Delayed low-dose methotrexate excretion in a rheumatoid arthritis patient: A case report and literature review

RATIONALE

Low-dose methotrexate has a relatively good safety profile. However, in cases where patients with multiple risk factors, a delayed excretion has been observed, resulting in the occurrence of severe adverse reactions. It is necessary to supervise and intervene throughout the entire process of treating patients with multiple risk factors for methotrexate, and to strengthen the rational application of methotrexate.

PATIENT CONCERNS AND DIAGNOSES

A 66-year-old male patient was admitted to our hospital with rheumatoid arthritis and underlying conditions such as chronic obstructive pulmonary disease (COPD). This patient received treatment with low-dose MTX (10 mg/week) and experienced adverse reactions including anemia. He was diagnosed with methotrexate-induced bone marrow suppression.

INTERVENTIONS AND OUTCOMES

The therapeutic drug monitoring revealed that the serum drug concentration of methotrexate was at a critical level and the patient was rescue with calcium folinate and other adjuvant therapy such as transfusions of red blood cells, plasma, platelets, oral Yixuesheng tablets and Leucogen tablets. We conducted a 1-month follow-up, and there was no recurrence of bone marrow suppression and anemia.

LESSONS

To ensure rational administration of methotrexate, it is important to fully evaluate the clinical manifestations and physical condition of patients and regularly detecting the serum drug concentration of methotrexate when patients with multiple risk factors, Otherwise, even low-dose methotrexate administration may cause delayed excretion, resulting in severe adverse reactions.

TPMT and NUDT15 Variants Predict Discontinuation of Azathioprine for Myelotoxicity in Patients with Inflammatory Disease: Real-World Clinical Results

Azathioprine is used frequently to treat several inflammatory conditions. However, treatment is limited by adverse events-in particular, myelotoxicity. Thiopurine-S-methyltransferase (TPMT) and nudix hydrolase-15 (NUDT15) are enzymes involved in azathioprine metabolism; variants in the genes encoding these enzymes increase the risk for azathioprine myelotoxicity. The Clinical Pharmacogenetics Implementation Consortium (CPIC) has recommended dose adjustments based on the results of TPMT and NUDT15 genotyping. However, little is known about the importance of this genetic information in routine clinical care. We hypothesized that in patients with inflammatory diseases, TPMT and NUDT15 genotype data predict the risk of discontinuing azathioprine due to myelotoxicity. This was a retrospective cohort study in 1,403 new adult azathioprine users for the management of inflammatory conditions for whom we had genetic information and clinical data. Among patients who discontinued azathioprine, we adjudicated the reason(s). Genotyping was performed using the Illumina Infinium Expanded Multi-Ethnic Genotyping Array plus custom content. We used CPIC guidelines to determine TPMT and NUDT15 metabolizer status; patients were grouped as either: (i) poor/intermediate, or (ii) normal/indeterminate metabolizers. We classified 110 patients as poor/intermediate, and 1,293 patients as normal/indeterminate metabolizers. Poor/intermediate status was associated with a higher risk for azathioprine discontinuation due to myelotoxicity compared to normal/indeterminate metabolizers (hazard ratio (HR) = 2.90, 95% confidence interval (CI): 1.58-5.31, P = 0.001). This association remained significant after adjustment for race, age at initiation, sex, primary indication, and initial daily dose of azathioprine (adjusted HR (aHR) = 2.67, 95% CI: 1.44-4.94, P = 0.002). In conclusion, TPMT and NUDT15 metabolizer status predicts discontinuation due to myelotoxicity for patients taking azathioprine for inflammatory conditions.

Association between the genetic polymorphisms of the pharmacokinetics of anthracycline drug and myelosuppression in a patient with breast cancer with anthracycline-based chemotherapy

AIMS

Exploring the genetic polymorphisms involved in the metabolism of anthracyclines can explain the causes of individual differences in myelosuppression during anthracycline-based chemotherapy.

MAIN METHODS

By PCR and Sanger sequencing, SNP of candidate genes participating into the pharmacokinetics of anthracycline, including chemotherapeutic drug intake (SLC22A16 rs6907567), metabolism (AKR1A1 rs2088102, CBR1 rs20572) and transfer (ABCG2 rs2231142) are detected in 194 breast cancer patients undergoing anthracycline-based postoperative adjuvant chemotherapy.

KEY FINDINGS

The CBR1 rs20572 (C>T) polymorphic allele, the ABCG2 rs2231142 (G>T) polymorphic allele, or the two polymorphic allele in combination significantly reduced the risk of leukopenia (OR 0.412, 95% CI 0.187-0.905, p = 0.025) and neutropenia (OR 0.354, 95% CI 0.148-0.846, p = 0.018). Either polymorphic allele T of CBR1 rs20572, or polymorphic allele C of AKR1A1 rs2088102 combined with the presence of both ABCG2 rs2231142(G>T) and SLC22A16 rs6907567(A>G) mutations were at extremely low risk of severe anemia of grades 3 and 4 (OR 0.058, 95% CI 0.006-0.554, p = 0.008, OR 0.065, 95% CI 0.006-0.689, p = 0.022, OR 0.037, 95% CI 0.004-0.36, p = 0.015, respectively).

SIGNIFICANCE

These results suggested CBR1 rs20572, ABCG2 rs2231142, SLC22A16 rs6907567 and AKR1A1 rs2088102 might be potential protective factors for the reduction of hematologic toxicity incidence during anthracycline-based chemotherapy in breast cancer patients.

Traditional Chinese medicine on treating myelosuppression after chemotherapy: A protocol for systematic review and meta-analysis

BACKGROUND

Myelosuppression after chemotherapy is a common adverse reaction in the process of chemotherapy, mainly manifested as anemia, increased risk of bleeding, infection, the results seriously affect the quality of life and prognosis of patients, become the main cause of death. Since ancient times, traditional Chinese medicine (TCM) has been widely used in East Asia (such as China, Japan, South Korea) in the clinical treatment of bone marrow suppression after chemotherapy, which plays the role of synergism, toxicity reduction, immune regulation, and gradually developed into an indispensable role. Therefore, the purpose of this study was to use a network meta-analysis to evaluate the evidence that traditional Chinese medicine is related to the efficacy and safety of chemotherapy-induced myelosuppression.

