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Kattamis A, Aydinok Y, Taher A. Optimising management of deferasirox therapy for patients with transfusion-dependent thalassaemia and lower-risk myelodysplastic syndromes. Eur J Haematol 2018; 101:272-282. [PMID: 29904950 DOI: 10.1111/ejh.13111] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/11/2018] [Indexed: 01/19/2023]
Abstract
Effective iron chelation therapy is an important part of treatment in patients with transfusion-dependent thalassaemia and lower-risk myelodysplastic syndromes (MDS). Key strategies for optimising iron chelation therapy include ensuring good adherence and preventing and managing adverse events (AEs). Good adherence to iron chelation therapy with deferoxamine and deferasirox has been linked to improved survival and/or reductions in complications related to iron overload; however, maintaining good adherence to iron chelators can be challenging. Patients with transfusion-dependent thalassaemia or lower-risk MDS showed better adherence to the deferasirox film-coated tablet (FCT) formulation than to the deferasirox dispersible tablet formulation in the ECLIPSE trial, reflecting in part the improved palatability and convenience of deferasirox FCT. As well as affecting adherence, AEs may lead to dose reduction, interruption or discontinuation, resulting in suboptimal iron chelation therapy. Preventing and successfully managing AEs may help limit their impact on adherence, and following dosage and administration recommendations for iron chelators such as deferasirox may help minimise AEs and optimise treatment in patients with transfusion-dependent thalassaemia and lower-risk MDS.
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Affiliation(s)
- Antonis Kattamis
- First Department of Pediatrics, National and Kapodistrian University of Athens, Athens, Greece
| | - Yesim Aydinok
- Department of Pediatric Hematology, Ege University Hospital, Izmir, Turkey
| | - Ali Taher
- Naef K. Basile Cancer Institute, American University of Beirut Medical Center, Beirut, Lebanon
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Predicting factors for liver iron overload at the first magnetic resonance in children with thalassaemia major. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2018; 17:165-170. [PMID: 30036179 DOI: 10.2450/2018.0092-18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 06/05/2018] [Indexed: 01/01/2023]
Abstract
BACKGROUND Transfusion dependency determines iron overload in thalassaemia major, with devastating complications. Significant liver iron overload has been observed from early childhood and we aimed to evaluate factors that could predict liver iron overload at the first magnetic resonance imaging (MRI). MATERIALS AND METHODS All transfusion-dependent children who underwent MRI to assess iron overload were retrospectively studied. Age, weight, height, blood requirement, chelation drug and dosage, serum ferritin and liver enzymes were evaluated at three specific steps: start of transfusion regimen, start of chelation therapy, and first MRI. RESULTS Among 198 patients, 25 children met inclusion criteria. No differences were detected in all the assessed parameters at start of transfusion regimen and chelation therapy (p>0.05) between patients with good iron balance (liver iron concentration [LIC] <7 mg Fe/g dry weight [dw]) and liver iron overload (LIC >7). At the first MRI, patients with iron overload had significantly higher serum ferritin (3,080.3±1,078.5 vs 1,672.0±705.3 ng/mL; p<0.01) while patients with good iron control maintained a stable ferritin value from the start of chelation therapy but showed significantly lower height Z-score (-1.48±1.02 vs -0.36±1.55; p=0.04). Serum ferritin >1,770 ng/mL was detected as the best threshold for predicting liver iron overload at the first MRI (p=0.0003). CONCLUSION In order to prevent liver iron overload at the first MRI, children should maintain a stable level of serum ferritin below 1,770 from the start of chelation therapy. However, strict monitoring of growth is mandatory.
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Shammo JM, Komrokji RS. Clinical consequences of iron overload in patients with myelodysplastic syndromes: the case for iron chelation therapy. Expert Rev Hematol 2018; 11:577-586. [PMID: 29902097 DOI: 10.1080/17474086.2018.1486188] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Patients with myelodysplastic syndromes (MDS) are at increased risk of iron overload due to ineffective erythropoiesis and chronic transfusion therapy. The clinical consequences of iron overload include cardiac and/or hepatic failure, endocrinopathies, and infection risk. Areas covered: Iron chelation therapy (ICT) can help remove excess iron and ultimately reduce the clinical consequences of iron overload. The authors reviewed recent (last five years) English-language articles from PubMed on the topic of iron overload-related complications and the use of ICT (primarily deferasirox) to improve outcomes in patients with MDS. Expert commentary: While a benefit of ICT has been more firmly established in other transfusion-dependent conditions, such as thalassemia, its role in reducing iron overload in MDS remains controversial due to the lack of prospective controlled data demonstrating a survival benefit. Orally administered chelation agents (e.g. deferasirox) are now available, and observational and/or retrospective data support a survival benefit of using ICT in MDS. The placebo-controlled TELESTO trial (NCT00940602) is currently examining the use of deferasirox in MDS patients with iron overload, and is evaluating specifically whether use of ICT to alleviate iron overload can also reduce iron overload-related complications in MDS and improve survival.
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Affiliation(s)
- Jamile M Shammo
- a Department of Internal Medicine, Division of Hematology/Oncology , Rush University Medical Center , Chicago , IL , USA
| | - Rami S Komrokji
- b Malignant Hematology Department , Moffitt Cancer Center , Tampa , FL , USA
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Abstract
Thalassemia is a disease with an extensive morbidity profile affecting almost every organ system. Renal involvement, once considered rare, is an underestimated and poorly studied complication that has been on the rise ever since medical advances granted patients longer life spans. Several studies and reports have emerged recently to shed light on the seriousness of this complication, although data is still lacking in terms of pathophysiology, diagnosis, prevention and treatment. In this review, we evaluate and compare renal involvement in the transfusion-dependent and independent variants of β-Thalassemia, highlighting the pathophysiology of kidney damage that involves iron overload, chronic anemia, and iron chelation therapy. An in-depth and focused review of the types of injuries incurred is also presented along with the diagnostic biomarkers accompanying each type of injury. Most research so far has focused on the transfusion-dependent thalassemia population being the group with most renal involvement, however recent reports have shown evidence of comparable, if not worse, involvement of the non-transfusion dependent population, sometimes leading to end-stage renal disease. As such, we try to shed light on distinct renal involvements in NTDT whenever available.
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Bou-Fakhredin R, Elias J, Taher AT. Iron Overload and Chelation Therapy in Hemoglobinopathies. THALASSEMIA REPORTS 2018. [DOI: 10.4081/thal.2018.7478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Iron overload (IOL) is highly prevalent among patients with hemoglobinopathies; both transfusion dependent thalassemia (TDT) and non-transfusion dependent thalassemia (NTDT). Whether IOL is secondary to regular transfusions like in TDT, or develops from increased intestinal absorption like in NTDT, it can cause significant morbidity and mortality. In TDT patients, iron accumulation in organ tissues is highly evident, and leads to organ toxicity and dysfunction. IOL in NTDT patients is cumulative with advancing age, and concern with secondary morbidity starts beyond the age of 10 years, as shown by the OPTIMAL CARE study. Several modalities are available for the diagnosis and monitoring of IOL. Serum ferritin (SF) assessment is widely available and heavily relied on in resource-poor countries. Non-invasive iron monitoring using MRI has become the gold standard to diagnose IOL. Three iron chelators are currently available for the treatment of IOL: deferoxamine (DFO) in subcutaneous or intravenous injection, oral deferiprone (DFP) in tablet or solution form, and oral deferasirox (DFX) in dispersible tablet (DT) and film-coated tablet (FCT). Today, the goal of ICT is to maintain safe levels of body iron at all times. Appropriate tailoring ICT with chelator choices and dose adjustment must be implemented in a timely manner. Clinical decision to initiate, adjust and stop ICT is based on SF, MRI-LIC and cardiac T2*. In this article, we review the mechanism of IOL in both TDT and NTDT, the pathophysiology behind it, its complications, and the different ways to assess and quantify it. We will also discuss the different ICT modalities available, and the emergence of novel therapies.
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Abstract
Iron-overload syndromes may be hereditary or acquired. Patients may be asymptomatic early in the disease. Once heart failure develops, there is rapid deterioration. Cardiac hemochromatosis is characterized by a dilated cardiomyopathy with dilated ventricles, reduced ejection fraction, and reduced fractional shortening. Deposition of iron may occur in the entire cardiac conduction system, especially the atrioventricular node. Cardiac hemochromatosis should be considered in any patient with unexplained heart failure. Screening for systemic iron overload with serum ferritin and transferin saturation should be performed. If these tests are consistent with iron overload, further noninvasive and histologic confirmation is indicated to confirm organ involvement with iron overload. Cardiac magnetic resonance imaging is superior to other diagnostic tests since it can quantitatively assess myocardial iron load. Therapeutic phlebotomy is the therapy of choice in nonanemic patients with cardiac hemochromatosis. Therapeutic phlebotomy should be started in men with serum ferritin levels of 300 μg/l or more and in women with serum ferritin levels of 200 μg/l or more. Therapeutic phlebotomy consists of removing 1 unit of blood (450 to 500 ml) weekly until the serum ferritin level is 10 to 20 μg/l and maintenance of the serum ferritin level at 50 μg/l or lower thereafter by periodic removal of blood. Phlebotomy is not a treatment option in patients with anemia (secondary iron-overload disorders) nor in patients with severe congestive heart failure. In these patients, the treatment of choice is iron chelation therapy.
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Affiliation(s)
- Wilbert S Aronow
- Cardiology Division, Department of Medicine, Westchester Medical Center/New York Medical College, Valhalla, NY, USA
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Abstract
Introduction of MRI techniques for identifying and monitoring tissue iron overload and the current understanding of iron homeostasis in transfusion-dependent (TDT) and non-transfusion-dependent thalassemia have allowed for a more robust administration of iron chelation therapies. The development of safe and efficient oral iron chelators and the insights gained from large-scale prospective studies using these agents have improved iron overload management. A significant reduction in iron toxicity-induced morbidity and mortality and improvements in quality of life were observed in TDT. The appropriate management of tissue-specific iron loading in TDT has been portrayed using evidence-based data obtained from investigational studies.
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Affiliation(s)
- Yesim Aydinok
- Department of Pediatric Hematology and Oncology, Ege University Children's Hospital, Bornova, Izmir 35100, Turkey.
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Abstract
Inherited haemoglobin disorders, including thalassaemia and sickle-cell disease, are the most common monogenic diseases worldwide. Several clinical forms of α-thalassaemia and β-thalassaemia, including the co-inheritance of β-thalassaemia with haemoglobin E resulting in haemoglobin E/β-thalassaemia, have been described. The disease hallmarks include imbalance in the α/β-globin chain ratio, ineffective erythropoiesis, chronic haemolytic anaemia, compensatory haemopoietic expansion, hypercoagulability, and increased intestinal iron absorption. The complications of iron overload, arising from transfusions that represent the basis of disease management in most patients with severe thalassaemia, might further complicate the clinical phenotype. These pathophysiological mechanisms lead to an array of clinical manifestations involving numerous organ systems. Conventional management primarily relies on transfusion and iron-chelation therapy, as well as splenectomy in specific cases. An increased understanding of the molecular and pathogenic factors that govern the disease process have suggested routes for the development of new therapeutic approaches that address the underlying chain imbalance, ineffective erythropoiesis, and iron dysregulation, with several agents being evaluated in preclinical models and clinical trials.
