040019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Haemoglobinopathies, including thalassaemias and sickle-cell syndromes, are demanding, lifelong conditions that pose a significant burden to patients, families, and healthcare systems. Despite the therapeutic advances and the resulting improvements in prognosis accomplished in past decades, these patients still face important challenges, including suboptimal access to quality care in areas with developing economies, changing epidemiology due to massive migration flows, an evolving clinical spectrum due to ageing in well-treated patients, and limited access to novel high-cost therapies. We herein describe the organization of healthcare services for haemoglobinopathies in Cyprus—with particular focus on beta-thalassaemia, the most prevalent condition in this region—along with selected patient outcomes. This report aims at underscoring the fact that nationally funded and well-coordinated prevention and care programmes for chronic and complex conditions, such as haemoglobinopathies, with active involvement from patient organizations lead to effective disease control and excellent outcomes in survival, quality of life, social adaptation, and public health savings, and allow timely and effective responses to emerging crises, such as the COVID-19 pandemic. The Cyprus paradigm could therefore serve as a blueprint for the organization or adaptation of haemoglobinopathy programs in other countries since these disorders are still widely occurring.
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Meloni A, Pistoia L, Maffei S, Marcheschi P, Casini T, Spasiano A, Bitti PP, Cuccia L, Corigliano E, Sanna PMG, Massei F, Positano V, Cademartiri F. Gender Differences in Knowledge and Perception of Cardiovascular Disease among Italian Thalassemia Major Patients. J Clin Med 2022; 11:3736. [PMID: 35807036 PMCID: PMC9267613 DOI: 10.3390/jcm11133736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 06/14/2022] [Accepted: 06/25/2022] [Indexed: 11/16/2022] Open
Abstract
We evaluated gender differences in knowledge and perception of cardiovascular disease (CVD) among Italian thalassemia major (TM) patients. An anonymous questionnaire was completed by 139 β-TM patients (87 (62.7%) females, 40.90 ± 8.03 years). Compared to females, males showed a significantly higher frequency of CVDs, and they less frequently selected tumors in general as the greatest health problem for people of the same age and gender (48.1% vs. 66.7%; p = 0.031) and as the greatest danger to their future health (26.9% vs. 43.7%; p = 0.048). CVDs were designated as the greatest danger to their future health by a significantly higher percentage of males than females (53.8% vs. 36.8%; p = 0.048). Both males and females showed a good knowledge of cardiovascular risk factors and preventive measures for CVDs. No gender differences were detected in the subjective well-being and the perceived cardiovascular risk. The perceived risk was not influenced by age, presence of cardiovascular risk factors, or disease, but no patient with a low perceived CVD risk had myocardial iron overload. Our findings highlight the need to implement future educational programs aimed at increasing the awareness of CVD as the greatest health issue, especially among the female TM population, and at informing TM patients of the different actors, besides iron, that play a role in the development of cardiovascular complications.
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Affiliation(s)
- Antonella Meloni
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, 56124 Pisa, Italy; (A.M.); (L.P.); (V.P.)
- Unità Operativa Complessa di Bioingegneria, Fondazione G. Monasterio CNR-Regione Toscana, 56124 Pisa, Italy
| | - Laura Pistoia
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, 56124 Pisa, Italy; (A.M.); (L.P.); (V.P.)
| | - Silvia Maffei
- Cardiovascular and Gynaecological Endocrinology Unit, Fondazione G. Monasterio CNR-Regione Toscana, 56124 Pisa, Italy;
| | - Paolo Marcheschi
- Reparto INFOTEL, Fondazione G Monasterio CNR-Regione Toscana, 56124 Pisa, Italy;
| | - Tommaso Casini
- Centro Talassemie ed Emoglobinopatie, Ospedale “Meyer”, 50132 Firenze, Italy;
| | - Anna Spasiano
- Unità Operativa Semplice Dipartimentale Malattie Rare del Globulo Rosso, Azienda Ospedaliera di Rilievo Nazionale “A. Cardarelli”, 80131 Napoli, Italy;
| | - Pier Paolo Bitti
- Servizio Immunoematologia e Medicina Trasfusionale, Dipartimento dei Servizi, Presidio Ospedaliero “San Francesco” ASL Nuoro, 08100 Nuoro, Italy;
| | - Liana Cuccia
- Unità Operativa Complessa Ematologia con Talassemia, Azienda di Rilievo Nazionale ad Alta Specializzazione Civico “Benfratelli-Di Cristina”, 90127 Palermo, Italy;
| | - Elisabetta Corigliano
- Ematologia Microcitemia, Ospedale San Giovanni di Dio, Azienda Sanitaria Provinciale di Crotone, 88900 Crotone, Italy;
| | - Paola Maria Grazia Sanna
- Servizio Trasfusionale Aziendale, Azienda Ospedaliero Universitaria di Sassari, 07100 Sassari, Italy;
| | - Francesco Massei
- Unità Operativa Oncoematologia Pediatrica, Azienda Ospedaliero Universitaria Pisana, Stabilimento S. Chiara, 56100 Pisa, Italy;
| | - Vincenzo Positano
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, 56124 Pisa, Italy; (A.M.); (L.P.); (V.P.)
- Unità Operativa Complessa di Bioingegneria, Fondazione G. Monasterio CNR-Regione Toscana, 56124 Pisa, Italy
| | - Filippo Cademartiri
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, 56124 Pisa, Italy; (A.M.); (L.P.); (V.P.)
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Bayraktaroglu S, Karadas N, Onen S, Karapinar DY, Aydinok Y. Modern management of iron overload in thalassemia major patients guided by MRI techniques: real-world data from a long-term cohort study. Ann Hematol 2022; 101:521-529. [DOI: 10.1007/s00277-021-04748-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 12/15/2021] [Indexed: 01/19/2023]
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Westwood MA, Pennell DJ. Reducing mortality by myocardial T2* cardiovascular magnetic resonance at national level. Eur Heart J 2021; 43:2493-2495. [PMID: 34907427 DOI: 10.1093/eurheartj/ehab814] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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10
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Pepe A, Pistoia L, Gamberini MR, Cuccia L, Lisi R, Cecinati V, Maggio A, Sorrentino F, Filosa A, Rosso R, Messina G, Missere M, Righi R, Renne S, Vallone A, Dalmiani S, Positano V, Midiri M, Meloni A. National networking in rare diseases and reduction of cardiac burden in thalassemia major. Eur Heart J 2021; 43:2482-2492. [PMID: 34907420 DOI: 10.1093/eurheartj/ehab851] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Revised: 06/18/2021] [Accepted: 12/09/2021] [Indexed: 12/11/2022] Open
Abstract
AIMS A tailored chelation therapy guided by magnetic resonance imaging (MRI) is a strategy to improve the prognosis in iron-loaded patients, in many cases still hampered by limited MRI availability. In order to address this issue, the Myocardial Iron Overload in Thalassemia (MIOT) network was established in Italy and we aimed to describe the impact of 10-year activity of this network on cardiac burden in thalassemia major (TM). METHODS AND RESULTS Within the MIOT network, 1746 TM patients (911 females; mean age 31.2 ± 9.1 years) were consecutively enrolled and prospectively followed by 70 thalassemia and 10 MRI centres. Patients were scanned using a multiparametric approach for assessing myocardial iron overload (MIO), biventricular function, and myocardial fibrosis. At the last MRI scan, a significant increase in global heart T2* values and a significantly higher frequency of patients with no MIO (all segmental T2* ≥20 ms) were detected, with a concordant improvement in biventricular function, particularly in patients with baseline global heart T2* <20 ms. Forty-seven percentage of patients changed the chelation regimen based on MRI. The frequency of heart failure (HF) significantly decreased after baseline MRI from 3.5 to 0.8% (P < 0.0001). Forty-six patients died during the study, and HF accounted for 34.8% of deaths. CONCLUSION Over 10 years, continuous monitoring of cardiac iron and a tailored chelation therapy allowed MIO reduction, with consequent improvement of cardiac function and reduction of cardiac complications and mortality from MIO-related HF. A national networking for rare diseases therefore proved effective in improving the care and reducing cardiac outcomes of TM patients. KEY QUESTION Which was the impact on cardiac outcomes in thalassemia major by a national network among thalassemia and magnetic resonance imaging centres ensuring the continuous and standardized monitoring of the cardiac iron levels? KEY FINDING There was a reduction of myocardial iron overload (MIO) in almost 70% of patients, with consequent improvement of cardiac function and reduction of cardiac complications and mortality from MIO-related heart failure. TAKE HOME MESSAGE A national clinical and imaging networking in rare diseases was effective in improving the care and in reducing the cardiac burden in thalassemia major patients.
