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

Controlled release of deferiprone using iron-responsive nanoparticles integrated with dissolving microneedle for novel alternative treatments of β-thalassemia major

Iron chelating agents (ICs) such as conventional deferiprone are often ineffective when exposed to normal conditions due to their uncontrolled release when treating iron overload in ß-thalassemia major (ß-TM) due to the effects of blood transfusion. Iron deficiency and gastrointestinal side effects are crucial problems that can occur. Therefore, DFP was prepared as nanoparticles (NPs) coated with an iron-responsive (IR) polymer with an average particle size of 354.70 ± 10 nm to control its release. To facilitate optimal delivery, NP-IR-DFP was integrated into a dissolving microneedle (DMN) fabricated with biodegradable and biocompatible poly(vinylpyrrolidone) and poly(vinyl alcohol) polymers. The results showed that the NP-IR-DMN provided excellent insertion and mechanical strength and dissolved quickly after application. In vitro and ex-vivo studies revealed the more controllable release of NP-IR-DFP after integration with the DMN (NP-IR-DMN) for up to 24 h. Most importantly, the developed formula was hemocompatible and did not irritate the skin or cause tissue damage. Furthermore, the in vivo pharmacokinetics were further investigated for 24 h, which revealed short concentration (Cmax of 0.07 ± 0.03 μg/mL) and t1/2 (3.66 ± 0.76 h) under normal conditions and long-term iron overload-modeling conditions with Cmax (2.90 ± 0.14 μg/mL) and t1/2 (10.13 ± 1.00 h). This approach can extend beyond oral delivery by controlling the release of DFP, which can only be released in conditions of iron overload, and has the potential to prevent iron deficiency and excess, thus increasing the efficacy of DFP in β-TM therapy.

Integrated bioinformatics and experiment validation reveal cuproptosis-related biomarkers and therapeutic targets in sepsis-induced myocardial dysfunction

BACKGROUND

Sepsis-induced myocardial dysfunction (SIMD) is a serious sepsis complication with high mortality, yet current diagnostic and therapeutic approaches remain limited. The lack of early, specific biomarkers and effective treatments necessitates exploration of novel mechanisms. Recently, cuproptosis has been implicated in various diseases, but its role in SIMD is unclear. This study aimed to identify cuproptosis-related biomarkers and potential therapeutic agents, supported by animal model validation.

METHODS

Four GEO datasets (GSE79962, GSE267388, GSE229925, GSE229298) were analyzed using Limma and WGCNA to identify overlapping genes from differentially expressed genes (DEGs), cuproptosis-related DEGs (DE-CRGs), and module-associated genes. Gene Set Enrichment Analysis (GSEA) and single-sample GSEA (ssGSEA) were performed to assess biological functions and immune cell infiltration, respectively. ceRNA and transcription factor networks were constructed to explore gene regulatory mechanisms, while consensus clustering was employed to define cuproptosis-related subtypes. Diagnostic genes were selected through SVM-RFE, LASSO, and random forest models. Additionally, potential gene-targeting agents were predicted using drug-gene interaction analysis. The findings were validated in SIMD animal models through qPCR and immunohistochemical analysis to confirm gene expression.

RESULTS

PDHB and DLAT emerged as key cuproptosis-related biomarkers. GSEA indicated upregulation of oxidative phosphorylation and downregulation of chemokine signaling. ssGSEA revealed negative correlations with several immune cell types. A ceRNA network (51 nodes, 56 edges) was constructed. Machine learning identified PDHB, NDUFA9, and TIMMDC1 as diagnostic genes, with PDHB showing high accuracy (AUC = 0.995 in GSE79962; AUC = 0.960, 0.864, and 0.984 in external datasets). Using the DSigDB database, we predicted six drugs that exhibit significant binding activity with PDHB. qPCR and immunohistochemistry confirmed reduced PDHB and DLAT expression in SIMD animal models.

CONCLUSION

This study identifies PDHB and DLAT as cuproptosis-related biomarkers, addressing the diagnostic and therapeutic gaps in SIMD by unveiling novel molecular insights for early intervention and targeted treatment.

CLINICAL TRIAL NUMBER

Not applicable.

