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Young DJ, Fan X, Groarke EM, Patel B, Desmond R, Winkler T, Larochelle A, Calvo KR, Young NS, Dunbar CE. Long-term eltrombopag for bone marrow failure depletes iron. Am J Hematol 2022; 97:791-801. [PMID: 35312200 DOI: 10.1002/ajh.26543] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 03/16/2022] [Accepted: 03/17/2022] [Indexed: 11/09/2022]
Abstract
Eltrombopag (EPAG) has been approved for the treatment of aplastic anemia and for immune thrombocytopenia, and a subset of patients require long-term therapy. Due to polyvalent cation chelation, prolonged therapy leads to previously underappreciated iron depletion. We conducted a retrospective review of patients treated at the NIH for aplastic anemia, myelodysplastic syndrome, and unilineage cytopenias, comparing those treated with EPAG to a historical cohort treated with immunosuppression without EPAG. We examined iron parameters, duration of therapy, response assessment, relapse rates, and common demographic parameters. We included 521 subjects treated with (n = 315) or without EPAG (n = 206) across 11 studies with multiyear follow-up (3.6 vs. 8.5 years, respectively). Duration of EPAG exposure correlated with ferritin reduction (p = 4 × 10-14 ) regardless of response, maximum dose, or degree of initial iron overload. Clearance followed first-order kinetics with faster clearance (half-life 15.3 months) compared with historical responders (47.5 months, p = 8 × 10-10 ). Risk of iron depletion was dependent upon baseline ferritin and duration of therapy. Baseline ferritin did not correlate with response of marrow failure to EPAG or to relapse risk, and timing of iron clearance did not correlate with disease response. In conclusion, EPAG efficiently chelates total body iron comparable to clinically available chelators. Prolonged use can deplete iron and ultimately lead to iron-deficiency anemia mimicking relapse, responsive to iron supplementation.
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Affiliation(s)
- David J. Young
- Translational Stem Cell Biology Branch National Heart, Lung, and Blood Institute, NIH Bethesda Maryland USA
| | - Xing Fan
- Translational Stem Cell Biology Branch National Heart, Lung, and Blood Institute, NIH Bethesda Maryland USA
| | - Emma M. Groarke
- Hematology Branch National Heart, Lung, and Blood Institute, NIH Bethesda Maryland USA
| | - Bhavisha Patel
- Hematology Branch National Heart, Lung, and Blood Institute, NIH Bethesda Maryland USA
| | - Ronan Desmond
- Hematology Branch National Heart, Lung, and Blood Institute, NIH Bethesda Maryland USA
- Department of Haematology (Laboratory) Tallaght University Hospital Dublin Ireland
| | - Thomas Winkler
- Translational Stem Cell Biology Branch National Heart, Lung, and Blood Institute, NIH Bethesda Maryland USA
| | - Andre Larochelle
- Cellular and Molecular Therapeutics Branch National Heart, Lung, and Blood Institute, NIH Bethesda Maryland USA
| | - Katherine R. Calvo
- Department of Laboratory Medicine Clinical Center, NIH Bethesda Maryland USA
| | - Neal S. Young
- Hematology Branch National Heart, Lung, and Blood Institute, NIH Bethesda Maryland USA
| | - Cynthia E. Dunbar
- Translational Stem Cell Biology Branch National Heart, Lung, and Blood Institute, NIH Bethesda Maryland USA
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Kaka S, Jahangirnia A, Beauregard N, Davis A, Tinmouth A, Chin-Yee N. Red blood cell transfusion in myelodysplastic syndromes: A systematic review. Transfus Med 2021; 32:3-23. [PMID: 34927286 DOI: 10.1111/tme.12841] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 11/06/2021] [Accepted: 11/11/2021] [Indexed: 11/28/2022]
Abstract
Patients with myelodysplastic syndrome (MDS) frequently receive red blood cell (RBC) transfusions for anaemia resulting from ineffective erythropoiesis. While RBC transfusions may rapidly increase haemoglobin values, their impact on clinical and health services outcomes in MDS patients has not previously been summarized. We conducted a systematic review of the literature to evaluate risks and benefits of RBC transfusions in MDS patients. We searched electronic databases (MEDLINE, Embase, CENTRAL, CINAHL) from inception through June 4, 2021 to identify studies reporting data on RBC transfusions in MDS patients. Full text publications that assessed RBC transfusions as an intervention and reported at least one clinical, laboratory, or healthcare outcome associated with transfusion were included. Study characteristics, transfusion information and transfusion-related outcomes were extracted and reported. We identified 1243 original studies, of which 38 met eligibility requirements and were included. Fourteen reported on survival following diagnosis of MDS, with the majority reporting poorer survival among patients receiving or requiring more frequent transfusions. Nine reported on transfusion-related iron overload and its complications. Other outcomes included rates of allo/autoimmunization and adverse transfusion reactions, and healthcare costs incurred by patients with a greater transfusion burden. Only two studies reported on symptom relief following transfusion. This review underscores transfusion dependence as a negative prognostic factor for MDS patients and highlights the paucity of evidence surrounding quality of life and symptom-related outcomes following RBC transfusions in this population. Further study of patient-important outcomes associated with transfusion in MDS patients is warranted to improve therapeutic recommendations and inform resource allocation.
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Affiliation(s)
- Shaima Kaka
- Faculty of Medicine, University of Ottawa/The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Ashkan Jahangirnia
- Faculty of Medicine, University of Ottawa/The Ottawa Hospital, Ottawa, Ontario, Canada
| | | | - Alexandra Davis
- Faculty of Medicine, University of Ottawa/The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Alan Tinmouth
- Faculty of Medicine, University of Ottawa/The Ottawa Hospital, Ottawa, Ontario, Canada.,The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Nicolas Chin-Yee
- University of Toronto, Toronto, Ontario, Canada.,Department of Medicine, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
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Patnaik MM, Tefferi A. Myelodysplastic syndromes with ring sideroblasts (MDS-RS) and MDS/myeloproliferative neoplasm with RS and thrombocytosis (MDS/MPN-RS-T) - "2021 update on diagnosis, risk-stratification, and management". Am J Hematol 2021; 96:379-394. [PMID: 33428785 DOI: 10.1002/ajh.26090] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Accepted: 01/04/2021] [Indexed: 12/17/2022]
Abstract
DISEASE OVERVIEW Ring sideroblasts (RS) are erythroid precursors with abnormal perinuclear mitochondrial iron accumulation. Two myeloid neoplasms defined by the presence of RS, include myelodysplastic syndromes with RS (MDS-RS) and MDS/myeloproliferative neoplasm with RS and thrombocytosis (MDS/MPN-RS-T). DIAGNOSIS MDS-RS is a lower risk MDS, with single or multilineage dysplasia (MDS-RS-SLD/MLD), <5% bone marrow (BM) blasts, <1% peripheral blood blasts and ≥15% BM RS (≥5% in the presence of SF3B1 mutations). MDS/MPN-RS-T, now a formal entity in the MDS/MPN overlap syndromes, has diagnostic features of MDS-RS-SLD, along with a platelet count ≥450 × 109 /L and large atypical megakaryocytes. MUTATIONS AND KARYOTYPE Mutations in SF3B1 are seen in ≥80% of patients with MDS-RS-SLD and MDS/MPN-RS-T, and strongly correlate with the presence of BM RS; MDS/MPN-RS-T patients also demonstrate JAK2V617F (50%), DNMT3A, TET2 and ASXL1 mutations. Cytogenetic abnormalities are uncommon in both. RISK STRATIFICATION Most patients with MDS-RS-SLD are stratified into lower risk groups by the revised-IPSS. Disease outcome in MDS/MPN-RS-T is better than that of MDS-RS-SLD, but worse than that of essential thrombocythemia (MPN). Both diseases are associated with a low risk of leukemic transformation. TREATMENT Anemia and iron overload are complications seen in both and are managed similar to lower risk MDS and MPN. Luspatercept, a first-in-class erythroid maturation agent is now approved for the management of anemia in patients with MDS-RS and MDS/MPN-RS-T. Aspirin therapy is reasonable in MDS/MPN-RS-T, especially in the presence of JAK2V617F, but the value of platelet-lowering drugs remains to be defined.
