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Meloni A, Pistoia L, Vassalle C, Spasiano A, Fotzi I, Bagnato S, Putti MC, Cossu A, Massei F, Giovangrossi P, Maffei S, Positano V, Cademartiri F. Low Vitamin D Levels Are Associated with Increased Cardiac Iron Uptake in Beta-Thalassemia Major. Diagnostics (Basel) 2023; 13:3656. [PMID: 38132240 PMCID: PMC10742632 DOI: 10.3390/diagnostics13243656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 12/12/2023] [Accepted: 12/13/2023] [Indexed: 12/23/2023] Open
Abstract
We evaluated the association of vitamin D and parathormone (PTH) levels with cardiac iron and function in beta-thalassemia major (β-TM) patients. Two-hundred and seventy-eight TM patients (39.04 ± 8.58 years, 56.8% females) underwent magnetic resonance imaging for the assessment of iron overload (T2* technique), biventricular function parameters (cine images), and replacement myocardial fibrosis (late gadolinium enhancement technique). Vitamin D levels were deficient (<20 ng/dL) in 107 (38.5%) patients, insufficient (20-30 ng/dL) in 96 (34.5%) patients, and sufficient (≥30 ng/dL) in 75 (27.0%) patients. Deficient vitamin D patients had a significantly higher frequency of myocardial iron overload (MIO; global heart T2* < 20 ms) than patients with sufficient and insufficient vitamin D levels and a significantly higher left ventricular end-diastolic volume index and mass index than patients with sufficient vitamin D levels. PTH was not associated with cardiac iron, function, or fibrosis. In the multivariate regression analysis, vitamin D, serum ferritin, and pancreatic iron levels were the strongest predictors of global heart T2* values. In receiver operating characteristic curve analysis, a vitamin D level ≤ 17.3 ng/dL predicted MIO with a sensitivity of 81.5% and a specificity of 75.3% (p < 0.0001). In TM, the periodic and regular assessment of vitamin D levels can be beneficial for the prevention of cardiac iron accumulation and subsequent overt dysfunction.
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Affiliation(s)
- Antonella Meloni
- Bioengineering Unit, Fondazione G. Monasterio CNR—Regione Toscana, 56124 Pisa, Italy; (A.M.); (V.P.)
- Department of Radiology, Fondazione G. Monasterio CNR—Regione Toscana, 56124 Pisa, Italy;
| | - Laura Pistoia
- Department of Radiology, Fondazione G. Monasterio CNR—Regione Toscana, 56124 Pisa, Italy;
- Unità Operativa Complessa Ricerca Clinica, Fondazione G. Monasterio CNR—Regione Toscana, 56124 Pisa, Italy
| | - Cristina Vassalle
- Medicina di Laboratorio, Fondazione G. Monasterio CNR—Regione Toscana, 56124 Pisa, Italy;
| | - Anna Spasiano
- Unità Operativa Semplice Dipartimentale Malattie Rare del Globulo Rosso, Azienda Ospedaliera di Rilievo Nazionale “A. Cardarelli”, 80131 Napoli, Italy;
| | - Ilaria Fotzi
- Oncologia, Ematologia e Trapianto di Cellule Staminali Emopoietiche, Meyer Children’s Hospital IRCCS, 50139 Firenze, Italy;
| | - Sergio Bagnato
- Ematologia Microcitemia, Ospedale San Giovanni di Dio—ASP Crotone, 88900 Crotone, Italy;
| | - Maria Caterina Putti
- Dipartimento della Salute della Donna e del Bambino, Clinica di Emato-Oncologia Pediatrica, Azienda Ospedaliero Università di Padova, 35128 Padova, Italy;
| | - Antonella Cossu
- Ambulatorio Trasfusionale—Servizio Immunoematologia e Medicina Trasfusionale Dipartimento dei Servizi, Presidio Ospedaliero “San Francesco”, 08100 Nuoro, Italy;
| | - Francesco Massei
- Unità Operativa Oncoematologia Pediatrica, Azienda Ospedaliero Universitaria Pisana—Stabilimento S. Chiara, 56126 Pisa, Italy;
| | - Piera Giovangrossi
- Servizio di Immunoematologia e Medicina Trasfusionale, Ospedale S. M. Goretti, 04100 Latina, Italy;
| | - Silvia Maffei
- Cardiovascular and Gynaecological Endocrinology Unit, Fondazione G. Monasterio CNR—Regione Toscana, 56124 Pisa, Italy;
| | - Vincenzo Positano
- Bioengineering Unit, Fondazione G. Monasterio CNR—Regione Toscana, 56124 Pisa, Italy; (A.M.); (V.P.)