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Affiliation(s)
- Ali T Taher
- Department of Internal Medicine, American University of Beirut Medical Centre, Beirut, Lebanon.
| | - David J Weatherall
- MRC Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, UK
| | - Maria Domenica Cappellini
- Department of Clinical Sciences and Community, University of Milan, IRCCS Ca'Granda Foundation Maggiore Policlinico Hospital, Milan, Italy
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Taher AT, Saliba AN. Iron overload in thalassemia: different organs at different rates. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2017; 2017:265-271. [PMID: 29222265 PMCID: PMC6142532 DOI: 10.1182/asheducation-2017.1.265] [Citation(s) in RCA: 146] [Impact Index Per Article: 20.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Abstract
Thalassemic disorders lie on a phenotypic spectrum of clinical severity that depends on the severity of the globin gene mutation and coinheritance of other genetic determinants. Iron overload is associated with increased morbidity in both patients with transfusion-dependent thalassemia (TDT) and non-transfusion-dependent thalassemia (NTDT). The predominant mechanisms driving the process of iron loading include increased iron burden secondary to transfusion therapy in TDT and enhanced intestinal absorption secondary to ineffective erythropoiesis and hepcidin suppression in NTDT. Different organs are affected differently by iron overload in TDT and NTDT owing to the underlying iron loading mechanism and rate of iron accumulation. Serum ferritin measurement and noninvasive imaging techniques are available to diagnose iron overload, quantify its extent in different organs, and monitor clinical response to therapy. This chapter discusses the general approach to iron chelation therapy based on organ involvement using the available iron chelators: deferoxamine, deferiprone, and deferasirox. Other novel experimental options for treatment and prevention of complications associated with iron overload in thalassemia are briefly discussed.
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Affiliation(s)
- Ali T. Taher
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon; and
| | - Antoine N. Saliba
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
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Allegra S, Massano D, De Francia S, Longo F, Piccione F, Pirro E, Cusato J, D'Avolio A, Piga A. Clinical relevance of deferasirox trough levels in β-thalassemia patients. Clin Exp Pharmacol Physiol 2017; 45:213-216. [DOI: 10.1111/1440-1681.12879] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Revised: 10/13/2017] [Accepted: 10/13/2017] [Indexed: 01/19/2023]
Affiliation(s)
- Sarah Allegra
- Department of Medical Sciences; Unit of Infectious Diseases; University of Turin; Amedeo di Savoia Hospital; Turin Italy
| | - Davide Massano
- Department of Paediatrics; Centre for Microcitemie; University of Turin; S. Luigi Gonzaga Hospital; Orbassano Italy
| | - Silvia De Francia
- Department of Biological and Clinical Sciences; University of Turin; S. Luigi Gonzaga Hospital; Orbassano Italy
| | - Filomena Longo
- Department of Paediatrics; Centre for Microcitemie; University of Turin; S. Luigi Gonzaga Hospital; Orbassano Italy
| | - Francesca Piccione
- Department of Biological and Clinical Sciences; University of Turin; S. Luigi Gonzaga Hospital; Orbassano Italy
| | - Elisa Pirro
- Department of Biological and Clinical Sciences; University of Turin; S. Luigi Gonzaga Hospital; Orbassano Italy
| | - Jessica Cusato
- Department of Medical Sciences; Unit of Infectious Diseases; University of Turin; Amedeo di Savoia Hospital; Turin Italy
| | - Antonio D'Avolio
- Department of Medical Sciences; Unit of Infectious Diseases; University of Turin; Amedeo di Savoia Hospital; Turin Italy
| | - Antonio Piga
- Department of Paediatrics; Centre for Microcitemie; University of Turin; S. Luigi Gonzaga Hospital; Orbassano Italy
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Du Y, Long Z, Chen M, Han B, Hou B, Feng F. Observational Monitoring of Patients with Aplastic Anemia and Low/Intermediate-1 Risk of Myelodysplastic Syndromes Complicated with Iron Overload. Acta Haematol 2017; 138:119-128. [PMID: 28866669 DOI: 10.1159/000479422] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Accepted: 07/10/2017] [Indexed: 01/19/2023]
Abstract
BACKGROUND This study focuses on the iron overload (IOL) of patients with transfused aplastic anemia (AA) or a low/intermediate-1 risk of myelodysplastic syndrome (MDS). METHODS Ninety-two AA or MDS patients with IOL were prospectively recruited. Clinical data were collected every 6 months, and organ magnetic resonance imaging T2* values were collected annually. Patients with IOL were chelated. RESULTS Serum ferritin was correlated with liver T2* and pancreatic T2* in the AA and MDS groups. Transfusion amounts were correlated with serum ferritin values, liver T2*, and pancreatic T2* in the AA group. At the 6-month and 1-year evaluations, patients with sufficient chelation experienced significant decreases in serum ferritin, and those with decreased serum ferritin experienced an obvious increase in hemoglobin. At their 1-year-follow-up, patients with adequate chelation showed significant increases in hepatic T2*, cardiac T2*, and left ventricular ejection fraction (LVEF). Patients with decreased serum ferritin (including those without chelation) experienced an increase in hemoglobin, hepatic T2*, cardiac T2*, and LVEF. CONCLUSION The transfusion amount was more reliable at predicting IOL in patients with AA than in those with MDS. Adequate iron chelation can decrease serum ferritin levels and may improve hepatic T2*, cardiac T2*, and LVEF levels. A decrease in serum ferritin, even in the absence of chelation, may also benefit patients.
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Affiliation(s)
- Yali Du
- Department of Hematology, Chinese Academy of Medical Sciences, Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
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Vichinsky E, El-Beshlawy A, Al Zoebie A, Kamdem A, Koussa S, Chotsampancharoen T, Bruederle A, Gilotti G, Han J, Elalfy M. Long-term safety and efficacy of deferasirox in young pediatric patients with transfusional hemosiderosis: Results from a 5-year observational study (ENTRUST). Pediatr Blood Cancer 2017; 64. [PMID: 28296163 DOI: 10.1002/pbc.26507] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Revised: 01/30/2017] [Accepted: 02/02/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND Children with red blood cell disorders may receive regular transfusions from an early age and consequently accumulate iron. Adequate iron chelation therapy can prevent organ damage and delayed growth/development. Deferasirox is indicated for treatment of pediatric patients with chronic iron overload due to transfusional hemosiderosis; however, fewer than 10% of patients in the registration studies were aged 2 to less than 6 years. PROCEDURE Deferasirox, a once-daily oral iron chelator, was evaluated in young pediatric patients with transfusional hemosiderosis during the observational 5-year ENTRUST study. Patients aged 2 to less than 6 years at enrollment received deferasirox according to local prescribing information, with the primary objective of evaluating safety, specifically renal and hepatic function. Serum ferritin was observed as a surrogate efficacy parameter. RESULTS In total, 267 patients (mean age 3.2 years) predominantly with β-thalassemia (n = 176, 65.9%) were enrolled. Mean ± standard deviation deferasirox dose was 25.8 ± 6.5 mg/kg per day over a median of 59.9 months. A total of 145 patients (54.3%) completed 5 years' treatment. The proportion of patients with two or more consecutive postbaseline measurements (≥7 days apart) of serum creatinine higher than age-adjusted upper limit of normal (ULN) and alanine aminotransferase more than five times the ULN was 4.4% (95% confidence interval [CI]: 2.1-7.9) and 4.0% (95% CI: 1.8-7.4), respectively. Median serum ferritin decreased from 1,702 ng/ml at baseline to 1,127 ng/ml at 5 years. There were no new safety signals. CONCLUSIONS Safety and efficacy of deferasirox in young pediatric patients in this long-term, observational study in everyday clinical practice were consistent with the known deferasirox profile.
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Affiliation(s)
- Elliott Vichinsky
- UCSF Benioff Children's Hospital & Research Center Oakland, Oakland, California
| | | | | | - Annie Kamdem
- Centre Hospitalier Intercommunal, Créteil, France
| | | | | | | | | | - Jackie Han
- Novartis Pharmaceuticals, East Hanover, New Jersey
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Bollig C, Schell LK, Rücker G, Allert R, Motschall E, Niemeyer CM, Bassler D, Meerpohl JJ. Deferasirox for managing iron overload in people with thalassaemia. Cochrane Database Syst Rev 2017; 8:CD007476. [PMID: 28809446 PMCID: PMC6483623 DOI: 10.1002/14651858.cd007476.pub3] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Thalassaemia is a hereditary anaemia due to ineffective erythropoiesis. In particular, people with thalassaemia major develop secondary iron overload resulting from regular red blood cell transfusions. Iron chelation therapy is needed to prevent long-term complications.Both deferoxamine and deferiprone are effective; however, a review of the effectiveness and safety of the newer oral chelator deferasirox in people with thalassaemia is needed. OBJECTIVES To assess the effectiveness and safety of oral deferasirox in people with thalassaemia and iron overload. SEARCH METHODS We searched the Cystic Fibrosis and Genetic Disorders Group's Haemoglobinopathies Trials Register: 12 August 2016.We also searched MEDLINE, Embase, the Cochrane Library, Biosis Previews, Web of Science Core Collection and three trial registries: ClinicalTrials.gov; the WHO International Clinical Trials Registry Platform; and the Internet Portal of the German Clinical Trials Register: 06 and 07 August 2015. SELECTION CRITERIA Randomised controlled studies comparing deferasirox with no therapy or placebo or with another iron-chelating treatment. DATA COLLECTION AND ANALYSIS Two authors independently assessed risk of bias and extracted data. We contacted study authors for additional information. MAIN RESULTS Sixteen studies involving 1807 randomised participants (range 23 to 586 participants) were included. Twelve two-arm studies compared deferasirox to placebo (two studies) or deferoxamine (seven studies) or deferiprone (one study) or the combination of deferasirox and deferoxamine to deferoxamine alone (one study). One study compared the combination of deferasirox and deferiprone to deferiprone in combination with deferoxamine. Three three-arm studies compared deferasirox to deferoxamine and deferiprone (two studies) or the combination of deferasirox and deferiprone to deferiprone and deferasirox monotherapy respectively (one study). One four-arm study compared two different doses of deferasirox to matching placebo groups.The two studies (a pharmacokinetic and a dose-escalation study) comparing deferasirox to placebo (n = 47) in people with transfusion-dependent thalassaemia showed that deferasirox leads to net iron excretion. In these studies, safety was acceptable and further investigation in phase II and phase III studies was warranted.Nine studies (1251 participants) provided data for deferasirox versus standard treatment with deferoxamine. Data suggest that a similar efficacy can be achieved depending on the ratio of doses of deferoxamine and deferasirox being compared. In the phase III study, similar or superior efficacy for the intermediate markers ferritin and liver iron concentration (LIC) could only be achieved in the highly iron-overloaded subgroup at a mean ratio of 1 mg of deferasirox to 1.8 mg of deferoxamine corresponding to a mean dose of 28.2 mg per day and 51.6 mg per day respectively. The pooled effects across the different dosing ratios are: serum ferritin, mean difference (MD) 454.42 ng/mL (95% confidence interval (CI) 337.13 to 571.71) (moderate quality evidence); LIC evaluated by biopsy or SQUID, MD 2.37 mg Fe/g dry weight (95% CI 1.68 to 3.07) (moderate quality evidence) and responder analysis, LIC 1 to < 7 mg Fe/g dry weight, risk ratio (RR) 0.80 (95% CI 0.69 to 0.92) (moderate quality evidence). The substantial heterogeneity observed could be explained by the different dosing ratios. Data on mortality (low quality evidence) and on safety at the presumably required doses for effective chelation therapy are limited. Patient satisfaction was better with deferasirox among those who had previously received deferoxamine treatment, RR 2.20 (95% CI 1.89 to 2.57) (moderate quality evidence). The rate of discontinuations was similar for both drugs (low quality evidence).For the remaining comparisons in people with transfusion-dependent thalassaemia, the quality of the evidence for outcomes assessed was low to very low, mainly due to the very small number of participants included. Four studies (205 participants) compared deferasirox to deferiprone; one of which (41 participants) revealed a higher number of participants experiencing arthralgia in the deferiprone group, but due to the large number of different types of adverse events reported and compared this result is uncertain. One study (96 participants) compared deferasirox combined with deferiprone to deferiprone with deferoxamine. Participants treated with the combination of the oral iron chelators had a higher adherence compared to those treated with deferiprone and deferoxamine, but no participants discontinued the study. In the comparisons of deferasirox versus combined deferasirox and deferiprone and that of deferiprone versus combined deferasirox and deferiprone (one study, 40 participants), and deferasirox and deferoxamine versus deferoxamine alone (one study, 94 participants), only a few patient-relevant outcomes were reported and no significant differences were observed.One study (166 participants) included people with non-transfusion dependent thalassaemia and compared two different doses of deferasirox to placebo. Deferasirox treatment reduced serum ferritin, MD -306.74 ng/mL (95% CI -398.23 to -215.24) (moderate quality evidence) and LIC, MD -3.27 mg Fe/g dry weight (95% CI -4.44 to -2.09) (moderate quality evidence), while the number of participants experiencing adverse events and rate of discontinuations (low quality evidence) was similar in both groups. No participant died, but data on mortality were limited due to a follow-up period of only one year (moderate quality evidence). AUTHORS' CONCLUSIONS Deferasirox offers an important treatment option for people with thalassaemia and secondary iron overload. Based on the available data, deferasirox does not seem to be superior to deferoxamine at the usually recommended ratio of 1 mg of deferasirox to 2 mg of deferoxamine. However, similar efficacy seems to be achievable depending on the dose and ratio of deferasirox compared to deferoxamine. Whether this will result in similar efficacy and will translate to similar benefits in the long term, as has been shown for deferoxamine, needs to be confirmed. Data from randomised controlled trials on rare toxicities and long-term safety are still limited. However, after a detailed discussion of the potential benefits and risks, deferasirox could be offered as the first-line option to individuals who show a strong preference for deferasirox, and may be a reasonable treatment option for people showing an intolerance or poor adherence to deferoxamine.