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Affiliation(s)
- Mrinal M. Patnaik
- Division of Hematology, Department of Internal Medicine Mayo Clinic Rochester Minnesota
| | - Ayalew Tefferi
- Division of Hematology, Department of Internal Medicine Mayo Clinic Rochester Minnesota
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Leitch HA, Gattermann N. Hematologic improvement with iron chelation therapy in myelodysplastic syndromes: Clinical data, potential mechanisms, and outstanding questions. Crit Rev Oncol Hematol 2019; 141:54-72. [DOI: 10.1016/j.critrevonc.2019.06.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 11/25/2018] [Accepted: 06/03/2019] [Indexed: 12/25/2022] Open
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Serum ferritin levels at diagnosis predict prognosis in patients with low blast count myelodysplastic syndromes. Int J Hematol 2019; 110:533-542. [DOI: 10.1007/s12185-019-02710-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 07/12/2019] [Accepted: 07/17/2019] [Indexed: 12/13/2022]
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Patnaik MM, Tefferi A. Refractory anemia with ring sideroblasts (RARS) and RARS with thrombocytosis: "2019 Update on Diagnosis, Risk-stratification, and Management". Am J Hematol 2019; 94:475-488. [PMID: 30618061 DOI: 10.1002/ajh.25397] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Accepted: 01/02/2019] [Indexed: 12/17/2022]
Abstract
DISEASE OVERVIEW Ring sideroblasts (RS) are erythroid precursors with abnormal perinuclear mitochondrial iron accumulation. Two myeloid neoplasms defined by the presence of RS, include refractory anemia with ring sideroblasts (RARS), now classified under myelodysplastic syndromes with RS (MDS-RS) and RARS with thrombocytosis (RARS-T); now called myelodysplastic/myeloproliferative neoplasm with RS and thrombocytosis (MDS/MPN-RS-T). DIAGNOSIS MDS-RS is a lower-risk MDS, with single or multilineage dysplasia (SLD/MLD), <5% bone marrow (BM) blasts and ≥ 15% BM RS (≥5% in the presence of SF3B1 mutations). MDS/MPN-RS-T, now a formal entity in the MDS/MPN overlap syndromes, has diagnostic features of MDS-RS-SLD, along with a platelet count ≥450 × 10(9)/L and large atypical megakaryocytes. MUTATIONS AND KARYOTYPE Mutations in SF3B1 are seen in ≥80% of patients with MDS-RS-SLD and MDS/MPN-RS-T, and strongly correlate with the presence of BM RS; MDS/MPN-RS-T patients also demonstrate JAK2V617F, ASXL1, DNMT3A, SETBP1, and TET2 mutations. Cytogenetic abnormalities are uncommon in both. RISK STRATIFICATION Most patients with MDS-RS-SLD are stratified into lower-risk groups by the revised-IPSS. Disease outcome in MDS/MPN-RS-T is better than that of MDS-RS-SLD, but worse than that of essential thrombocythemia. Both diseases have a low risk of leukemic transformation. TREATMENT Anemia and iron overload are complications seen in both and are managed similar to lower-risk MDS and MPN. The advent of luspatercept, a first-in-class erythroid maturation agent will tremendously boost the ability to manage anemia. Aspirin therapy is reasonable in MDS/MPN-RS-T, especially in the presence of JAK2V617F, but the value of platelet-lowering drugs remains uncertain.
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Affiliation(s)
- Mrinal M. Patnaik
- Division of Hematology, Department of Internal Medicine Mayo Clinic Rochester Minnesota
| | - Ayalew Tefferi
- Division of Hematology, Department of Internal Medicine Mayo Clinic Rochester Minnesota
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Zeidan AM, Griffiths EA. To chelate or not to chelate in MDS: That is the question! Blood Rev 2018; 32:368-377. [PMID: 29602612 DOI: 10.1016/j.blre.2018.03.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 02/16/2018] [Accepted: 03/06/2018] [Indexed: 01/19/2023]
Abstract
Myelodysplastic syndromes (MDS) are a heterogeneous group of hemopathies that exhibit physical manifestations with clinical consequences of bone marrow failure and inherent risk of progression to acute myeloid leukemia. Iron overload (IO) is common in MDS due to chronic transfusion support and disease-related alterations in iron metabolism. IO has been conclusively associated with inferior outcomes among MDS patients. Despite lack of randomized trials showing a survival impact of iron chelation therapy (ICT), ICT is recommended by experts and guidelines for select MDS patients with IO and is often used. The availability of effective oral ICT agents has reignited the controversy regarding ICT use in patients with MDS and IO. Here we summarize the studies evaluating the value of ICT in MDS and suggest a practical approach for use of these therapies. We also highlight controversies regarding use of ICT in MDS and discuss some ongoing efforts to answer these questions.
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Affiliation(s)
- Amer M Zeidan
- Section of Hematology, Department of Medicine, Yale University, Yale Cancer Center, New Haven, CT, USA.
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Wong CAC, Wong SAY, Leitch HA. Iron overload in lower international prognostic scoring system risk patients with myelodysplastic syndrome receiving red blood cell transfusions: Relation to infections and possible benefit of iron chelation therapy. Leuk Res 2018; 67:75-81. [PMID: 29477023 DOI: 10.1016/j.leukres.2018.02.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Revised: 02/03/2018] [Accepted: 02/06/2018] [Indexed: 01/27/2023]
Abstract
BACKGROUND An increased incidence of infections and infectious mortality has been reported in myelodysplastic syndromes (MDS) patients receiving red blood cell (RBC) transfusions. METHODS We examined incidence of infections requiring antibiotics, antifungal or antiviral medications in transfused lower International Prognostic Scoring System (IPSS) risk MDS patients and whether this differed with iron chelation therapy (ICT). RESULTS 138 transfused MDS patients were lower IPSS risk. 59 received ICT; median duration was 13 months. There was no significant difference between groups in neutrophil count at first RBC transfusion or first infection. Infections included: bacterial, n = 88; viral; fungal; and mycobacterial; n = 2 each. In ICT and non-ICT patients, respectively, infections were (number [%]): patients, 23 (40.0%) and 22 (27.8%); episodes (median [range]), 2 (1-6) and 2 (1-5); hospitalizations, 16 (27.1%) and 8 (10.1%); and deaths, 0 (0%) and 1 (1.3%), p = NS for all. Median overall survival (OS) from first RBC transfusion was superior in ICT patients, p = 0.01, and remained significant in a multivariate analysis (MVA), p = 0.003. Median time to first infection (TTI) was 27 and 7.8 months, respectively, p < 0.0001, and ICT remained significant for TTI in an MVA, p = 0.02, hazard ratio 0.3. For ICT patients with blast count <5%, TTI was significantly superior (p = 0.004). CONCLUSIONS In this retrospective analysis, for lower IPSS risk MDS patients receiving RBC transfusions, though number and type of infections were similar between groups and despite similar neutrophil counts, time to first infection was significantly longer in ICT patients (p < 0.0001). These results should be confirmed in larger, prospective analyses.
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Affiliation(s)
| | | | - Heather A Leitch
- Division of Hematology, St. Paul's Hospital, University of British Columbia, Vancouver, Canada.
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10
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de Swart L, Reiniers C, Bagguley T, van Marrewijk C, Bowen D, Hellström-Lindberg E, Tatic A, Symeonidis A, Huls G, Cermak J, van de Loosdrecht AA, Garelius H, Culligan D, Macheta M, Spanoudakis M, Panagiotidis P, Krejci M, Blijlevens N, Langemeijer S, Droste J, Swinkels DW, Smith A, de Witte T. Labile plasma iron levels predict survival in patients with lower-risk myelodysplastic syndromes. Haematologica 2017; 103:69-79. [PMID: 29122992 PMCID: PMC5777192 DOI: 10.3324/haematol.2017.171884] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Accepted: 10/27/2017] [Indexed: 01/01/2023] Open
Abstract
Red blood cell transfusions remain one of the cornerstones in supportive care of lower-risk patients with myelodysplastic syndromes. We hypothesized that patients develop oxidant-mediated tissue injury through the formation of toxic iron species, caused either by red blood cell transfusions or by ineffective erythropoiesis. We analyzed serum samples from 100 lower-risk patients with myelodysplastic syndromes at six-month intervals for transferrin saturation, hepcidin-25, growth differentiation factor 15, soluble transferrin receptor, non-transferrin bound iron and labile plasma iron in order to evaluate temporal changes in iron metabolism and the presence of potentially toxic iron species and their impact on survival. Hepcidin levels were low in 34 patients with ringed sideroblasts compared to 66 patients without. Increases of hepcidin and non-transferrin bound iron levels were visible early in follow-up of all transfusion-dependent patient groups. Hepcidin levels significantly decreased over time in transfusion-independent patients with ringed sideroblasts. Increased soluble transferrin receptor levels in transfusion-independent patients with ringed sideroblasts confirmed the presence of ineffective erythropoiesis and suppression of hepcidin production in these patients. Detectable labile plasma iron levels in combination with high transferrin saturation levels occurred almost exclusively in patients with ringed sideroblasts and all transfusion-dependent patient groups. Detectable labile plasma iron levels in transfusion-dependent patients without ringed sideroblasts were associated with decreased survival. In conclusion, toxic iron species occurred in all transfusion-dependent patients and in transfusion-independent patients with ringed sideroblasts. Labile plasma iron appeared to be a clinically relevant measure for potential iron toxicity and a prognostic factor for survival in transfusion-dependent patients. clinicaltrials.gov Identifier: 00600860.