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Affiliation(s)
- Alessia Pepe
- Magnetic Resonance Imaging Unit, Fondazione G. Monasterio CNR-Regione Toscana, Via Moruzzi 1, Pisa 56124, Italy
| | - Laura Pistoia
- Magnetic Resonance Imaging Unit, Fondazione G. Monasterio CNR-Regione Toscana, Via Moruzzi 1, Pisa 56124, Italy
| | - Maria Rita Gamberini
- Dipartimento della Riproduzione e dell'Accrescimento, Day Hospital della Talassemia e delle Emoglobinopatie, Azienda Ospedaliero-Universitaria Arcispedale "S. Anna", Via Aldo Moro 8, Ferrara 44124, Italy
| | - Liana Cuccia
- Unità Operativa Complessa Ematologia con Talassemia, ARNAS Civico "Benfratelli-Di Cristina", Piazza N. Leotta 4, Palermo 90134, Italy
| | - Roberto Lisi
- Unità Operativa Dipartimentale Talassemia, Presidio Ospedaliero Garibaldi-Centro-ARNAS Garibaldi, Piazza Santa Maria di Gesù 7, Catania 95100, Italy
| | - Valerio Cecinati
- Struttura Semplice di Microcitemia, Ospedale "SS. Annunziata" ASL Taranto, Via Bruno 1, Taranto 74123, Italy
| | - Aurelio Maggio
- Ematologia II con Talassemia, Ospedale "V. Cervello", Via Trabucco 180, Palermo 90100, Italy
| | - Francesco Sorrentino
- Unità Operativa Semplice Dipartimentale Day Hospital Talassemici, Ospedale "Sant'Eugenio", Piazzale Umanesimo 10, Roma 00143, Italy
| | - Aldo Filosa
- Unità Operativa Semplice Dipartimentale Malattie Rare del Globulo Rosso, Azienda Ospedaliera di Rilievo Nazionale "A. Cardarelli", Via Cardarelli 9, Napoli 80131, Italy
| | - Rosamaria Rosso
- Unità Operativa Talassemie ed Emoglobinopatie, Azienda Ospedaliero-Universitaria Policlinico "Vittorio Emanuele", Via S. Sofia 74, Catania 95100, Italy
| | - Giuseppe Messina
- Centro Microcitemie, Azienda Ospedaliera "Bianchi-Melacrino-Morelli", Viale Europa, Reggio Calabria 89100, Italy
| | - Massimiliano Missere
- Dipartimento di Immagini, Fondazione di Ricerca e Cura "Giovanni Paolo II", Largo A. Gemelli 1, Campobasso 86100, Italy
| | - Riccardo Righi
- Diagnostica per Immagini e Radiologia Interventistica, Ospedale del Delta, Via Valle Oppio 2, Lagosanto, FE 44023, Italy
| | - Stefania Renne
- Struttura Complessa di Cardioradiologia-UTIC, Presidio Ospedaliero "Giovanni Paolo II", Via A. Perugini, Lamezia Terme, CZ 88046, Italy
| | - Antonino Vallone
- Reparto di Radiologia, Azienda Ospedaliera "Garibaldi" Presidio Ospedaliero Nesima, Via Palermo 636, Catania 95126, Italy
| | - Stefano Dalmiani
- Unità Operativa Sistemi Informatici, Fondazione G. Monasterio CNR-Regione Toscana, Via Moruzzi 1, Pisa 56124, Italy
| | - Vincenzo Positano
- Magnetic Resonance Imaging Unit, Fondazione G. Monasterio CNR-Regione Toscana, Via Moruzzi 1, Pisa 56124, Italy
| | - Massimo Midiri
- Sezione di Scienze Radiologiche-Dipartimento di Biopatologia e Biotecnologie Mediche, Policlinico "Paolo Giaccone", Via del Vespro 127, Palermo 90127, Italy
| | - Antonella Meloni
- Magnetic Resonance Imaging Unit, Fondazione G. Monasterio CNR-Regione Toscana, Via Moruzzi 1, Pisa 56124, Italy
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Morse LA, Sawh RN. Transfer of Care for People with Severe Forms of Thalassemia: Learning from Past Experiences to Create a Transition Plan. J Pediatr Nurs 2021; 61:378-386. [PMID: 34600243 DOI: 10.1016/j.pedn.2021.08.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 08/10/2021] [Accepted: 08/11/2021] [Indexed: 01/19/2023]
Abstract
PURPOSE To demonstrate the need for developing standardized healthcare transition plans for persons with severe forms of thalassemia as life expectancy continues to improve. DESIGN AND METHODS This study utilized an original questionnaire to explore the factors that determined whether individuals residing in North America transferred their thalassemia care from a pediatric to an adult specialist, and what components they believed should be included in a healthcare transition plan. RESULTS Approximately one-third of respondents remained under the care of a pediatric hematologist, most commonly citing the thalassemia knowledge of the specialist as their reason for not transferring their care. Additionally, this group also reported more thalassemia-related services available at their healthcare facility, better access to flexible hours for blood transfusions and increased satisfaction with their care. Adults with thalassemia recommend enhanced communication between patient and provider and building opportunities for patients to assume the role of self advocate as key components for a healthcare transition plan. CONCLUSIONS There is an inconsistency in the transfer-of-care experience of adults with severe forms of thalassemia living in North America. Development of a healthcare transition program would benefit from the input of those who have gone through this process. PRACTICE IMPLICATIONS A well informed healthcare transition program can enhance the quality of life of those with thalassemia. The training and educational background of nurses and genetic counselors make them uniquely qualified to guide patients on how to advocate for themselves and to ensure continuity of care during a healthcare transition.
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Affiliation(s)
- Lauren A Morse
- The Joan H. Marks Graduate Program in Human Genetics, NY, United States of America.
| | - Radhika N Sawh
- The Joan H. Marks Graduate Program in Human Genetics, NY, United States of America
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Kountouris P, Michailidou K, Christou S, Hadjigavriel M, Sitarou M, Kolnagou A, Kleanthous M, Telfer P. Effect of HBB genotype on survival in a cohort of transfusion-dependent thalassemia patients in Cyprus. Haematologica 2021; 106:2458-2468. [PMID: 32732363 PMCID: PMC8409026 DOI: 10.3324/haematol.2020.260224] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Indexed: 12/14/2022] Open
Abstract
Initiation of regular transfusion in transfusion-dependent thalassemia (TDT) is based on the assessment of clinical phenotype. Pathogenic HBB variants causing β-thalassemia are important determinants of phenotype and could be used to aid decision-making. We investigated the association of HBB genotype with survival in a cohort study in the four thalassemia centers in Cyprus. HBB genotype was classified as severe (β0/β0 or β+/β0), moderate (β+/β+), or mild (β0/β++ or β+/β++). Risk factors for mortality were evaluated using multivariate Cox proportional- hazards regression. Of the 537 subjects who were followed for a total of 20,963 person-years, 80.4% (95% confidence interval [95% CI]: 76.4-84.7) survived to 50 years of age with increasing rates of liver-, infectionand malignancy-related deaths observed during recent follow-up. We evaluated non-modifiable risk factors and found worse outcomes associated with male sex (hazard ratio 1.9, 95% CI: 1.1-3.0, P=0.01) and milder genotype (hazard ratio 1.6, 95% CI: 1.1-2.3, P=0.02). The effect of genotype was confirmed in a second model, which included treatment effects. Patients with a milder genotype initiated transfusion significantly later and had reduced blood requirements compared to those with moderate or severe genotypes, although pre-transfusion hemoglobin levels did not differ between genotypes. Our results suggest that early treatment decisions to delay transfusion and different long-term treatment strategies in individuals with milder genotypes have led to adverse longterm effects of under-treated thalassemia and worse survival. We propose that HBB genotype determination and use of this information to aid in decision-making can improve long-term outcomes of thalassemia patients.
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Affiliation(s)
- Petros Kountouris
- Cyprus Institute of Neurology and Genetics, Cyprus School of Molecular Medicine, Nicosia, Cyprus
| | - Kyriaki Michailidou
- Cyprus Institute of Neurology and Genetics, Cyprus School of Molecular Medicine, Nicosia, Cyprus
| | | | | | - Maria Sitarou
- Thalassemia Centre, Larnaca General Hospital, Larnaca, Cyprus
| | - Anita Kolnagou
- Thalassemia Centre, Paphos General Hospital, Paphos, Cyprus
| | - Marina Kleanthous
- Cyprus Institute of Neurology and Genetics, Cyprus School of Molecular Medicine, Nicosia, Cyprus
| | - Paul Telfer
- Centre for Genomics and Child Health, Blizard Institute, Queen Mary University of London, UK
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Kontoghiorghes GJ. Differences between the European Union and United States of America in Drug Regulatory Affairs Affect Global Patient Safety Standards and Public Health Awareness: The Case of Deferasirox and Other Iron Chelating Drugs. MEDICINES (BASEL, SWITZERLAND) 2021; 8:medicines8070036. [PMID: 34357152 PMCID: PMC8304852 DOI: 10.3390/medicines8070036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 06/17/2021] [Accepted: 07/05/2021] [Indexed: 06/13/2023]
Abstract
Regulatory policies on drugs have a major impact on patient safety and survival. Some pharmaceutical companies employ all possible methods to achieve maximum sales in relation to the monopoly of their patented drugs, leading sometimes to irregularities and illegal activities. Misinformation on the orphan drug deferasirox has reached the stage of criminal investigations and fines exceeding USD 100 million. Additional lawsuits of USD 3.5 billion for damages and civil fines were also filed by the FBI of the USA involving deferasirox and mycophenolic acid, which were later settled with an additional fine of USD 390 million. Furthermore, a USD 345 million fine was also settled for bribes and other illegal overseas operations including an EU country. However, no similar fines for illegal practises or regulatory control violations have been issued in the EU. Misconceptions and a lack of clear guidelines for the use of deferasirox in comparison to deferiprone and deferoxamine appear to reduce the effective treatment prospects and to increase the toxicity risks for thalassaemia and other iron loaded patients. Similar issues have been raised for the activities of other pharmaceutical companies promoting the use of new patented versus generic drugs. Treatments for different categories of patients using new patented drugs are mostly market driven with no clear safeguards or guidelines for risk/benefit assessment indications or for individualised effective and safe optimum therapies. There is a need for the establishment of an international organisation, which can monitor and assess the risk/benefit assessment and marketing of drugs in the EU and globally for the benefit of patients. The pivotal role of the regulatory drug authorities and the prescribing physicians for identifying individualised optimum therapies is essential for improving the survival and safety of millions of patients worldwide.
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Affiliation(s)
- George J Kontoghiorghes
- Postgraduate Research Institute of Science, Technology, Environment and Medicine, Limassol 3021, Cyprus
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14
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Jobanputra M, Paramore C, Laird SG, McGahan M, Telfer P. Co-morbidities and mortality associated with transfusion-dependent beta-thalassaemia in patients in England: a 10-year retrospective cohort analysis. Br J Haematol 2020; 191:897-905. [PMID: 33094842 DOI: 10.1111/bjh.17091] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 07/30/2020] [Indexed: 12/28/2022]
Abstract
A retrospective cohort analysis to explore 10-year mortality and prevalence of transfusion-dependent β-thalassaemia (TDT)-associated co-morbidities in patients with TDT was undertaken using Hospital Episode Statistics (HES) data from the National Health Service (NHS) in England. A 10-year forward-looking cohort analysis for the period 2009-2018 was completed using HES admitted patient care (APC), outpatient data, and linked HES/Office of National Statistics mortality data for patients with β-thalassaemia (ICD-10 diagnosis code D56.1). TDT-associated co-morbidity rates were high in the 612 patients with TDT, with 76% having at least one co-morbidity, 54% suffering from two of more, and 37% three or more. The three most common TDT-associated co-morbidities, occurring in more than one third of patients were: endocrine disorders (excluding diabetes) 40%, osteoporosis 40%, and diabetes 34%. Cardiac disease was observed in 18% of patients overall, with atrial fibrillation and heart failure being the most common with a prevalence of 11% and 9%, respectively. The crude 10-year mortality rate in the TDT cohort was 6·2% (38/612), significantly greater than the 1·2% age/sex-adjusted mortality rate of the general population (P < 0·001). These data support the notion that the unmet need in TDT remains significant, with high rates of co-morbidity and mortality.
