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Niklasson J, Rönnblom A, Lidian A, Thor A. Oral manifestations and dental considerations of patients with hereditary hemorrhagic telangiectasia: a scoping review. Oral Surg Oral Med Oral Pathol Oral Radiol 2023; 136:691-702. [PMID: 37752017 DOI: 10.1016/j.oooo.2023.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 07/20/2023] [Accepted: 08/05/2023] [Indexed: 09/28/2023]
Abstract
OBJECTIVE We examined the range, nature, and extent of research conducted regarding the oral and dental implications of hereditary hemorrhagic telangiectasia (HHT) to identify gaps in the research and knowledge of the field. STUDY DESIGN We performed a scoping review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews and 2017 Guidance for the Conduct of Joanna Briggs Institute Scoping Reviews. We searched the MEDLINE and Web of Science databases for all full-text articles published in English from December 1946 to October 2022. RESULTS We identified 103 articles describing oral and dental considerations of patients with HHT, primarily case reports. Most reported oral telangiectasias of the tongue, lips, and palate. Many reported management of bleeding and the use or recommendation of prophylactic antibiotics before dental procedures. CONCLUSIONS Oral telangiectasias are commonly found in patients with hereditary hemorrhagic telangiectasia, and dental professionals may be the first to diagnose it in their patients. Early detection and diagnosis are important to prevent potentially fatal outcomes, and prophylactic antibiotics before procedures may be warranted.
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Affiliation(s)
- Julia Niklasson
- Department of Plastic and Oral and Maxillofacial Surgery, Uppsala University, Uppsala, Sweden.
| | - Anders Rönnblom
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Adnan Lidian
- Department of Otorhinolaryngology and Head and Neck Surgery, Uppsala University, Uppsala, Sweden
| | - Andreas Thor
- Department of Plastic and Oral and Maxillofacial Surgery, Uppsala University, Uppsala, Sweden
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Schild Y, Bosserhoff J, Droege F, Littwitz-Salomon E, Fandrey J, Wrobeln A. Hypoxia-Inducible Factor-Prolyl Hydroxylase Inhibitor Improves Leukocyte Energy Metabolism in Hereditary Hemorrhagic Telangiectasia. Life (Basel) 2023; 13:1708. [PMID: 37629565 PMCID: PMC10456096 DOI: 10.3390/life13081708] [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: 07/10/2023] [Revised: 08/01/2023] [Accepted: 08/07/2023] [Indexed: 08/27/2023] Open
Abstract
The interplay between hypoxia-inducible factors (HIFs) and transforming growth factor beta (TGF-β) is critical for both inflammation and angiogenesis. In hereditary hemorrhagic telangiectasia (HHT), we have previously observed that impairment of the TGF-β pathway is associated with downregulation of HIF-1α. HIF-1α accumulation is mandatory in situations of altered energy demand, such as during infection or hypoxia, by adjusting cell metabolism. Leukocytes undergo a HIF-1α-dependent switch from aerobic mitochondrial respiration to anaerobic glycolysis (glycolytic switch) after stimulation and during differentiation. We postulate that the decreased HIF-1α accumulation in HHT leads to a clinically observed immunodeficiency in these patients. Examination of HIF-1α and its target genes in freshly isolated peripheral blood mononuclear cells (PBMCs) from HHT patients revealed decreased gene expression and protein levels of HIF-1α and HIF-1α-regulated glycolytic enzymes. Treatment of these cells with the HIF-prolyl hydroxylase inhibitor, Roxadustat, rescued their ability to accumulate HIF-1α protein. Functional analysis of metabolic flux using a Seahorse FX extracellular flux analyzer showed that the extracellular acidification rate (indicator of glycolytic turnover) after Roxadustat treatment was comparable to non-HHT controls, while oxygen consumption (indicator of mitochondrial respiration) was slightly reduced. HIF stabilization may be a potential therapeutic target in HHT patients suffering from infections.