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Affiliation(s)
- Claudia Bollig
- Medical Center – Univ. of Freiburg, Faculty of Medicine, Univ. of FreiburgCochrane GermanyBreisacher Straße 153FreiburgGermany79110
| | | | - Gerta Rücker
- Faculty of Medicine and Medical Center – University of FreiburgInstitute for Medical Biometry and StatisticsStefan‐Meier‐Str. 26FreiburgGermany79104
| | - Roman Allert
- University Hospital Frankfurt, Goethe UniversityDepartment of Obstetrics and GynaecologyFrankfurtGermany
| | - Edith Motschall
- Medical Center ‐ University of Freiburg, Faculty of Medicine, University of FreiburgCenter for Medical Biometry and Medical InformaticsStefan‐Meier‐Str. 26FreiburgGermany79104
| | - Charlotte M Niemeyer
- University Medical Center FreiburgPediatric Hematology & Oncology, Center for Pediatrics & Adolescent MedicineMathildenstrasse 1FreiburgGermany79106
| | - Dirk Bassler
- University Hospital Zurich and University of ZurichDepartment of NeonatologyFrauenklinikstrasse 10ZurichSwitzerland
| | - Joerg J Meerpohl
- Medical Center – Univ. of Freiburg, Faculty of Medicine, Univ. of FreiburgCochrane GermanyBreisacher Straße 153FreiburgGermany79110
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Krittayaphong R, Viprakasit V, Saiviroonporn P, Siritanaratkul N, Siripornpitak S, Meekaewkunchorn A, Kirawittaya T, Sripornsawan P, Jetsrisuparb A, Srinakarin J, Wong P, Phalakornkul N, Sinlapamongkolkul P, Wood J. Prevalence and predictors of cardiac and liver iron overload in patients with thalassemia: A multicenter study based on real-world data. Blood Cells Mol Dis 2017; 66:24-30. [PMID: 28806577 DOI: 10.1016/j.bcmd.2017.08.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2017] [Revised: 08/04/2017] [Accepted: 08/04/2017] [Indexed: 01/19/2023]
Abstract
Prevalence of cardiac and liver iron overload in patients with thalassemia in real-world practice may vary among different regions especially in the era of widely-used iron chelation therapy. The aim of this study was to determine the prevalence of cardiac and liver iron overload in and the management patterns of patients with thalassemia in real-world practice in Thailand. We established a multicenter registry for patients with thalassemia who underwent magnetic resonance imaging (MRI) as part of their clinical evaluation. All enrolled patients underwent cardiac and liver MRI for assessment of iron overload. There were a total of 405 patients enrolled in this study. The mean age of patients was 18.8±12.5years and 46.7% were male. Two hundred ninety-six (73.1%) of patients received regular blood transfusion. Prevalence of cardiac iron overload (CIO) and liver iron overload (LIO) was 5.2% and 56.8%, respectively. Independent predictors for iron overload from laboratory information were serum ferritin and transaminase for both CIO and LIO. Serum ferritin can be used as a screening tool to rule-out CIO and to diagnose LIO. Iron chelation therapy was given in 74.6%; 15.3% as a combination therapy.
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Affiliation(s)
- Rungroj Krittayaphong
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand.
| | - Vip Viprakasit
- Division of Hematology, Department of Pediatrics, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Pairash Saiviroonporn
- Department of Radiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Noppadol Siritanaratkul
- Division of Hematology, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Suvipaporn Siripornpitak
- Department of Diagnostic and Therapeutic Radiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | | | | | - Pornpun Sripornsawan
- Division of Hematology, Department of Pediatrics, Faculty of Medicine, Prince of Songkla University, Songkla, Thailand
| | - Arunee Jetsrisuparb
- Division of Hematology, Department of Pediatrics, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Jiraporn Srinakarin
- Department of Radiology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Peerapon Wong
- Division of Hematology, Department of Medicine, Faculty of Medicine, Naresuan University, Phitsanulok, Thailand
| | - Nuttaporntira Phalakornkul
- Division of Hematology, Department of Medicine, Faculty of Medicine, Bhumibol Adulyadej Hospital, Royal Thai Air Force, Bangkok, Thailand
| | - Phakatip Sinlapamongkolkul
- Division of Hematology, Department of Pediatrics, Faculty of Medicine, Thammasat University, Pathumthani, Thailand
| | - John Wood
- Division of Cardiology, Children's Hospital Los Angeles, Los Angeles, California, United States
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Potential use of lactic acid bacteria Leuconostoc mesenteroides as a probiotic for the removal of Pb(II) toxicity. J Microbiol 2017; 55:296-303. [DOI: 10.1007/s12275-017-6642-x] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Revised: 02/09/2017] [Accepted: 02/09/2017] [Indexed: 10/19/2022]
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66
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Davies GI, Davies D, Charles S, Barnes SL, Bowden D. Successful desensitization to deferasirox in a paediatric patient with β-Thalassaemia major. Pediatr Allergy Immunol 2017; 28:199-201. [PMID: 27797415 DOI: 10.1111/pai.12677] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
| | - Domenica Davies
- Department of Pharmacy, Monash Health, Clayton, Vic., Australia
| | - Sarah Charles
- Department of Pharmacy, Monash Health, Clayton, Vic., Australia
| | - Sara Laura Barnes
- Departments of Allergy and General Medicine, Monash Health, Clayton, Vic., Australia.,Monash University, Clayton, Vic., Australia
| | - Donald Bowden
- Monash University, Clayton, Vic., Australia.,Thalassaemia Services, Monash Health, Clayton, Vic., Australia
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Jaiswal S, Hishikar R, Khandwal O, Agarwal M, Joshi U, Halwai A, Maheshwari B, Sheohare R. Efficacy of Deferasirox as an Oral Iron Chelator in Paediatric Thalassaemia Patients. J Clin Diagn Res 2017; 11:FC01-FC03. [PMID: 28384880 DOI: 10.7860/jcdr/2017/22650.9395] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Accepted: 10/22/2016] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Thalassaemia Major patients require frequent blood transfusion leading to iron overload. Excessive iron gets deposited in vital organs and leads to dysfunction of the heart, liver, anterior pituitary, pancreas, and joints. Our body has limited mechanism to excrete iron, so patients with iron overload and its complications need safe and effective iron chelation therapy. AIM To assess the efficacy of Deferasirox (DFX) as an iron chelator, with specific reference to reduction in serum ferritin level. MATERIALS AND METHODS This is a prospective; observational study done in 45 multitransfused Thalassaemia Major Children receiving DFX therapy at registered Thalassaemia society Raipur Chhattisgarh. DFX was given in an initial dose of 20 mg/kg/day and according to response increased to a maximum of 40 mg/kg/day. Serum ferritin level was estimated at time of registration and at every three monthly intervals (four times during study period). The primary end point of the study was change in serum ferritin level after 12 months of DFX therapy. RESULTS The mean serum ferritin before DFX therapy of all cases was 3727.02 ng/mL. After 12 months of mean dose of 38 mg/kg/day of DFX, the mean decline in serum ferritin was 1207.11 ng/mL (drop by 32.38%, p-value <0.001). CONCLUSION DFX monotherapy has a good safety profile and effectively chelates total body iron in Thalassaemia major patients.
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Affiliation(s)
- Shikha Jaiswal
- Assistant Professor, Department of Pharmacology, PT JNM Medical College , Raipur, Chhattisgarh, India
| | - Rajesh Hishikar
- Professor and Head, Department of Pharmacology, PT JNM Medical college , Raipur, Chhattisgarh, India
| | - Onkar Khandwal
- Professor, Department of Paediatrics, PT JNM Medical College , Raipur, Chhattisgarh, India
| | - Manju Agarwal
- Assistant Professor, Department of Pharmacology, PT JNM Medical College , Raipur, Chhattisgarh, India
| | - Usha Joshi
- Associate Professor, Department of Pharmacology, PT JNM Medical College , Raipur, Chhattisgarh, India
| | - Ajay Halwai
- Assistant Professor, Department of Pharmacology, PT JNM Medical College , Raipur, Chhattisgarh, India
| | - Basant Maheshwari
- Associate Professor, Department of Pharmacology, PT JNM Medical College , Raipur, Chhattisgarh, India
| | - Raka Sheohare
- Consultant Diabetologist and Non Invasive Cardiologist, Lifeline Hospital , Raipur, Chhattisgarh, India
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Inati A, Kahale M, Sbeiti N, Cappellini MD, Taher AT, Koussa S, Nasr TA, Musallam KM, Abbas HA, Porter JB. One-year results from a prospective randomized trial comparing phlebotomy with deferasirox for the treatment of iron overload in pediatric patients with thalassemia major following curative stem cell transplantation. Pediatr Blood Cancer 2017; 64:188-196. [PMID: 27576370 DOI: 10.1002/pbc.26213] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Revised: 06/28/2016] [Accepted: 07/20/2016] [Indexed: 01/19/2023]
Abstract
BACKGROUND Iron overload is well documented in patients with β-thalassemia major, and patients who have undergone hematopoietic stem cell transplantation (HSCT) remain at risk as a result of pre- and immediate post-HSCT transfusions. PROCEDURE This is a prospective, randomized, 1-year clinical trial that compares the efficacy and safety of the once-daily oral iron chelator deferasirox versus phlebotomy for the treatment of iron overload in children with β-thalassemia major following HSCT. RESULTS Patients (aged 12.4 years) received deferasirox (n = 12, 10 mg/kg/day starting dose) or phlebotomy (n = 14, 6 ml/kg/2 weeks) for 1 year. In two and five patients, deferasirox dose was increased to 15 and 20 mg/kg/day, respectively. Magnetic resonance imaging (MRI)-assessed liver iron concentration (LIC) decreased with deferasirox (mean 12.5 ± 10.1 to 8.5 ± 9.3 mg Fe/g dry weight [dw]; P = 0.0005 vs. baseline) and phlebotomy (10.2 ± 6.8 to 8.3 ± 9.2 mg Fe/g dw; P = 0.05). LIC reductions were greater with deferasirox than with phlebotomy for patients with baseline serum ferritin 1,000 ng/ml or higher (-8.1 ± 1.5 vs. -3.5 ± 5.7 mg Fe/g dw; P = 0.048). Serum ferritin and non-transferrin-bound iron also decreased significantly. In two patients with severe cardiac siderosis, a clinically relevant improvement in myocardial T2* was seen, following phlebotomy and deferasirox therapy (n = 1 each). Adverse effects with deferasirox were skin rash, gastrointestinal upset, and increased liver function tests (all n = 1), while those for phlebotomy were difficulty with venous access (n = 4) and distress during procedure (n = 1). Parents of 13/14 children receiving phlebotomy wished to switch to deferasirox, with 1/14 being satisfied with phlebotomy. CONCLUSIONS Deferasirox treatment or phlebotomy reduces iron burden in pediatric patients with β- thalassemia major post-HSCT, with a manageable safety profile.