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Affiliation(s)
| | | | | | | | - Paul Telfer
- Centre for Genomics and Child Health, Blizard Institute, Queen Mary University of London, London, UK
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15
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Bilgin BK, Yozgat AK, Isik P, Çulha V, Kacar D, Kara A, Ozbek NY, Yarali N. The effect of deferasirox on endocrine complications in children with thalassemia. Pediatr Hematol Oncol 2020; 37:455-464. [PMID: 32131650 DOI: 10.1080/08880018.2020.1734124] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Endocrine system dysfunctions are the significant complications of excessive iron overload in beta thalassemia patients. The aim of this study was to evaluate the long-term effect of chelation with deferasirox on endocrine complications. The study group consisted of children with beta thalassemia who had been evaluated for the growth and pubertal development, bone metabolism, thyroid/parathyroid functions, glucose metabolism dysfunctions in the department of pediatric hematology of Ankara Dışkapı Child Health and Diseases Hematology Oncology Training And Research Hospital between 2009-2011 and reevaluated after deferasirox chelation therapy in 2018. Thirty-one transfusion dependent beta-thalassemia patients were enrolled for the study. Seventeen (54.8%) patients were male and the mean age was 16.9 ± 3.8 (9-23) years. Splenectomy was performed in 11 patients (35.5%). In the initial evaluation, 26 patients (84%) received deferoxamine and/or deferiprone and five (17%) patients received deferasirox as a chelator; in the final evaluation all patients were receiving deferasirox. The mean duration of deferasirox treatment was 5.9 ± 2.02 years (1-10 years). Of the 26 patients who had endocrine complications between 2009-2011, 18 were recovered. In the final evaluation, eight patients (25%) developed new endocrinopathies. The frequency of endocrine complications seen before the deferasirox treatment (83%) was higher than the frequency of complications while receiving deferasirox treatment (25.8%) (p < 0,05). In this study, it was determined that both existing endocrine abnormalities were reduced and recent developed problems were less likely with long-term deferasirox treatment in thalassemia patients.
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Affiliation(s)
- Burçak Kurucu Bilgin
- Department of Pediatric Hematology, Ankara Dışkapı Child Health and Diseases Hematology Oncology Training and Research Hospital, Ankara, Turkey
| | - Ayça Koca Yozgat
- Department of Pediatric Hematology, Ankara Dışkapı Child Health and Diseases Hematology Oncology Training and Research Hospital, Ankara, Turkey
| | - Pamir Isik
- Department of Pediatric Hematology, Ankara Dışkapı Child Health and Diseases Hematology Oncology Training and Research Hospital, Ankara, Turkey
| | - Vildan Çulha
- Department of Pediatric Hematology, Ankara Dışkapı Child Health and Diseases Hematology Oncology Training and Research Hospital, Ankara, Turkey
| | - Dilek Kacar
- Department of Pediatric Hematology, Ankara Dışkapı Child Health and Diseases Hematology Oncology Training and Research Hospital, Ankara, Turkey
| | - Abdurrahman Kara
- Department of Pediatric Hematology, Ankara Dışkapı Child Health and Diseases Hematology Oncology Training and Research Hospital, Ankara, Turkey
| | - Namık Yasar Ozbek
- Department of Pediatric Hematology, Ankara Dışkapı Child Health and Diseases Hematology Oncology Training and Research Hospital, Ankara, Turkey
| | - Nese Yarali
- Department of Pediatric Hematology, Ankara Dışkapı Child Health and Diseases Hematology Oncology Training and Research Hospital, Ankara, Turkey
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Hepatocellular carcinoma in adult thalassemia patients: an expert opinion based on current evidence. BMC Gastroenterol 2020; 20:251. [PMID: 32746786 PMCID: PMC7398335 DOI: 10.1186/s12876-020-01391-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 07/21/2020] [Indexed: 02/07/2023] Open
Abstract
Beta-thalassemia represents a heterogeneous group of haemoglobin inherited disorders, among the most common genetic diseases in the world, frequent in the Mediterranean basin. As beta-thalassemia patients' survival has increased over time, previously unknown complications are observed with increasing frequency. Among them, an increased risk of hepatocellular carcinoma (HCC) has been registered. Our aim is to reduce inequalities in diagnosis and treatment and to offer patients univocal recommendations in any institution.The members of the panel - gastroenterologists, radiologists, surgeons and oncologists -were selected on the basis of their publication records and expertise. Thirteen clinical questions, derived from clinical needs, and an integration of all the committee members' suggestions, were formulated. Modified Delphi approach involving a detailed literature review and the collective judgement of experts, was applied to this work.Thirteen statements were derived from expert opinions' based on the current literature, on recently developed reviews and on technological advancements. Each statement is discussed in a short paragraph reporting the current key evidence. As this is an emerging issue, the number of papers on HCC in beta-thalassemia patients is limited and based on anecdotal cases rather than on randomized controlled studies. Therefore, the panel has discussed, step by step, the possible differences between beta-thalassemia and non beta-thalassemia patients. Despite the paucity of the literature, practical and concise statements were generated.This paper offers a practical guide organized by statements describing how to manage HCC in patients with beta-thalassemia.
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17
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The History of Deferiprone (L1) and the Paradigm of the Complete Treatment of Iron Overload in Thalassaemia. Mediterr J Hematol Infect Dis 2020; 12:e2020011. [PMID: 31934321 PMCID: PMC6951358 DOI: 10.4084/mjhid.2020.011] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Accepted: 12/18/2019] [Indexed: 01/19/2023] Open
Abstract
Deferiprone (L1) was originally designed, synthesised and screened in vitro and in vivo in 1981 by Kontoghiorghes G. J. following his discovery of the novel alpha-ketohydroxypyridine class of iron chelators (1978–1981), which were intended for clinical use. The journey through the years for the treatment of thalassaemia with L1 has been a very difficult one with an intriguing turn of events, which continue until today. Despite many complications, such as the extensive use of L1 suboptimal dose protocols, the aim of chelation therapy-namely, the complete removal of excess iron in thalassaemia major patients, has been achieved in most cases following the introduction of specific L1 and L1/deferoxamine combinations. Many such patients continue to maintain normal iron stores. Thalassemia has changed from a fatal to chronic disease; also thanks to L1 therapy and thalassaemia patients are active professional members in all sectors of society, have their own families with children and grandchildren and their lifespan is approaching that of normal individuals. No changes in the low toxicity profile of L1 have been observed in more than 30 years of clinical use and prophylaxis against the low incidence of agranulocytosis is maintained using mandatory monitoring of weekly white blood cells’ count. Thousands of thalassaemia patients are still denied the cardioprotective and other beneficial effects of L1 therapy. The safety of L1 in thalassaemia and other non-iron loaded diseases resulted in its selection as one of the leading therapeutics for the treatment of Friedreich’s ataxia, pantothenate kinase-associated neurodegeneration and other similar cases. There are also increasing prospects for the application of L1 as a main, alternative or adjuvant therapy in many pathological conditions including cancer, infectious diseases and as a general antioxidant for diseases related to free radical pathology.
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18
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Abstract
BACKGROUND Thalassaemia is a genetic disorder of the haemoglobin protein in red blood cells. It has been historically classified into thalassaemia minor, intermedia and major, depending on the genetic defect and severity of the disease. The clinical presentation of β-thalassaemia varies widely from a mild asymptomatic form in thalassaemia minor, to a severe disease in thalassaemia major where individuals are dependant on life-long blood transfusions. The hallmark of thalassaemia syndromes is the production of defective red blood cells that are removed by the spleen resulting in an enlarged hyperfunctioning spleen (splenomegaly). Removal of the spleen may thus prolong red blood cell survival by reducing the amount of red blood cells removed from circulation and may ultimately result in the reduced need for blood transfusions. OBJECTIVES To assess the efficacy and safety of splenectomy in people with β-thalassaemia major or intermedia. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Review Group's Haemoglobinopathies Trials Register, compiled from searches of electronic databases and the handsearching of journals and conference abstract books. We also searched online trial registries and the reference lists of relevant articles and reviews (27 July 2018).Date of the most recent search of the Group's trials register: 02 August 2019. SELECTION CRITERIA We included randomised controlled and quasi-randomised controlled studies of people of any age with thalassaemia major or intermedia, evaluating splenectomy in comparison to conservative treatment (transfusion therapy and iron chelation) or other forms of splenectomy compared to each other (laparoscopic, open, radio-frequency). DATA COLLECTION AND ANALYSIS Two authors independently selected and extracted data from the single included study using a customised data extraction form and assessed the risk of bias. The quality of the evidence was assessed using GRADE. MAIN RESULTS One study, including 28 participants was included in the review; the results were described, primarily, in a narrative manner. This study assessed the feasibility of splenectomy using a laparoscopic approach versus open surgery. Given the lack of detail regarding the study methods beyond randomisation, the overall risk of bias for this study was unclear. The study was carried out over a period of 3.5 years, with each participant followed up only until discharge (less than one week after the intervention); it did not assess the majority of the outcomes outlined in this review (including two of the three primary outcomes, frequency of transfusion and quality of life). A total of three serious post-operative adverse events (the review's third primary outcome) were reported in the laparoscopic splenectomy group (one case of atelectasis and two cases of bleeding), compared to two events of atelectasis in the open surgery group; however, there were no significant differences between the groups for either atelectasis, risk ratio (RR) 0.50 (95% confidence interval (CI) 0.05 to 4.90) or for bleeding, RR 5.00 (95% CI 0.26 to 95.61) (very low-quality evidence). In addition, the study also reported three serious cases of intra-operative bleeding in the laparoscopic group which mandated conversion to open surgery, although the difference between groups was not statistically significant, RR 7.00 (95% CI 0.39 to 124.14) (very low-quality evidence). These effect estimates are based on very small numbers and hence are unreliable and imprecise. From this small study, there appeared to be an advantage for the laparoscopic approach, in terms of post-operative hospital stay, although the group difference was not large (median difference of 1.5 days, P = 0.03). AUTHORS' CONCLUSIONS The review was unable to find good quality evidence, in the form of randomised controlled studies, regarding the efficacy of splenectomy for treating thalassaemia major or intermedia. The single included study provided little information about the efficacy of splenectomy, and compared open surgery and laparoscopic methods. Further studies need to evaluate the long-term effectiveness of splenectomy and the comparative advantages of surgical methods. Due to a lack of high quality evidence from randomised controlled studies, well-conducted observational studies may be used to answer this question.