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Affiliation(s)
- Louise de Swart
- Department of Hematology, Radboud university medical center, Nijmegen, the Netherlands
| | - Chloé Reiniers
- Department of Hematology, University Medical Centre, Groningen, the Netherlands
| | - Timothy Bagguley
- Epidemiology and Cancer Statistics Group, University of York, UK
| | - Corine van Marrewijk
- Department of Hematology, Radboud university medical center, Nijmegen, the Netherlands
| | - David Bowen
- St. James's Institute of Oncology, Leeds Teaching Hospitals, UK
| | - Eva Hellström-Lindberg
- Department of Medicine, Division of Hematology, Karolinska Institutet, Stockholm, Sweden
| | - Aurelia Tatic
- Center of Hematology and Bone Marrow Transplantation, Fundeni Clinical Institute, Bucharest, Romania
| | - Argiris Symeonidis
- Department of Medicine, Division of Hematology, University of Patras Medical School, Greece
| | - Gerwin Huls
- Department of Hematology, University Medical Centre, Groningen, the Netherlands
| | - Jaroslav Cermak
- Department of Clinical Hematology, Institute of Hematology & Blood Transfusion, Prague, Czech Republic
| | | | - Hege Garelius
- Department of Medicine, Section of Hematology and Coagulation, Sahlgrenska University Hospital, Göteborg, Sweden
| | | | - Mac Macheta
- Department of Haematology, Blackpool Victoria Hospital, Lancashire, UK
| | | | - Panagiotis Panagiotidis
- Department of Hematology, Laikon General Hospital, National and Kapodistrian University of Athens, Greece
| | - Marta Krejci
- Department of Internal Medicine, Hematology and Oncology, University Hospital Brno and Masaryk University, Czech Republic
| | - Nicole Blijlevens
- Department of Hematology, Radboud university medical center, Nijmegen, the Netherlands
| | - Saskia Langemeijer
- Department of Hematology, Radboud university medical center, Nijmegen, the Netherlands
| | - Jackie Droste
- Department of Hematology, Radboud university medical center, Nijmegen, the Netherlands
| | - Dorine W Swinkels
- Department of Laboratory Medicine, Hepcidinanalysis.com, and Radboudumc expertise center for iron disorders, Radboud university medical center, Nijmegen, the Netherlands and
| | - Alex Smith
- Department of Hematology, University Medical Centre, Groningen, the Netherlands
| | - Theo de Witte
- Nijmegen Center for Molecular Life Sciences, Department of Tumor Immunology, Radboud university medical center, the Netherlands
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Leitch HA, Parmar A, Wells RA, Chodirker L, Zhu N, Nevill TJ, Yee KWL, Leber B, Keating MM, Sabloff M, St Hilaire E, Kumar R, Delage R, Geddes M, Storring JM, Kew A, Shamy A, Elemary M, Lenis M, Mamedov A, Ivo J, Francis J, Zhang L, Buckstein R. Overall survival in lower IPSS risk MDS by receipt of iron chelation therapy, adjusting for patient-related factors and measuring from time of first red blood cell transfusion dependence: an MDS-CAN analysis. Br J Haematol 2017; 179:83-97. [PMID: 28677895 DOI: 10.1111/bjh.14825] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2017] [Accepted: 05/25/2017] [Indexed: 01/23/2023]
Abstract
Analyses suggest iron overload in red blood cell (RBC) transfusion-dependent (TD) patients with myleodysplastic syndrome (MDS) portends inferior overall survival (OS) that is attenuated by iron chelation therapy (ICT) but may be biassed by unbalanced patient-related factors. The Canadian MDS Registry prospectively measures frailty, comorbidity and disability. We analysed OS by receipt of ICT, adjusting for these patient-related factors. TD International Prognostic Scoring System (IPSS) low and intermediate-1 risk MDS, at RBC TD, were included. Predictive factors for OS were determined. A matched pair analysis considering age, revised IPSS, TD severity, time from MDS diagnosis to TD, and receipt of disease-modifying agents was conducted. Of 239 patients, 83 received ICT; frailty, comorbidity and disability did not differ from non-ICT patients. Median OS from TD was superior in ICT patients (5·2 vs. 2·1 years; P < 0·0001). By multivariate analysis, not receiving ICT independently predicted inferior OS, (hazard ratio for death 2·0, P = 0·03). In matched pair analysis, OS remained superior for ICT patients (P = 0·02). In this prospective, non-randomized analysis, receiving ICT was associated with superior OS in lower IPSS risk MDS, adjusting for age, frailty, comorbidity, disability, revised IPSS, TD severity, time to TD and receiving disease-modifying agents. This provides additional evidence that ICT may confer clinical benefit.
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Affiliation(s)
- Heather A Leitch
- Hematology, St. Paul's Hospital and the University of British Columbia, Vancouver, BC, Canada
| | | | - Richard A Wells
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Lisa Chodirker
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Nancy Zhu
- Hematology/Oncology, University of Alberta, Edmonton, AB, Canada
| | - Thomas J Nevill
- Division of Hematology, Leukemia/BMT Program of British Columbia, Vancouver, BC, Canada
| | - Karen W L Yee
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | | | | | | | - Eve St Hilaire
- Centre d'Oncologie, Dr-Leon-Richard, Moncton, NB, Canada
| | - Rajat Kumar
- Hematology/Oncology, CancerCare Manitoba, Winnipeg, MB, Canada
| | - Robert Delage
- Hematology Department, Centre Hospitalier Universitaire, Laval University, Quebec, QC, Canada
| | - Michelle Geddes
- Department of Medicine/Hematology, Foothills Medical Centre, Calgary, AB, Canada
| | | | - Andrea Kew
- Queen Elizabeth II Health Sciences Center, Halifax, NS, Canada
| | - April Shamy
- Sir Mortimer B Davis Hospital, McGill University, Montreal, QC, Canada
| | - Mohamed Elemary
- Saskatoon Cancer Center, University of Saskatchewan, Saskatoon, SK, Canada
| | - Martha Lenis
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Alexandre Mamedov
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Jessica Ivo
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Janika Francis
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Liying Zhang
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Rena Buckstein
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
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Role of serum ferritin level on overall survival in patients with myelodysplastic syndromes: Results of a meta-analysis of observational studies. PLoS One 2017. [PMID: 28622367 PMCID: PMC5473533 DOI: 10.1371/journal.pone.0179016] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The role of serum ferritin (SF) as a prognostic factor has been analyzed in patients with myelodysplastic syndromes (MDS) who have undergone hematopoietic stem cell transplantation (HSCT), but the prognostic role of elevated SF levels is still controversial in lower risk MDS patients. Therefore, we performed a meta-analysis of all available published literature to evaluate whether elevated SF levels are associated with a worse overall survival (OS) among patients with low risk MDS. MATERIAL AND METHODS A systematic bibliographic search of relevant studies was undertaken in accordance with guidelines for meta-analysis of observational studies in epidemiology. Electronic databases were searched through July 2016 for studies examining the level of SF as a prognostic factor in the adults affected by MDS. RESULTS Six articles were included in the meta-analysis. A significant association between OS and SF was achieved for the threshold of SF≥1000 ng/mL, when the only study that used SF cut-off ≥2000 ng/mL was not included in the meta-analysis (RR = 1.33; 95% CI = 1.06-1.67). The estimated risk was 2.58 (95% CI = 1.41-4.74) when a SF cut-off≥500 ng/mL was considered. CONCLUSIONS Our findings underlined a worse survival in patients with MDS who had higher SF levels. The association was stronger and achieved statistical significance after stratification of analyses in which we excluded cut-offs of SF level considered as outliers. These results suggest that negative impact on OS already exist at SF level ≥500 ng/mL. Prospective studies, are needed to better understand this relationship and, above all, to clarify whether earlier iron chelation therapy could improve patients' OS.