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Affiliation(s)
- Yves Schild
- Institute of Physiology, University Hospital Essen, University of Duisburg-Essen, 45147 Essen, Germany; (Y.S.); (J.B.); (J.F.)
| | - Jonah Bosserhoff
- Institute of Physiology, University Hospital Essen, University of Duisburg-Essen, 45147 Essen, Germany; (Y.S.); (J.B.); (J.F.)
| | - Freya Droege
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Essen, University of Duisburg-Essen, 45147 Essen, Germany;
| | - Elisabeth Littwitz-Salomon
- Institute for Virology, University Hospital Essen, University of Duisburg-Essen, 45147 Essen, Germany;
- Institute for Translational HIV Research, University Hospital Essen, University of Duisburg-Essen, 45147 Essen, Germany
| | - Joachim Fandrey
- Institute of Physiology, University Hospital Essen, University of Duisburg-Essen, 45147 Essen, Germany; (Y.S.); (J.B.); (J.F.)
| | - Anna Wrobeln
- Institute of Physiology, University Hospital Essen, University of Duisburg-Essen, 45147 Essen, Germany; (Y.S.); (J.B.); (J.F.)
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Joyce KE, Onabanjo E, Brownlow S, Nur F, Olupona K, Fakayode K, Sroya M, Thomas GA, Ferguson T, Redhead J, Millar CM, Cooper N, Layton DM, Boardman-Pretty F, Caulfield MJ, Shovlin CL. Whole genome sequences discriminate hereditary hemorrhagic telangiectasia phenotypes by non-HHT deleterious DNA variation. Blood Adv 2022; 6:3956-3969. [PMID: 35316832 PMCID: PMC9278305 DOI: 10.1182/bloodadvances.2022007136] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 02/21/2022] [Indexed: 11/20/2022] Open
Abstract
The abnormal vascular structures of hereditary hemorrhagic telangiectasia (HHT) often cause severe anemia due to recurrent hemorrhage, but HHT causal genes do not predict the severity of hematological complications. We tested for chance inheritance and clinical associations of rare deleterious variants in which loss-of-function causes bleeding or hemolytic disorders in the general population. In double-blinded analyses, all 104 patients with HHT from a single reference center recruited to the 100 000 Genomes Project were categorized on new MALO (more/as-expected/less/opposite) sub-phenotype severity scales, and whole genome sequencing data were tested for high impact variants in 75 HHT-independent genes encoding coagulation factors, or platelet, hemoglobin, erythrocyte enzyme, and erythrocyte membrane constituents. Rare variants (all gnomAD allele frequencies <0.003) were identified in 56 (75%) of these 75 HHT-unrelated genes. Deleteriousness assignments by Combined Annotation Dependent Depletion (CADD) scores >15 were supported by gene-level mutation significance cutoff scores. CADD >15 variants were identified in 38/104 (36.5%) patients with HHT, found for 1 in 10 patients within platelet genes; 1 in 8 within coagulation genes; and 1 in 4 within erythrocyte hemolytic genes. In blinded analyses, patients with greater hemorrhagic severity that had been attributed solely to HHT vessels had more CADD-deleterious variants in platelet (Spearman ρ = 0.25; P = .008) and coagulation (Spearman ρ = 0.21; P = .024) genes. However, the HHT cohort had 60% fewer deleterious variants in platelet and coagulation genes than expected (Mann-Whitney test P = .021). In conclusion, patients with HHT commonly have rare variants in genes of relevance to their phenotype, offering new therapeutic targets and opportunities for informed, personalized medicine strategies.