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Affiliation(s)
- Akshay Sharma
- St Jude Children's Research Hospital262 Danny Thomas PlaceMS 260MemphisTennesseeUSA38105
| | - Manu Easow Mathew
- Christian Medical CollegeSouth Asian Cochrane Network & Center, Prof. BV Moses Center for Evidence‐Informed Health Care and Health PolicyCarman Block II FloorCMC Campus, BagayamVelloreTamil NaduIndia632002
| | - Latika Puri
- St. Jude Children's Research Hospital262 Danny Thomas PlaceMemphisTennessee 38105USAMS 260
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Hodroj MH, Bou-Fakhredin R, Nour-Eldine W, Noureldine HA, Noureldine MHA, Taher AT. Thalassemia and malignancy: An emerging concern? Blood Rev 2019; 37:100585. [DOI: 10.1016/j.blre.2019.06.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 05/05/2019] [Accepted: 06/20/2019] [Indexed: 01/29/2023]
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Ngim CF, Lee MY, Othman N, Lim SM, Ng CS, Ramadas A. Prevalence and Risk Factors for Cardiac and Liver Iron Overload in Adults with Thalassemia in Malaysia. Hemoglobin 2019; 43:95-100. [PMID: 31179787 DOI: 10.1080/03630269.2019.1599906] [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] [Indexed: 12/22/2022]
Abstract
We explored the severity and risk factors for cardiac and liver iron overload (IOL) in 69 thalassemia patients who underwent T2* magnetic resonance imaging (T2* MRI) in a Malaysian tertiary hospital from 2011 to 2015. Fifty-three patients (76.8%) had transfusion-dependent thalassemia (TDT) and 16 (23.2%) had non transfusion-dependent thalassemia (NTDT). Median serum ferritin prior to T2* MRI was 3848.0 μg/L (TDT) and 3971.0 μg/L (NTDT). Cardiac IOL was present in 16 (30.2%) TDT patients and two (12.5%) NTDT patients, in whom severe cardiac IOL defined as T2* <10 ms affected six (11.3%) TDT patients. Liver IOL was present in 51 (96.2%) TDT and 16 (100%) NTDT patients, 37 (69.8%) TDT and 13 (81.3%) NTDT patients were in the most severe category (>15 mgFe/gm dry weight). Serum ferritin showed a significantly strong negative correlation with liver T2* in both TDT (rs = -0.507, p = 0.001) and NTDT (r = -0.762, p = 0.002) but no correlation to cardiac T2* in TDT (r = -0.252, p = 0.099) as well as NTDT (r = -0.457, p = 0.100). For the TDT group, regression analysis showed that cardiac IOL was more severe in males (p = 0.022) and liver IOL was more severe in the Malay ethnic group (p = 0.028) and those with higher serum ferritin levels (p = 0.030). The high prevalence of IOL in our study and the poor correlation between serum ferritin and cardiac T2* underline the need to routinely screen thalassemia patients using T2* MRI to enable the early detection of cardiac IOL.
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Affiliation(s)
- Chin F Ngim
- a Jeffrey Cheah School of Medicine and Health Sciences , Monash University Malaysia , Johor Bahru , Malaysia
| | - Mei Y Lee
- a Jeffrey Cheah School of Medicine and Health Sciences , Monash University Malaysia , Johor Bahru , Malaysia
| | - Norliza Othman
- b Department of Radiology , Hospital Sultanah Aminah Johor Bahru , Johor Bahru , Malaysia
| | - Soo M Lim
- c Haematology Unit, Department of Medicine , Hospital Sultanah Aminah Johor Bahru , Johor Bahru , Malaysia
| | - Chen S Ng
- d Department of Nuclear Medicine , Hospital Sultanah Aminah Johor Bahru , Johor Bahru , Malaysia
| | - Amutha Ramadas
- a Jeffrey Cheah School of Medicine and Health Sciences , Monash University Malaysia , Johor Bahru , Malaysia
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21
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Thyroid Function in Chronically Transfused Children with Beta Thalassemia Major: A Cross-Sectional Hospital Based Study. Int J Pediatr 2018; 2018:9071213. [PMID: 30305822 PMCID: PMC6165584 DOI: 10.1155/2018/9071213] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 06/22/2018] [Accepted: 08/30/2018] [Indexed: 12/04/2022] Open
Abstract
Background Thalassemia is the most common genetic disorder worldwide. Use of iron chelators has improved survival but endocrine complications have become more frequent. The frequency of hypothyroidism in Beta Thalassemia Major (BTM) children ranges from 6 to 30 %. Thyroid dysfunction mainly occurs by gland infiltration, chronic tissue hypoxia, free radical injury, and organ siderosis. Objectives (a) To evaluate the thyroid function status in chronically transfused children with BTM, in the first and second decade of life and (b) to study the influence of factors like duration and amount of blood transfusions, serum ferritin level, and iron chelation therapy on thyroid function. Methodology BTM children, 3 years old and above, on regular blood transfusions with serum ferritin > 1500 mcg/l were included in the study. Thyroid function and ferritin assessment was done using ELISA kits. Autoimmune thyroiditis was ruled out by antithyroid peroxidase and antithyroglobulin antibody testing. Results A study population of 83 children consisted of 49 boys (59%) and 34 girls (41%). 4.8% of the children had evidence of subclinical hypothyroidism. Among them two belonged to the first decade and the other two to the second decade of life. Mean TSH, FT4, and ferritin values among children with thyroid dysfunction were 6.38 ± 0.83 mIU/ml, 1.08 ± 0.45 ng/dl, and 3983.0±1698.30 ng/ml, respectively. The severity of thyroid dysfunction was statistically significantly associated with higher serum TSH values in children in the second decade of life with a p value = 0.001. No other significant correlation was found between oral chelation, amount and duration of blood transfusion, or serum ferritin levels. Conclusion Subclinical hypothyroidism was the thyroid dysfunction observed in our study. Regular blood transfusions with adequate chelation may decrease incidence of thyroid dysfunction.
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Ballas SK, Zeidan AM, Duong VH, DeVeaux M, Heeney MM. The effect of iron chelation therapy on overall survival in sickle cell disease and β-thalassemia: A systematic review. Am J Hematol 2018; 93:943-952. [PMID: 29635754 DOI: 10.1002/ajh.25103] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 03/26/2018] [Accepted: 03/29/2018] [Indexed: 12/31/2022]
Abstract
Red blood cell transfusions have become standard of care for the prevention of life-threatening anemia in patients with β-thalassemia and sickle cell disease (SCD). However, frequent transfusions can lead to accumulation of iron that can result in liver cirrhosis, diabetes mellitus, arthritis, arrhythmias, cardiomyopathy, heart failure, and hypogonadotropic hypogonadism. Iron chelation therapy has been shown to reduce serum ferritin levels and liver iron content, but limitations of trial design have prevented any demonstration of improved survival. The objective of this systematic review was to investigate the impact of iron chelation therapy on overall and event-free survival in patients with β-thalassemia and SCD. Eighteen articles discussing survival in β-thalassemia and 3 in SCD were identified. Overall iron chelation therapy resulted in better overall survival, especially if it is instituted early and compliance is maintained. Comparative studies did not show any significant differences between available iron chelation agents, although there is evidence that deferiprone is better tolerated than deferoxamine and that compliance is more readily maintained with the newer oral drugs, deferiprone and deferasirox. Iron chelation therapy, particularly the second-generation oral agents, appears to be associated with improved overall and event-free survival in transfusion-dependent patients with β-thalassemia and patients with SCD.
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Affiliation(s)
| | | | - Vu H. Duong
- University of Maryland School of Medicine; Baltimore Maryland
| | | | - Matthew M. Heeney
- Harvard Medical School, Dana-Farber/Boston Children's Cancer and Blood Disorders Center; Boston Massachusetts
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Growth and Endocrine Function in Tunisian Thalassemia Major Patients. Mediterr J Hematol Infect Dis 2018; 10:e2018031. [PMID: 29755708 PMCID: PMC5937976 DOI: 10.4084/mjhid.2018.031] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 04/16/2018] [Indexed: 12/04/2022] Open
Abstract
β-thalassemia major (β–TM) is among the most common hereditary disorders imposing high expenses on health-care system worldwide. The patient’s survival is dependent on lifetime blood transfusion which leads to iron overload and its toxicity in various organs including endocrine glands. This article provides an overview of endocrine disorders in beta-TM patients. This single center investigation enrolled 28 β-TM patients (16 males, 12 females) regularly transfused with packed red cell since early years of life. For each patient were determined: age, sex, number of transfusions received, history of splenectomy and anthropometric parameters. All patients underwent an evaluation of hormonal status including growth, gonadal, thyroid, adrenal cortex, and parathyroid glands. Dual-energy X-ray absorptiometry was used to diagnose low bone mass. Assessment of iron overload status was performed by measuring the serum ferritin concentration and the results of magnetic resonance imaging T2*. Growth retardation was found in 16 of the 28 studied patients (57 %). Thirteen among them had delayed puberty. Spontaneous puberty was achieved in 16 cases. Growth hormone (GH) deficiency was found in 10 cases (35 %). Seventeen among the studied patients (60 %) developed disorders of glucose homeostasis. Subclinical hypothyroidism was found in six patients (21 %). Intensive chelation therapy had allowed the reversibility of this complication in five cases. Adrenal Insufficiency was observed in 9 cases (32%). Hypoparathyroidism has occurred in one case. Ten of the 28 studied patients had low bone mass (35%). Twenty-three of the 28 studied patients (82%) had at least one endocrine complication.
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Abstract
PURPOSE OF REVIEW Thalassemia is the most common form of inherited anemia, characterized by variable clinical phenotypes. The purpose of this review is to summarize the transfusion support in thalassemia patients and the management of transfusion-related iron overload. RECENT FINDINGS The most recent evidence on transfusion strategy and iron chelation therapy in thalassemia arising from clinical trials as well as from recommendation guidelines are critically discussed. SUMMARY Enhancements in the global care of thalassemia, resulting from the combination of an appropriate transfusion approach and iron chelation therapy, have produced a significant improvement in the quality of life and, finally, in the prognosis of patients affected by this inherited hematologic disorder.