Beyond blood transfusions: exploring iron chelation therapies in transfusion-dependent beta-thalassemia

Introduction

Abnormal hemoglobin, or hemoglobinopathy, affects about 7% of the global population. Major hemoglobinopathies like beta-thalassemia and sickle cell disease require regular blood transfusions, leading to chronic iron overload. This review examines the efficacy and safety of deferiprone, an oral iron chelator, in managing iron overload in pediatric patients with transfusion-dependent conditions.

Methods

Data were sourced from PubMed, Google Scholar, and relevant articles, focusing on randomized controlled trials (RCTs) published between 2010 and 2023. The search terms included "deferiprone," "iron chelation," "transfusion," "iron overload," "hemoglobinopathies," and "thalassemia." Three RCTs met the inclusion criteria, involving 521 pediatric patients.

Results

The START trial demonstrated that early-start deferiprone significantly reduced iron load compared to placebo, with no severe adverse events. The DEEP-2 study found deferiprone non-inferior to deferasirox in terms of efficacy and safety. Another trial highlighted the benefits of early deferiprone therapy in delaying iron overload symptoms without serious side effects. Common adverse effects included pyrexia, nasopharyngitis, and decreased neutrophil count, but no significant differences in growth parameters, creatinine, or prolactin levels were observed.

Conclusion

Deferiprone shows significant promise in managing iron overload in pediatric patients, with comparable effectiveness to existing therapies and a favorable safety profile. Its oral administration is advantageous for young children. However, long-term studies are needed to fully understand its safety and efficacy. Addressing challenges such as patient compliance and adverse effects through education, personalized medicine, and advanced monitoring techniques can further improve treatment outcomes for beta-thalassemia patients.

New Insights into Aspirin's Anticancer Activity: The Predominant Role of Its Iron-Chelating Antioxidant Metabolites

Epidemiological studies have suggested that following long-term, low-dose daily aspirin (LTLDA) administration for more than 5 years at 75-100 mg/day, 20-30% of patients (50-80 years old) had a lower risk of developing colorectal cancer (CRC) and about the same proportion in developing iron deficiency anemia (IDA). In cases of IDA, an increase in iron excretion is suspected, which is caused by aspirin chelating metabolites (ACMs): salicylic acid, salicyluric acid, 2,5-dihydroxybenzoic acid, and 2,3-dihydroxybenzoic acid. The ACMs constitute 70% of the administered aspirin dose and have much longer half-lives than aspirin in blood and tissues. The mechanisms of cancer risk reduction in LTLDA users is likely due to the ACM's targeting of iron involved in free radical damage, iron-containing toxins, iron proteins, and associated metabolic pathways such as ferroptosis. The ACMs from non-absorbed aspirin (about 30%) may also mitigate the toxicity of heme and nitroso-heme and other iron toxins from food, which are responsible for the cause of colorectal cancer. The mode of action of aspirin as a chelating antioxidant pro-drug of the ACMs, with continuous presence in LTLDA users, increases the prospect for prophylaxis in cancer and other diseases. It is suggested that the anticancer effects of aspirin depend primarily on the iron-chelating antioxidant activity of the ACMs. The role of aspirin in cancer and other diseases is incomplete without considering its rapid biotransformation and the longer half-life of the ACMs.

Resynthesis of Damaged Fe-S Cluster Proteins Protects Aspergillus fumigatus Against Oxidative Stress in the Absence of Mn-Superoxide Dismutase

The importance of manganese superoxide dismutase (Mn-SOD), an evolutionarily ancient metalloenzyme that maintains the integrity and function of mitochondria, was studied in oxidative stress-treated Aspergillus fumigatus cultures. Deletion of the Mn-SOD gene (sodB) increased both the menadione sodium bisulfite (MSB)-elicited oxidative stress and the deferiprone (DFP)-induced iron limitation stress sensitivity of the strain. Moreover, DFP treatment enhanced the MSB sensitivity of both the gene deletion mutant and the reference strain. The lack of SodB also increased the susceptibility of conidia to killing by human macrophages. Concurring with the stress sensitivity data, RNS sequencing data also demonstrated that the deletion of sodB largely altered the MSB-induced oxidative stress response. The difference between the oxidative stress responses of the two strains manifested mainly in the intensity of the response. Importantly, upregulation of "Ribosome protein", "Iron uptake", and "Fe-S cluster assembly" genes, alterations in the transcription of "Fe-S cluster protein" genes, and downregulation of "Heme binding protein" genes under MSB stress were characteristic only for the ΔsodB gene deletion mutant. We assume that the elevated superoxide level generated by MSB treatment may have destroyed Fe-S cluster proteins of mitochondria in the absence of SodB. This intensified the resynthesis of Fe-S cluster proteins, which was accompanied with enhanced translation and iron acquisition, leading to increased DFP sensitivity.