METHODS

This study will search the following Chinese and English databases electronically: 4 Chinese literature databases, including China biology and medicine database, China National Knowledge Infrastructure, VIP, and Wan fang database, and 3 British literature databases including PubMed, EMBASE, and Cochrane Library. The search keywords were (traditional Chinese medicine or medicinal plants or extracts of traditional Chinese medicine or traditional Chinese medicine formula or preparation) and (myelosuppression after chemotherapy) and (randomized controlled trials) (RCTs). The search time limit is set to December 2020, and Chinese and English languages will be included. The included subjects must be diagnosed with myelosuppression after chemotherapy and RCTs should be conducted at the same time. The main outcome was elevated hemoglobin, platelets, leukocytes, and neutrophils. The secondary results were reticulocyte absolute value, reticulocyte percentage, low-fluorescence reticulocyte red, medium-fluorescent reticulocyte red, and high-fluorescence reticulocyte red. We will conduct a risk and quality assessment of the included studies using the Cochrane tool, and carefully calculate data synthesis after meta-analysis using Rev Man software (version 5.3.5) and R software (version 3.6.1).

RESULTS

The study is aim to evaluate the efficacy and safety of the treatment that traditional Chinese medicine for myelosuppression after chemotherapy.

CONCLUSION

This study of the meta-analysis could provide evidence for clinicians and help patients to make a better choice.

INPLASY REGISTRATION NUMBER

INPLASY2020120097.

Hematopoietic effects of Azadirachta indica methanolic extract in cyclophosphamide mediated myelosuppressed albino rat

Myelosuppression or bone marrow suppression is one of the most common side effects caused by anti-cancer drugs. Certain nonsteroidal anti-inflammatory drugs (NSAIDs), antibiotics and viruses like B19 virus can also cause bone marrow suppression resulting in serious consequences like leukopenia, anemia and thrombocytopenia. Currently, it is mainly treated by Filgrastim, use of which is not without side effects. Certain natural drugs can be a safer alternative to treat myelosuppression. Azadirachta indica, commonly known as Neem, is an important medicinal plant of subcontinent. Keeping in view the traditional uses of Neem, present study aims to investigate its potential role in reversing myelosuppression. Albino rats were used to determine hematopoietic activity of Neem leaves after inducing myelosuppression by cyclophosphamide given subcutaneously. Filgrastim was used as reference standard to compare the antimyelosuppressant activity of the drug. The drug was evaluated in three doses i.e. 50mg/kg, 100mg/kg and 200mg/kg body weight, while blood samples were drawn on 0, 1st, 7th, 14th and 21st day. The drug was found to be effective in reversing bone marrow suppression in all three doses based on the hematological parameters (mean WBC, RBC, platelets, Hb, Hct etc.) which improved significantly. The results suggest that the drug can be used as antimyelosuppressant after establishing its safety and identifying its active constituents with their mechanism of action.

Evaluation of adverse events associated with filgrastim originator and biosimilar using a spontaneous reporting system database

Biosimilar products of filgrastim have become available for improved sustainability of cancer care; however, the real-world safety profile remains unknown. The purpose of this study was to clarify the adverse events associated with filgrastim originator and its biosimilar using the Japanese Adverse Drug Event Report (JADER) database. Adverse event reports submitted to the Pharmaceuticals and Medical Devices Agency between 2014-2018 were extracted. We calculated the reporting odds ratio and 95% confidence interval for each adverse event. We obtained 584 reports of adverse events associated with filgrastim originator and 102 reports with its biosimilar. Signals were detected for bone marrow failure and febrile neutropenia with both filgrastim originator and its biosimilar; whereas those for drug resistance and hypoxia only involved filgrastim originator, and those for interstitial lung disease only involved its biosimilar. The safety profiles of filgrastim originator and its biosimilar were partly different. Further studies are needed to confirm these findings.

Low-Intensity Pulsed Ultrasound Relieves Mild and Severe Myelosuppression Induced by Cyclophosphamide in Rabbits

OBJECTIVE

This study aimed to investigate the effect of low-intensity pulsed ultrasound (LIPUS) on cyclophosphamide (CTX)-induced rabbit myelosuppression.

METHODS

Rabbits (n = 90) were randomly divided into a mild myelosuppression group (n = 40), a severe myelosuppression group (n = 40), and a normal control group (group Cu₂₈ ; n = 10). The mild and severe myelosuppression models were established by daily ear vein injection of 15- and 40-mg/kg CTX for 4 continuous days, respectively. Then they were randomly divided into LIPUS groups (A_u and B_u ) and control groups (A_c and B_c ). LIPUS was applied once per day for 20 minutes for 7 (A_u7 and B_u7 ) and 28 (A_u28 and B_u28 ) days. Physical conditions, mortality, blood cell counts, and bone marrow proliferation were calculated. Erythropoietin interleukin 3, and granulocyte-macrophage colony-stimulating factor levels were measured by an enzyme-linked immunosorbent assay. Flow cytometry was used to detect the granulocyte phagocytosis rate. Hematoxylin-eosin staining was performed to analyze changes of skin and muscle.

RESULTS

Compared with the control group, LIPUS improved the number of peripheral blood cells (P < .05) and bone marrow nucleated cells and reduced the mortality of rabbits with myelosuppression of different degrees. Long-term treatment for 28 days had no effect on the levels of erythropoietin, interleukin 3, and granulocyte-macrophage colony-stimulating factor and granulocyte phagocytosis (P > .05). The parts of the skin where LIPUS was applied did not show any burning marks, and the muscle tissue in the path of LIPUS acoustic channels showed no obvious pathologic changes.

CONCLUSIONS

Low-intensity pulsed ultrasound is a safe and effective method to relieve CTX-induced myelosuppression.

Severe bone marrow suppression due to methotrexate toxicity following aceclofenac-induced acute kidney injury

Methotrexate is one of the most commonly used drugs in autoimmune disorders like rheumatoid arthritis. Gastrointestinal symptoms like nausea and stomatitis, skin rashes, alopecia, central nervous system symptoms like headache and confusion, hepatotoxicity and myelosuppression are some of the adverse effects. However, low oral doses on a weekly basis seldom show any signs of toxicity. Leucovorin or folinic acid is given along with methotrexate as rescue to reduce the toxic effects like bone marrow suppression. Non-steroidal anti-inflammatory drugs, like aceclofenac, are also used in chronic inflammatory conditions like rheumatoid arthritis and osteoarthritis. Nephrotoxicity is one of the adverse effects of both methotrexate and non-steroidal anti-inflammatory drugs; and its combined administration should be done with caution. This is a case of an elderly woman, a known case of rheumatoid arthritis, who presented in severe bone marrow suppression due to methotrexate toxicity following aceclofenac-induced acute kidney injury.