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Stahl M, Zeidan AM. Management of lower-risk myelodysplastic syndromes without del5q: current approach and future trends. Expert Rev Hematol 2017; 10:345-364. [PMID: 28277851 DOI: 10.1080/17474086.2017.1297704] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Myelodysplastic syndromes (MDS) are characterized by progressive bone marrow failure manifesting as blood cytopenia and a variable risk of progression into acute myeloid leukemia. MDS is heterogeneous in biology and clinical behavior. MDS are generally divided into lower-risk (LR) and higher-risk (HR) MDS. Goals of care in HR-MDS focus on changing the natural history of the disease, whereas in LR-MDS symptom control and quality of life are the main goals. Areas covered: We review the epidemiology, tools of risk assessment, and the available therapeutic modalities for LR-MDS. We discuss the use of erythropoiesis stimulating agents (ESAs), immunosuppressive therapy (IST), lenalidomide and the hypomethylating agents (HMAs). We also discuss the predictors of response, combination treatment modalities, and management of iron overload. Lastly, we overview the most promising investigational agents for LR-MDS. Expert commentary: It remains unclear how to best incorporate a wealth of new genetic and epigenetic prognostic markers into risk assessment tools especially for LR-MDS patients. Only a subset of patients respond to current treatment modalities and most responders eventually lose their response. Once standard therapeutic options fail, management becomes more challenging. Combination-based approaches have been largely unsuccessful. Among the most promising investigational are the TPO agonists, TGF- β pathway inhibitors, telomerase inhibitors, and the splicing modifiers.
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Affiliation(s)
- Maximilian Stahl
- a Section of Hematology, Department of Internal Medicine, Section of Hematology, Yale University and the Yale Comprehensive Cancer Center , Yale University School of Medicine , New Haven , CT , USA
| | - Amer M Zeidan
- a Section of Hematology, Department of Internal Medicine, Section of Hematology, Yale University and the Yale Comprehensive Cancer Center , Yale University School of Medicine , New Haven , CT , USA
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Myelodysplastic Syndromes and Iron Chelation Therapy. Mediterr J Hematol Infect Dis 2017; 9:e2017021. [PMID: 28293409 PMCID: PMC5333736 DOI: 10.4084/mjhid.2017.021] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 01/27/2017] [Indexed: 01/19/2023] Open
Abstract
Over recent decades we have been fortunate to witness the advent of new technologies and of an expanded knowledge and application of chelation therapies to the benefit of patients with iron overload. However, extrapolation of learnings from thalassemia to the myelodysplastic syndromes (MDS) has resulted in a fragmented and uncoordinated clinical evidence base. We’re therefore forced to change our understanding of MDS, looking with other eyes to observational studies that inform us about the relationship between iron and tissue damage in these subjects. The available evidence suggests that iron accumulation is prognostically significant in MDS, but levels of accumulation historically associated with organ damage (based on data generated in the thalassemias) are infrequent. Emerging experimental data have provided some insight into this paradox, as our understanding of iron-induced tissue damage has evolved from a process of progressive bulking of organs through high-volumes iron deposition, to one of ‘toxic’ damage inflicted through multiple cellular pathways. Damage from iron may, therefore, occur prior to reaching reference thresholds, and similarly, chelation may be of benefit before overt iron overload is seen. In this review, we revisit the scientific and clinical evidence for iron overload in MDS to better characterize the iron overload phenotype in these patients, which differs from the classical transfusional and non-transfusional iron overload syndrome. We hope this will provide a conceptual framework to better understand the complex associations between anemia, iron and clinical outcomes, to accelerate progress in this area.
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Patnaik MM, Tefferi A. Refractory anemia with ring sideroblasts (RARS) and RARS with thrombocytosis (RARS-T): 2017 update on diagnosis, risk-stratification, and management. Am J Hematol 2017; 92:297-310. [PMID: 28188970 DOI: 10.1002/ajh.24637] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Revised: 12/23/2016] [Accepted: 12/23/2016] [Indexed: 02/06/2023]
Abstract
DISEASE OVERVIEW Ring sideroblasts (RS) are erythroid precursors with abnormal perinuclear mitochondrial iron accumulation. Two myeloid neoplasms defined by the presence of RS, include refractory anemia with ring sideroblasts (RARS), now classified under myelodysplastic syndromes with RS (MDS-RS) and RARS with thrombocytosis (RARS-T); now called myelodysplastic/myeloproliferative neoplasm with RS and thrombocytosis (MDS/MPN-RS-T). DIAGNOSIS MDS-RS is a lower risk MDS, with single or multilineage dysplasia (SLD/MLD), <5% bone marrow (BM) blasts and ≥15% BM RS (≥5% in the presence of SF3B1 mutations). MDS/MPN-RS-T, now a formal entity in the MDS/MPN overlap syndromes, has diagnostic features of MDS-RS-SLD, along with a platelet count ≥ 450 × 10(9)/L and large atypical megakaryocytes (similar to BCR-ABL1 negative MPN). MUTATIONS AND KARYOTYPE Mutations in SF3B1 are seen in ≥80% of patients with MDS-RS-SLD and MDS/MPN-RS-T, and strongly correlate with the presence of BM RS; MDS/MPN-RS-T patients also demonstrate JAK2V617F, ASXL1, DNMT3A, SETBP1, and TET2 mutations; with ASXL1/SETBP1 mutations adversely impacting survival. Cytogenetic abnormalities are uncommon in both diseases. RISK STRATIFICATION Most patients with MDS-RS-SLD are stratified into lower risk groups by the revised-International Prognostic Scoring System (R-IPSS). Disease outcome in MDS/MPN-RS-T is better than that of MDS-RS-SLD, but worse than that of essential thrombocythemia. Both diseases have a low risk of leukemic TREATMENT: Anemia and iron overload are complications seen in both and are managed similar to lower risk MDS and MPN. Aspirin therapy is reasonable in MDS/MPN-RS-T, especially in the presence of JAK2V617F, but the value of platelet-lowering drugs is uncertain.
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Affiliation(s)
- Mrinal M. Patnaik
- Division of Hematology, Department of Internal MedicineMayo ClinicRochester Minnesota
| | - Ayalew Tefferi
- Division of Hematology, Department of Internal MedicineMayo ClinicRochester Minnesota
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Imran F, Phatak P. Decision points in the treatment of transfusional iron overload in patients with myelodysplastic syndromes: why, when, and how to chelate. Expert Rev Hematol 2016; 10:53-64. [DOI: 10.1080/17474086.2017.1268910] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Farhan Imran
- Lipson Cancer and Blood Center, Rochester Regional Health System, Rochester, NY, USA
| | - Pradyumna Phatak
- Lipson Cancer and Blood Center, Rochester Regional Health System, Rochester, NY, USA
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Harnan S, Ren S, Gomersall T, Everson-Hock ES, Sutton A, Dhanasiri S, Kulasekararaj A. Association between Transfusion Status and Overall Survival in Patients with Myelodysplastic Syndromes: A Systematic Literature Review and Meta-Analysis. Acta Haematol 2016; 136:23-42. [PMID: 27160308 DOI: 10.1159/000445163] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Accepted: 03/02/2016] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Multiple studies show that transfusion independence (TI) in myelodysplastic syndrome (MDS) has a positive impact on overall survival (OS). To assess this, a systematic review and meta-analysis of the association between TI and OS in patients with MDS was conducted (PROSPERO ID: CRD42014007264). METHODS Comprehensive searches of 5 key bibliographic databases were conducted and supplemented with additional search techniques. Included were studies that had recruited adults aged >18 years with MDS and had examined the impact of transfusion status on OS. RESULTS Fifty-five studies (89 citations) were included. The vast majority reported a statistically significant hazard ratio (HR) for OS in favor of TI patients or in patients who acquired TI after treatment. A random-effects meta-analysis was conducted. Patients classed as TI at baseline showed a 59% decrease in the risk of death compared with transfusion-dependent (TD) patients [HR 0.41; 95% credible interval (CrI) 0.29-0.56], and this effect did not appear to interact significantly with illness severity (interaction coefficient HR 1.38; 95% CrI 0.62-3.41). A meta-analysis of studies where patients acquired TI was not possible, but those studies consistently reported a survival benefit for those who acquired TI. CONCLUSION The findings revealed a 59% pooled reduction in mortality among TI patients when compared with TD patients.