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Affiliation(s)
- Adlette Inati
- Lebanese American University and University Medical Center Rizk Hospital.,Rafik Hariri University Hospital, Beirut, Lebanon
| | - Mario Kahale
- Rafik Hariri University Hospital, Beirut, Lebanon
| | | | | | - Ali T Taher
- American University of Beirut, Beirut, Lebanon
| | | | | | | | - Hussein A Abbas
- University of Texas MD Anderson Cancer Center, Houston, Texas
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Dong AC, Rivella S. Gene Addition Strategies for β-Thalassemia and Sickle Cell Anemia. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2017; 1013:155-176. [PMID: 29127680 DOI: 10.1007/978-1-4939-7299-9_6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Beta-thalassemia and sickle cell anemia are two of the most common diseases related to the hemoglobin protein. In these diseases, the beta-globin gene is mutated, causing severe anemia and ineffective erythropoiesis. Patients can additionally present with a number of life-threatening co-morbidities, such as stroke or spontaneous fractures. Current treatment involves transfusion and iron chelation; allogeneic bone marrow transplant is the only curative option, but is limited by the availability of matching donors and graft-versus-host disease. As these two diseases are monogenic diseases, they make an attractive setting for gene therapy. Gene therapy aims to correct the mutated beta-globin gene or add back a functional copy of beta- or gamma-globin. Initial gene therapy work was done with oncoretroviral vectors, but has since shifted to lentiviral vectors. Currently, there are a few clinical trials underway to test the curative potential of some of these lentiviral vectors. This review will highlight the work done thus far, and present the challenges still facing gene therapy, such as genome toxicity concerns and achieving sufficient transgene expression to cure those with the most severe forms of thalassemia.
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Affiliation(s)
- Alisa C Dong
- Division of Hematology-Oncology, Department of Pediatrics, Weill Cornell Medical College, 515 E. 71st St., Room S-709, New York, NY, 10021, USA
| | - Stefano Rivella
- Division of Hematology-Oncology, Department of Pediatrics, Weill Cornell Medical College, 515 E. 71st St., S702, Box 284, New York, NY, 10021, USA.
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70
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Matched sibling donor hematopoietic stem cell transplantation for thalassemia. Curr Opin Hematol 2016; 23:508-514. [DOI: 10.1097/moh.0000000000000286] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Allegra S, De Francia S, Cusato J, Pirro E, Massano D, Piga A, D'Avolio A. Deferasirox pharmacokinetic and toxicity correlation in β-thalassaemia major treatment. ACTA ACUST UNITED AC 2016; 68:1417-1421. [PMID: 27672004 DOI: 10.1111/jphp.12638] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Accepted: 08/10/2016] [Indexed: 01/19/2023]
Abstract
OBJECTIVES Deferasirox adverse effects include the following: gastrointestinal disturbance, mild elevations in serum creatinine levels and intermittent proteinuria; these events are dose-dependent and reversible with drug discontinuation, but this solution can lead to an inadequate iron chelation. For these reasons, interindividual variability of drug plasma concentration could help the clinical management of deferasirox dosage. We sought to describe deferasirox plasma exposure in a cohort of 60 adult patients. METHODS A fully validated chromatographic method was used to quantify deferasirox concentration in plasma collected from β-thalassaemia adult patients. Samples obtained before and after 2, 4, 6 and 24 h drug administration were evaluated. Associations between variables were tested using the Pearson test. KEY FINDINGS Concerning pharmacokinetic parameters, a higher interindividual variability was shown. A positive correlation was found between deferasirox area under the concentration curve over 24 h and serum creatinine (r = 0.314; P = 0.018) and between area and drug dose (r = 0.311; P = 0.016). Moreover, a negative correlation resulted among area under the concentration curve over 24 h and serum ferritin (r = -0.291; P = 0.026) and among drug half-life and its dose (r = -0.319; P = 0.013). CONCLUSIONS Treatment decision based on the individual characteristics could strongly contribute to minimize toxicity and increase efficacy of deferasirox therapy.
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Affiliation(s)
- Sarah Allegra
- Unit of Infectious Diseases, Department of Medical Sciences, Amedeo di Savoia Hospital, University of Turin, Turin, Italy
| | - Silvia De Francia
- Department of Biological and Clinical Sciences, S. Luigi Gonzaga Hospital, University of Turin, Orbassano (TO), Italy
| | - Jessica Cusato
- Unit of Infectious Diseases, Department of Medical Sciences, Amedeo di Savoia Hospital, University of Turin, Turin, Italy
| | - Elisa Pirro
- Department of Biological and Clinical Sciences, S. Luigi Gonzaga Hospital, University of Turin, Orbassano (TO), Italy
| | - Davide Massano
- Department of Biological and Clinical Sciences, S. Luigi Gonzaga Hospital, University of Turin, Orbassano (TO), Italy
| | - Antonio Piga
- Department of Biological and Clinical Sciences, S. Luigi Gonzaga Hospital, University of Turin, Orbassano (TO), Italy
| | - Antonio D'Avolio
- Unit of Infectious Diseases, Department of Medical Sciences, Amedeo di Savoia Hospital, University of Turin, Turin, Italy.
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Papneja K, Bhatt MD, Kirby-Allen M, Arora S, Wiernikowski JT, Athale UH. Fanconi Syndrome Secondary to Deferasirox in Diamond-Blackfan Anemia: Case Series and Recommendations for Early Diagnosis. Pediatr Blood Cancer 2016; 63:1480-3. [PMID: 27082377 DOI: 10.1002/pbc.25995] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Accepted: 02/29/2016] [Indexed: 11/07/2022]
Abstract
Deferasirox is an oral iron chelator used to treat patients with transfusion-related iron overload. We report, from two institutions, two children with Diamond-Blackfan anemia who developed Fanconi syndrome secondary to deferasirox administration, along with a review of the literature. The current recommendation for the laboratory monitoring of patients receiving deferasirox does not include serum electrolytes or urine analysis. Thus, despite routine clinic visits and bloodwork, these two patients presented with life-threatening electrolyte abnormalities requiring hospitalization. Hence, we propose the inclusion of serum electrolytes and urine analysis as part of routine monitoring to facilitate the early diagnosis of Fanconi syndrome in the context of high doses of deferasirox therapy.
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Affiliation(s)
- Koyelle Papneja
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, McMaster Children's Hospital, McMaster University, Hamilton, Ontario, Canada
| | - Mihir D Bhatt
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, McMaster Children's Hospital, McMaster University, Hamilton, Ontario, Canada
| | - Melanie Kirby-Allen
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Steven Arora
- Division of Nephrology, Department of Pediatrics, McMaster Children's Hospital, McMaster University, Hamilton, Ontario, Canada
| | - John T Wiernikowski
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, McMaster Children's Hospital, McMaster University, Hamilton, Ontario, Canada
| | - Uma H Athale
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, McMaster Children's Hospital, McMaster University, Hamilton, Ontario, Canada
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Origa R, Zappu A, Foschini ML, Leoni G, Morittu M, Moi P, Corpino M, Dessì C. Deferasirox and children: From clinical trials to the real world. Am J Hematol 2016; 91:E304-5. [PMID: 26950047 DOI: 10.1002/ajh.24353] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2016] [Accepted: 03/03/2016] [Indexed: 11/05/2022]
Affiliation(s)
- Raffaella Origa
- Department of Public Health; Clinical and Molecular Medicine, University of Cagliari; Cagliari Italy
| | - Antonietta Zappu
- Ospedale Pediatrico Microcitemico “a.Cao”- a.O. G.Brotzu; Cagliari Italy
| | | | | | - Maddalena Morittu
- Ospedale Pediatrico Microcitemico “a.Cao”- a.O. G.Brotzu; Cagliari Italy
| | - Paolo Moi
- Department of Public Health; Clinical and Molecular Medicine, University of Cagliari; Cagliari Italy
| | - Mara Corpino
- Ospedale Pediatrico Microcitemico “a.Cao”- a.O. G.Brotzu; Cagliari Italy
| | - Carlo Dessì
- Ospedale Pediatrico Microcitemico “a.Cao”- a.O. G.Brotzu; Cagliari Italy
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Allegra S, Cusato J, De Francia S, Pirro E, Massano D, Piga A, D'Avolio A. Deferasirox pharmacokinetic evaluation in β-thalassaemia paediatric patients. ACTA ACUST UNITED AC 2016; 69:525-528. [PMID: 27230486 DOI: 10.1111/jphp.12559] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Accepted: 03/29/2016] [Indexed: 01/19/2023]
Abstract
OBJECTIVES Iron chelation in the transfusion-dependent anaemias management is essential to prevent end-organ damage and to improve survival. Deferasirox is a once-daily orally active tridentate selective iron chelator which pharmacokinetic disposition could influence treatment efficacy and toxicity. Therapeutic drug monitoring is an important tool for optimizing drug utilization and doses. METHODS A fully validated chromatographic method was used to quantify deferasirox concentration in plasma collected from paediatric patients with β-thalassaemia. Samples obtained after 5 days of washout or in naïve patients before and after 2, 4, 6 and 24 h drug administration were evaluated. KEY FINDINGS Associations between variables were tested using the Pearson test. Twenty paediatric patients were enrolled; they were mainly men (13.65%), with median age of 6.35 years and body mass index of 15.45 kg/m2 . Concerning pharmacokinetic parameters, a higher interindividual variability was shown. A positive, but not significant, correlation (r = 0.363; P = 0.115) was found between deferasirox area under the concentration curve over 24 h (AUC) and drug dose. CONCLUSIONS Monitoring plasma deferasirox concentrations appears beneficial for guiding appropriate patient treatment, enhancing effectiveness and minimizing toxicity.