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Pepe A, Gamberini MR, Missere M, Pistoia L, Mangione M, Cuccia L, Spasiano A, Maffei S, Cadeddu C, Midiri M, Borgna C, Meloni A. Gender differences in the development of cardiac complications: a multicentre study in a large cohort of thalassaemia major patients to optimize the timing of cardiac follow-up. Br J Haematol 2018; 180:879-888. [DOI: 10.1111/bjh.15125] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Accepted: 11/24/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Alessia Pepe
- Magnetic Resonance Imaging Unit; Fondazione G. Monasterio CNR-Regione Toscana; Pisa Italy
| | - Maria R. Gamberini
- Unità Operativa di Day Hospital della Talassemia e delle Emoglobinopatie; Azienda Ospedaliero-Universitaria “S. Anna”; Cona (FE) Italy
| | - Massimiliano Missere
- Dipartimento di Immagini; Fondazione di Ricerca e Cura “Giovanni Paolo II”; Campobasso Italy
| | - Laura Pistoia
- Magnetic Resonance Imaging Unit; Fondazione G. Monasterio CNR-Regione Toscana; Pisa Italy
| | - Maurizio Mangione
- U.O.S. Sistemi informativi (UOSI); Fondazione G. Monasterio CNR-Regione Toscana; Pisa Italy
| | - Liana Cuccia
- Unità Operativa Complessa Ematologia con Talassemia; ARNAS Civico “Benfratelli-Di Cristina”; Palermo Italy
| | - Anna Spasiano
- Unità Operativa Semplice Dipartimentale Malattie Rare del Globulo Rosso; Azienda Ospedaliera di Rilievo Nazionale “A. Cardarelli”; Napoli Italy
| | - Silvia Maffei
- UOC Endocrinologia Vascolare e Metabolismo; Fondazione G. Monasterio CNR-Regione Toscana; Pisa Italy
| | - Christian Cadeddu
- Dipartimento di Scienze Mediche ‘Mario Aresu’; Università di Cagliari; Cagliari Italy
| | - Massimo Midiri
- Sezione di Scienze Radiologiche - Dipartimento di Biopatologia e Biotecnologie Mediche; Policlinico “Paolo Giaccone”; Palermo Italy
| | - Caterina Borgna
- Clinica Pediatrica; Università di Ferrara - Arcispedale “S. Anna”; Cona (FE) Italy
| | - Antonella Meloni
- Magnetic Resonance Imaging Unit; Fondazione G. Monasterio CNR-Regione Toscana; Pisa Italy
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Mavrogeni S, Kolovou G, Bigalke B, Rigopoulos A, Noutsias M, Adamopoulos S. Transplantation in patients with iron overload: is there a place for magnetic resonance imaging? : Transplantation in iron overload. Heart Fail Rev 2018; 23:173-180. [PMID: 29359261 DOI: 10.1007/s10741-018-9670-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
In iron overload diseases (thalassemia, sickle cell, and myelodysplastic syndrome), iron is deposited in all internal organs, leading to functional abnormalities. Hematopoietic stem cell transplantation (HSCT) is the only treatment offering a potential cure in these diseases. Our aim was to describe the experience in the field and the role of magnetic resonance imaging in the evaluation of iron overload before and after HSCT. Magnetic resonance imaging (MRI), using T2*, is the most commonly used tool to diagnose myocardial-liver iron overload and guide tailored treatment. Currently, HSCT offers complete cure in thalassemia major, after overcoming the immunologic barrier, and should be considered for all patients who have a suitable donor. The overall thalassemia-free survival of low-risk, HLA-matched sibling stem cell transplantation patients is 85-90%, with a 95% overall survival. The problems of rejection and engraftment are improving with the use of adequate immunosuppression. However, a detailed iron assessment of both heart and liver is necessary for pre- and post-transplant evaluation. In iron overload diseases, heart and liver iron evaluation is indispensable not only for the patients' survival, but also for evaluation before and after HSCT.
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Affiliation(s)
- Sophie Mavrogeni
- Onassis Cardiac Surgery Center, 50 Esperou Street, 175-61, Palaeo Faliro, Athens, Greece. .,, Athens, Greece.
| | - Genovefa Kolovou
- Onassis Cardiac Surgery Center, 50 Esperou Street, 175-61, Palaeo Faliro, Athens, Greece
| | - Boris Bigalke
- Department of Cardiology, Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin (CBF), Hindenburgdamm 30, 12200, Berlin, Germany
| | - Angelos Rigopoulos
- Department of Cardiology, Leopoldina Hospital, 97422, Schweinfurt, Germany
| | - Michel Noutsias
- Department of Internal Medicine I, Division of Cardiology, Pneumology, Angiology and Intensive Medical Care, University Hospital Jena, Friedrich-Schiller-University Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Stamatis Adamopoulos
- Onassis Cardiac Surgery Center, 50 Esperou Street, 175-61, Palaeo Faliro, Athens, Greece
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Boulad F, Mansilla-Soto J, Cabriolu A, Rivière I, Sadelain M. Gene Therapy and Genome Editing. Hematol Oncol Clin North Am 2018; 32:329-342. [PMID: 29458735 DOI: 10.1016/j.hoc.2017.11.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
The β-thalassemias are inherited blood disorders that result from insufficient production of the β-chain of hemoglobin. More than 200 different mutations have been identified. β-Thalassemia major requires life-long transfusions. The only cure for severe β-thalassemia is to provide patients with hematopoietic stem cells. Globin gene therapy promises a curative autologous stem cell transplantation without the immunologic complications of allogeneic transplantation. The future directions of gene therapy include enhancement of lentiviral vector-based approaches, fine tuning of the conditioning regimen, and the design of safer vectors. Progress in genetic engineering bodes well for finding a cure for severe globin disorders.
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Affiliation(s)
- Farid Boulad
- Center for Cell Engineering, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA; Department of Pediatrics, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA.
| | - Jorge Mansilla-Soto
- Center for Cell Engineering, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Annalisa Cabriolu
- Center for Cell Engineering, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Isabelle Rivière
- Center for Cell Engineering, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Michel Sadelain
- Center for Cell Engineering, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
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Marsella M, Ammirabile M, Di Matola T, Pepe A, Costantini S, Filosa A, Ricchi P. Is there a difference in phenotype between males and females with non-transfusion-dependent thalassemia? A cross-sectional evaluation. Hematology 2018; 23:522-525. [DOI: 10.1080/10245332.2017.1413789] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Affiliation(s)
| | - Massimiliano Ammirabile
- Laboratory of Clinical Chemistry and Microbiology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- UOSD Malattie Rare del Globulo Rosso, AORN A. Cardarelli, Naples, Italy
| | - Tiziana Di Matola
- UOC Biochimica Clinica, AORN Ospedale dei Colli, P.O. Monaldi, Naples, Italy
| | - Alessia Pepe
- Magnetic Resonance Imaging Unit, Fondazione G. Monasterio, CNR-Regione Toscana, Pisa, Italy
| | - Silvia Costantini
- UOSD Malattie Rare del Globulo Rosso, AORN A. Cardarelli, Naples, Italy
| | - Aldo Filosa
- UOSD Malattie Rare del Globulo Rosso, AORN A. Cardarelli, Naples, Italy
| | - Paolo Ricchi
- UOSD Malattie Rare del Globulo Rosso, AORN A. Cardarelli, Naples, Italy
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29
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Secondary solid cancer following hematopoietic cell transplantation in patients with thalassemia major. Bone Marrow Transplant 2017; 53:39-43. [PMID: 28991245 DOI: 10.1038/bmt.2017.214] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Revised: 08/22/2017] [Accepted: 08/27/2017] [Indexed: 01/20/2023]
Abstract
Hematopoietic cell transplant (HCT) recipients have a substantial risk of developing secondary solid cancers (SSCs). The aim of this retrospective study was to compare the incidence of SSC in a monocentric cohort of thalassemia major (TM) patients (n=122) who received HCT versus an hematopoietic cell donor monocentric cohort (n=122) and versus a large multicenter cohort of age- and sex-matched TM patients (n=244) who received conventional therapy. With a median follow-up of 24 years, 8 transplanted patients were diagnosed with SSC at a median of 18 years after HCT and at a median age of 33 years. Three patients died of cancer progression and 5 are living after a follow-up ranging from 10 months to 16 years after SSC diagnosis. The 30-year cumulative incidence of developing SSC was 13.24%. The occurrence of solid cancers in the hematopoietic cell donor cohort was limited to only one case for a significantly lower cumulative incidence (3.23%, P=0.02) and to 3 cases in the cohort of nontransplant patients for a significantly lower cumulative incidence (1.32%, P=0.005). This study shows that the magnitude of increased risk of SST is fourfold to sixfold for patients treated with HCT as compared with hematopoietic cell donors and nontransplant patients.
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Di Maggio R, Maggio A. The new era of chelation treatments: effectiveness and safety of 10 different regimens for controlling iron overloading in thalassaemia major. Br J Haematol 2017; 178:676-688. [DOI: 10.1111/bjh.14712] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Rosario Di Maggio
- Campus of Haematology Franco and Piera Cutino; AOR Villa Sofia-V. Cervello; Palermo Italy
| | - Aurelio Maggio
- Campus of Haematology Franco and Piera Cutino; AOR Villa Sofia-V. Cervello; Palermo Italy
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Efficacy and Safety of Combined Oral Chelation With Deferiprone and Deferasirox in Children With β-Thalassemia Major: An Experience From North India. J Pediatr Hematol Oncol 2017; 39:209-213. [PMID: 28221264 DOI: 10.1097/mph.0000000000000780] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVE A combination of desferrioxamine with either deferiprone (DFP) or deferasirox (DFX) for patients with β-thalassemia major who do not achieve negative iron balance with monotherapy has been studied widely. However, poor compliance resulting from the need for parentral administration of desferrioxamine and its cost necessicitates combining 2 oral chelators. METHODS A prospective study was conducted in patients with transfusion-dependent β-thalassemia major in a tertiary care center over 2 years. Patients on either DFP or DFX who were not improving on monotherapy over a long period and persistently maintaining serum ferritin >2500 µg/L were enrolled. Efficacy was assessed by serum ferritin levels assessed at 12 months and 2 years. Complete blood counts and liver and kidney function tests were monitored to assess the safety of the combination of drugs. RESULTS In total, 33 patients with a mean age of 12.67 years (7.5 to 17.5 y) and a mean ferritin of 4835.2394±1443.85 µg/L formed the study cohort.In total, 28 patients completed the 1-year study period; and 12 patients completed 2 years. Mean serum ferritin reduction at 1 and 2 years was 34.99%±18.13% (range, -34.36% to 56.17%) and 44.67%±13.78% (range, 22.17% to 62.74%), respectively. The combination therapy was well tolerated. CONCLUSIONS Combined oral chelation with DFP and DFX has better efficacy than either drug used alone. The combination of drugs was well tolerated and no new adverse effects were observed.
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Mansilla-Soto J, Riviere I, Boulad F, Sadelain M. Cell and Gene Therapy for the Beta-Thalassemias: Advances and Prospects. Hum Gene Ther 2016; 27:295-304. [PMID: 27021486 DOI: 10.1089/hum.2016.037] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
The beta-thalassemias are inherited anemias caused by mutations that severely reduce or abolish expression of the beta-globin gene. Like sickle cell disease, a related beta-globin gene disorder, they are ideal candidates for performing a genetic correction in patient hematopoietic stem cells (HSCs). The most advanced approach utilizes complex lentiviral vectors encoding the human β-globin gene, as first reported by May et al. in 2000. Considerable progress toward the clinical implementation of this approach has been made in the past five years, based on effective CD34+ cell mobilization and improved lentiviral vector manufacturing. Four trials have been initiated in the United States and Europe. Of 16 evaluable subjects, 6 have achieved transfusion independence. One of them developed a durable clonal expansion, which regressed after several years without transformation. Although globin lentiviral vectors have so far proven to be safe, this occurrence suggests that powerful insulators with robust enhancer-blocking activity will further enhance this approach. The combined discovery of Bcl11a-mediated γ-globin gene silencing and advances in gene editing are the foundations for another gene therapy approach, which aims to reactivate fetal hemoglobin (HbF) production. Its clinical translation will hinge on the safety and efficiency of gene targeting in true HSCs and the induction of sufficient levels of HbF to achieve transfusion independence. Altogether, the progress achieved over the past 15 years bodes well for finding a genetic cure for severe globin disorders in the next decade.