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Affiliation(s)
- Katie E. Joyce
- Imperial College School of Medicine, Imperial College, London, United Kingdom
- Genomics England Respiratory Clinical Interpretation Partnership (GeCIP), London, United Kingdom
| | - Ebun Onabanjo
- West London Genomic Medicine Centre, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Sheila Brownlow
- West London Genomic Medicine Centre, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Fadumo Nur
- West London Genomic Medicine Centre, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Kike Olupona
- West London Genomic Medicine Centre, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Kehinde Fakayode
- West London Genomic Medicine Centre, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Manveer Sroya
- Department of Surgery and Cancer, Imperial College, London, United Kingdom
| | | | - Teena Ferguson
- West London Genomic Medicine Centre, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Julian Redhead
- West London Genomic Medicine Centre, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Carolyn M. Millar
- West London Genomic Medicine Centre, Imperial College Healthcare NHS Trust, London, United Kingdom
- Centre for Haematology, Department of Immunology and Inflammation, Imperial College, London, United Kingdom
| | - Nichola Cooper
- West London Genomic Medicine Centre, Imperial College Healthcare NHS Trust, London, United Kingdom
- Centre for Haematology, Department of Immunology and Inflammation, Imperial College, London, United Kingdom
| | - D. Mark Layton
- West London Genomic Medicine Centre, Imperial College Healthcare NHS Trust, London, United Kingdom
- Centre for Haematology, Department of Immunology and Inflammation, Imperial College, London, United Kingdom
| | | | - Mark J. Caulfield
- Genomics England Research Consortium, Genomics England, London, United Kingdom
- William Harvey Research Institute, Queen Mary University of London, London, United Kingdom; and
| | | | - Claire L. Shovlin
- Genomics England Respiratory Clinical Interpretation Partnership (GeCIP), London, United Kingdom
- West London Genomic Medicine Centre, Imperial College Healthcare NHS Trust, London, United Kingdom
- National Heart and Lung Institute, Imperial College, London, United Kingdom
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Shovlin CL, Buscarini E, Sabbà C, Mager HJ, Kjeldsen AD, Pagella F, Sure U, Ugolini S, Torring PM, Suppressa P, Rennie C, Post MC, Patel MC, Nielsen TH, Manfredi G, Lenato GM, Lefroy D, Kariholu U, Jones B, Fialla AD, Eker OF, Dupuis O, Droege F, Coote N, Boccardi E, Alsafi A, Alicante S, Dupuis-Girod S. The European Rare Disease Network for HHT Frameworks for management of hereditary haemorrhagic telangiectasia in general and speciality care. Eur J Med Genet 2022; 65:104370. [PMID: 34737116 DOI: 10.1016/j.ejmg.2021.104370] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 09/24/2021] [Accepted: 10/26/2021] [Indexed: 12/22/2022]
Abstract
Hereditary haemorrhagic telangiectasia (HHT) is a complex, multisystemic vascular dysplasia affecting approximately 85,000 European Citizens. In 2016, eight founding centres operating within 6 countries, set up a working group dedicated to HHT within what became the European Reference Network on Rare Multisystemic Vascular Diseases. By launch, combined experience exceeded 10,000 HHT patients, and Chairs representing 7 separate specialties provided a median of 24 years' experience in HHT. Integrated were expert patients who focused discussions on the patient experience. Following a 2016-2017 survey to capture priorities, and underpinned by more than 40 monthly meetings, and new data acquisitions, VASCERN HHT generated position statements that distinguish expert HHT care from non-expert HHT practice. Leadership was by specialists in the relevant sub-discipline(s), and 100% consensus was required amongst all clinicians before statements were published or disseminated. One major set of outputs targeted all healthcare professionals and their HHT patients, and include the new Orphanet definition; Do's and Don'ts for common situations; Outcome Measures suitable for all consultations; COVID-19; and anticoagulation. The second output set span aspects of vascular pathophysiology where greater understanding will assist organ-specific specialist clinicians to provide more informed care to HHT patients. These cover cerebral vascular malformations and screening; mucocutaneous telangiectasia and differential diagnosis; anti-angiogenic therapies; circulatory interplays between anaemia and arteriovenous malformations; and microbiological strategies to counteract loss of normal pulmonary capillary function. Overall, the integrated outputs, and documented current practices, provide frameworks for approaches that augment the health and safety of HHT patients in diverse health-care settings.
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Affiliation(s)
- C L Shovlin
- VASCERN HHT Reference Centre, Imperial College Healthcare National Health Service Trust, London, UK; National Heart and Lung Institute, Imperial College London, UK.
| | - E Buscarini
- VASCERN HHT Reference Centre, ASST Maggiore Hospital, Crema, Italy.
| | - C Sabbà
- VASCERN HHT Reference Centre, Centro Sovraziendale Malattie Rare, "Frugoni" Internal Medicine Unit, University of Bari "A. Moro", Italy.
| | - H J Mager
- VASCERN HHT Reference Centre, St Antonius Ziekenhuis, Nieuwegein, Netherlands.
| | - A D Kjeldsen
- VASCERN HHT Reference Centre, Odense University Hospital, Syddansk Universitet, Odense, Denmark.
| | - F Pagella
- VASCERN HHT Reference Centre, University of Pavia, IRCCS Policlinico San Matteo Foundation, Pavia, Italy.
| | - U Sure
- VASCERN HHT Reference Centre, Essen University Hospital, Essen, Germany; Department of Neurosurgery and Spine Surgery, University Hospital Essen, Germany.
| | - S Ugolini
- VASCERN HHT Reference Centre, University of Pavia, IRCCS Policlinico San Matteo Foundation, Pavia, Italy.