Combination Chemiotherapy with 5-(3,3 dimethyl-1-triazeno) imidazole-4-carboxamide (DTIC; NSC-45388), 1,3-bis (2-chloroethyl)-1-nitrosourea (BCNU; NSC-409962) and Vincristine (VCR; NSC - 67574) in Metastatic Malignant Melanoma

The toxic and therapeutic effects obtained with a triple drug combination (BCNU, DTIC and VCR) administered in a cyclic fashion to 41 unselected evaluable patients with metastatic malignant melanoma are reported. Side effects were moderate and reversible. The overall regression rate was 44% without difference between males and females. Partial remission (> 50%) plus complete remission was 19.5% with an average duration of 5.1 months (1–20+). With the exclusion of bone lesions, all types of metastases showed regression especially those located in the soft tissues (lymph nodes and skin). The actuarial analysis of survival shows that responders live twice as long as non responders (median survival 12 months versus 6 months). However, the superior therapeutic efficacy of BCNU + DTIC + VCR over DTIC alone in metastatic melanoma remains to be demonstrated. A controlled study with different triple combinations is now in progress.

Dose Intensification of Chemotherapy in Advanced Breast Cancer: A Feasibility Phase II Study

Aims and background

Dose intensification of chemotherapy is associated with increased response rates in advanced breast cancer. Achievement of dose incrementation is usually limited by drug-dependent bone marrow toxicity. The recent availability of recombinant human colony-stimulating factors (CSFs) have made it possibile to evaluate their potential in ameliorating chemoterapy-induced myelosuppression. The aim of this study was to evaluate tolerability and effectiveness of an intensified mitoxantrone, methotrexate and mitomycin-C (3M) regimen, given with G-CSF support in patients with advanced breast cancer (ABC).

Study design

Twenty-eight eligible patients with advanced breast cancer were treated with mitomycin -C (7 mg/sqm iv every 4 weeks), methotrexate (35 mg/sqm iv) and mitoxantrone (7 mg/sqm iv every 2 weeks) for 6 cycles. Recombinant human granulocyte colony-stimulating factor (r-HuG-CSF, Filgrastim) (5 μg/kg/day) was given subcutaneously from day 2 to day 12 after each chemotherapy administration to prevent leukopenia.

Results

Of the 27 evaluable patients, 4 had complete response and 14 achieved partial response; the overall response rate was 63% (95% Cl; 46.8%-82.2%). The median duration of response was 8 months (range, 4-13+). Chemotherapy-related toxicity was mild: only 3 out of 163 courses had to be postponed due to myelotoxicity.

Conclusions

The 3M regimen given at 2- week intervals is a feasible, active and well toleratel treatment in patients not previously treated for metastatic breast cancer.

4-Demethoxydaunorubicin Administered Orally in Advanced Breast Cancer

Twenty-five patients with advanced breast cancer were treated with 4-demethoxydaunorubicin (4-DMDR), a new antitumor analogue of daunorubicin, at the dose of 15-20 mg/m2/day X 3 days by oral route every 3-4 weeks. All patients were previously treated with chemotherapy and/or hormone therapy but none with anfhracyclines. Of 23 evaluable patients, 1 complete and 5 partial remissions (26%) were observed for a median duration of 4+ months. Leukopenia and nausea occurred in 61% of the patients, vomiting in 30%, diarrhea in 17% and alopecia in 43%. There were 2 cases with minimal and transient EKG variations. 4-DMDR, administered orally in advanced breast cancer, was found to be generally well tolerated. Nevertheless, randomized trials with adriamycin or epirubicin are necessary to compare and to define the therapeutic activity and the toxicity of 4-DMDR.

A Phase II Clinical Trial of Flutamide in the Treatment of Advanced Breast Cancer

An antiandrogenic agent flutamide was used in the treatment of one male and 14 female postmenopausal breast cancer patients. Only a mild and transient response was seen in 2 female patients. Therefore, flutamide cannot be used solely in the treatment of female postmenopausal breast cancer.

Phase II Study of a 5-Fluorouracil, Teniposide and Mitomycin-C Combination Chemotherapy in Advanced Colorectal Carcinomas

Fifteen patients (median age 62, with a mean Karnofsky performance status of 70%) presenting with advanced colorectal carcinoma were included in the study. The treatment combination consisted of 5-fluorouracil (800 mg/m2 in a 30 min infusion, days 1 and 8), teniposide (80 mg/m2 in i.v. push, day 1), and mitomycin-C (10 mg/m2 in i.v. push, day 1); therapy was resumed every 29 days. A partial objective response (for 4 months) was noted in one patient who had received no prior chemotherapy; the overall median survival of the 15 patients was 5 months. Toxicity was acceptable, with leukopenia (1 case), mucositis (1 case) and diarrhea (1 case), leading to drug dose reduction. Chemotherapy was stopped once owing to severe hematologic toxicity. With the doses and schedule used, the drug combination appears to have minimal activity in advanced colorectal cancer.

Weekly Multi-agent Chemotherapy (CMF-b) for Advanced Non-melanoma Skin Cancer

BACKGROUND/AIM

Advanced unresectable and metastatic non-melanoma skin cancers (NMSC) are rare, but often arise in elderly patients. When surgery or irradiation are no longer feasible, chemotherapy is often precluded by the patient's age and comorbidities. Whether low-dose multi-agent chemotherapy could be an alternative for this vulnerable population in an outpatient setting was the issue examined in this retrospective analysis.

PATIENTS AND METHODS

Twenty-six patients with advanced unresectable or metastatic NMSC received weekly multi-agent chemotherapy with carboplatin at an area under the curve of 2 or 40 mg total dose of cisplatin, with 15 IU total dose of bleomycin, 40 mg total dose of methotrexate, and 500 mg total dose of 5-fluorouracil (CMF-b) until best response, toxicity, or progression of their disease.

RESULTS

Twenty-four patients were treated as outpatients; two were hospitalized. Twenty-three patients were previously treated with surgery or radiotherapy. The median age was 68 years (range=44-100 years). The median number of cycles was 6 (range=1 to 17). The overall response rate was 61.5% (seven complete remissions, nine partial remissions) for the entire cohort and 63.6% (two complete remissions and five partial remissions) for patients >80 years. The median duration of response was 6.1 months (range=1.6-63 months). Responses longer than 6 months were obtained in 11/26 (42.3%) of the entire cohort and in 4/11 (36.3%) patients >80 years. Symptom improvement was observed in 17 patients (65.3%). Toxicity was acceptable, with grade 3 renal failure (n=1) and grade 3 or 4 myelotoxicity (n=2).