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Affiliation(s)
- Jorge Mansilla-Soto
- 1 Center for Cell Engineering, Memorial Sloan Kettering Cancer Center , New York, New York
| | - Isabelle Riviere
- 1 Center for Cell Engineering, Memorial Sloan Kettering Cancer Center , New York, New York
| | - Farid Boulad
- 1 Center for Cell Engineering, Memorial Sloan Kettering Cancer Center , New York, New York.,2 Department of Pediatrics, Memorial Sloan Kettering Cancer Center , New York, New York
| | - Michel Sadelain
- 1 Center for Cell Engineering, Memorial Sloan Kettering Cancer Center , New York, New York
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Taher AT, Porter JB, Kattamis A, Viprakasit V, Cappellini MD. Efficacy and safety of iron-chelation therapy with deferoxamine, deferiprone, and deferasirox for the treatment of iron-loaded patients with nontransfusion-dependent thalassemia syndromes. DRUG DESIGN DEVELOPMENT AND THERAPY 2016; 10:4073-4078. [PMID: 28008230 PMCID: PMC5170616 DOI: 10.2147/dddt.s117080] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- Ali T Taher
- Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
| | - John B Porter
- Department of Haematology, University College London, London, UK
| | - Antonis Kattamis
- First Department of Pediatrics, University of Athens, Athens, Greece
| | - Vip Viprakasit
- Department of Pediatrics and Thalassemia Center, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - M Domenica Cappellini
- Department of Internal Medicine, Università di Milano, Ca Granda Foundation IRCCS, Milan, Italy
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Negre O, Eggimann AV, Beuzard Y, Ribeil JA, Bourget P, Borwornpinyo S, Hongeng S, Hacein-Bey S, Cavazzana M, Leboulch P, Payen E. Gene Therapy of the β-Hemoglobinopathies by Lentiviral Transfer of the β(A(T87Q))-Globin Gene. Hum Gene Ther 2016; 27:148-65. [PMID: 26886832 PMCID: PMC4779296 DOI: 10.1089/hum.2016.007] [Citation(s) in RCA: 123] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
β-globin gene disorders are the most prevalent inherited diseases worldwide and result from abnormal β-globin synthesis or structure. Novel therapeutic approaches are being developed in an effort to move beyond palliative management. Gene therapy, by ex vivo lentiviral transfer of a therapeutic β-globin gene derivative (β(AT87Q)-globin) to hematopoietic stem cells, driven by cis-regulatory elements that confer high, erythroid-specific expression, has been evaluated in human clinical trials over the past 8 years. β(AT87Q)-globin is used both as a strong inhibitor of HbS polymerization and as a biomarker. While long-term studies are underway in multiple centers in Europe and in the United States, proof-of-principle of efficacy and safety has already been obtained in multiple patients with β-thalassemia and sickle cell disease.
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Affiliation(s)
- Olivier Negre
- 1 bluebird bio, Cambridge, Massachusetts.,2 CEA, Institute of Emerging Disease and Innovative Therapies (iMETI) , Fontenay aux Roses, France
| | | | - Yves Beuzard
- 2 CEA, Institute of Emerging Disease and Innovative Therapies (iMETI) , Fontenay aux Roses, France .,3 UMR 007, University of Paris 11 and CEA , CEA-iMETI, Fontenay aux Roses, France
| | | | - Philippe Bourget
- 4 Necker Hospital , Assistance Publique-Hôpitaux de Paris, Paris, France
| | | | | | - Salima Hacein-Bey
- 6 Immunology Laboratory, Groupe Hospitalier Universitaire Paris-Sud , Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Marina Cavazzana
- 4 Necker Hospital , Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Philippe Leboulch
- 2 CEA, Institute of Emerging Disease and Innovative Therapies (iMETI) , Fontenay aux Roses, France .,3 UMR 007, University of Paris 11 and CEA , CEA-iMETI, Fontenay aux Roses, France .,5 Mahidol University , Bangkok, Thailand .,7 Harvard Medical School and Genetics Division, Department of Medicine, Brigham & Women's Hospital , Boston, Massachusetts
| | - Emmanuel Payen
- 2 CEA, Institute of Emerging Disease and Innovative Therapies (iMETI) , Fontenay aux Roses, France .,3 UMR 007, University of Paris 11 and CEA , CEA-iMETI, Fontenay aux Roses, France .,8 INSERM , Paris, France
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Leecharoenkiat K, Lithanatudom P, Sornjai W, Smith DR. Iron dysregulation in beta-thalassemia. ASIAN PAC J TROP MED 2016; 9:1035-1043. [PMID: 27890361 DOI: 10.1016/j.apjtm.2016.07.035] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2016] [Revised: 08/01/2016] [Accepted: 10/14/2016] [Indexed: 11/24/2022] Open
Abstract
Iron deficiency anemia and iron overload conditions affect more than one billion people worldwide. Iron homeostasis involves the regulation of cells that export iron into the plasma and cells that utilize or store iron. The cellular iron balance in humans is primarily mediated by the hepcidin-ferroportin axis. Ferroportin is the sole cellular iron export protein, and its expression is regulated transcriptionally, post-transcriptionally and post-translationally. Hepcidin, a hormone produced by liver cells, post-translationally regulates ferroportin expression on iron exporting cells by binding with ferroportin and promoting its internalization by endocytosis and subsequent degradation by lysosomes. Dysregulation of iron homeostasis leading to iron deposition in vital organs is the main cause of death in beta-thalassemia patients. Beta-thalassemia patients show marked hepcidin suppression, ineffective erythropoiesis, anemia and iron overload. Beta-thalassemia is common in the Mediterranean region, Southeast Asia and the Indian subcontinent, and the focus of this review is to provide an update on the factors mediating hepcidin related iron dysregulation in beta-thalassemia disease. Understanding this process may pave the way for new treatments to ameliorate iron overloading and improve the long term prognosis of these patients.
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Affiliation(s)
- Kamonlak Leecharoenkiat
- Department of Clinical Microscopy, Faculty of Allied Health Sciences, Chulalongkorn University, 154 Rama 4 Road, Bangkok 10330, Thailand
| | - Pathrapol Lithanatudom
- Department of Biology, Faculty of Science, Chiang Mai University, 239 Huaykaew Road, Amphur Muang, Chiang Mai 50200, Thailand
| | - Wannapa Sornjai
- Molecular Pathology Laboratory, Institute of Molecular Biosciences, Mahidol University, 25/25 Phuttamonthon 4 Road, Salaya, Nakhon Pathom 73170, Thailand
| | - Duncan R Smith
- Molecular Pathology Laboratory, Institute of Molecular Biosciences, Mahidol University, 25/25 Phuttamonthon 4 Road, Salaya, Nakhon Pathom 73170, Thailand.
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Russo V, Rago A, Papa AA, Nigro G. Electrocardiographic Presentation, Cardiac Arrhythmias, and Their Management in β-Thalassemia Major Patients. Ann Noninvasive Electrocardiol 2016; 21:335-42. [PMID: 27324981 DOI: 10.1111/anec.12389] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Beta-thalassemia major (β-TM) is a genetic hemoglobin disorder characterized by an absent synthesis of globin chains that are essential for hemoglobin formation, causing chronic hemolytic anemia. Clinical management of thalassemia major consists in regular long-life red blood cell transfusions and iron chelation therapy to remove iron introduced in excess with transfusions. Iron deposition in combination with inflammatory and immunogenic factors is involved in the pathophysiology of cardiac dysfunction in these patients. Heart failure and arrhythmias, caused by myocardial siderosis, are the most important life-limiting complications of iron overload in beta-thalassemia patients. Cardiac complications are responsible for 71% of global death in the beta-thalassemia major patients. The aim of this review was to describe the most frequent electrocardiographic abnormalities and arrhythmias observed in β-TM patients, analyzing their prognostic impact and current treatment strategies.
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Affiliation(s)
- Vincenzo Russo
- Second University of Naples - Monaldi Hospital, Naples, Italy
| | - Anna Rago
- Second University of Naples - Monaldi Hospital, Naples, Italy
| | | | - Gerardo Nigro
- Second University of Naples - Monaldi Hospital, Naples, Italy
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37
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Farhangi H, Badiei Z, Moghaddam HM, Keramati MR. Assessment of Heart and Liver Iron Overload in Thalassemia Major Patients Using T2* Magnetic Resonance Imaging. Indian J Hematol Blood Transfus 2016; 33:228-234. [PMID: 28596656 DOI: 10.1007/s12288-016-0696-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Accepted: 06/07/2016] [Indexed: 01/19/2023] Open
Abstract
Accumulation of excess iron in heart can lead to cardiac dysfunction, which is the most common cause of death in thalassemia major patients. Biopsy is an invasive procedure and therefore not an ideal option to assess iron load. However, standard/usual non-invasive methods, such as ferritin measurement, have some limitations and the results show poor correlations with iron load. Magnetic Response Imaging (MRI-T2*), as a non-invasive and reliable method for iron load assessment in organs such as liver and heart, can be suggested as a favorable alternative. This cross-sectional study was implemented in Thalassemia and Hemophilia Clinic Center (Sarvar) affiliated with Mashhad University of Medical Sciences, Mashhad, Iran, from 2012 to 2013. After the approval of the research protocol by the local ethic committee, laboratory tests, including CBC and serum ferritin, were carried out, and echocardiography and heart and liver MRI-T2* were performed. All statistical analysis was done through SPSS software (version 11.5), using independent sample t test and Pearson's correlation coefficient test. A P value ≤0.05 was considered to be significant. 88 patients with the mean (±SD) age of 21.2 (±5.6) years, (range 11-37 years) were observed. Iron load was assessed using MRI-T2* with the following results: Out of 88 patients, 48.9 % had mild to severe cardiac siderosis, and 75.2 % had mild to severe liver siderosis. We demonstrated a correlation between liver MRI-T2* and serum ferritin, and heart MRI-T2* and ejection fraction. However, no correlation between liver and heart MRI-T2* was observed. Heart and liver siderosis is a common and serious problem in thalassemia major patients, and MRI-T2* as a sensitive and non-invasive technique can be used for early/timely detection of siderosis and good therapeutic monitoring in these patients.