- Department of Radiology, Fondazione G. Monasterio CNR—Regione Toscana, 56124 Pisa, Italy;
| | - Filippo Cademartiri
- Department of Radiology, Fondazione G. Monasterio CNR—Regione Toscana, 56124 Pisa, Italy;
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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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Salem A, Desai P, Elgebaly A. Efficacy and Safety of Combined Deferiprone and Deferasirox in Iron-Overloaded Patients: A Systematic Review. Cureus 2023; 15:e48276. [PMID: 38058350 PMCID: PMC10695738 DOI: 10.7759/cureus.48276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 11/04/2023] [Indexed: 12/08/2023] Open
Abstract
Despite the established efficacy of iron chelation therapy in transfusion-induced iron-overloaded patients, there is no universal agreement regarding the choice of an optimal chelating regimen. Deferasirox (DFX) and deferiprone (DFP) are two oral iron chelators, and combination usage demonstrated effectiveness as an alternative to monotherapies in patients with a limited response to monotherapy. The present systematic review aimed to assess the evidence regarding the outcomes of combined DFP and DFX in iron-overloaded patients. An online search was conducted in PubMed, Scopus, Web of Science, and CENTRAL databases. Interventional and observational studies that assessed the outcomes of combined DFP and DFX in iron-overloaded patients were included. Eleven studies (12 reports) were considered in this meta-analysis. The studies included dual iron chelation strategies for a number of diagnoses. Single-arm studies (n =7) showed a reduction of serum ferritin, which reached the level of statistical significance in three studies. Likewise, most studies reported a numerical reduction in liver iron concentration (LIC) and increased cardiac MRI-T2* values after chelating therapy. Alternatively, comparative studies showed no significant difference in post-treatment serum ferritin between DFX plus DFP and DFX/DFP plus deferoxamine (DFO). The adherence to combination therapy was good to average in nearly 66.7-100% of the patients across four studies. One study reported a poor adherence rate. The combined regimen was generally tolerable, with no reported incidence of serious adverse events among the included studies. In conclusion, the DFP and DFX combination is a safe and feasible option for iron overload patients with a limited response to monotherapy.
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Affiliation(s)
- Ahmed Salem
- Department of Pharmacology and Therapeutics, Levien Cancer Institute, Atrium Health, Charlotte, USA
| | - Payal Desai
- Department of Hematologic Malignancies and Blood Disorders, Levine Cancer Institute, Charlotte, USA
- Department of Internal Medicine, Wake Forest School of Medicine, Charlotte, USA
| | - Ahmed Elgebaly
- Department of Medical Informatics, University of East London, London, GBR
- Department of Internal Medicine, Al-Azhar University, Cairo, EGY
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Aydinok Y. Combination chelation therapy. Ann N Y Acad Sci 2023; 1529:33-41. [PMID: 37594980 DOI: 10.1111/nyas.15052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/20/2023]
Abstract
Combination chelation therapies are considered in transfusion-dependent thalassemia patients for whom monotherapy regimens have failed to achieve iron balance or intensification of iron chelation therapy is required for the rapid reduction of excess iron to avoid permanent organ damage. Combination chelation may provide a more flexible approach for individualizing chelation therapy, thereby improving tolerability, adherence, and quality of life. In principle, iron chelators can be combined with an infinite number of dosing regimens; these involve simultaneous or sequential exposure to the chelators on the same day or alternating the drugs on different days. Clinical studies have established the safety and efficacy of chelation combinations. However, real-life data with combination therapies indicate the significance of compliance for a meaningful reduction in iron overload compared to monotherapies.
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Affiliation(s)
- Yesim Aydinok
- Department of Pediatric Hematology, School of Medicine, Ege University, Izmir, Turkey
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Schreiner OD, Schreiner TG. Iron chelators as a therapeutic option for Alzheimer's disease-A mini-review. FRONTIERS IN AGING 2023; 4:1234958. [PMID: 37602277 PMCID: PMC10433644 DOI: 10.3389/fragi.2023.1234958] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 07/17/2023] [Indexed: 08/22/2023]
Abstract
Neurodegenerative disorders, particularly Alzheimer's disease (AD), remain a great challenge regarding the finding of effective treatment, one main reason being the incomplete understanding of their etiology. With many intensely debated hypotheses, a newer approach based on the impact of iron imbalance in sustaining neurodegeneration in the central nervous system becomes increasingly popular. Altered iron homeostasis leads to increased iron accumulation in specific brain areas, explaining the clinical picture of AD patients. Moreover, growing evidence sustains the significant impact of iron metabolism in relationship to other pathological processes encountered in the AD-affected brain, such as the amyloidogenic pathway, chronic inflammation, or oxidative stress. In this context, this mini-review aims to summarize the novel data from the continuously expanding literature on this topic in a didactic manner. Thus, in the first part, the authors briefly highlight the most relevant aspects related to iron absorption, transport, regulation, and elimination at the cerebral level, focusing on the role of the blood-brain barrier and the newer concept of ferroptosis. Subsequently, currently available iron chelation therapies are discussed, including an overview of the most relevant clinical trials on this topic. In the final part, based on the latest results from in vitro and in vivo studies, new research directions are suggested to enhance the development of effective antidementia therapies.
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Affiliation(s)
- Oliver Daniel Schreiner
- Grigore T. Popa University of Medicine and Pharmacy, Iasi, Romania
- Medical Oncology Department, Regional Institute of Oncology, Iasi, Romania
| | - Thomas Gabriel Schreiner
- Grigore T. Popa University of Medicine and Pharmacy, Iasi, Romania
- Faculty of Electrical Engineering and Information Technology, Gheorghe Asachi Technical University of Iasi, Iasi, Romania
- Faculty of Medicine, University of Medicine and Pharmacy “Carol Davila”, Bucharest, Romania
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Ricchi P, Forni GL. Special Issue: “Emerging Therapies and Strategies in Thalassemia: Toward a New Era in Management”. J Clin Med 2022; 11:jcm11175175. [PMID: 36079104 PMCID: PMC9457055 DOI: 10.3390/jcm11175175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Accepted: 07/08/2022] [Indexed: 11/16/2022] Open
Abstract
This Special Issue on “Emerging Therapies and Strategies in Thalassemia: Toward a New Era in management” aims to update researchers and clinicians regarding the field of thalassemia syndromes [...]
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Affiliation(s)
- Paolo Ricchi
- Center for Rare Red Blood Cell Diseases, AORN A. Cardarelli, 80131 Naples, Italy
- Correspondence:
| | - Gian Luca Forni
- Center for Congenital Anemias and Iron Dysmetabolism, Galliera Hospital, 16128 Genoa, Italy
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