CONCLUSION

CMF-b is a safe, weekly low-dose multi-agent regimen that offers palliation for vulnerable patients with NMSC.

Human Immunodeficiency Virus: Adolescent Emergencies

Many adolescents are at high risk for HIV infection, and those who are infected or at-risk commonly present to the ED, often as their only or frequent source of care. It is important to consider routine screening and to have a high index of suspicion for AHI in this setting. If a diagnosis of HIV infection is made, immediate linkage to care with a specialist in adolescent and young adult HIV infection should be prioritized. For the known HIV-infected patient, management must consider unique possibilities of OIs, IRIS, and medication side effects. For any patient on ART, drug-drug interactions must be noted as part of any treatment plan. If a young person presents with a recent sexual or needlestick exposure of concern, every effort to prescribe and ensure follow-up for PEP should be made. It is essential for physicians to understand and comply with local regulations regarding HIV testing and adolescents' rights for associated confidential care. Finally, physicians who see adolescents in acute care settings have a tremendous opportunity to make a difference in ensuring improved health outcomes for youth living with HIV and to prevent new infections.

Comparison of different platelet count thresholds to guide administration of prophylactic platelet transfusion for preventing bleeding in people with haematological disorders after myelosuppressive chemotherapy or stem cell transplantation

BACKGROUND

Platelet transfusions are used in modern clinical practice to prevent and treat bleeding in people who are thrombocytopenic due to bone marrow failure. Although considerable advances have been made in platelet transfusion therapy in the last 40 years, some areas continue to provoke debate, especially concerning the use of prophylactic platelet transfusions for the prevention of thrombocytopenic bleeding.This is an update of a Cochrane review first published in 2004, and previously updated in 2012 that addressed four separate questions: prophylactic versus therapeutic-only platelet transfusion policy; prophylactic platelet transfusion threshold; prophylactic platelet transfusion dose; and platelet transfusions compared to alternative treatments. This review has now been split into four smaller reviews looking at these questions individually; this review compares prophylactic platelet transfusion thresholds.

OBJECTIVES

To determine whether different platelet transfusion thresholds for administration of prophylactic platelet transfusions (platelet transfusions given to prevent bleeding) affect the efficacy and safety of prophylactic platelet transfusions in preventing bleeding in people with haematological disorders undergoing myelosuppressive chemotherapy or haematopoietic stem cell transplantation (HSCT).

SEARCH METHODS

We searched for randomised controlled trials (RCTs) in the Cochrane Central Register of Controlled Trials (CENTRAL) (Cochrane Library 2015, Issue 6, 23 July 2015), MEDLINE (from 1946), Embase (from 1974), CINAHL (from 1937), the Transfusion Evidence Library (from 1950), and ongoing trial databases to 23 July 2015.

SELECTION CRITERIA

We included RCTs involving transfusions of platelet concentrates, prepared either from individual units of whole blood or by apheresis, and given to prevent bleeding in people with haematological disorders (receiving myelosuppressive chemotherapy or undergoing HSCT) that compared different thresholds for administration of prophylactic platelet transfusions (low trigger (5 x 10(9)/L); standard trigger (10 x 10(9)/L); higher trigger (20 x 10(9)/L, 30 x 10(9)/L, 50 x 10(9)/L); or alternative platelet trigger (for example platelet mass)).

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane.

MAIN RESULTS

Three trials met our predefined inclusion criteria and were included for analysis in the review (499 participants). All three trials compared a standard trigger (10 x 10(9)/L) versus a higher trigger (20 x 10(9)/L or 30 x 10(9)/L). None of the trials compared a low trigger versus a standard trigger or an alternative platelet trigger. The trials were conducted between 1991 and 2001 and enrolled participants from fairly comparable patient populations.The original review contained four trials (658 participants); in the previous update of this review we excluded one trial (159 participants) because fewer than 80% of participants had a haematological disorder. We identified no new trials in this update of the review.Overall, the methodological quality of the studies was low across different outcomes according to GRADE methodology. None of the included studies were at low risk of bias in every domain, and all the included studies had some threats to validity.Three studies reported the number of participants with at least one clinically significant bleeding episode within 30 days from the start of the study. There was no evidence of a difference in the number of participants with a clinically significant bleeding episode between the standard and higher trigger groups (three studies; 499 participants; risk ratio (RR) 1.35, 95% confidence interval (CI) 0.95 to 1.90; low-quality evidence).One study reported the number of days with a clinically significant bleeding event (adjusted for repeated measures). There was no evidence of a difference in the number of days of bleeding per participant between the standard and higher trigger groups (one study; 255 participants; relative proportion of days with World Health Organization Grade 2 or worse bleeding (RR 1.71, 95% CI 0.84 to 3.48, P = 0.162; authors' own results; low-quality evidence).Two studies reported the number of participants with severe or life-threatening bleeding. There was no evidence of any difference in the number of participants with severe or life-threatening bleeding between a standard trigger level and a higher trigger level (two studies; 421 participants; RR 0.99, 95% CI 0.52 to 1.88; low-quality evidence).Only one study reported the time to first bleeding episode. There was no evidence of any difference in the time to the first bleeding episode between a standard trigger level and a higher trigger level (one study; 255 participants; hazard ratio 1.11, 95% CI 0.64 to 1.91; low-quality evidence).Only one study reported on all-cause mortality within 30 days from the start of the study. There was no evidence of any difference in all-cause mortality between standard and higher trigger groups (one study; 255 participants; RR 1.78, 95% CI 0.83 to 3.81; low-quality evidence).Three studies reported on the number of platelet transfusions per participant. Two studies reported on the mean number of platelet transfusions per participant. There was a significant reduction in the number of platelet transfusions per participant in the standard trigger group (two studies, mean difference -2.09, 95% CI -3.20 to -0.99; low-quality evidence).One study reported on the number of transfusion reactions. There was no evidence to demonstrate any difference in transfusion reactions between the standard and higher trigger groups (one study; 79 participants; RR 0.07, 95% CI 0.00 to 1.09).None of the studies reported on quality of life.

AUTHORS' CONCLUSIONS

In people with haematological disorders who are thrombocytopenic due to myelosuppressive chemotherapy or HSCT, we found low-quality evidence that a standard trigger level (10 x 10(9)/L) is associated with no increase in the risk of bleeding when compared to a higher trigger level (20 x 10(9)/L or 30 x 10(9)/L). There was low-quality evidence that a standard trigger level is associated with a decreased number of transfusion episodes when compared to a higher trigger level (20 x 10(9)/L or 30 x 10(9)/L).Findings from this review were based on three studies and 499 participants. Without further evidence, it is reasonable to continue with the current practice of administering prophylactic platelet transfusions using the standard trigger level (10 x 10(9)/L) in the absence of other risk factors for bleeding.