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Affiliation(s)
- Sarah Allegra
- Unit of Infectious Diseases, Department of Medical Sciences, Amedeo di Savoia Hospital, University of Turin, Turin, Italy
| | - Jessica Cusato
- Unit of Infectious Diseases, Department of Medical Sciences, Amedeo di Savoia Hospital, University of Turin, Turin, Italy
| | - Silvia De Francia
- Department of Biological and Clinical Sciences, S. Luigi Gonzaga Hospital, University of Turin, Orbassano, Turin, Italy
| | - Elisa Pirro
- Department of Biological and Clinical Sciences, S. Luigi Gonzaga Hospital, University of Turin, Orbassano, Turin, Italy
| | - Davide Massano
- Department of Pediatrics, Centre for Microcitemie, S. Luigi Gonzaga Hospital, University of Turin, Orbassano, Turin, Italy
| | - Antonio Piga
- Department of Pediatrics, Centre for Microcitemie, S. Luigi Gonzaga Hospital, University of Turin, Orbassano, Turin, Italy
| | - Antonio D'Avolio
- Unit of Infectious Diseases, Department of Medical Sciences, Amedeo di Savoia Hospital, University of Turin, Turin, Italy
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Hassan MAM, Tolba OA. Iron chelation monotherapy in transfusion-dependent beta-thalassemia major patients: a comparative study of deferasirox and deferoxamine. Electron Physician 2016; 8:2425-31. [PMID: 27382454 PMCID: PMC4930264 DOI: 10.19082/2425] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2016] [Accepted: 04/06/2016] [Indexed: 01/19/2023] Open
Abstract
Introduction Iron overload is the primary cause of mortality and morbidity in thalassemia major (TM) despite advances in chelation therapy. The aim of this study was to compare the effectiveness and safety of deferasirox (DFX) and deferoxamine (DFO) as iron-chelating agents in patients with transfusion-dependent β-thalassemia major. Methods This prospective randomized study included 60 patients with transfusion-dependent β-TM during the period from September 2014 to September 2015. Their ages were ≥ 6 years, and they had serum ferritin above 1500 μg/L and were on irregular DFO therapy. Patients had regular packed red cell transfusion in a dose of 10 mL/kg/session. They were randomized to receive DFX (single oral daily dose of 20–40 mg/kg/day) or DFO (20–50 mg/kg/day via subcutaneous infusion over 8–10 hours, 5 days a week). Iron overload was determined by serum ferritin level. The primary endpoint was decrease of serum ferritin level below 1500 μg/L. The secondary endpoint was drug safety. Results Both drugs significantly reduced serum ferritin (p < 0.001). At the end of follow-up, there were no significant differences between the two groups in serum ferritin levels (p = 0.673) and in percent reduction of ferritin (p = 0.315). There were no significant differences between the two groups in the total amount of blood transfusion (p = 0.166) and average iron intake (p = 0.227). There were no mortalities or any serious adverse effects, neutropenia, arthropathy, or pulmonary toxicity. Gastrointestinal upset and skin rash occurred more frequently with DFX than with DFO (p = 0.254 and 0.095, respectively). Conclusion With appropriate dosing and compliance with drugs, both DFX and DFO are generally well tolerated, safe, and effective in reducing serum ferritin levels in iron-overloaded, regularly-transfused thalassemia major patients. Therefore, oral DFX is recommended for more convenience and adherence to the treatment regimen.
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Affiliation(s)
| | - Omar Atef Tolba
- Ph.D., Consultant of Pediatrics, Cairo University Children's Hospital, Department of Pediatrics, Cairo University, Egypt
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76
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Saliba AN, Taher AT. Morbidities in non-transfusion-dependent thalassemia. Ann N Y Acad Sci 2016; 1368:82-94. [DOI: 10.1111/nyas.13083] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Revised: 04/06/2016] [Accepted: 04/07/2016] [Indexed: 01/19/2023]
Affiliation(s)
- Antoine N. Saliba
- Department of Medicine; Indiana University School of Medicine; Indianapolis Indiana
| | - Ali T. Taher
- Department of Internal Medicine; American University of Beirut Medical Center; Beirut Lebanon
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Vill K, Müller-Felber W, Teusch V, Blaschek A, Gerstl L, Huetker S, Albert MH. Proximal muscular atrophy and weakness: An unusual adverse effect of deferasirox iron chelation therapy. Neuromuscul Disord 2016; 26:322-5. [PMID: 27068298 DOI: 10.1016/j.nmd.2016.02.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Revised: 02/11/2016] [Accepted: 02/16/2016] [Indexed: 11/17/2022]
Abstract
Deferasirox is a standard treatment for chronic transfusional iron overload. Adverse effects of deferasirox have been reported in large prospective studies. We report two cases of monozygotic twins manifesting with proximal muscular atrophy and weakness under deferasirox. Discontinuation of deferasirox resulted in symptom improvement and ultimately in complete remission five months after successful haematopoietic stem cell transplantation. Broad diagnostic work-up could not bring evidence of another aetiology of muscular weakness. Iron overload or beta thalassemia itself as a cause is considered unlikely in our patients because the chronological coincidence of muscular symptoms was contra-directional to serum ferritin levels and significant clinical improvement was observed promptly after cessation of deferasirox even before transplantation. These observations suggest that the development of muscular weakness in patients on deferasirox should be recognised as a possible adverse effect of the drug.
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Affiliation(s)
- K Vill
- Department of Pediatric Neurology and Developmental Medicine, Dr. v. Hauner Children's Hospital, Ludwig-Maximilians-University, Munich, Germany.
| | - W Müller-Felber
- Department of Pediatric Neurology and Developmental Medicine, Dr. v. Hauner Children's Hospital, Ludwig-Maximilians-University, Munich, Germany
| | - V Teusch
- Department of Pediatric Radiology, Dr. v. Hauner Children's Hospital, Ludwig-Maximilians-University, Munich, Germany
| | - A Blaschek
- Department of Pediatric Neurology and Developmental Medicine, Dr. v. Hauner Children's Hospital, Ludwig-Maximilians-University, Munich, Germany
| | - L Gerstl
- Department of Pediatric Neurology and Developmental Medicine, Dr. v. Hauner Children's Hospital, Ludwig-Maximilians-University, Munich, Germany
| | - S Huetker
- Department of Pediatric Hematology and Oncology, Dr. v. Hauner Children's Hospital, Ludwig-Maximilians-University, Munich, Germany
| | - M H Albert
- Department of Pediatric Hematology and Oncology, Dr. v. Hauner Children's Hospital, Ludwig-Maximilians-University, Munich, Germany
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Wong P, Polkinghorne K, Kerr PG, Doery JCG, Gillespie MT, Larmour I, Fuller PJ, Bowden DK, Milat F. Deferasirox at therapeutic doses is associated with dose-dependent hypercalciuria. Bone 2016; 85:55-8. [PMID: 26802257 DOI: 10.1016/j.bone.2016.01.011] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Revised: 12/26/2015] [Accepted: 01/07/2016] [Indexed: 01/19/2023]
Abstract
Deferasirox is an oral iron chelator used widely in the treatment of thalassemia major and other transfusion-dependent hemoglobinopathies. Whilst initial long-term studies established the renal safety of deferasirox, there are now increasing reports of hypercalciuria and renal tubular dysfunction. In addition, urolithiasis with rapid loss of bone density in patients with β thalassemia major has been reported. We conducted a cross-sectional cohort study enrolling 152 adult patients comprising of β thalassemia major (81.5%), sickle cell disease (8%), thalassemia intermedia (2%), HbH disease (6.5%) and E/β thalassemia (2%). Cases were matched with normal control subjects on age, gender and serum creatinine. Iron chelator use was documented and urine calcium to creatinine ratios measured. At the time of analysis, 88.8% of patients were receiving deferasirox and 11.2% were on deferoxamine. Hypercalciuria was present in 91.9% of subjects on deferasirox in a positive dose-dependent relationship. This was not seen with subjects receiving deferoxamine. At a mean dose of 30.2±8.8mg/kg/day, deferasirox was associated with an almost 4 fold increase in urine calcium to creatinine ratio (UCa/Cr). Hypercalciuria was present at therapeutic doses of deferasirox in a dose-dependent manner and warrants further investigation and vigilance for osteoporosis, urolithiasis and other markers of renal dysfunction.
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Affiliation(s)
- Phillip Wong
- Hudson Institute of Medical Research, Victoria, Australia; Department of Endocrinology, Monash Health, Victoria, Australia; Department of Medicine, Monash University, Victoria, Australia.
| | - Kevan Polkinghorne
- Department of Medicine, Monash University, Victoria, Australia; Department of Nephrology, Monash Health, Victoria, Australia
| | - Peter G Kerr
- Department of Medicine, Monash University, Victoria, Australia; Department of Nephrology, Monash Health, Victoria, Australia
| | - James C G Doery
- Department of Medicine, Monash University, Victoria, Australia; Department of Pathology, Monash Health, Victoria, Australia
| | - Matthew T Gillespie
- Hudson Institute of Medical Research, Victoria, Australia; Department of Biochemistry and Molecular Biology, Monash University, Victoria, Australia
| | - I Larmour
- Department of Pharmacy, Monash Health, Victoria, Australia
| | - Peter J Fuller
- Hudson Institute of Medical Research, Victoria, Australia; Department of Endocrinology, Monash Health, Victoria, Australia; Department of Medicine, Monash University, Victoria, Australia; Department of Biochemistry and Molecular Biology, Monash University, Victoria, Australia
| | | | - Frances Milat
- Hudson Institute of Medical Research, Victoria, Australia; Department of Endocrinology, Monash Health, Victoria, Australia; Department of Medicine, Monash University, Victoria, Australia
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79
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Longitudinal changes of endocrine and bone disease in adults with β-thalassemia major receiving different iron chelators over 5 years. Ann Hematol 2016; 95:757-63. [DOI: 10.1007/s00277-016-2633-y] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Accepted: 02/29/2016] [Indexed: 01/19/2023]
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80
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Vitrano A, Calvaruso G, Tesé L, Gioia F, Cassarà F, Campisi S, Butera F, Commendatore V, Rizzo M, Santoro V, Cigna V, Quota A, Bagnato S, Argento C, Fidone C, Schembari D, Gerardi C, Barbiera F, Bellisssima G, Giugno G, Polizzi G, Rosso R, Abbate G, Caruso V, Chiodi E, Gamberini MR, Giorgi B, Putti MC, Filosa A, De Ritis MR, Oliva E, Arcadi N, Fustaneo M, Mistretta L, Di Maggio R, Sacco M, Veronica DS, Giangreco A, Maggio A. Real-life experience with liver iron concentration R2 MRI measurement in patients with hemoglobinopathies: baseline data from LICNET. Eur J Haematol 2016; 97:361-70. [DOI: 10.1111/ejh.12740] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/22/2016] [Indexed: 01/19/2023]
Affiliation(s)
- Angela Vitrano
- Campus of Haematology Franco e Piera Cutino- A.O.O.R. ‘Villa Sofia-Cervello’; Palermo Italy
| | - Giuseppina Calvaruso
- Campus of Haematology Franco e Piera Cutino- A.O.O.R. ‘Villa Sofia-Cervello’; Palermo Italy
| | - Lorenzo Tesé
- Campus of Haematology Franco e Piera Cutino- A.O.O.R. ‘Villa Sofia-Cervello’; Palermo Italy
| | - Francesco Gioia
- Campus of Haematology Franco e Piera Cutino- A.O.O.R. ‘Villa Sofia-Cervello’; Palermo Italy
| | - Filippo Cassarà
- Campus of Haematology Franco e Piera Cutino- A.O.O.R. ‘Villa Sofia-Cervello’; Palermo Italy
| | | | | | | | | | | | | | | | | | - Crocetta Argento
- U.O.S. di Talassemia Ospedale San Giovanni di Dio; Agrigento Italy
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Aldo Filosa
- U.O.D. Malattie Rare del Globulo Rosso; A.O.R.N. ‘A. Cardarelli’; Napoli Italy
| | | | - Esther Oliva
- A.O. ‘Bianchi-Melacrino-Morelli’; Reggio Calabria Italy
| | - Nicola Arcadi
- A.O. ‘Bianchi-Melacrino-Morelli’; Reggio Calabria Italy
| | - Maria Fustaneo
- Campus of Haematology Franco e Piera Cutino- A.O.O.R. ‘Villa Sofia-Cervello’; Palermo Italy
| | - Laura Mistretta
- Campus of Haematology Franco e Piera Cutino- A.O.O.R. ‘Villa Sofia-Cervello’; Palermo Italy
| | - Rosario Di Maggio
- Campus of Haematology Franco e Piera Cutino- A.O.O.R. ‘Villa Sofia-Cervello’; Palermo Italy
| | - Massimiliano Sacco
- Campus of Haematology Franco e Piera Cutino- A.O.O.R. ‘Villa Sofia-Cervello’; Palermo Italy
| | - Di Salvo Veronica
- Campus of Haematology Franco e Piera Cutino- A.O.O.R. ‘Villa Sofia-Cervello’; Palermo Italy
| | - Antonino Giangreco
- Campus of Haematology Franco e Piera Cutino- A.O.O.R. ‘Villa Sofia-Cervello’; Palermo Italy
| | - Aurelio Maggio
- Campus of Haematology Franco e Piera Cutino- A.O.O.R. ‘Villa Sofia-Cervello’; Palermo Italy
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81
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Iron chelation therapy of transfusion-dependent β-thalassemia during pregnancy in the era of novel drugs: is deferasirox toxic? Int J Hematol 2016; 103:537-44. [DOI: 10.1007/s12185-016-1945-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Revised: 01/25/2016] [Accepted: 01/26/2016] [Indexed: 12/20/2022]
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82
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Saliba AN, El Rassi F, Taher AT. Clinical monitoring and management of complications related to chelation therapy in patients with β-thalassemia. Expert Rev Hematol 2015; 9:151-68. [DOI: 10.1586/17474086.2016.1126176] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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83
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Borgna-Pignatti C, Marsella M. Iron Chelation in Thalassemia Major. Clin Ther 2015; 37:2866-77. [PMID: 26519233 DOI: 10.1016/j.clinthera.2015.10.001] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Revised: 10/01/2015] [Accepted: 10/02/2015] [Indexed: 01/19/2023]
Abstract
PURPOSE Iron chelation has improved survival and quality of life of patients with thalassemia major. there are currently 3 commercially available iron-chelating drugs with different pharmacokinetic and pharmacodynamic activity. The choice of adequate chelation treatment should be tailored to patient needs and based on up-to-date scientific evidence. METHODS A review of the most recent literature was performed. FINDINGS The ability of the chelators to bind the redox active component of iron, labile plasma iron, is crucial for protecting the cells. Chelation therapy should be guided by magnetic resonance imaging that permits the tailoring of therapy according to the needs of the patient because different chelators preferentially clear iron from different sites. Normal levels of body iron seem to decrease the need for hormonal and cardiac therapy. IMPLICATIONS The 3 chelators currently available have different benefits, different safety profiles, and different acceptance on the part of the patients. Good-quality, well-designed, randomized, long-term clinical trials continue to be needed.