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Affiliation(s)
- Sue Harnan
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, UK
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Patnaik MM, Tefferi A. Chronic Myelomonocytic Leukemia: Focus on Clinical Practice. Mayo Clin Proc 2016; 91:259-72. [PMID: 26848006 DOI: 10.1016/j.mayocp.2015.11.011] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Accepted: 11/23/2015] [Indexed: 12/23/2022]
Abstract
Chronic myelomonocytic leukemia (CMML) is a clonal stem cell disorder with features that overlap those of myelodysplastic syndromes (MDSs) and myeloproliferative neoplasms (MPNs). Chronic myelomonocytic leukemia often results in peripheral blood monocytosis and has an inherent tendency to transform to acute myeloid leukemia. Clonal cytogenetic changes are seen in approximately 30% of patients, and molecular abnormalities are seen in more than 90%. Gene mutations involving TET2 (∼60%), SRSF2 (∼50%), ASXL1 (∼40%), and RAS (∼30%) are frequent, with nonsense and frameshift ASXL1 mutations being the only mutations identified thus far to have an independent negative prognostic effect on overall survival. Contemporary molecularly integrated prognostic models (inclusive of ASXL1 mutations) include the Molecular Mayo Model and the Groupe Français des Myélodysplasies model. Given the lack of formal treatment and response criteria, management of CMML is often extrapolated from MDS and MPN, with allogeneic stem cell transplant being the only curative option. Hydroxyurea and other cytoreductive agents have been used to control MPN-like features, while epigenetic modifiers such as hypomethylating agents have been used for MDS-like features. Given the relatively poor response to these agents and the inherent risks associated with hematopoietic stem cell transplant, newer drugs exploiting molecular and epigenetic abnormalities in CMML are being developed. The creation of CMML-specific response criteria is a much needed step in order to improve clinical outcomes.
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Affiliation(s)
- Mrinal M Patnaik
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Ayalew Tefferi
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN.
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Transfusion dependency at diagnosis and transfusion intensity during initial chemotherapy are associated with poorer outcomes in adult acute myeloid leukemia. Ann Hematol 2015. [DOI: 10.1007/s00277-015-2456-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Nolte F, Angelucci E, Breccia M, Gattermann N, Santini V, Vey N, Hofmann WK. Updated recommendations on the management of gastrointestinal disturbances during iron chelation therapy with Deferasirox in transfusion dependent patients with myelodysplastic syndrome - Emphasis on optimized dosing schedules and new formulations. Leuk Res 2015; 39:1028-33. [PMID: 26293555 DOI: 10.1016/j.leukres.2015.06.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Revised: 06/04/2015] [Accepted: 06/16/2015] [Indexed: 11/29/2022]
Abstract
Myelodysplastic syndromes (MDS) are oligoclonal hematopoietic disorders characterized by peripheral cytopenias with anemias being the most prevalent feature. The majority of patients will depend on regular transfusions of packed red blood cells (PRBC) during the course of the disease. Particularly patients with MDS and low risk for transformation into acute myeloid leukemia and low risk of early death will receive PRBC transfusions on a regular basis, which puts them at high risk for transfusional iron overload. Transfusion dependence has been associated with negative impact on organ function and reduced life expectancy. Recently, several retrospective but also some prospective studies have indicated, that transfusion dependent patients with MDS might benefit from consequent iron chelation with regard to morbidity and mortality. However, low treatment adherence due to adverse events mainly gastrointestinal in nature is an important obstacle in achieving sufficient iron chelation in MDS patients. Here, we will summarize and discuss the existing data on Deferasirox in low risk MDS published so far and provide recommendations for optimal management of gastrointestinal adverse events during iron chelation aiming at improving treatment compliance and, hence, sufficiently removing excess iron from the patients.
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Affiliation(s)
- Florian Nolte
- Department of Hematology and Oncology, University Hospital Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Germany.
| | - Emanuele Angelucci
- Hematology and Bone Marrow Transplant Unit, and Medical Oncology Department, Ospedale Oncologico "Armando Businco", Cagliari, Italy
| | - Massimo Breccia
- Department of Cellular Biotechnologies and Hematology, "La Sapienza" University, Rome, Italy
| | - Norbert Gattermann
- Comprehensive Cancer Center and Department of Hematology, Oncology, and Clinical Immunology, Heinrich Heine University, Düsseldorf, Germany
| | - Valeria Santini
- Division of Hematology, University of Florence, Florence, Italy
| | - Norbert Vey
- Department of Hematology, Institute Paoli Calmettes, Marseille, France
| | - Wolf-Karsten Hofmann
- Department of Hematology and Oncology, University Hospital Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Germany
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Patnaik MM, Tefferi A. Refractory anemia with ring sideroblasts and RARS with thrombocytosis. Am J Hematol 2015; 90:549-59. [PMID: 25899435 DOI: 10.1002/ajh.24038] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Accepted: 04/17/2015] [Indexed: 12/25/2022]
Abstract
DISEASE OVERVIEW Ring sideroblasts (RS) are erythroid precursors with abnormal perinuclear mitochondrial iron accumulation. Two myeloid neoplasms defined by the presence of RS, include refractory anemia with ring sideroblasts (RARS) and RARS with thrombocytosis (RARS-T). DIAGNOSIS RARS is a lower risk myelodysplastic syndrome (MDS) with dysplasia limited to the erythroid lineage, <5% bone marrow (BM) blasts and ≥15% BM RS. RARS-T is a provisional entity in the MDS/MPN (myeloproliferative neoplasm) overlap syndromes, with diagnostic features of RARS, along with a platelet count ≥450 × 10(9)/L and large atypical megakaryocytes similar to those observed in BCR-ABL1 negative MPN. Mutations and Karyotype: Mutations in the SF3B1 gene are seen in ≥80% of patients with RARS and RARS-T, and strongly correlate with the presence of BM RS; RARS-T patients have additional mutations such as, JAK2V617F (∼60%), MPL (<5%), and CALR (<5%). Cytogenetic abnormalities are uncommon in both RARS and RARS-T. RISK STRATIFICATION Most patients with RARS are stratified into lower risk groups by the International Prognostic Scoring System (IPSS) for MDS and the revised IPSS. Disease outcome in RARS-T is better than that of RARS, but worse than that of essential thrombocytosis. Both RARS and RARS-T have a low risk of leukemic transformation. TREATMENT Anemia and iron overload are complications in both diseases and are managed similar to lower risk MDS. Aspirin therapy is reasonable in RARS-T, especially in the presence of JAK2V617F, but the value of platelet-lowering drugs is uncertain. Case reports of RARS-T therapy with lenalidomide warrant additional studies.
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Affiliation(s)
- Mrinal M. Patnaik
- Division of Hematology, Department of Internal Medicine; Mayo Clinic; Rochester Minnesota
| | - Ayalew Tefferi
- Division of Hematology, Department of Internal Medicine; Mayo Clinic; Rochester Minnesota
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An increase in hemoglobin, platelets and white blood cells levels by iron chelation as single treatment in multitransfused patients with myelodysplastic syndromes: clinical evidences and possible biological mechanisms. Ann Hematol 2015; 94:771-7. [DOI: 10.1007/s00277-015-2341-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2014] [Accepted: 02/16/2015] [Indexed: 12/16/2022]
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Meerpohl JJ, Schell LK, Rücker G, Fleeman N, Motschall E, Niemeyer CM, Bassler D. Deferasirox for managing iron overload in people with myelodysplastic syndrome. Cochrane Database Syst Rev 2014; 2014:CD007461. [PMID: 25348770 PMCID: PMC7202239 DOI: 10.1002/14651858.cd007461.pub3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The myelodysplastic syndrome (MDS) comprises a diverse group of haematopoietic stem cell disorders. Due to symptomatic anaemia, most people with MDS require supportive therapy including repeated red blood cell (RBC) transfusions. In combination with increased iron absorption, this contributes to the accumulation of iron resulting in secondary iron overload and the risk of organ dysfunction and reduced life expectancy. Since the human body has no natural means of removing excess iron, iron chelation therapy, i.e. the pharmacological treatment of iron overload, is usually recommended. However, it is unclear whether or not the newer oral chelator deferasirox leads to relevant benefit. OBJECTIVES To evaluate the effectiveness and safety of oral deferasirox for managing iron overload in people with myelodysplastic syndrome (MDS). SEARCH METHODS We searched the following databases up to 03 April 2014: MEDLINE, EMBASE, The Cochrane Library, Biosis Previews, Web of Science, Derwent Drug File and four trial registries: Current Controlled Trials (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov), ICTRP (www.who.int./ictrp/en/), and German Clinical Trial Register (www.drks.de). SELECTION CRITERIA Randomised controlled trials (RCTs) comparing deferasirox with no therapy, placebo or with another iron-chelating treatment schedule. DATA COLLECTION AND ANALYSIS We did not identify any trials eligible for inclusion in this review. MAIN RESULTS No trials met our inclusion criteria. However, we identified three ongoing and one completed trial (published as an abstract only and in insufficient detail to permit us to decide on inclusion) comparing deferasirox with deferoxamine, placebo or no treatment. AUTHORS' CONCLUSIONS We planned to report evidence from RCTs that evaluated the effectiveness of deferasirox compared to either placebo, no treatment or other chelating regimens, such as deferoxamine, in people with MDS. However, we did not identify any completed RCTs addressing this question.We found three ongoing and one completed RCT (published as an abstract only and in insufficient detail) comparing deferasirox with deferoxamine, placebo or no treatment and data will hopefully be available soon. These results will be important to inform physicians and patients on the advantages and disadvantages of this treatment option.