Meta-Analysis of Doxorubicin-Eluting Beads via Transcatheter Arterial Chemoembolization in the Treatment of Unresectable Hepatocellular Carcinoma

BACKGROUND/AIMS

To evaluate the efficacy and safety of doxorubicin-eluting beads combined with transcatheter arterial chemoembolization (DEB-TACE) compared with conventional TACE (cTACE).

METHODOLOGY

PubMed, EMBASE, MEDLINE and Cochrane Controlled Trials Register were searched for articles published to identify randomized controlled trials evaluating efficacy and side effects between DEB-TACE and cTACE. The RR (relative risk) with a 95% confidence interval (CI) was calculated by the Revman 5.0 software.

RESULTS

Totally 4 studies, including 527 patients, compared the efficacy and safety of DEB-TACE with cTACE. The DEB-TACE achieved fewer side effects in alopecia (p = 0.0002, RR = 0.05, 95% CI: 0.01-0.24) and myelosuppression (p = 0.009, RR = 0.32, 95% CI: 0.14-0.75). Meanwhile, there was no significant difference in efficacy evaluation including complete response (p = 0.16, RR = 1.36, 95% CI: 0.89-2.08), partial response (p = 0.48, RR = 1.14, 95% CI: 0.80-1.62), stable disease (p = 0.73, RR = 0.93,95% CI: 0.60-1.40), progressive disease (p 0.19, RR = 0.80, 95% CI: 0.56-1.12), objective response (p = 0.26, RR 0.91, 95% CI: 0.48-1.72) and disease control (p = 0.05, RR = 1.18, 95% CI: 1.00-1.39).

CONCLUSIONS

DEB-TACE shows similar therapeutic efficacy to cTACE method and fewer adverse events.

SUCCINCT: an open-label, single-arm, non-randomised, phase 2 trial of gemcitabine and cisplatin chemotherapy in combination with sunitinib as first-line treatment for patients with advanced urothelial carcinoma

Gemcitabine and cisplatin chemotherapy (GC regimen) represents a standard treatment for advanced urothelial carcinoma. We performed an open-label, single-arm, non-randomised, phase 2 trial evaluating the addition of sunitinib to standard GC chemotherapy (SGC regimen). Overall, 63 treatment-naïve participants were recruited and received up to six 21-d cycles of cisplatin 70 mg/m2 (intravenously [IV], day 1) and gemcitabine 1000 mg/m2 (IV, days 1 and 8) combined with sunitinib 37.5 mg (orally, days 2-15). Following review of toxicity after the first six patients, the sunitinib dose was reduced to 25 mg for all patients. Overall response rate was 64%, with response noted in 37 of 58 patients. At 6 mo, 30 of 58 assessable patients (52%; 90% confidence interval [CI], 40-63%) were progression free. Median overall survival was 12 mo (95% CI, 9-15) and was heavily influenced by Bajorin prognostic group. Grade 3-4 toxicities were predominantly haematologic and limited the deliverability of the triple SGC regimen. The trial did not meet its prespecified primary end point of >60% patients progression free at 6 mo. Cumulative myelosuppression led to treatment delays of gemcitabine and cisplatin and dose reduction and/or withdrawal of sunitinib in the majority of cases. The triple-drug combination was not well tolerated. Phase 3 evaluation of the triple SGC regimen in advanced transitional cell carcinoma is not recommended.

PATIENT SUMMARY

The addition of sunitinib to standard cisplatin and gemcitabine chemotherapy was poorly tolerated and did not improve outcomes in advanced urothelial carcinoma. Treatment delivery was limited by myelotoxicity.

[Adjuvant function of guilu erxian glue cataplasm in treating carcinoma of the large intestine patients with myelosuppression after chemotherapy: a clinical observation]

OBJECTIVE

To observe the clinical effect of Guilu Erxian Glue Cataplasm (GEGC) on carcinoma of the large intestine patients with myelosuppression after chemotherapy, and further to confirm its efficiency and safety.

METHODS

Totally 60 patients with carcinoma of the large intestine were randomly assigned to two groups. Meanwhile, they all accepted FOLFIRI chemotherapy. Patients in the treatment group were additionally applied at Shenque (RN8), exchanging once per every other day, for 14 successive days. Patients in the control group took placebos with the same dose and dosage as the treatment group. The blood cell counts (WBC, NE, and PLT) were detected before chemotherapy, at day 7, 10, and 14. The TCM symptoms integrals, Karnofsky performance score (KPS), liver and kidney functions were observed before chemotherapy, at day 7 and day 14. Adverse skin reactions were observed each day. And the usage of hematopoietic growth factors was recorded.

RESULTS

(1) The KPS score at day 7 was more stable in the treatment group than in the control group; the WBC and NE counts in the peripheral blood at day 14 were higher in the treatment group than in the control group; and TCM symptoms integrals at day 14 was lower in the treatment group than in the control group, all with statistical difference (P < 0.05). (2) Compared with the control group, the PLT count was higher in the treatment group than in the control group, the usage of rhG-CSF and antibiotics was less in the treatment group than in the control group, all with no statistical difference (P > 0.05). (3) No obvious adverse reactions such as liver injury, renal injury, or skin allergy were observed.

CONCLUSIONS

Adjuvant treatment of GEGC could improve carcinoma of the large intestine patients with myelosuppression to some extent. No relevant adverse reactions were found.

The inhibition of subchondral bone lesions significantly reversed the weight-bearing deficit and the overexpression of CGRP in DRG neurons, GFAP and Iba-1 in the spinal dorsal horn in the monosodium iodoacetate induced model of osteoarthritis pain

BACKGROUND

Chronic pain is the most prominent and disabling symptom of osteoarthritis (OA). Clinical data suggest that subchondral bone lesions contribute to the occurrence of joint pain. The present study investigated the effect of the inhibition of subchondral bone lesions on joint pain.

METHODS

Osteoarthritic pain was induced by an injection of monosodium iodoacetate (MIA) into the rat knee joint. Zoledronic acid (ZOL), a third generation of bisphosphonate, was used to inhibit subchondral bone lesions. Joint histomorphology was evaluated using X-ray micro computed tomography scanning and hematoxylin-eosin staining. The activity of osteoclast in subchondral bone was evaluated using tartrate-resistant acid phosphatase staining. Joint pain was evaluated using weight-bearing asymmetry, the expression of calcitonin gene-related peptide (CGRP) in the dorsal root ganglion (DRG), and spinal glial activation status using glial fibrillary acidic protein (GFAP) and ionized calcium binding adaptor molecule-1 (Iba-1) immunofluorescence. Afferent neurons in the DRGs that innervated the joints were identified using retrograde fluorogold labeling.