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Affiliation(s)
| | - Maria Marsella
- Pediatrics and Adolescentology Unit, Maternal and Child Health Department, "G. Rummo" Hospital, Benevento, Italy
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84
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Fragomeno C, Roccabruna E, D'Ascola DG. Effect of deferasirox on iron overload in patients with transfusion-dependent haemoglobinopathies. Blood Cells Mol Dis 2015; 55:382-6. [PMID: 26460263 DOI: 10.1016/j.bcmd.2015.04.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Revised: 04/20/2015] [Accepted: 04/20/2015] [Indexed: 01/19/2023]
Abstract
BACKGROUND Patients with haematopoietic disorders requiring long-term blood transfusions are at risk of iron overload. This study aimed to investigate the efficacy and safety of long-term deferasirox monotherapy in patients with transfusion-dependent anaemia in the routine clinical practice setting. METHODS This was a retrospective analysis of patients who commenced deferasirox therapy at the Hospital Bianchi Melacrino Morelli in Reggio Calabria, Italy. Data collected included cardiac and hepatic iron load (assessed by magnetic resonance imaging); left ventricular ejection fraction (LVEF). Patients were divided into two groups for analysis: group A (baseline information collected prior to deferasirox initiation) and group B (baseline information collected after deferasirox initiation). RESULTS Forty-six patients were included (group A: n=25; group B: n=21). The overall population was 63% male, with a mean age of 33 years. The majority of patients (65%) had thalassaemia major. In the overall population, cardiac iron levels between the baseline and first follow-up visits improved in both groups A and B (29.2 vs. 32.5 ms; p=0.04 and 28.4 vs. 31.4 ms; p=0.038). Liver iron levels improved significantly from baseline to visit 1 in group A (7.2 vs. 12.1 ms; p<0.004) and from baseline to visit 3 (6.9 vs. 10.7; p=0.049) in group B. Generally, there was no correlation between cardiac and liver iron levels. LVEF remained stable throughout the study period. Deferasirox was well tolerated and was not associated with significant adverse events. CONCLUSION Long-term treatment with deferasirox is effective and safe in patients with transfusion-dependent haemoglobinopathies monitored in the clinical practice setting.
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Affiliation(s)
- Concetta Fragomeno
- SSD Microcythemia Center, Hospital Bianchi Melacrino Morelli, Reggio Calabria, Italy
| | - Emilio Roccabruna
- SSD Microcythemia Center, Hospital Bianchi Melacrino Morelli, Reggio Calabria, Italy
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85
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Chang HH, Lu MY, Peng SSF, Yang YL, Lin DT, Jou ST, Lin KH. The long-term efficacy and tolerability of oral deferasirox for patients with transfusion-dependent β-thalassemia in Taiwan. Ann Hematol 2015; 94:1945-52. [PMID: 26404899 PMCID: PMC4604499 DOI: 10.1007/s00277-015-2476-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Accepted: 08/10/2015] [Indexed: 01/12/2023]
Abstract
Deferasirox is a novel once-daily, oral iron chelator. The aim of this study was to evaluate the long-term efficacy and tolerability of deferasirox in Taiwanese patients with transfusion-dependent β-thalassemia who have been treated with deferasirox for 7 years. Taiwanese patients aged ≥2 years with transfusion-dependent β-thalassemia whose serum ferritin levels were ≥1000 ng/mL and had started deferasirox treatment since December 2005 at the National Taiwan University Hospital were enrolled. Sixty patients were recruited for analysis, and 11 (18.3 %) patients discontinued deferasirox during the study. In the 42 patients included in the efficacy analysis, the mean serum ferritin levels decreased significantly by 2566 ng/mL after 7 years of treatment (P < 0.001). Forty-one of these patients received a cardiac T2* evaluation after 3 years of deferasirox treatment, and the mean cardiac T2* value increased significantly from 30.6 ± 16.6 to 45.9 ± 22.6 ms after 7 years of deferasirox treatment (P < 0.001). Deferasirox-related adverse events assessed by investigators were reported in 46 (76.7 %) patients. The most common adverse events related to deferasirox were skin rashes (n = 29, 48.3 %), followed by abdominal pain (n = 23, 38.3 %) and diarrhea (n = 16, 26.7 %). Most adverse events were manageable. This study demonstrated that long-term treatment with deferasirox was effective in improving iron overload, including cardiac iron overload, in patients with transfusion-dependent β-thalassemia. Deferasirox was well tolerated; however, the incidences of common adverse events related to deferasirox appeared higher in our Taiwanese patients than other studies.
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Affiliation(s)
- Hsiu-Hao Chang
- Department of Pediatrics, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Meng-Yao Lu
- Department of Pediatrics, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Steven Shinn-Forng Peng
- Department of Medical Imaging, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Yung-Li Yang
- Department of Pediatrics, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan.,Department of Laboratory Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Dong-Tsamn Lin
- Department of Pediatrics, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan.,Department of Laboratory Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Shiann-Tarng Jou
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, National Taiwan University Hospital, National Taiwan University College of Medicine, 8 Chung-Shan South Road, Taipei, 100, Taiwan.
| | - Kai-Hsin Lin
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, National Taiwan University Hospital, National Taiwan University College of Medicine, 8 Chung-Shan South Road, Taipei, 100, Taiwan.
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86
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Marano M, Bottaro G, Goffredo B, Stoppa F, Pisani M, Marinaro AM, Deodato F, Dionisi-Vici C, Clementi E, Falvella FS. Deferasirox-induced serious adverse reaction in a pediatric patient: pharmacokinetic and pharmacogenetic analysis. Eur J Clin Pharmacol 2015; 72:247-8. [PMID: 26403473 DOI: 10.1007/s00228-015-1956-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Accepted: 09/18/2015] [Indexed: 10/23/2022]
Affiliation(s)
- M Marano
- DEA Intensive Care Unit, IRCCS "Bambino Gesù" Children Hospital, Piazza S. Onofrio 4, Rome, 00165, Italy.
| | - G Bottaro
- Department of Pediatrics "Tor Vergata University", Rome, Italy
| | - B Goffredo
- Laboratory of Analytical Biochemistry, IRCCS "Bambino Gesù" Children Hospital, Rome, Italy
| | - F Stoppa
- DEA Intensive Care Unit, IRCCS "Bambino Gesù" Children Hospital, Piazza S. Onofrio 4, Rome, 00165, Italy
| | - M Pisani
- DEA, IRCCS "Bambino Gesù" Children Hospital, Rome, Italy
| | - A M Marinaro
- Department of Pediatrics, Section of Pediatrics Haematology and Oncology, University of Sassari, Sassari, Italy
| | - F Deodato
- Department of Pediatric Medicine, Division of Metabolism, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - C Dionisi-Vici
- Department of Pediatric Medicine, Division of Metabolism, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - E Clementi
- Scientific Institute IRCCS Eugenio Medea, 23842 Bosisio Parini, Lecco, Italy.,Department of Biomedical and Clinical Sciences L. Sacco, Unit of Clinical Pharmacology, CNR Institute of Neuroscience, "Luigi Sacco" University Hospital, University of Milano, Milan, Italy
| | - F S Falvella
- Department of Biomedical and Clinical Sciences, Unit of Clinical Pharmacology, "Luigi Sacco" University Hospital, University of Milano, Milan, Italy
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87
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Efficacy and safety of deferasirox in non-thalassemic patients with elevated ferritin levels after allogeneic hematopoietic stem cell transplantation. Bone Marrow Transplant 2015; 51:89-95. [DOI: 10.1038/bmt.2015.204] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Revised: 07/18/2015] [Accepted: 07/23/2015] [Indexed: 12/22/2022]
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88
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Ejaz MS, Baloch S, Arif F. Efficacy and adverse effects of oral chelating therapy (deferasirox) in multi-transfused Pakistani children with β-thalassemia major. Pak J Med Sci 2015; 31:621-5. [PMID: 26150856 PMCID: PMC4485283 DOI: 10.12669/pjms.313.6972] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2014] [Revised: 04/16/2015] [Accepted: 03/12/2015] [Indexed: 02/05/2023] Open
Abstract
Objective: To determine the efficacy and adverse effects of oral chelation therapy (deferasirox) in multi-transfused β-thalassemia major patients visiting pediatric thalassemia clinic in Civil Hospital Karachi. Methods: This prospective study was conducted at pediatric thalassemia clinic of Civil Hospital Karachi. Hundred multi-transfused β-thalassemia patients registered in the clinic for oral iron chelation therapy were included in the study. Information regarding clinical and laboratory parameters including abdominal pain, jaundice, serum ferritin, creatinine and serum transaminase levels were recorded on a Performa and data was analyzed through SPSS 16. Results: Hundred patients were stratified into two age groups, 54% were below and 46% were above nine year. Majority were males, 62% and 38% were females. Abdominal pain 41%, nausea 31%, vomiting 15%, jaundice 15% and elevated serum creatinine 11.5% were frequently observed clinical adverse effects in this study. Serum glutamic pyruvic transaminase (SGPT) level was statistically significant compared with initial visit and six months after optimal chelation therapy (p=0.030). Although Serum ferritin was decreased but it was not statistically significant (p=0.929). Conclusion: Deferasirox is an effective oral chelation agent for β-thalassemia major patients. Most common adverse effects of the drug are abdominal pain, nausea, vomiting, and elevation of liver enzymes.