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Affiliation(s)
- Joerg J Meerpohl
- Medical Center ‐ University of FreiburgGerman Cochrane CentreBerliner Allee 29FreiburgGermany79110
| | - Lisa K Schell
- Medical Center ‐ University of FreiburgGerman Cochrane CentreBerliner Allee 29FreiburgGermany79110
| | - Gerta Rücker
- Medical Center ‐ University of FreiburgCenter for Medical Biometry and Medical InformaticsStefan‐Meier‐Str. 26FreiburgGermany79104
| | - Nigel Fleeman
- University of LiverpoolLiverpool Reviews & Implementation Group2nd Floor, Sherrington BuildingsAshton StreetLiverpoolUKL69 3GE
| | - Edith Motschall
- Medical Center ‐ 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 ZurichDepartment of NeonatologyFrauenklinikstrasse 10ZurichSwitzerland
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Impact of iron overload and potential benefit from iron chelation in low-risk myelodysplastic syndrome. Blood 2014; 124:873-81. [PMID: 24923296 DOI: 10.1182/blood-2014-03-563221] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Myelodysplastic syndromes (MDSs) are a group of heterogeneous clonal bone marrow disorders characterized by ineffective hematopoiesis, peripheral blood cytopenias, and potential for malignant transformation. Lower/intermediate-risk MDSs are associated with longer survival and high red blood cell (RBC) transfusion requirements resulting in secondary iron overload. Recent data suggest that markers of iron overload portend a relatively poor prognosis, and retrospective analysis demonstrates that iron chelation therapy is associated with prolonged survival in transfusion-dependent MDS patients. New data provide concrete evidence of iron's adverse effects on erythroid precursors in vitro and in vivo. Renewed interest in the iron field was heralded by the discovery of hepcidin, the main serum peptide hormone negative regulator of body iron. Evidence from β-thalassemia suggests that regulation of hepcidin by erythropoiesis dominates regulation by iron. Because iron overload develops in some MDS patients who do not require RBC transfusions, the suppressive effect of ineffective erythropoiesis on hepcidin may also play a role in iron overload. We anticipate that additional novel tools for measuring iron overload and a molecular-mechanism-driven description of MDS subtypes will provide a deeper understanding of how iron metabolism and erythropoiesis intersect in MDSs and improve clinical management of this patient population.
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Merkel DG, Nagler A. Toward resolving the unsettled role of iron chelation therapy in myelodysplastic syndromes. Expert Rev Anticancer Ther 2014; 14:817-29. [PMID: 24641787 DOI: 10.1586/14737140.2014.896208] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Transfusion dependent low risk myelodysplastic syndromes (MDS) patients, eventually develop iron overload. Iron toxicity, via oxidative stress, can damage cellular components and impact organ function. In thalassemia major patients, iron chelation therapy lowered iron levels with recovery of cardiac and liver functions and significant improvement in survival. Several noncontrolled studies show inferior survival in MDS patients with iron overload, including an increase in transplant-related mortality and infection risk while iron chelation appears to improve survival in both lower risk MDS patients and in stem cell transplant settings. Collated data are presented on the pathophysiological impact of iron overload; measuring techniques and chelating agents' therapy positive impact on hematological status and overall survival are discussed. Although suggested by retrospective analyses, the lack of clear prospective data of the beneficial effects of iron chelation on morbidity and survival, the role of iron chelation therapy in MDS patients remains controversial.
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Affiliation(s)
- Drorit G Merkel
- Division of Hematology, Chaim Sheba Medical Center, Tel Aviv University, Tel-Hashomer, Israel
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27
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Imran F, Phatak P. Pharmacoeconomic benefits of deferasirox in the management of iron overload syndromes. Expert Rev Pharmacoecon Outcomes Res 2014; 9:297-304. [DOI: 10.1586/erp.09.26] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Steensma DP, Gattermann N. When is iron overload deleterious, and when and how should iron chelation therapy be administered in myelodysplastic syndromes? Best Pract Res Clin Haematol 2013; 26:431-44. [DOI: 10.1016/j.beha.2013.09.009] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Rose C, Pascal L, Fenaux P. Cardiac iron overload assessed by T2* magnetic resonance imaging and cardiac function in regularly transfused myelodysplastic syndrome patients, the GFM experience: response to Bowenet al. Br J Haematol 2013; 164:612-3. [DOI: 10.1111/bjh.12653] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Christian Rose
- Service d'Onco-Hématologie; Université Catholique de Lille; Lille France
| | - Laurent Pascal
- Service d'Onco-Hématologie; Université Catholique de Lille; Lille France
| | - Pierre Fenaux
- Service d'hématologie séniors; Hôpital St Louis / Université Paris 7; Paris France
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Abstract
Anemia leading to transfusion dependency (TD) and iron overload (IO) is commonly observed in patients with myelodysplastic syndromes (MDS). In MDS, TD and IO have been retrospectively associated with inferior survival and worse clinical outcomes, including cardiac, hepatic and endocrine dysfunction, and, in some analyses, with leukemic progression and infectious complications. Although suggested by retrospective analyses, clear prospective documentation of the beneficial effects of iron chelation therapy (ICT) on organ function and survival in MDS patients with TD and IO is currently lacking. Consequently, the role of ICT in MDS patients with TD and IO remains a very controversial aspect in the management of MDS. In this review, the authors summarize the current knowledge regarding IO in MDS and the role of ICT.
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Affiliation(s)
- Mhairi Mitchell
- School of Medicine and Dentistry, University of Aberdeen, Aberdeen, UK
| | - Steven D Gore
- The Sidney Kimmel Comprehensive Cancer Center at the Johns Hopkins University, Department of Oncology, 1650 Orleans Street, CRB1 building, Room 186, Baltimore, MD 21287, USA
| | - Amer M Zeidan
- The Sidney Kimmel Comprehensive Cancer Center at the Johns Hopkins University, Department of Oncology, 1650 Orleans Street, CRB1 building, Room 186, Baltimore, MD 21287, USA
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Abstract
Lower-risk myelodysplastic syndromes (MDSs) are defined as having low or intermediate 1 risk by the International Prognostic Scoring System and are characterized mainly by anemia in most cases. Supportive care--primarily red blood cell transfusions--remains an important component of their treatment, but exposes patients to insufficient correction of anemia, alloimmunization, and organ iron overload (for which the role of iron chelation remains debated). Treatment aimed at preventing anemia recurrence should therefore be used whenever possible. Erythropoiesis stimulating agents remain the first-line treatment of anemia in most lower-risk MDS without del(5q), whereas anemia of low-risk MDS with del 5q responds to lenalidomide in two-thirds of the cases, but this drug should be used cautiously because profound cytopenias may occur initially. Treatment after failure of those first-line therapies are disappointing overall, with many patients eventually requiring long-term transfusions, but encouraging results have been reported with hypomethylating agents and lenalidomide. Selected patients respond to antithymocyte globulins, and thrombopoietin receptor agonists are under investigation in lower-risk MDS with thrombocytopenia. Some patients, while remaining at a "lower risk" MDS level, have severe cytopenias and/or poor prognostic factors, found using newer prognostic parameters, or resistance to treatment, making them urgent candidates for more intensive approaches, including allogeneic stem cell transplantation.