RESULTS

MIA injections induced significant histomorphological alterations and joint pain. The inhibition of subchondral bone lesions by ZOL significantly reduced the MIA-induced weight-bearing deficit and overexpression of CGRP in DRG neurons, GFAP and Iba-1 in the spinal dorsal horn at 3 and 6 weeks after MIA injection; however, joint swelling and synovial reaction were unaffected.

CONCLUSIONS

The inhibition of subchondral bone lesions alleviated joint pain. Subchondral bone lesions should be a key target in the management of osteoarthritic joint pain.

[Review of evidence of thalidomide and lenalidomide in different hematological diseases: chronic lymphocytic leukemia, primary amyloidosis, myelofibrosis and syndrome myelodysplastic]

Lenalidomide is an immunomodulatory drug approved by the AEMPS and the EMA, in combination with dexamethasone, for the treatment of multiple myeloma in adult patients who have received at least one prior therapy. Moreover, it has recently been approved for the treatment of patients with transfusion-dependent anaemia due to low- or intermediate-1-risk myelodysplastic syndromes associated with an isolated deletion 5q cytogenetic abnormality when other therapeutic options are insufficient or inadequate. It has also shown to be active in other hematologic and no hematologic diseases. Growing evidence of its use entails a challenge when situating the drug in a cost-effective way to treat these diseases. On this article we review the available evidence on the use of lenalidomide in the second line treatment of patients with chronic lymphocytic leukemia, primary amyloidosis and primary myelofibrosis, and in the first line treatment of patients with myelodysplastic syndrome, and also the evidence of other immunomodulators. Different clinical practice guidelines and scientific evidence portals consider lenalidomide a valid alternative in the first-line treatment of patients with myelodysplastic syndromes, specially those with the deletion of 5q, and in second line for patients with chronic lymphocytic leukemia. However, the available evidence of lenalidomide in the treatment of patients with primary amyloidosis and primary myelofibrosis is limited, ant thus is not considered as the first choice treatment. In any case, the treatment of choice should consider the safety profile in each patient, the previous treatments that has received and the own therapeutic protocols of each center.

Timed-sequential chemotherapy as induction and/or consolidation regimen for younger adults with acute myelogenous leukemia

Increasing the intensity of induction chemotherapy has generated considerable recent interest in the treatment of acute myeloid leukemia. Achieving complete remission is a sine qua non condition for prolonged disease-free survival and may affect long-term outcome. In this setting, administering a repeat course of induction shortly after completion of the first course, known as timed-sequential chemotherapy (TSC), has been tested and may lead to an improved long-term outcome. Whether these results are due to the biologic recruitment of cell cycle-specific agents is unknown. However, this strategy to intensify induction may lead to more profound myelosuppression and to potential toxicities. Here we review the results of timed-sequential chemotherapy, used as induction regimen in de novo, relapsed or refractory AML or used as post-remission therapy, and compare them with those from other types of regimens.

Should we test TPMT enzyme levels before starting azathioprine?

Thiopurine methyltransferase (TPMT) is the main enzyme responsible for inactivating toxic products of azathioprine (AZA) metabolism. Patients with homozygous deficiency of this enzyme have no enzyme activity and ideally should not be given AZA. Patients with heterozygous deficiency have 50% of enzyme activity and have been shown to respond well and tolerate half a standard dose. We describe a patient with homozygous deficiency of TPMT who developed life threatening neutropenic sepsis, and advocate that all patients should be tested for TPMT activity prior to starting AZA therapy.

Understanding, recognizing, and managing toxicities of targeted anticancer therapies

Answer questions and earn CME/CNE Advances in genomics and molecular biology have identified aberrant proteins in cancer cells that are attractive targets for cancer therapy. Because these proteins are overexpressed or dysregulated in cancer cells compared with normal cells, it was assumed that their inhibitors will be narrowly targeted and relatively nontoxic. However, this hope has not been achieved. Current targeted agents exhibit the same frequency and severity of toxicities as traditional cytotoxic agents, with the main difference being the nature of the toxic effects. Thus, the classical chemotherapy toxicities of alopecia, myelosuppression, mucositis, nausea, and vomiting have been generally replaced by vascular, dermatologic, endocrine, coagulation, immunologic, ocular, and pulmonary toxicities. These toxicities need to be recognized, prevented, and optimally managed.

In vitro and in vivo immunomodulatory activities of iridoids fraction from Barleria prionitis Linn

ETHNOPHARMACOLOGICAL RELEVANCE

Barleria prionitis Linn. (Family: Acanthaceae), one of the important Ayurvedic medicinal plant in India, has long been used to treat variety of ailments including swellings, gout, arthritic and rheumatic disorders, nervine and skin diseases, and also acts as immunorestorative.

AIM OF THE STUDY

The present study was aimed to explore in vitro and in vivo immunomodulatory activities of the iridoids fraction i.e. n-butanol fraction of methanol extract from Barleria prionitis aerial parts (IFBp).

MATERIALS AND METHODS

IFBp was studied for in vitro [nitroblue tetrazolium (NBT) test and neutrophils candidacidal assay] and in vivo immunomodulatory activity on cellular and humoral immune responses to the antigenic challenge by sheep red blood cells (SRBCs) and by neutrophil adhesion test, phagocytic activity and cyclophosphamide-induced myelosuppression. The study comprised the preliminary phytochemical screening, HPTLC standardization and maximum tolerable dose determination of IFBp.

RESULTS

IFBp (50, 100 and 200μg/ml) significantly (P≤0.01) increased the intracellular killing activity of stimulated neutrophils assayed by in vitro NBT reduction test and neutrophils candidacidal assay. Pretreatment of IFBp (100 and 200mg/kg; p.o.) evoked a significant increase in percent neutrophils and neutrophils adhesion to nylon fibres. Oral administration of IFBp augmented the humoral immune response to SRBCs, evidenced by increase in antibody titres and dose dependently potentiated the delayed-type hypersensitivity reaction induced by SRBCs in mice. IFBp potentiated significantly (P≤0.01) the macrophage phagocytic activity and ameliorated the red blood cells, total white blood cells and platelets count and haemoglobin concentration, and also restored the myelosuppressive effects induced by cyclophosphamide. The content (% w/w; mean±SD, n=3) of main iridoids i.e. shanzhiside methyl ester and barlerin was found to be 21.55±2.40 and 10.03±1.69 in IFBp of BP, respectively.