| | - P M Torring
- VASCERN HHT Reference Centre, Odense University Hospital, Syddansk Universitet, Odense, Denmark.
| | - P Suppressa
- VASCERN HHT Reference Centre, Centro Sovraziendale Malattie Rare, "Frugoni" Internal Medicine Unit, University of Bari "A. Moro", Italy.
| | - C Rennie
- VASCERN HHT Reference Centre, Imperial College Healthcare National Health Service Trust, London, UK.
| | - M C Post
- VASCERN HHT Reference Centre, St Antonius Ziekenhuis, Nieuwegein, Netherlands; Department of Cardiology, University Medical Center Utrecht, The Netherlands.
| | - M C Patel
- VASCERN HHT Reference Centre, Imperial College Healthcare National Health Service Trust, London, UK.
| | - T H Nielsen
- VASCERN HHT Reference Centre, Odense University Hospital, Syddansk Universitet, Odense, Denmark.
| | - G Manfredi
- VASCERN HHT Reference Centre, ASST Maggiore Hospital, Crema, Italy.
| | - G M Lenato
- VASCERN HHT Reference Centre, Centro Sovraziendale Malattie Rare, "Frugoni" Internal Medicine Unit, University of Bari "A. Moro", Italy.
| | - D Lefroy
- VASCERN HHT Reference Centre, Imperial College Healthcare National Health Service Trust, London, UK.
| | - U Kariholu
- VASCERN HHT Reference Centre, Imperial College Healthcare National Health Service Trust, London, UK.
| | - B Jones
- VASCERN HHT Reference Centre, Imperial College Healthcare National Health Service Trust, London, UK.
| | - A D Fialla
- VASCERN HHT Reference Centre, Odense University Hospital, Syddansk Universitet, Odense, Denmark.
| | - O F Eker
- VASCERN HHT Reference Centre, Hospices Civils de Lyon, Lyon, France.
| | - O Dupuis
- VASCERN HHT Reference Centre, Hospices Civils de Lyon, Lyon, France.
| | - F Droege
- VASCERN HHT Reference Centre, Essen University Hospital, Essen, Germany; Department of ENT Surgery, University Hospital Essen, Germany.
| | - N Coote
- VASCERN HHT Reference Centre, Imperial College Healthcare National Health Service Trust, London, UK.
| | - E Boccardi
- VASCERN HHT Reference Centre, ASST Maggiore Hospital, Crema, Italy; Niguarda Hospital, Milan, Italy.
| | - A Alsafi
- VASCERN HHT Reference Centre, Imperial College Healthcare National Health Service Trust, London, UK.
| | - S Alicante
- VASCERN HHT Reference Centre, ASST Maggiore Hospital, Crema, Italy.
| | - S Dupuis-Girod
- VASCERN HHT Reference Centre, Hospices Civils de Lyon, Lyon, France.
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Anderson E, Green R, Swift A, Semple MG. Hereditary haemorrhagic telangiectasia: development of a regional life-course collaborative clinical care pathway. Br J Hosp Med (Lond) 2021; 82:1-9. [PMID: 34817258 DOI: 10.12968/hmed.2020.0537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Hereditary haemorrhagic telangiectasia is a rare, genetic disorder that can present at any age. It is characterised by epistaxis, mucocutaneous telangiectasia and visceral arteriovenous malformations, which can affect multiple organs. Early diagnosis and management reduces the morbidity and mortality associated with the disease. There is a well-established hereditary haemorrhagic telangiectasia clinic in London, and excellent links across Europe via the European Reference Network. However, local coordinated care for patients with hereditary haemorrhagic telangiectasia across the UK can be variable and often absent for children and young people. Some patients travel long distances to receive care in London, while others are referred to local clinicians or lost to follow up entirely. This article presents the experience to date from two regional UK centres (Liverpool and Dundee) where care for patients with hereditary haemorrhagic telangiectasia is being coordinated and streamlined. While there is still a lot to learn, this article highlights some of the successes and challenges identified so far, with suggestions for how these could be addressed. Collaborative regional networks such as these can facilitate the sharing of best practice and ensure that all patients with hereditary haemorrhagic telangiectasia are able to access safe, high-quality care.