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McQuilten ZK, Polizzotto MN, Wood EM, Sundararajan V. Myelodysplastic syndrome incidence, transfusion dependence, health care use, and complications: an Australian population-based study 1998 to 2008. Transfusion 2013; 53:1714-21. [DOI: 10.1111/trf.12054] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2012] [Revised: 09/20/2012] [Accepted: 09/25/2012] [Indexed: 12/01/2022]
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Selective toxicity towards myelodysplastic hematopoietic progenitors – Another rationale for iron chelation in MDS. Leuk Res 2012; 36:962-3. [DOI: 10.1016/j.leukres.2012.04.030] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2012] [Revised: 04/18/2012] [Accepted: 04/30/2012] [Indexed: 11/21/2022]
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List AF, Baer MR, Steensma DP, Raza A, Esposito J, Martinez-Lopez N, Paley C, Feigert J, Besa E. Deferasirox Reduces Serum Ferritin and Labile Plasma Iron in RBC Transfusion–Dependent Patients With Myelodysplastic Syndrome. J Clin Oncol 2012; 30:2134-9. [DOI: 10.1200/jco.2010.34.1222] [Citation(s) in RCA: 146] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
PurposeThis 3-year, prospective, multicenter trial assessed the safety and efficacy of deferasirox in low- or intermediate-1–risk myelodysplastic syndrome (MDS).Patients and MethodsEligible patients had serum ferritin ≥ 1,000 μg/L and had received ≥ 20 units of RBCs with ongoing transfusion requirements. The starting dose of deferasirox was 20 mg/kg/d, with dose escalation up to 40 mg/kg/d permitted.ResultsA total of 176 patients were enrolled, and 173 patients received therapy. Median serum ferritin decreased 23% in the 53% of patients who completed 12 months of treatment (n = 91), 36.7% in patients who completed 2 years (n = 49), and 36.5% in patients who completed 3 years (n = 33) despite continued transfusion requirement. Reduction in serum ferritin significantly correlated with ALT improvement (P < .001). Labile plasma iron (LPI) was measured quarterly during the first year of the study. Sixty-eight patients (39.3%) had elevated LPI at baseline. By week 13, LPI levels normalized in all patients with abnormal baseline level. Fifty-one (28%) of 173 patients experienced hematologic improvement by International Working Group 2006 criteria; of these, only seven patients received growth factors or MDS therapy. Over the 3-year study, 138 (79.8%) of 173 patients discontinued therapy, 43 patients (24.8%) because of adverse events or disease progression and 23 patients (13.2%) because of abnormal laboratory values. The most common drug-related adverse events were gastrointestinal disturbances and increased serum creatinine. There were 28 deaths, none of which were considered related to deferasirox.ConclusionDeferasirox reduces serum ferritin and LPI in transfusion-dependent patients with MDS. A subset of patients had an improvement in hematologic and hepatic parameters.
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Affiliation(s)
- Alan F. List
- Alan F. List, H. Lee Moffitt Cancer Center, Tampa, FL; Maria R. Baer, Roswell Park Cancer Institute, Buffalo; Azra Raza, Columbia University, New York, NY; David P. Steensma, Dana-Farber Cancer Institute, Boston, MA; Jason Esposito, Noelia Martinez-Lopez, and Carole Paley, Novartis Pharmaceuticals Corporation, East Hanover, NJ; John Feigert, Fairfax Northern Virginia Hematology/Oncology, Arlington, VA; and Emmanuel Besa, Thomas Jefferson University, Philadelphia, PA
| | - Maria R. Baer
- Alan F. List, H. Lee Moffitt Cancer Center, Tampa, FL; Maria R. Baer, Roswell Park Cancer Institute, Buffalo; Azra Raza, Columbia University, New York, NY; David P. Steensma, Dana-Farber Cancer Institute, Boston, MA; Jason Esposito, Noelia Martinez-Lopez, and Carole Paley, Novartis Pharmaceuticals Corporation, East Hanover, NJ; John Feigert, Fairfax Northern Virginia Hematology/Oncology, Arlington, VA; and Emmanuel Besa, Thomas Jefferson University, Philadelphia, PA
| | - David P. Steensma
- Alan F. List, H. Lee Moffitt Cancer Center, Tampa, FL; Maria R. Baer, Roswell Park Cancer Institute, Buffalo; Azra Raza, Columbia University, New York, NY; David P. Steensma, Dana-Farber Cancer Institute, Boston, MA; Jason Esposito, Noelia Martinez-Lopez, and Carole Paley, Novartis Pharmaceuticals Corporation, East Hanover, NJ; John Feigert, Fairfax Northern Virginia Hematology/Oncology, Arlington, VA; and Emmanuel Besa, Thomas Jefferson University, Philadelphia, PA
| | - Azra Raza
- Alan F. List, H. Lee Moffitt Cancer Center, Tampa, FL; Maria R. Baer, Roswell Park Cancer Institute, Buffalo; Azra Raza, Columbia University, New York, NY; David P. Steensma, Dana-Farber Cancer Institute, Boston, MA; Jason Esposito, Noelia Martinez-Lopez, and Carole Paley, Novartis Pharmaceuticals Corporation, East Hanover, NJ; John Feigert, Fairfax Northern Virginia Hematology/Oncology, Arlington, VA; and Emmanuel Besa, Thomas Jefferson University, Philadelphia, PA
| | - Jason Esposito
- Alan F. List, H. Lee Moffitt Cancer Center, Tampa, FL; Maria R. Baer, Roswell Park Cancer Institute, Buffalo; Azra Raza, Columbia University, New York, NY; David P. Steensma, Dana-Farber Cancer Institute, Boston, MA; Jason Esposito, Noelia Martinez-Lopez, and Carole Paley, Novartis Pharmaceuticals Corporation, East Hanover, NJ; John Feigert, Fairfax Northern Virginia Hematology/Oncology, Arlington, VA; and Emmanuel Besa, Thomas Jefferson University, Philadelphia, PA
| | - Noelia Martinez-Lopez
- Alan F. List, H. Lee Moffitt Cancer Center, Tampa, FL; Maria R. Baer, Roswell Park Cancer Institute, Buffalo; Azra Raza, Columbia University, New York, NY; David P. Steensma, Dana-Farber Cancer Institute, Boston, MA; Jason Esposito, Noelia Martinez-Lopez, and Carole Paley, Novartis Pharmaceuticals Corporation, East Hanover, NJ; John Feigert, Fairfax Northern Virginia Hematology/Oncology, Arlington, VA; and Emmanuel Besa, Thomas Jefferson University, Philadelphia, PA
| | - Carole Paley
- Alan F. List, H. Lee Moffitt Cancer Center, Tampa, FL; Maria R. Baer, Roswell Park Cancer Institute, Buffalo; Azra Raza, Columbia University, New York, NY; David P. Steensma, Dana-Farber Cancer Institute, Boston, MA; Jason Esposito, Noelia Martinez-Lopez, and Carole Paley, Novartis Pharmaceuticals Corporation, East Hanover, NJ; John Feigert, Fairfax Northern Virginia Hematology/Oncology, Arlington, VA; and Emmanuel Besa, Thomas Jefferson University, Philadelphia, PA
| | - John Feigert
- Alan F. List, H. Lee Moffitt Cancer Center, Tampa, FL; Maria R. Baer, Roswell Park Cancer Institute, Buffalo; Azra Raza, Columbia University, New York, NY; David P. Steensma, Dana-Farber Cancer Institute, Boston, MA; Jason Esposito, Noelia Martinez-Lopez, and Carole Paley, Novartis Pharmaceuticals Corporation, East Hanover, NJ; John Feigert, Fairfax Northern Virginia Hematology/Oncology, Arlington, VA; and Emmanuel Besa, Thomas Jefferson University, Philadelphia, PA
| | - Emmanuel Besa
- Alan F. List, H. Lee Moffitt Cancer Center, Tampa, FL; Maria R. Baer, Roswell Park Cancer Institute, Buffalo; Azra Raza, Columbia University, New York, NY; David P. Steensma, Dana-Farber Cancer Institute, Boston, MA; Jason Esposito, Noelia Martinez-Lopez, and Carole Paley, Novartis Pharmaceuticals Corporation, East Hanover, NJ; John Feigert, Fairfax Northern Virginia Hematology/Oncology, Arlington, VA; and Emmanuel Besa, Thomas Jefferson University, Philadelphia, PA
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Butler A, Patton WN. Iron chelation therapy in myelodysplastic syndromes: we need more evidence, not more guidelines. Intern Med J 2012; 42:481-4. [PMID: 22616959 DOI: 10.1111/j.1445-5994.2012.02769.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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The clinical, quality of life, and economic consequences of chronic anemia and transfusion support in patients with myelodysplastic syndromes. Leuk Res 2012; 36:525-36. [DOI: 10.1016/j.leukres.2012.01.006] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2011] [Revised: 12/28/2011] [Accepted: 01/09/2012] [Indexed: 12/17/2022]
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Steensma DP. The relevance of iron overload and the appropriateness of iron chelation therapy for patients with myelodysplastic syndromes: a dialogue and debate. Curr Hematol Malig Rep 2011; 6:136-44. [PMID: 21373838 DOI: 10.1007/s11899-011-0084-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Accumulation of excessive amounts of iron in vulnerable organs and tissues, together with elevated plasma and intracellular concentrations of reactive iron molecules, are likely to be harmful to some patients with myelodysplastic syndromes (MDS) who have received numerous red blood cell transfusions. But what is the real magnitude of risks related to iron overload in MDS, and how strong is the evidence that reducing total body iron and labile plasma iron through treatment with chelating drugs is beneficial to patients? Available data can be interpreted in different ways, and as a result, these topics continue to be areas of heated debate among physicians who care for patients with MDS. Using the traditional but rarely employed format of a classical dialogue, I explore here the potential dangers of iron overload and the risks and benefits of iron chelation therapy for patients with MDS.