Noninvasive Ultra Low Intensity Light Photodynamic Treatment of Glioblastoma with Drug Augmentation: LoGlo PDT Regimen

This paper presents the basis for LoGlo PDT, a new treatment for glioblastoma. Glioblastoma is currently treated with maximal safe resection, temozolomide, and ionizing irradiation. Mortality in 2024 remains over 80% within several years from diagnosis. Oral 5-aminolevulinic acid (5-ALA) is an FDA/EMA approved drug that is selectively taken up by malignant cells, including by glioblastoma. In photodynamic treatment of glioblastoma, intense intraoperative light causes glioblastoma tissue that has taken up 5-ALA to generate cytotoxic reactive oxygen species. The requirement for intense light flux has restricted photodynamic treatment to a single one-hour intraoperative session. We analyze here published data showing that external light, illuminating the entire intact scalp, can attain low μW/cm2 flux several cm into intact brain that would be sufficient to mediate 5-ALA photodynamic treatment of glioblastoma if the light and 5-ALA are delivered continuously over 24 h. At the core of LoGlo PDT regimen is the dataset showing that, for a given fluence, as the duration of PDT light delivery goes down, light intensity (flux) delivered must go up to achieve the same glioblastoma cell cytotoxicity as would a weaker light (lower flux) delivered over a longer time. Thus, a repetitive, noninvasive PDT of glioblastoma using an external light source may be possible. We analyze 5-ALA cellular physiology to show that three non-oncology drugs, ciprofloxacin, deferiprone, and telmisartan, can be repurposed to increase light energy capture after 5-ALA, thereby increasing photodynamic treatment's glioblastoma cell cytotoxicity. The LoGlo PDT approach uses both drug augmentation and prolonged ultra-low noninvasive transcranial light delivery for a repetitive, noninvasive 5-ALA photodynamic treatment of glioblastoma.

Development of Nanocomposite Microspheres for Nasal Administration of Deferiprone in Neurodegenerative Disorders

Elevated brain iron levels are characteristic of many neurodegenerative diseases. As an iron chelator with short biological half-life, deferiprone leads to agranulocytosis and neutropenia with a prolonged therapeutic course. Its inclusion in sustained-release dosage forms may reduce the frequency of administration. On the other hand, when administered by an alternative route of administration, such as the nasal route, systemic exposure to deferiprone will be reduced, thereby reducing the occurrence of adverse effects. Direct nose-to-brain delivery has been raised as a non-invasive strategy to deliver drugs to the brain, bypassing the blood-brain barrier. The aim of the study was to develop and characterize nanocomposite microspheres suitable for intranasal administration by combining nano- and microparticle-based approaches. Nanoparticles with an average particle size of 213 ± 56 nm based on the biodegradable polymer poly-ε-caprolactone were developed using the solvent evaporation method. To ensure the deposition of the particles in the nasal cavity and avoid exhalation or deposition into the small airways, the nanoparticles were incorporated into composite structures of sodium alginate obtained by spray drying. Deferiprone demonstrated sustained release from the nanocomposite microspheres and high iron-chelating activity.

Iron overload: The achilles heel of β-thalassemia

Systematic transfusions coupled with iron chelation therapy have substantially improved the life expectancy of thalassemia patients in developed nations. As the human organism does not have a protective mechanism to remove excess iron, iron overload is a significant concern in thalassemia, leading to organ damage, especially in the heart and liver. Thus, iron chelation therapy is crucial to prevent or reverse organ iron overload. There are three widely used iron chelators, either as monotherapy or in combination. The choice of iron chelator depends on several factors, including local guidelines, drug availability, and the individual clinical scenario. Despite treatment advancements, challenges persist, especially in resource-limited settings, highlighting the need for improved global healthcare access. This review discusses clinical management, current treatments, and future directions for thalassemia, focusing on iron overload and its complications. Furthermore, it underscores the progress in transforming thalassemia into a manageable chronic condition and the potential of novel therapies to further enhance patient outcomes.