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Affiliation(s)
- Muzamil Shabana Ejaz
- Dr. Muzamil Shabana Ejaz, Associate Professor, Department of Pediatrics Dow University of Health Sciences Civil Hospital Karachi, Karachi - Pakistan
| | - Shagufta Baloch
- Dr. Shagufta Baloch, FCPS Trainee, Department of Pediatrics Dow University of Health Sciences Civil Hospital Karachi, Karachi - Pakistan
| | - Fehmina Arif
- Prof. Fehmina Arif, Professor, Department of Pediatrics Dow University of Health Sciences Civil Hospital Karachi, Karachi - Pakistan
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89
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Aydinok Y, Kattamis A, Cappellini MD, El-Beshlawy A, Origa R, Elalfy M, Kilinç Y, Perrotta S, Karakas Z, Viprakasit V, Habr D, Constantinovici N, Shen J, Porter JB. Effects of deferasirox-deferoxamine on myocardial and liver iron in patients with severe transfusional iron overload. Blood 2015; 125:3868-77. [PMID: 25934475 PMCID: PMC4490296 DOI: 10.1182/blood-2014-07-586677] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Accepted: 04/17/2015] [Indexed: 01/19/2023] Open
Abstract
Deferasirox (DFX) monotherapy is effective for reducing myocardial and liver iron concentrations (LIC), although some patients may require intensive chelation for a limited duration. HYPERION, an open-label single-arm prospective phase 2 study, evaluated combination DFX-deferoxamine (DFO) in patients with severe transfusional myocardial siderosis (myocardial [m] T2* 5-<10 ms; left ventricular ejection fraction [LVEF] ≥56%) followed by optional switch to DFX monotherapy when achieving mT2* >10 ms. Mean dose was 30.5 mg/kg per day DFX and 36.3 mg/kg per day DFO on a 5-day regimen. Geometric mean mT2* ratios (Gmeanmonth12/24/Gmeanbaseline) were 1.09 and 1.30, respectively, increasing from 7.2 ms at baseline (n = 60) to 7.7 ms at 12 (n = 52) and 9.5 ms at 24 months (n = 36). Patients (17 of 60; 28.3%) achieved mT2* ≥10 ms and ≥10% increase from baseline at month 24; 15 switched to monotherapy during the study based on favorable mT2*. LIC decreased substantially from a baseline of 33.4 to 12.8 mg Fe/g dry weight at month 24 (-52%). LVEF remained stable with no new arrhythmias/cardiac failure. Five patients discontinued with mT2* <5 ms and 1 died (suspected central nervous system infection). Safety was consistent with established monotherapies. Results show clinically meaningful improvements in mT2* in about one-third of patients remaining on treatment at month 24, alongside rapid decreases in LIC in this heavily iron-overloaded, difficult-to-treat population. Combination therapy may be useful when rapid LIC reduction is required, regardless of myocardial iron overload. This trial was registered at www.clinicaltrials.gov as #NCT01254227.
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Affiliation(s)
- Yesim Aydinok
- Department of Pediatric Hematology, Ege University Hospital, Izmir, Turkey
| | - Antonis Kattamis
- First Department of Pediatrics, University of Athens, Athens, Greece
| | - M Domenica Cappellini
- Universitá di Milano, Ca Granda Foundation Istituto Di Ricovero e Cura a Carattere Scientifico (IRCCS), Milan, Italy
| | - Amal El-Beshlawy
- Department of Hematology, Pediatric Hospital, Cairo University, Cairo, Egypt
| | - Raffaella Origa
- Ospedale Regionale per le Microcitemie, University of Cagliari, Cagliari, Italy
| | - Mohsen Elalfy
- Thalassemia Center, Children's Hospital, Ain Shams University, Cairo, Egypt
| | | | - Silverio Perrotta
- Department of Woman, Child and of General and Specialist Surgery, I°Policlinico II°Università di Napoli, Naples, Italy
| | - Zeynep Karakas
- Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Vip Viprakasit
- Department of Pediatrics and Thalassemia Center, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Dany Habr
- Novartis Pharmaceuticals, East Hanover, NJ
| | | | - Junwu Shen
- Novartis Pharmaceuticals, East Hanover, NJ
| | - John B Porter
- Department of Hematology, UCL Cancer Institute, University College London, London, United Kingdom
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90
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Milo G, Feige Gross Nevo R, Pazgal I, Gafter-Gvili A, Shpilberg O, Gafter U, Erman A, Stark P. GFR in Patients with β-Thalassemia Major. Clin J Am Soc Nephrol 2015; 10:1350-6. [PMID: 25964308 DOI: 10.2215/cjn.12181214] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Accepted: 04/14/2015] [Indexed: 01/19/2023]
Abstract
BACKGROUND AND OBJECTIVES Patients with β-thalassemia major (TM) may have tubular dysfunction and glomerular dysfunction, primarily hyperfiltration, based on eGFR. Assessment of GFR based on serum creatinine concentration may overestimate GFR in these patients. This study sought to determine GFR by using inulin clearance and compare it with measured creatinine clearance (Ccr) and eGFR. DESIGN, SETTING, PARTICIPANTS & MEASUREMENTS Patients followed up in an Israeli thalassemia clinic who had been regularly transfused for years and treated with deferasirox were included in the study. They were studied by inulin clearance, Ccr, the CKD Epidemiology Collaboration and the Modification of Diet in Renal Disease equations for eGFR, and the Cockcroft-Gault estimation for Ccr. Expected creatinine excretion rate and tubular creatinine secretion rate were calculated. RESULTS Nine white patients were studied. Results, given as medians, were as follows: serum creatinine was 0.59 mg/dl (below normal limits); GFR was low (76.6 ml/min per 1.73 m(2)) and reached the level of CKD; Ccr was 134.9 ml/min per 1.73 m(2), higher than the GFR because of a tubular creatinine secretion rate of 30.3 ml/min per 1.73 m(2) (this accounted for 40% of the Ccr); and eGFR calculated by the CKD Epidemiology Collaboration and Modification of Diet in Renal Disease equations and Cockcroft-Gault-estimated Ccr were 133, 141, and 168 ml/min per 1.73 m(2), respectively. These latter values were significantly higher than the GFR, reaching the hyperfiltration range, and indicated that the estimation techniques were clinically unacceptable as a method for measuring kidney function compared with the GFR according to Bland and Altman analyses. CONCLUSIONS Contrary to previous reports, patients in this study with TM had normal or reduced GFR. The estimating methods showed erroneous overestimation of GFR and were clinically unacceptable for GFR measurements in patients with TM by Bland and Altman analysis. Therefore, more accurate methods should be used for early detection of reduced GFR and prevention of its further decline toward CKD in these patients.
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Affiliation(s)
- Gai Milo
- Department of Nephrology and Hypertension, Rabin Medical Center, Petah-Tikva, Israel; Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel; and
| | - Revital Feige Gross Nevo
- Department of Nephrology and Hypertension, Rabin Medical Center, Petah-Tikva, Israel; Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel; and
| | - Idit Pazgal
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel; and Institute of Hematology, Rabin Medical Center, Petah-Tikva, Israel
| | - Anat Gafter-Gvili
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel; and Institute of Hematology, Rabin Medical Center, Petah-Tikva, Israel
| | - Ofer Shpilberg
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel; and Institute of Hematology, Rabin Medical Center, Petah-Tikva, Israel
| | - Uzi Gafter
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel; and Institute of Hematology, Rabin Medical Center, Petah-Tikva, Israel
| | - Arie Erman
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel; and Institute of Hematology, Rabin Medical Center, Petah-Tikva, Israel
| | - Pinhas Stark
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel; and Institute of Hematology, Rabin Medical Center, Petah-Tikva, Israel
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Guidelines for the Standard Monitoring of Patients With Thalassemia: Report of the Thalassemia Longitudinal Cohort. J Pediatr Hematol Oncol 2015; 37. [PMID: 26201037 PMCID: PMC4511957 DOI: 10.1097/mph.0000000000000307] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Chronic transfusion therapy has played a central role in extending life expectancy for patients with hemoglobinopathies such as thalassemia. However, this life-saving therapy is associated with numerous complications that now comprise the bulk of management considerations for patients with thalassemia. This review reports on the experience of the Thalassemia Longitudinal Cohort and reviews available literature to establish guidelines for the management of patients with thalassemia.
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92
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Marsella M, Borgna-Pignatti C. Transfusional iron overload and iron chelation therapy in thalassemia major and sickle cell disease. Hematol Oncol Clin North Am 2015; 28:703-27, vi. [PMID: 25064709 DOI: 10.1016/j.hoc.2014.04.004] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Iron overload is an inevitable consequence of blood transfusions and is often accompanied by increased iron absorption from the gut. Chelation therapy is necessary to prevent the consequences of hemosiderosis. Three chelators, deferoxamine, deferiprone, and deferasirox, are presently available and a fourth is undergoing clinical trials. The efficacy of all 3 available chelators has been demonstrated. Also, many studies have shown the efficacy of the combination of deferoxamine plus deferiprone as an intensive treatment of severe iron overload. Alternating chelators can reduce adverse effects and improve compliance. Adherence to therapy is crucial for good results.
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Affiliation(s)
- Maria Marsella
- Department of Medical Sciences, University of Ferrara, Azienda Ospedale-Università Via Aldo Moro 8, Cona, Ferrara, Italy
| | - Caterina Borgna-Pignatti
- Department of Medical Sciences, University of Ferrara, Azienda Ospedale-Università Via Aldo Moro 8, Cona, Ferrara, Italy.
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93
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Abstract
Iron accumulation is a consequence of regular red cell transfusions, and can occur as a result of ineffective erythropoiesis secondary to increased intestinal iron absorption, in patients with various anemias. Without appropriate treatment, iron overload can lead to increased morbidity and mortality. Deferasirox is an oral iron chelator effective for reduction of body iron in iron-overloaded patients with transfusion-dependent anemias and non-transfusion-dependent thalassemia, with a well-established safety profile. This review summarizes the clinical pharmacokinetics, pharmacodynamics, and drug-drug interaction profile of deferasirox, and the claims supporting once-daily dosing for effective chelation. Sustained labile plasma iron suppression is observed with no rebound between doses, protecting organs from potential tissue damage. Increased iron excretion positively correlates with increased deferasirox exposure; to optimize iron removal transfusional iron intake, body iron burden and safety parameters should also be considered. Deferasirox dispersible tablets should be taken ≥30 min before food due to an effect of food on bioavailability. Dosing is consistent across pediatric and adult patients and there is no ethnic sensitivity. Dose adjustment is required for patients with hepatic impairment and may be considered upon coadministration with strong uridine diphosphate glucuronosyltransferase inducers or bile acid sequestrants (coadministration should be avoided where possible), and patients should be monitored upon coadministration with cytochrome P450 (CYP) 3A4/5, CYP2C8, or CYP1A2 substrates. Coadministration with hydroxyurea, a fetal hemoglobin modulator, does not appear to impact deferasirox pharmacokinetics. In summary, a substantial body of clinical and pharmacokinetic data are available for deferasirox to guide its optimal use in multiple patient populations and clinical circumstances.