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Affiliation(s)
- Hamid Farhangi
- Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Zahra Badiei
- Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | | | - Mohammad Reza Keramati
- Faculty of Medicine, Cancer Molecular Pathology Research Center, Emam Reza Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
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Abstract
BACKGROUND Thalassaemia is a genetic disease of the haemoglobin protein in red blood cells. It is classified into thalassaemia minor, intermedia and major, depending on the severity of the disease and the genetic defect. Thalassaemia major and intermedia require frequent blood transfusions to compensate for the lack of well-functioning red blood cells, although this need is significantly less in thalassaemia intermedia.Damaged or defective red blood cells are normally eliminated in the spleen. In people with thalassaemia there is a large quantity of defective red blood cells which results in an enlarged hyperfunctioning spleen (splenomegaly). Removal of the spleen may thus prolong red blood cell survival by reducing the amount of red blood cells removed from circulation and may ultimately result in the reduced need for blood transfusions. OBJECTIVES To assess the efficacy and safety of splenectomy in people with beta-thalassaemia major or intermedia. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Review Group's Haemoglobinopathies Trials Register, compiled from searches of electronic databases and the handsearching of journals and conference abstract books. We also searched the reference lists of relevant articles and reviews.Date of the most recent search: 25 April 2016. SELECTION CRITERIA We included randomised controlled studies and quasi-randomised controlled studies of people of any age with thalassaemia major or intermedia, evaluating splenectomy in comparison to conservative treatment (transfusion therapy and iron chelation) or other forms of splenectomy compared to each other (laparoscopic, open, radio-frequency). DATA COLLECTION AND ANALYSIS Two authors independently selected and extracted data from the single included study using a customised data extraction form and assessed the risk of bias. MAIN RESULTS One study, including 28 participants was included in the review; the results were described, primarily, in a narrative manner. The study assessed the feasibility of splenectomy using laparoscopy in comparison to open surgery. Given the lack of detail regarding the study methods beyond randomisation, the overall risk of bias for this study was unclear. The study was carried out over a period of 3.5 years, with each participant followed up only until discharge (less than one week after the intervention); it did not assess the majority of the outcomes outlined in this review (including two of the three primary outcomes, frequency of transfusion and quality of life). A total of three serious post-operative adverse events (the review's third primary outcome) were reported in the laparoscopic splenectomy group (one case of atelectasis and two cases of bleeding), compared to two events of atelectasis in the open surgery group; however, there were no significant differences between the groups for either atelectasis, risk ratio 0.50 (95% confidence interval 0.05 to 4.90) or for bleeding, risk ratio 5.00 (95% confidence interval 0.26 to 95.61). In addition, the study also reported three serious cases of intra-operative bleeding in the laparoscopic group which mandated conversion to open surgery, although the difference between groups was not statistically significant, risk ratio 7.00 (95% confidence interval 0.39 to 124.14). These effect estimates are based on very small numbers and hence are unreliable and imprecise. From this small study, there appeared to be an advantage for the laparoscopic approach, in terms of post-operative hospital stay, although the group difference was not large (median difference of 1.5 days, P = 0.03). AUTHORS' CONCLUSIONS The review was unable to find good quality evidence, in the form of randomised controlled studies, regarding the efficacy of splenectomy for treating thalassaemia major or intermedia. The single included study provided little information about the efficacy of splenectomy, and compared open surgery and laparoscopic methods. Further studies need to evaluate the long-term effectiveness of splenectomy and the comparative advantages of surgical methods. Due to a lack of high quality evidence from randomised controlled studies, well-conducted observational studies may be used to answer this question.
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Affiliation(s)
- Manu Easow Mathew
- South Asian Cochrane Network & Center, Prof. BV Moses Center for Evidence-Informed Health Care and Health Policy, Christian Medical College, Carman Block II Floor, CMC Campus, Bagayam, Vellore, Tamil Nadu, India, 632002
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Kontoghiorghe CN, Kontoghiorghes GJ. New developments and controversies in iron metabolism and iron chelation therapy. World J Methodol 2016; 6:1-19. [PMID: 27019793 PMCID: PMC4804243 DOI: 10.5662/wjm.v6.i1.1] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2015] [Revised: 11/17/2015] [Accepted: 12/17/2015] [Indexed: 02/06/2023] Open
Abstract
Iron is essential for all organisms including microbial, cancer and human cells. More than a quarter of the human population is affected by abnormalities of iron metabolism, mainly from iron deficiency and iron overload. Iron also plays an important role in free radical pathology and oxidative damage which is observed in almost all major diseases, cancer and ageing. New developments include the complete treatment of iron overload and reduction of morbidity and mortality in thalassaemia using deferiprone and selected deferiprone/deferoxamine combinations and also the use of the maltol iron complex in the treatment of iron deficiency anaemia. There is also a prospect of using deferiprone as a universal antioxidant in non iron overloaded diseases such as neurodegenerative, cardiovascular, renal, infectious diseases and cancer. New regulatory molecules of iron metabolism such as endogenous and dietary chelating molecules, hepcidin, mitochondrial ferritin and their role in health and disease is under evaluation. Similarly, new mechanisms of iron deposition, removal, distribution and toxicity have been identified using new techniques such as magnetic resonance imaging increasing our understanding of iron metabolic processes and the targeted treatment of related diseases. The uniform distribution of iron in iron overload between organs and within each organ is no longer valid. Several other controversies such as the toxicity impact of non transferrin bound iron vs injected iron, the excess levels of iron in tissues causing toxicity and the role of chelation on iron absorption need further investigation. Commercial interests of pharmaceutical companies and connections to leading journals are playing a crucial role in shaping worldwide medical opinion on drug sales and use but also patients' therapeutic outcome and safety. Major controversies include the selection criteria and risk/benefit assessment in the use of deferasirox in thalassaemia and more so in idiopathic haemochromatosis, thalassaemia intermedia and ex-thalassaemia transplanted patients who are safely treated with venesection. Iron chelating drugs can override normal regulatory pathways, correct iron imbalance and minimise iron toxicity. The use of iron chelating drugs as main, alternative or adjuvant therapy is in progress in many conditions, especially those with non established or effective therapies.
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Zanella S, Garani MC, Borgna-Pignatti C. Malignancies and thalassemia: a review of the literature. Ann N Y Acad Sci 2016; 1368:140-8. [DOI: 10.1111/nyas.13005] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Revised: 12/16/2015] [Accepted: 12/18/2015] [Indexed: 12/12/2022]
Affiliation(s)
- Sara Zanella
- Department of Medical Sciences-Pediatrics; University of Ferrara; Ferrara Italy
| | - Maria Chiara Garani
- Department of Medical Sciences-Pediatrics; University of Ferrara; Ferrara Italy
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Kontoghiorghe CN, Kontoghiorghes GJ. Efficacy and safety of iron-chelation therapy with deferoxamine, deferiprone, and deferasirox for the treatment of iron-loaded patients with non-transfusion-dependent thalassemia syndromes. DRUG DESIGN DEVELOPMENT AND THERAPY 2016; 10:465-81. [PMID: 26893541 PMCID: PMC4745840 DOI: 10.2147/dddt.s79458] [Citation(s) in RCA: 84] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The prevalence rate of thalassemia, which is endemic in Southeast Asia, the Middle East, and the Mediterranean, exceeds 100,000 live births per year. There are many genetic variants in thalassemia with different pathological severity, ranging from a mild and asymptomatic anemia to life-threatening clinical effects, requiring lifelong treatment, such as regular transfusions in thalassemia major (TM). Some of the thalassemias are non-transfusion-dependent, including many thalassemia intermedia (TI) variants, where iron overload is caused by chronic increase in iron absorption due to ineffective erythropoiesis. Many TI patients receive occasional transfusions. The rate of iron overloading in TI is much slower in comparison to TM patients. Iron toxicity in TI is usually manifested by the age of 30-40 years, and in TM by the age of 10 years. Subcutaneous deferoxamine (DFO), oral deferiprone (L1), and DFO-L1 combinations have been effectively used for more than 20 years for the treatment of iron overload in TM and TI patients, causing a significant reduction in morbidity and mortality. Selected protocols using DFO, L1, and their combination can be designed for personalized chelation therapy in TI, which can effectively and safely remove all the excess toxic iron and prevent cardiac, liver, and other organ damage. Both L1 and DF could also prevent iron absorption. The new oral chelator deferasirox (DFX) increases iron excretion and decreases liver iron in TM and TI. There are drawbacks in the use of DFX in TI, such as limitations related to dose, toxicity, and cost, iron load of the patients, and ineffective removal of excess iron from the heart. Furthermore, DFX appears to increase iron and other toxic metal absorption. Future treatments of TI and related iron-loading conditions could involve the use of the iron-chelating drugs and other drug combinations not only for increasing iron excretion but also for preventing iron absorption.
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Affiliation(s)
| | - George J Kontoghiorghes
- Postgraduate Research Institute of Science, Technology, Environment and Medicine, Limassol, Cyprus
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Borgna-Pignatti C, Marsella M. Iron Chelation in Thalassemia Major. Clin Ther 2015; 37:2866-77. [PMID: 26519233 DOI: 10.1016/j.clinthera.2015.10.001] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Revised: 10/01/2015] [Accepted: 10/02/2015] [Indexed: 01/19/2023]
Abstract
PURPOSE Iron chelation has improved survival and quality of life of patients with thalassemia major. there are currently 3 commercially available iron-chelating drugs with different pharmacokinetic and pharmacodynamic activity. The choice of adequate chelation treatment should be tailored to patient needs and based on up-to-date scientific evidence. METHODS A review of the most recent literature was performed. FINDINGS The ability of the chelators to bind the redox active component of iron, labile plasma iron, is crucial for protecting the cells. Chelation therapy should be guided by magnetic resonance imaging that permits the tailoring of therapy according to the needs of the patient because different chelators preferentially clear iron from different sites. Normal levels of body iron seem to decrease the need for hormonal and cardiac therapy. IMPLICATIONS The 3 chelators currently available have different benefits, different safety profiles, and different acceptance on the part of the patients. Good-quality, well-designed, randomized, long-term clinical trials continue to be needed.
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Affiliation(s)
| | - Maria Marsella
- Pediatrics and Adolescentology Unit, Maternal and Child Health Department, "G. Rummo" Hospital, Benevento, Italy
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Saliba AN, Harb AR, Taher AT. Iron chelation therapy in transfusion-dependent thalassemia patients: current strategies and future directions. J Blood Med 2015; 6:197-209. [PMID: 26124688 PMCID: PMC4476479 DOI: 10.2147/jbm.s72463] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Transfusional iron overload is a major target in the care of patients with transfusion-dependent thalassemia (TDT) and other refractory anemias. Iron accumulates in the liver, heart, and endocrine organs leading to a wide array of complications. In this review, we summarize the characteristics of the approved iron chelators, deferoxamine, deferiprone, and deferasirox, and the evidence behind the use of each, as monotherapy or as part of combination therapy. We also review the different guidelines on iron chelation in TDT. This review also discusses future prospects and directions in the treatment of transfusional iron overload in TDT whether through innovation in chelation or other therapies, such as novel agents that improve transfusion dependence.