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Affiliation(s)
- Emily Anderson
- Liverpool Centre for Genomic Medicine, Liverpool Women's Hospital, Liverpool, UK
| | - Richard Green
- Department of Ear, Nose and Throat Surgery, Ninewells Hospital, Dundee, UK
| | - Andrew Swift
- Liverpool Head and Neck Centre, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Malcolm G Semple
- Department of Paediatric Respiratory Medicine, Alder Hey Children's Hospital, Liverpool, UK.,NIHR Health Protection Research Unit in Emerging and Zoonotic Infections, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK
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6
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Droege F, Dingemann J, Thangavelu K, Kuerten CHL, Dahlfrancis PM, Kaiser C, Kaster F, Zioga E, Meyer C, Lueb C, Sure U, Lang S, Geisthoff U. [Implementation and development of a center for hereditary hemorrhagic telangiectasia]. Laryngorhinootologie 2021; 100:372-381. [PMID: 33723832 DOI: 10.1055/a-1402-0543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Hereditary Hemorrhagic Telangiectasia (HHT) is a rare and systemic disorder which is characterized by recurrent epistaxis, mucocutaneous telangiectases, and visceral arteriovenous malformations (AVM). An interdisciplinary concept is recommended. MATERIAL AND METHODS We performed a retrospective review of consecutive patients who were referred to our newly established HHT Center of Excellence (HHT COE) for evaluation and treatment between April 2014 and August 2019. RESULTS A network of over 20 departments was established at the University Hospital Essen. In 261 of the 282 patients (93 %), who were referred to the hospital's COE, the HHT diagnosis was at least possible. Most patients suffered from several symptoms (epistaxis and / or telangiectasia: > 80 %, visceral involvement: 65 %) and received a variety of treatments, often in a multidisciplinary setting. Alongside this direct treatment, the COE leader manages the coordination of the center and its public relations, which involves more than 900 e-mails per year. International collaboration and exchanges of expertise within the European Reference Network on Rare Multisystemic Vascular Diseases (VASCERN) can improve the treatment of patients with HHT particularly where these cases are complex. CONCLUSIONS An HHT COE provides an interdisciplinary network where highly specialized diagnostic and therapeutic processes can be updated and optimized continuously.
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Affiliation(s)
- Freya Droege
- Klinik für Hals-Nasen-Ohrenheilkunde, Universitätsklinikum Essen, Germany
| | - Julia Dingemann
- Klinik für Hals-Nasen-Ohrenheilkunde, Universitätsklinikum Essen, Germany
| | - Kruthika Thangavelu
- Klinik für Hals-Nasen-Ohrenheilkunde, Universitätsklinikum Gießen und Marburg - Standort Marburg, Germany
| | | | | | - Christina Kaiser
- Klinik für Hals-Nasen-Ohrenheilkunde, Universitätsklinikum Essen, Germany
| | - Friederike Kaster
- Klinik für Hals-Nasen-Ohrenheilkunde, Universitätsklinikum Essen, Germany
| | - Eleni Zioga
- Klinik für Hals-Nasen-Ohrenheilkunde, Universitätsklinikum Essen, Germany
| | - Corinna Meyer
- Klinik für Hals-Nasen-Ohrenheilkunde, Universitätsklinikum Essen, Germany
| | - Carolin Lueb
- Klinik für Hals-Nasen-Ohrenheilkunde, Universitätsklinikum Essen, Germany
| | - Ulrich Sure
- Klinik für Neurochirurgie, Universitätsklinikum Essen, Germany
| | - Stephan Lang
- Klinik für Hals-Nasen-Ohrenheilkunde, Universitätsklinikum Essen, Germany
| | - Urban Geisthoff
- Klinik für Hals-Nasen-Ohrenheilkunde, Universitätsklinikum Gießen und Marburg - Standort Marburg, Germany
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Nguyen CM, Stauber J, Baliss M, Reynoso D. Life-Threatening Intraventricular Rupture of Brain Abscess in a Patient With Undiagnosed Hereditary Hemorrhagic Telangiectasia. Cureus 2020; 12:e8732. [PMID: 32714672 PMCID: PMC7377030 DOI: 10.7759/cureus.8732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant genetic condition associated with mucocutaneous and visceral arteriovenous malformations (AVMs), including pulmonary AVMs, which predispose patients to systemic paradoxical emboli that can lead to brain abscesses. Intraventricular rupture of brain abscess (IVROBA) is a feared complication with a high mortality rate. Here, we present a case with brain abscesses complicated by IVROBA and ventriculitis as the initial presentation of HHT in an undiagnosed patient. We also discuss the diagnostic and therapeutic approach that resulted in this patient’s clinical improvement.