CONCLUSION

The present investigation reveals that IFBp is a potent immunostimulant, stimulating both the specific and non-specific immune mechanisms.

[Role of pharmacokinetic monitoring of serum fluorouracil concentration in patients with local advanced and metastatic colorectal cancer and further improving efficacy of fluorouracil-based chemotherapy]

OBJECTIVE

To investigate the relationship between serum concentration of fluorouracil and therapeutic efficacy as well as adverse reactions in patients with unresectable locally advanced or measurable metastatic colorectal cancer, and to analyze its role in further improving therapeutic efficacy and reducing adverse reactions of fluorouracil-based chemotherapy.

METHODS

Eighty-six patients were randomly assigned into three groups according to the average plasma concentration of fluorouracil after three cycles of chemotherapy with the initial regimen of two weeks FOLFOX-4 (oxaliplatin + leucovorin + fluorouracil) or FOLFIRI (irinotecan + leucovorin + fluorouracil): group 1 (plasma concentration of fluorouracil < 25 ng/ml), group 2 (25 - 35 ng/ml) and group 3 (> 35 ng/ml). The blood samples were taken at 12 h after continuous infusion of fluorouracil in each cycle and the plasma concentration of fluorouracil was detected by high performance liquid chromatography (HPLC) (about 5 am ± 1 h). The relationship between the drug plasma concentration, therapeutic efficacy and adverse reactions in different fluorouracil plasma concentration arms was analyzed retrospectively.

RESULTS

The average plasma concentrations of fluorouracil of the three groups were (23.48 ± 1.95) ng/ml, (31.47 ± 2.33) ng/ml and (39.89 ± 3.87) ng/ml, respectively (P < 0.01). As for therapeutic efficacy, the median OS of the groups 2 and 3 were 18.0 and 17.5 months, significantly higher than that in the group 1 (13.0 months, P < 0.01). The PFS were 4.5, 7.5 and 8.0 months, respectively (P < 0.01). In terms of adverse reactions, the incidences of bone marrow suppression, mucositis and diarrhea in the group 3 were significantly higher than that in the first two groups (P = 0.02, P = 0.04 and P = 0.02).

CONCLUSIONS

The patients with local advanced and metastatic colorectal cancer, receiving fluorouracil-based chemotherapy, and with an average plasma concentration of fluorouracil between 25 - 35 mg/L have a better prognosis, and lower incidence of adverse reactions such as bone marrow suppression, mucositis and diarrhea.

[Analysis of relative factors of bone marrow suppression after chemotherapy with carboplatin and paclitaxel on the patients with ovarian cancer]

OBJECTIVE

To analyze the relative factors of bone marrow suppression after chemotherapy with different-dose carboplatin and paclitaxel (TC) on the patients with ovarian cancer.

METHODS

Sixty-two patients with ovarian cancer admitted in Beijing Obstetrics and Gynecology Hospital from January 2002 to December 2007, using TC regimen, a total of 196 cycles of chemotherapy, were divided into two groups by the doses of carboplatin [area under concentration-time curve (AUC) 4 - 6 for low-dose, AUC > 6 - 7 for hight-dose, the carboplatin dose calculated with AUC] or by the doses of paclitaxel (135- < 150 mg/m(2) low-dose, 150 - 175 mg/m(2) hight-dose). After each TC cycle, the routine blood was test to determine the graduation of the marrow suppression, and then the correlation factors were analyzed with logistic regression.

RESULTS

(1) The occurrence rate of bone marrow suppression: there were 159 cycles (81.1%) grade 0-II bone marrow suppression, while 37 cycles (18.9%) of grade III-IV. (2) Factors related to bone marrow suppression: the results shown that there were not related to bone marrow suppression, which incluced cellular differentiation, tumor type, height, weight and paclitaxel dose (P > 0.05). While, the different cycle, age, the later stages of tumor, serum creatinine concentration, endogenous creatinine clearance rate, AUC values were the relative factors of bone marrow suppression (P = 0.000, 0.000, 0.018, 0.033, 0.001, 0.000). Seven variables were conducted into the logistic regression and the results shown that the different cycles, the age, AUC grades were independent risk factors (P = 0.030, 0.043, 0.009). (3) When low-dose of paclitaxel was given, the occurrence of bone marrow suppression was related to the carboplatin dose AUC. The higher AUC values for carboplatin were chosen, the higher of severe bone marrow suppression would happen. (4/14 vs 0, P = 0.015). When the dose of high grade of paclitaxel was given, the occurrence of bone marrow suppression in cases with hight-dose carboplatin was statistically significant than that in cases treated with low-dose carboplatin [45.7% (16/35) vs 13.7% (17/124), P = 0.000].

CONCLUSIONS

The independent risk factors of myelosuppression after chemotherapy with TC regime on the patients with ovarian cancer including the cycles, age and AUC values. The carboplatin dose calculating with AUC is related to the occurrence of bone marrow suppression, the higher AUC values for carboplatin would chosen, the higher of severe bone marrow suppression would be happen.

Factors affecting bone marrow toxicity following administration of carboplatin and paclitaxel in patients with non-small cell lung cancer

BACKGROUND

Despite accounting for more than half of the patients diagnosed with non-small cell lung cancer (NSCLC), only 20% of elderly patients receive chemotherapy. One reason for withholding systemic therapy is the concern for an increased incidence of side-effects, especially cytopenia from bone marrow toxicity. Limited data exist regarding specific factors that affect blood count nadirs following chemotherapy.

PATIENTS AND METHODS

A retrospective chart review was conducted of chemotherapy-naïve patients who had received standard doses of carboplatin and paclitaxel for NSCLC. Hemoglobin levels, total white blood cell counts (WBC) and platelet counts before each chemotherapy cycle and nadir counts following each cycle were obtained. Wilcoxon test and Chi-square test were used for univariate comparisons of patient characteristics and unpaired t-test for hematological parameters. Multivariate analyses of change over time in the hematological parameters by age groups were performed using mixed models while adjusting for other clinical factors.

RESULTS

Of the 91 consecutive patients identified from the medical records between 1992 and 2007, 37 (41%) were <60 years old at diagnosis. Pre-chemotherapy and nadir values for hemoglobin, WBC and platelet counts did not vary by age over time. The nadir values correlated with the corresponding pre-chemotherapy values. Both the pre-chemotherapy and nadir values showed a decreasing trend with increasing numbers of chemotherapy cycles administered.