The Importance and Essentiality of Natural and Synthetic Chelators in Medicine: Increased Prospects for the Effective Treatment of Iron Overload and Iron Deficiency

The supply and control of iron is essential for all cells and vital for many physiological processes. All functions and activities of iron are expressed in conjunction with iron-binding molecules. For example, natural chelators such as transferrin and chelator-iron complexes such as haem play major roles in iron metabolism and human physiology. Similarly, the mainstay treatments of the most common diseases of iron metabolism, namely iron deficiency anaemia and iron overload, involve many iron-chelator complexes and the iron-chelating drugs deferiprone (L1), deferoxamine (DF) and deferasirox. Endogenous chelators such as citric acid and glutathione and exogenous chelators such as ascorbic acid also play important roles in iron metabolism and iron homeostasis. Recent advances in the treatment of iron deficiency anaemia with effective iron complexes such as the ferric iron tri-maltol complex (feraccru or accrufer) and the effective treatment of transfusional iron overload using L1 and L1/DF combinations have decreased associated mortality and morbidity and also improved the quality of life of millions of patients. Many other chelating drugs such as ciclopirox, dexrazoxane and EDTA are used daily by millions of patients in other diseases. Similarly, many other drugs or their metabolites with iron-chelation capacity such as hydroxyurea, tetracyclines, anthracyclines and aspirin, as well as dietary molecules such as gallic acid, caffeic acid, quercetin, ellagic acid, maltol and many other phytochelators, are known to interact with iron and affect iron metabolism and related diseases. Different interactions are also observed in the presence of essential, xenobiotic, diagnostic and theranostic metal ions competing with iron. Clinical trials using L1 in Parkinson's, Alzheimer's and other neurodegenerative diseases, as well as HIV and other infections, cancer, diabetic nephropathy and anaemia of inflammation, highlight the importance of chelation therapy in many other clinical conditions. The proposed use of iron chelators for modulating ferroptosis signifies a new era in the design of new therapeutic chelation strategies in many other diseases. The introduction of artificial intelligence guidance for optimal chelation therapeutic outcomes in personalised medicine is expected to increase further the impact of chelation in medicine, as well as the survival and quality of life of millions of patients with iron metabolic disorders and also other diseases.

Drug Selection and Posology, Optimal Therapies and Risk/Benefit Assessment in Medicine: The Paradigm of Iron-Chelating Drugs

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.

Iron Load Toxicity in Medicine: From Molecular and Cellular Aspects to Clinical Implications

Iron is essential for all organisms and cells. Diseases of iron imbalance affect billions of patients, including those with iron overload and other forms of iron toxicity. Excess iron load is an adverse prognostic factor for all diseases and can cause serious organ damage and fatalities following chronic red blood cell transfusions in patients of many conditions, including hemoglobinopathies, myelodyspasia, and hematopoietic stem cell transplantation. Similar toxicity of excess body iron load but at a slower rate of disease progression is found in idiopathic haemochromatosis patients. Excess iron deposition in different regions of the brain with suspected toxicity has been identified by MRI T2* and similar methods in many neurodegenerative diseases, including Alzheimer's disease and Parkinson's disease. Based on its role as the major biological catalyst of free radical reactions and the Fenton reaction, iron has also been implicated in all diseases associated with free radical pathology and tissue damage. Furthermore, the recent discovery of ferroptosis, which is a cell death program based on free radical generation by iron and cell membrane lipid oxidation, sparked thousands of investigations and the association of iron with cardiac, kidney, liver, and many other diseases, including cancer and infections. The toxicity implications of iron in a labile, non-protein bound form and its complexes with dietary molecules such as vitamin C and drugs such as doxorubicin and other xenobiotic molecules in relation to carcinogenesis and other forms of toxicity are also discussed. In each case and form of iron toxicity, the mechanistic insights, diagnostic criteria, and molecular interactions are essential for the design of new and effective therapeutic interventions and of future targeted therapeutic strategies. In particular, this approach has been successful for the treatment of most iron loading conditions and especially for the transition of thalassemia from a fatal to a chronic disease due to new therapeutic protocols resulting in the complete elimination of iron overload and of iron toxicity.