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Buscarini E, Botella LM, Geisthoff U, Kjeldsen AD, Mager HJ, Pagella F, Suppressa P, Zarrabeitia R, Dupuis-Girod S, Shovlin CL. Safety of thalidomide and bevacizumab in patients with hereditary hemorrhagic telangiectasia. Orphanet J Rare Dis 2019; 14:28. [PMID: 30717761 PMCID: PMC6360670 DOI: 10.1186/s13023-018-0982-4] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Accepted: 12/14/2018] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Hereditary hemorrhagic telangiectasia (HHT) is a multisystemic inherited vascular dysplasia that leads to nosebleeds and visceral arteriovenous malformations (AVMs). Anti-angiogenic drugs thalidomide and bevacizumab have been increasingly used off-label with variable results. The HHT working group within the ERN for Rare Multisystemic Vascular Diseases (VASCERN), developed a questionnaire-based retrospective capture of adverse events (AEs) classified using the Common Terminology Criteria for Adverse Events. RESULTS Sixty-nine HHT patients received bevacizumab, 37 (50.6%) for high output cardiac failure/hepatic AVMs, and 32 (49.4%) for bleeding; the 69 patients received bevacizumab for a mean of 11 months for a total of 63.8 person/years treatment. 67 received thalidomide, all for epistaxis and/or gastrointestinal bleeding; they received thalidomide for a mean of 13.4 months/patient for a total of 75 person/years treatment. AEs were reported in 58 patients, 33 with bevacizumab, 37 with thalidomide. 32 grade 1-3 AEs related to bevacizumab were reported with an average incidence rate of 50 per 100 person-years. 34 grade 1-3 AEs related to thalidomide were reported with an average incidence rate of 45.3 per 100 person-years. Bevacizumab AEs were more common in females (27 AEs in 46 women) than males (6 in 23, p < 0.001). Thalidomide AEs occurred at more similar rates in males (25 AEs in 41 men, 60.9%) and females (12 in 26 (46.2%), but were more common in ENG patients (17 in 17) than in ACVRL1 (14 in 34, p < 0.0001). For bevacizumab, the most common reports were of joint pains (7/69, 10%), headache (3/69, 4.4%) and proteinuria (2/69, 3%), and for thalidomide, peripheral neuropathy (12/67, 18%); drowsiness (8/67, 12%); and dizziness (6/67, 9%). Fatal adverse events were more common in males (p = 0.009), and in patients with ENG pathogenic variants (p = 0.012). One fatal AE was possibly related to bevacizumab (average incidence rate: 1.5 per 100 person-years); 3 fatal AEs were possibly related to thalidomide (average incidence rate: 4 per 100 person-years). CONCLUSIONS With potential increase in use of Bevacizumab and Thalidomide in HHT patients, data presented support appropriate weighing of the toxicities which can arise in HHT settings and the practice recommendations for their prevention and management.
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Affiliation(s)
| | - Luisa Maria Botella
- Department of Cell and Molecular Medicine Centro de Investigaciones Biológicas, CSIC, U707 CIBERER, Madrid, Spain
| | - Urban Geisthoff
- VASCERN HHT Reference Center, Essen University Hospital, Department of Otorhinolaryngology, University of Duisburg-Essen, Essen, Germany
| | - Anette D. Kjeldsen
- VASCERN HHT Reference Center, Odense Universitetshospital, Syddansk Universitet, Odense, Denmark
| | - Hans Jurgen Mager
- VASCERN HHT Reference Center, St Antonius Ziekenhuis, Nieuwegein, Netherlands
| | - Fabio Pagella
- VASCERN HHT Reference Center, Unità Operativa Complessa di Otorinolaringoiatria, University of Pavia, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | - Patrizia Suppressa
- VASCERN HHT Reference Center, Centro sovraziendale Malattie rare, “Frugoni” Internal Medicine Unit, University of Bari “A. Moro”, Bari, Italy
| | | | - Sophie Dupuis-Girod
- VASCERN HHT Reference Center, Genetic department, Hospices Civils de Lyon, Femme-Mère-Enfants Hospital, F-69677 Bron, France
| | - Claire L. Shovlin
- VASCERN HHT Reference Center, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, and Vascular Sciences, National Heart and Lung Institute, Imperial College London, London, UK
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