CONCLUSION

Age does not affect the nadir counts of hemoglobin, WBC and platelets following administration of carboplatin and paclitaxel for NSCLC. Pre-chemotherapy blood counts are more important determinants of hematologic toxicity following administration of carboplatin and paclitaxel for advanced NSCLC.

[Chemotherapy-induced myelosuppression and treatment efficacy in limited-stage disease small cell lung cancer]

We examined the association between chemotherapy-induced myelosuppression and prognosis in limited-stage disease small cell lung cancer (LD SCLC). We retrospectively analyzed 76 patients with LD SCLC who received combination cisplatin or carboplatin of etoposide or irinotecan. Patients were categorized into two groups (grade 0 to 2 or grade 3 to 4) according to the worst neutropenia, anemia, or thrombocytopenia during first-line chemotherapy and were analyzed for overall survival (OS) and time to progression (TTP). From univariate analysis, OS was significantly better in patients who developed grade 0 to 2 anemia or thrombocytopenia than those who developed grade 3 to 4. In addition, performance status, neuron-specific enolase (NSE), and pro-gastrin-releasing protein were identified as prognostic factors. By multi-variate analysis, NSE was an independent prognostic factor for OS. There were no independent prognostic factors for TTP. Myelosuppression during chemotherapy is not a prognostic factor in LD SCLC. Our results show doses of platinum doublet chemotherapy were adequate in patients with LD SCLC.

Development of acute lympboblastic leukemia in a patient with increased hematogones after toxic bone marrow damage

To the best of our knowledge we describe the first case showing the association of increased B cell precursors/hematogones in a regenerating post-toxic bone marrow with subsequent development of a B-ALL. Since all immunohistochemical/moleculargenetic anaylses have failed to identify the initial malignant leukemic clone, we suggest a close-meshed follow-up of such cases to identify potential mechanisms for the malignant transformation of B-cell precursors/hematogones and to prevent further fatal courses.

Estrogen-induced myelotoxicity in dogs: A review

Exogenous estrogens used for therapeutic purposes or endogenous estrogen sources such as functional Sertoli cell or ovarian granulosa cell tumors may cause bone marrow toxicity in dogs. The condition is characterized by hematologic abnormalities including thrombocytopenia, anemia, and leukocytosis or leukopenia. Despite intensive therapy with blood or platelet-rich transfusions, broad-spectrum antibiotics, steroids, and bone marrow stimulants, prognosis is unfavorable. Due to the the risk of stimulating the development of uterine diseases and the potential for inducing aplastic anemia, estrogen use in dogs is best avoided where possible. This paper describes the causes of estrogen-induced myelotoxicity, the clinical presentation of the patients, the diagnosis, and the treatment options in the dog.

Severe bone marrow aplasia following imatinib mesylate in a patient with chronic myelogenous leukemia

Imatinib mesylate, a signal transduction inhibitor molecule, has been introduced in the treatment of chronic myelogenous leukemia (CML) since May 2001. By its unique mechanism of action, the drug has revolutionized the management of chronic phase CML. The drug is generally well tolerated. A number of hematological and non-hematological side-effects have been reported. Fatal bone marrow (BM) aplasia has rarely been reported. A 46-year-old women with chronic phase CML was treated with imatinib. Six weeks later she developed severe pancytopenia associated with fever, chest infection and bleeding. A BM biopsy revealed hypoplasia (BM cellularity < 5%). She died of pulmonary mucormycosis. CML patients on imatinib therapy need close monitoring. Those pre-treated with busulfan and interferon-alpha may be at a higher risk of developing BM aplasia.

Reversible bone marrow granulomas-adverse effect of oxyphenbutazone therapy

A 48-year-old woman treated with oxyphenbutazone developed fever, gastrointestinal disturbances, mucocutaneous reactions, leukopenia, eosinophilia and thrombocytopenia. Bone marrow biopsy showed granulomatous lesions. Following withdrawal of the drug, all signs and symptoms subsided and the blood changes and the bone marrow biopsy normalized. The granulomatous reaction in the bone marrow is considered to be a hypersensitivity manifestation of oxyphenbutazone.

A tool for neutrophil guided dose adaptation in chemotherapy

Chemotherapy dosing in anticancer treatment is a balancing act between achieving concentrations that are effective towards the malignancy and that result in acceptable side-effects. Neutropenia is one major side-effect of many antitumor agents, and is related to an increased risk of infection. A model capable of describing the time-course of myelosuppression from administered drug could be used in individual dose selection. In this paper we describe the transfer of a previously developed semi-mechanistic model for myelosuppression from NONMEM to a dosing tool in MS Excel, with etoposide as an example. The tool proved capable to solve a differential equation system describing the pharmacokinetics and pharmacodynamics, with estimation performance comparable to NONMEM. In the dosing tool the user provides neutrophil measures from a previous treatment course and request for the dose that results in a desired nadir in the upcoming course through a Bayesian estimation procedure.

[Pancytopenia after methotrexate treatment]

The use of methotrexate is associated with the risk of numerous, sometimes life-threatening, side effects. We describe a 76-year-old female patient treated with methotrexate (MTX) due to vertebral joint disease of unknown etiology. During the outpatient therapy, which was not conformed to doctor's recommendations, acute liver failure and symptoms of bone marrow damage developed. Despite intensive hospital treatment, the patient died.

Advances in the use of hydroxyurea

Clinical experience with hydroxyurea for patients with sickle cell disease (SCD) has been accumulating for the past 25 years. The bulk of the current evidence suggests that hydroxyurea is well-tolerated, safe, and efficacious for most patients with SCD. Hydroxyurea has proven clinical efficacy for reducing acute vaso-occlusive events including pain episodes and acute chest syndrome. Salutary effects on hematological parameters include increases in fetal hemoglobin (HbF), hemoglobin, and MCV; also significant decreases occur in WBC, ANC, reticulocytes, LDH, and bilirubin. Treatment with hydroxyurea is usually considered for patients with recurrent vaso-occlusive events, but additional indications for treatment may include laboratory markers of disease severity and evidence of chronic organ dysfunction. Ten years ago, the US Food and Drug Administration approved hydroxyurea for adult patients with clinically severe SCD; however, its use in children remains off-label. Despite the large body of evidence regarding its efficacy and safety, hydroxyurea is currently prescribed only sparingly for patients with SCD and therefore has only limited effectiveness for this disorder; barriers to its use need to be identified and overcome.