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94
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EFFICACY AND SAFETY OF DEFERASIROX WHEN COMPARED TO D EFERIPRONE AS ORAL IRON CHELATING AGENT : A RANDOMIZED CONTROL TRIAL. ACTA ACUST UNITED AC 2015. [DOI: 10.14260/jemds/2015/601] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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95
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Şen V, Ece A, Uluca Ü, Söker M, Güneş A, Kaplan İ, Tan İ, Yel S, Mete N, Sahin C. Urinary early kidney injury molecules in children with beta-thalassemia major. Ren Fail 2015; 37:607-13. [PMID: 25656833 DOI: 10.3109/0886022x.2015.1007871] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND The aim of this study was to investigate novel urinary biomarkers including N-acetyl-β-D-glucosaminidase (NAG), neutrophil gelatinase-associated lipocalin (NGAL), kidney injury molecule-1 (KIM-1), and liver-type fatty acid binding protein (L-FABP) in children with β-thalassemia major (β-TM). MATERIALS AND METHODS Totally, 52 patients (29 boys, 23 girls) with β-TM and 29 healthy controls (3-17 years) were included. Various demographic characteristics and blood transfusions/year, disease duration, and chelation therapy were recorded. Serum urea, creatinine, electrolytes, and ferritin and urinary creatinine, protein, calcium, phosphorus, sodium, potassium, and uric acid in first morning urine samples were measured and estimated glomerular filtration rate (eGFR) was calculated. Routine serum and urinary biochemical variables, urinary NAG to Creatinine (U(NAG/Cr)), U(NGAL/Cr), U(KIM-1/Cr), and U(L-FABP/Cr) ratios were determined. RESULTS Patients had similar mean serum urea, creatinine and eGFR levels compared with controls (p > 0.05 for all). The mean urinary protein to creatinine (U(Protein/Cr)) ratio was significantly higher in patients compared to the healthy subjects (0.13 ± 0.09 mg/mg and 0.07 ± 0.04 mg/mg, respectively; p < 0.001). Significantly increased U(NAG/Cr) (0.48 ± 0.58 vs. 0.23 ± 0.16, p = 0.026) and U(NGAL/Cr) (22.1 ± 18.5 vs. 11.5 ± 6.17, p = 0.01) ratios were found in β-TM patients compared with healthy controls. However, no differences were found in serum and urinary electrolytes or U(KIM-1/Cr) and U(L-FABP/Cr) ratios between patients and controls (p > 0.05). Significant correlations were found between urinary biomarkers and urinary electrolytes (p < 0.05). CONCLUSIONS Our results suggest that urinary NAG and NGAL may be considered to be reliable markers to monitor renal injury in β-TM patients.
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Affiliation(s)
- Velat Şen
- Dicle University Medical School Department of Pediatrics , Diyarbakir , Turkey
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96
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Pennell DJ, Porter JB, Piga A, Lai Y, El‐Beshlawy A, Elalfy M, Yesilipek A, Kilinç Y, Habr D, Musallam KM, Shen J, Aydinok Y. Sustained improvements in myocardial T2* over 2 years in severely iron-overloaded patients with beta thalassemia major treated with deferasirox or deferoxamine. Am J Hematol 2015; 90:91-6. [PMID: 25345697 DOI: 10.1002/ajh.23876] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Revised: 10/14/2014] [Accepted: 10/23/2014] [Indexed: 02/03/2023]
Abstract
Long-term controlled studies are needed to inform on the clinical benefit of chelation therapy for myocardial iron removal in transfusion-dependent beta thalassemia patients. In a 1-year nonrandomized extension to the CORDELIA study, data collected from patients with myocardial siderosis provided additional information on deferasirox or deferoxamine (DFO) efficacy and safety. Myocardial (m)T2* increased from baseline 11.6 to 15.9 ms in patients receiving deferasirox for 24 months (n = 74; geometric mean [Gmean ] ratio of month 24/baseline 1.38 [95% confidence interval 1.28, 1.49]) and from 10.8 to 14.2 ms in those receiving DFO (n = 29; Gmean ratio 1.33 [1.13, 1.55]; P = 0.93 between groups). Improved mT2* with deferasirox was evident across all subgroups evaluated irrespective of baseline myocardial (mT2* < 10 vs. ≥ 10 ms) or liver (LIC <15 vs. ≥15 mg Fe/g dw) iron burden. Mean LVEF was stable and remained within normal limits with deferasirox or DFO. Liver iron concentration decreased from high baseline values of 30.6 ± 18.0 to 14.4 ± 16.6 mg Fe/g dw at month 24 in deferasirox patients and from 36.8 ± 15.6 to 11.0 ± 12.1 mg Fe/g dw in DFO patients. The long-term safety profile of deferasirox or DFO was consistent with previous reports; serious drug-related AEs were reported in 6.8% of deferasirox and 6.9% of DFO patients. Continued treatment of severely iron-overloaded beta thalassemia patients with deferasirox or DFO led to sustained improvements in myocardial iron irrespective of high or low baseline myocardial or liver iron burden, in parallel with substantial improvements in liver iron (Clinicaltrials.gov identifier: NCT00600938).
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Affiliation(s)
- Dudley J. Pennell
- NIHR Cardiovascular Biomedical Research UnitRoyal Brompton HospitalLondon United Kingdom
| | - John B. Porter
- Department of HaematologyUniversity College LondonLondon United Kingdom
| | - Antonio Piga
- Department of PaediatricsUniversity of TurinTurin Italy
| | - Yong‐Rong Lai
- Department of HematologyThe First Affiliated Hospital of Guangxi Medical UniversityNanning China
| | | | - Mohsen Elalfy
- Department of PediatricsAin Shams UniversityCairo Egypt
| | - Akif Yesilipek
- Department of Pediatric Hematology‐OncologyAkdeniz UniversityAntalya Turkey
| | - Yurdanur Kilinç
- Department of BiochemistryCukurova University Medical FacilityAdana Turkey
| | - Dany Habr
- Novartis PharmaceuticalsEast Hanover New Jersey
| | | | - Junwu Shen
- Novartis PharmaceuticalsEast Hanover New Jersey
| | - Yesim Aydinok
- Department of Pediatric HematologyEge University HospitalIzmir Turkey
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97
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A 5-year follow-up in deferasirox treatment: improvement of cardiac and hepatic iron overload and amelioration in cardiac function in thalassemia major patients. Ann Hematol 2015; 94:939-45. [DOI: 10.1007/s00277-014-2291-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Accepted: 12/20/2014] [Indexed: 01/19/2023]
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98
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Sarigianni M, Liakos A, Vlachaki E, Paschos P, Athanasiadou E, Montori VM, Murad MH, Tsapas A. Accuracy of magnetic resonance imaging in diagnosis of liver iron overload: a systematic review and meta-analysis. Clin Gastroenterol Hepatol 2015; 13:55-63.e5. [PMID: 24993364 DOI: 10.1016/j.cgh.2014.05.027] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Revised: 04/01/2014] [Accepted: 05/30/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Guidelines advocate use of magnetic resonance imaging (MRI) to estimate concentrations of iron in liver, to identify patients with iron overload, and to guide titration of chelation therapy. However, this recommendation was not based on a systematic synthesis and analysis of the evidence for MRI's diagnostic accuracy. METHODS We conducted a systematic review and meta-analysis to investigate the diagnostic accuracy of MRI in identifying liver iron overload in patients with hereditary hemochromatosis, hemoglobinopathy, or myelodysplastic syndrome; liver biopsy analysis was used as the reference standard. We searched MEDLINE and EMBASE databases, the Cochrane Library, and gray literature, and computed summary receiver operating curves by fitting hierarchical models. We assessed methodologic quality using the Quality Assessment of Diagnostic Accuracy Studies 2 tool. RESULTS Our final analysis included 20 studies (819 patients, total). Sensitivity and specificity values varied greatly, ranging from 0.00 to 1.00 and from 0.50 to 1.00, respectively. Because of substantial heterogeneity and variable positivity thresholds, we calculated only summary receiver operating curves (and summary estimate points for studies that used the same MRI sequences). T2 spin echo and T2* gradient-recalled echo MRI sequences accurately identified patients without liver iron overload (liver iron concentration > 7 mg Fe/g dry liver weight) (negative likelihood ratios, 0.10 and 0.05 respectively). However, these MRI sequences are less accurate in establishing a definite diagnosis of liver iron overload (positive likelihood ratio, 8.85 and 4.86, respectively). CONCLUSIONS Based on a meta-analysis, measurements of liver iron concentration by MRI may be accurate enough to rule out iron overload, but not to definitely identify patients with this condition. Most studies did not use explicit and prespecified MRI thresholds for iron overload, therefore some patients may have been diagnosed inaccurately with this condition. More studies are needed of standardized MRI protocols and to determine the effects of MRI surveillance on the development of chronic liver disease and patient survival.
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Affiliation(s)
- Maria Sarigianni
- Clinical Research and Evidence-Based Medicine Unit, Second Medical Department, Aristotle University Thessaloniki, Thessaloniki, Greece; Knowledge and Evaluation Research Unit, College of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Aris Liakos
- Clinical Research and Evidence-Based Medicine Unit, Second Medical Department, Aristotle University Thessaloniki, Thessaloniki, Greece
| | - Efthymia Vlachaki
- Thalassemia Unit, Second Medical Department, Aristotle University Thessaloniki, Thessaloniki, Greece
| | - Paschalis Paschos
- Clinical Research and Evidence-Based Medicine Unit, Second Medical Department, Aristotle University Thessaloniki, Thessaloniki, Greece
| | - Eleni Athanasiadou
- Clinical Research and Evidence-Based Medicine Unit, Second Medical Department, Aristotle University Thessaloniki, Thessaloniki, Greece
| | - Victor M Montori
- Knowledge and Evaluation Research Unit, College of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Mohammad Hassan Murad
- Knowledge and Evaluation Research Unit, College of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Apostolos Tsapas
- Clinical Research and Evidence-Based Medicine Unit, Second Medical Department, Aristotle University Thessaloniki, Thessaloniki, Greece; Harris Manchester College, University of Oxford, Oxford, United Kingdom.
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99
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Kaya B. Overview of Chelation Recommendations for Thalassaemia and Sickle Cell Disease. THALASSEMIA REPORTS 2014. [DOI: 10.4081/thal.2014.4860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The long term consequences of iron toxicity are mostly reversible with effective iron chelation therapy. Recommendations for use of chelation therapy in transfusion dependent thalassaemia (TDT), sickle cell disease (SCD) and non transfusion dependent thalassaemia (NTDT) continue to evolve as our knowledge and clinical experience increases. Improved chelation options including drug combinations and a better understanding of condition specific factors may help to improve efficiency of chelation regimens and meet the needs of patients more effectively.
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100
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Piga A, Fracchia S, Lai ME, Cappellini MD, Hirschberg R, Habr D, Wegener A, Bouillaud E, Forni GL. Deferasirox effect on renal haemodynamic parameters in patients with transfusion-dependent β thalassaemia. Br J Haematol 2014; 168:882-90. [PMID: 25402221 DOI: 10.1111/bjh.13217] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Accepted: 10/01/2014] [Indexed: 01/19/2023]
Abstract
Some patients with β thalassaemia experience non-progressive creatinine increases with deferasirox, mostly within normal limits; the mechanisms involved are not fully elucidated. The effects of deferasirox on renal haemodynamics, including glomerular filtration rate (GFR) and renal plasma flow (RPF), were investigated in a Phase I, open-label study in β thalassaemia major patients with iron overload. Patients received deferasirox 30 mg/kg/d up to Week 8, followed by a 2-week washout period, and extended treatment up to Week 104 with a 4-week washout period. In the short-term study (n = 11), mean GFR and RPF declined from baseline to Week 8 (mean [%] change:-9·2 [-9·5%] and -105·7 ml/min [-17·8%], respectively). A similar pattern was observed during the long-term study (n = 5); mean GFR and RPF decreased up to Week 52 (-19·1 [-17·7%] and -155·6 ml/min [-26·1%]), with similar change at Week 104 (-18·4 [-17·2%] and -115·9 ml/min [-19·6%]). Measures returned to baseline values after each washout. Serum creatinine and creatinine clearance followed a similar pattern. Effects of deferasirox on renal haemodynamics were mild and reversible for up to 2 years of treatment, with no progressive worsening of renal function over time. www.clinicaltrials.gov: NCT00560820.
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