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Affiliation(s)
- Antoine N Saliba
- Department of Internal Medicine, Division of Hematology/Oncology, American University of Beirut, Beirut, Lebanon
| | - Afif R Harb
- Department of Internal Medicine, Division of Hematology/Oncology, American University of Beirut, Beirut, Lebanon
| | - Ali T Taher
- Department of Internal Medicine, Division of Hematology/Oncology, American University of Beirut, Beirut, Lebanon
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Marsella M, Borgna-Pignatti C. Transfusional iron overload and iron chelation therapy in thalassemia major and sickle cell disease. Hematol Oncol Clin North Am 2015; 28:703-27, vi. [PMID: 25064709 DOI: 10.1016/j.hoc.2014.04.004] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Iron overload is an inevitable consequence of blood transfusions and is often accompanied by increased iron absorption from the gut. Chelation therapy is necessary to prevent the consequences of hemosiderosis. Three chelators, deferoxamine, deferiprone, and deferasirox, are presently available and a fourth is undergoing clinical trials. The efficacy of all 3 available chelators has been demonstrated. Also, many studies have shown the efficacy of the combination of deferoxamine plus deferiprone as an intensive treatment of severe iron overload. Alternating chelators can reduce adverse effects and improve compliance. Adherence to therapy is crucial for good results.
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Affiliation(s)
- Maria Marsella
- Department of Medical Sciences, University of Ferrara, Azienda Ospedale-Università Via Aldo Moro 8, Cona, Ferrara, Italy
| | - Caterina Borgna-Pignatti
- Department of Medical Sciences, University of Ferrara, Azienda Ospedale-Università Via Aldo Moro 8, Cona, Ferrara, Italy.
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Kolnagou A, Kontoghiorghe CN, Kontoghiorghes GJ. Transition of Thalassaemia and Friedreich ataxia from fatal to chronic diseases. World J Methodol 2014; 4:197-218. [PMID: 25541601 PMCID: PMC4274580 DOI: 10.5662/wjm.v4.i4.197] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2014] [Revised: 07/22/2014] [Accepted: 10/16/2014] [Indexed: 02/06/2023] Open
Abstract
Thalassaemia major (TM) and Friedreich’s ataxia (FA) are autosomal recessive inherited diseases related to the proteins haemoglobin and frataxin respectively. In both diseases abnormalities in iron metabolism is the main cause of iron toxicity leading to increased morbidity and mortality. Major efforts are directed towards the prevention of these diseases and also in their treatment using iron chelation therapy. Both TM and FA are endemic in Cyprus, where the frequency per total population of asymptomatic heterozygote carriers and patients is the highest worldwide. Cyprus has been a pioneering nation in preventing and nearly eliminating the birth of TM and FA patients by introducing an organized health structure, including prenatal and antenatal diagnosis. Effective iron chelation therapy, improved diagnostic methods and transfusion techniques as well as supportive therapy from other clinical specializations have improved the survival and quality of life of TM patients. Despite the tiresome clinical management regimes many TM patients are successful in their professional lives, have families with children and some are now living well into their fifties. The introduction of deferiprone led to the elimination of cardiac failure induced by iron overload toxicity, which was the major cause of mortality in TM. Effective combinations of deferiprone with deferoxamine in TM patients caused the fall of body iron to normal physiological ranges. In FA different mechanisms of iron metabolism and toxicity apply to that of TM, which can be targeted with specific iron chelation protocols. Preliminary findings from the introduction of deferiprone in FA patients have increased the hopes for improved and effective therapy in this untreatable condition. New and personalised treatments are proposed in TM and FA. Overall, advances in treatments and in particular of chelation therapy using deferiprone are transforming TM and FA from fatal to chronic conditions. The paradigm of Cyprus in the prevention and treatment of TM can be used for application worldwide.
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Shah F. Addressing Adherence to Treatment: A Longstanding Concern. The Health Care Professional. THALASSEMIA REPORTS 2014. [DOI: 10.4081/thal.2014.4864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Today a patient born with thalassaemia major can expect to have a near normal life expectancy and remain free of complications of iron overload with good monitoring and excellent transfusion and chelation regimes. Unfortunately patients still develop complications as a consequence of iron overload including endocrinopathies and cardiac failure. The main reason behind this failure of effective treatment is inadequate treatment. This can be due to either clinician related factors, patient related factors or lack of adequate provision of medicines and services. In this short paper I will highlight where the challenges lie with regards adherence to treatment and suggest approaches to manage this.
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Mavrogeni S, Markousis-Mavrogenis G, Kolovou G. The Role of Magnetic Resonance Imaging in the Evaluation of Thalassemic Syndromes: Current Practice and Future Perspectives. THALASSEMIA REPORTS 2014. [DOI: 10.4081/thal.2014.1859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Iron can be deposited in all internal organs, leading to different types of functional abnormalities. However, myocardial iron overload that contributes to heart failure remains one of the main causes of death in thalassemia major. Using magnetic resonance imaging, tissue iron is detected indirectly by the effects on relaxation times of ferritin and hemosiderin iron interacting with hydrogen nuclei. The presence of iron in the human body results in marked alterations of tissue relaxation times. Currently, cardiovascular magnetic resonance using T2* is routinely used in many countries to identify patients with myocardial iron loading and guide chelation therapy, specifically tailored to the heart. Myocardial T2* is the only clinically validated non-invasive measure of myocardial iron loading and is superior to surrogates such as serum ferritin, liver iron, ventricular ejection fraction and tissue Doppler parameters. Finally, the substantial amelioration of patients’ survival, allows the detection of other organs’ abnormalities due to iron overload, apart from the heart, missed in the past. Recent studies revealed that iron deposition has a different pattern in various parenchymal organs, which is independent from serum ferritin and follows an individual way after chelation treatment application. This new upcoming reality orders a closer monitoring of all organs of the body in order to detect preclinical lesions and early apply adequate treatment.
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Kontoghiorghe CN, Andreou N, Constantinou K, Kontoghiorghes GJ. World health dilemmas: Orphan and rare diseases, orphan drugs and orphan patients. World J Methodol 2014; 4:163-188. [PMID: 25332915 PMCID: PMC4202455 DOI: 10.5662/wjm.v4.i3.163] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Revised: 04/05/2014] [Accepted: 06/27/2014] [Indexed: 02/06/2023] Open
Abstract
According to global annual estimates hunger/malnutrition is the major cause of death (36 of 62 million). Cardiovascular diseases and cancer (5.44 of 13.43 million) are the major causes of death in developed countries, while lower respiratory tract infections, human immunodeficiency virus infection/acquired immunodeficiency syndrome, diarrhoeal disease, malaria and tuberculosis (10.88 of 27.12 million) are the major causes of death in developing countries with more than 70% of deaths occurring in children. The majority of approximately 800 million people with other rare diseases, including 100000 children born with thalassaemia annually receive no treatment. There are major ethical dilemmas in dealing with global health issues such as poverty and the treatment of orphan and rare diseases. Of approximately 50000 drugs about 10% are orphan drugs, with annual sales of the latter approaching 100 billion USD. In comparison, the annual revenue in 2009 from the top 12 pharmaceutical companies in Western countries was 445 billion USD and the top drug, atorvastatin, reached 100 billion USD. In the same year, the total government expenditure for health in the developing countries was 410 billion USD with only 6%-7% having been received as aid from developed countries. Drugs cost the National Health Service in the United Kingdom more than 20 billion USD or 10% of the annual health budget. Uncontrollable drug prices and marketing policies affect global health budgets, clinical practice, patient safety and survival. Fines of 5.3 billion USD were imposed on two pharmaceutical companies in the United States, the regulatory authority in France was replaced and clinicians were charged with bribery in order to overcome recent illegal practises affecting patient care. High expenditure for drug development is mainly related to marketing costs. However, only 2 million USD was spent developing the drug deferiprone (L1) for thalassaemia up to the stage of multicentre clinical trials. The criteria for drug development, price levels and use needs to be readdressed to improve drug safety and minimise costs. New global health policies based on cheaper drugs can help the treatment of many categories of orphan and rare diseases and millions of orphan patients in developing and developed countries.
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Borgna-Pignatti C, Garani MC, Forni GL, Cappellini MD, Cassinerio E, Fidone C, Spadola V, Maggio A, Restivo Pantalone G, Piga A, Longo F, Gamberini MR, Ricchi P, Costantini S, D'Ascola D, Cianciulli P, Lai ME, Carta MP, Ciancio A, Cavalli P, Putti MC, Barella S, Amendola G, Campisi S, Capra M, Caruso V, Colletta G, Volpato S. Hepatocellular carcinoma in thalassaemia: an update of the Italian Registry. Br J Haematol 2014; 167:121-6. [PMID: 24992281 DOI: 10.1111/bjh.13009] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Accepted: 05/16/2014] [Indexed: 01/27/2023]
Abstract
The risk of developing hepatocellular carcinoma (HCC) in patients with thalassaemia is increased by transfusion-transmitted infections and haemosiderosis. All Italian Thalassaemia Centres use an ad hoc form to report all diagnoses of HCC to the Italian Registry. Since our last report, in 2002, up to December 2012, 62 new cases were identified, 52% of whom were affected by thalassaemia major (TM) and 45% by thalassaemia intermedia (TI). Two had sickle-thalassaemia (ST). The incidence of the tumour is increasing, possibly because of the longer survival of patients and consequent longer exposure to the noxious effects of the hepatotropic viruses and iron. Three patients were hepatitis B surface antigen-positive, 36 patients showed evidence of past infection with hepatitis B virus (HBV). Fifty-four patients had antibodies against hepatitis C virus (HCV), 43 of whom were HCV RNA positive. Only 4 had no evidence of exposure either to HCV or HBV. The mean liver iron concentration was 8 mg/g dry weight. Therapy included chemoembolization, thermoablation with radiofrequency and surgical excision. Three patients underwent liver transplant, 21 received palliative therapy. As of December 2012, 41 patients had died. The average survival time from HCC detection to death was 11·5 months (1·4-107·2 months). Ultrasonography is recommended every 6 months to enable early diagnosis of HCC, which is crucial to decrease mortality.
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Borgna-Pignatti C, Gamberini MR. Complications of thalassemia major and their treatment. Expert Rev Hematol 2014; 4:353-66. [DOI: 10.1586/ehm.11.29] [Citation(s) in RCA: 85] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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