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Affiliation(s)
- David P Steensma
- Division of Hematologic Malignancies, Dana-Farber Cancer Institute, Harvard Medical School, 450 Brookline Avenue, Suite D1B30 (Mayer 1B21), Boston, MA 02215, USA.
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Ferritin level at diagnosis is not correlated with poorer survival in non RBC transfusion dependent lower risk de novo MDS. Leuk Res 2011; 35:1530-3. [PMID: 21803419 DOI: 10.1016/j.leukres.2011.07.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2011] [Revised: 06/29/2011] [Accepted: 07/04/2011] [Indexed: 11/22/2022]
Abstract
We evaluated the prognostic value of serum ferritin (SF) level at diagnosis in 318 newly diagnosed IPSS low and int 1 (lower) risk MDS patients included in the French MDS registry, who did not require RBC transfusions and had baseline SF level determination. Increased baseline SF level (>300 ng/ml) was correlated with male gender, more pronounced anaemia, and diagnosis of RARS but had no negative impact on progression to AML or survival.
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Pardanani A, Tefferi A. Prognostic relevance of anemia and transfusion dependency in myelodysplastic syndromes and primary myelofibrosis. Haematologica 2011; 96:8-10. [PMID: 21193428 DOI: 10.3324/haematol.2010.035519] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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Leitch HA. Optimizing therapy for iron overload in the myelodysplastic syndromes: recent developments. Drugs 2011; 71:155-77. [PMID: 21275444 DOI: 10.2165/11585280-000000000-00000] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The myelodysplastic syndromes (MDS) are characterized by cytopenias and risk of progression to acute myeloid leukaemia (AML). Most MDS patients eventually require transfusion of red blood cells for anaemia, placing them at risk of transfusional iron overload. In β-thalassaemia major, transfusional iron overload leads to organ dysfunction and death; however, with iron chelation therapy, organ function is improved, and survival improved to near normal and correlated with the degree of compliance with chelation. In lower-risk MDS, several nonrandomized studies suggest an adverse effect of iron overload on survival and that lowering iron with chelation may minimize this impact. Emerging data indicate that chelation may improve organ function, particularly hepatic function, and a minority of patients may have improvement in cell counts and decreased transfusion requirements. While guidelines for MDS generally recommend chelation in selected lower-risk patients, data from nonrandomized trials suggest iron overload may impact adversely on the outcome of higher-risk MDS and stem cell transplantation (SCT). This effect may be due to increased transplant-related mortality, infection and AML progression, and preliminary data suggest that lowering iron may be beneficial in this patient group. Other areas of active and future investigation include optimizing the monitoring of iron overload using imaging such as T2* MRI and measures of labile iron and oxidative stress; correlating new methods of measuring iron to clinical outcomes; clarifying the contribution of different cellular and extracellular iron pools to iron toxicity; optimizing chelation by using agents that access the appropriate iron pools to minimize the relevant clinical consequences in individual patients; and incorporating measures of quality of life and co-morbidities into clinical trials of chelation in MDS. It should be noted that chelation is costly and potentially toxic, and in MDS should be initiated after weighing potential risks and benefits for each patient until more definitive data are available. In this review, data on the impact of iron overload in MDS and SCT are discussed; for example, several noncontrolled studies show inferior survival in patients with iron overload in these clinical settings, including an increase in transplant-related mortality and infection risk. Possible mechanisms of iron toxicity include oxidative stress, which can damage cellular components, and the documented impact of lowering iron on organ function with measures such as iron chelation therapy includes an improvement in elevated liver transaminases. Lowering iron also appears to improve survival in both lower-risk MDS and SCT in nonrandomized studies. Selected aspects of iron metabolism, transport, storage and distribution that may be amenable to future intervention and improved removal of iron from important cellular sites are discussed, as are attempts to quantify quality of life and the importance of co-morbidities in measures to treat MDS, including chelation therapy.
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Affiliation(s)
- Heather A Leitch
- Division of Hematology, St Paul's Hospital and the University of British Columbia, 440–1144 Burrard Street, Vancouver, BC, Canada.
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Durairaj S, Chew S, Hyslop A, Keenan N, Groves MJ, Tauro S. Predicted costs of iron-chelators in myelodysplastic syndromes: a 10-year analysis based on actual prevalence and red cell transfusion rates. Am J Hematol 2011; 86:406-10. [PMID: 21523799 DOI: 10.1002/ajh.22001] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Consideration of iron-chelation (IC) in transfusion-dependent patients is recommended in most clinical-practice guidelines on myelodysplastic syndromes (MDS). The financial impact of IC on health-care systems is predicted through economic modeling, but an analysis based on actual prevalence is lacking. Here, we have investigated the potential drug-costs and need for IC in a cohort of 189 United Kingdom-based MDS patients diagnosed from 2000 to 2010. Patients with low or intermediate-1 IPSS scores were identified as eligible for IC if ≥24 red cell units (RCU) had been transfused over 12 consecutive months or the transfusion-intensity averaged ≥2 RCU per month. Drug-costs were calculated from the time patients qualified for IC until death or last follow-up. In 159 patients with low/intermediate-1 MDS, survival was superior with a low IPSS score (P = 0.014), age <70 years (P = 0.043), transfusion-independence at diagnosis (P = 0.0056) and transfusion-intensity of <2 RCU per month (P = 0.009). Reflecting the time elapsed since diagnosis, longer survival was observed with a cumulative red cell load of ≥75 U (P = 0.046). By logistic-regression analysis, transfusion-intensity independently predicted survival (P = 0.0035) in low and intermediate-1 risk MDS patients. Forty-one patients fulfilled criteria for consideration of IC. Of these, 6 patients died within 1 month; 35 patients survived for a median of 16 months (range 1-61). Had patients commenced IC, the anticipated drug-costs alone would have been ~$526,880-$2,064,800 over 10 years. The lack of association between cumulative transfusion-load and survival calls for a prospective evaluation of the cost-utility of IC in patients surviving long-term, to enable evidence-based recommendations in MDS management.
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Pereira A, Nomdedeu M, Aguilar JL, Belkaid M, Carrió A, Cobo F, Costa D, Rozman M, Sanz C, Nomdedeu B. Transfusion intensity, not the cumulative red blood cell transfusion burden, determines the prognosis of patients with myelodysplastic syndrome on chronic transfusion support. Am J Hematol 2011; 86:245-50. [PMID: 21328437 DOI: 10.1002/ajh.21959] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2010] [Accepted: 12/02/2010] [Indexed: 11/10/2022]
Abstract
Transfusion-dependency is associated with poor prognosis in patients with MDS although the causal link for such association is disputed. This study tests thee hypotheses on the association between transfusion burden and prognosis in the MDS: (1) the cumulative transfusion burden is a confounder merely reflecting the time elapsed from diagnosis; (2) it is a surrogate for higher transfusion intensity, which would reflect a more severe disease; and (3) it is the total amount of transfused RBC units that influences on prognosis. We studied 191 transfusion-dependent patients with MDS or chronic myelomonocytic leukemia. Transfusion intensity was calculated at the time of each transfusion as the yearly-equivalent number of RBC units. The main outcome was acute leukemia-free survival from first transfusion. Median transfusion burden was 30 (range: 4-330) RBC units and 112 patients received ≥ 25 units after a median of 9 months from first transfusion. In nested Cox models, having received ≥ 25 RBC units had a significant effect on survival (P < 0.001) that was not abrogated by including follow-up ≥ 9 months as a time-dependent covariate. Including transfusion intensity in the model had a significant effect on leukemia-free survival (P < 0.001) and cancelled the prognostic value of having received ≥ 25 RBC units. In conclusion, transfusion intensity, instead of the cumulative transfusion burden, is the transfusion-related variable really influencing on the prognosis of patients with transfusion-dependent MDS.
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Affiliation(s)
- Arturo Pereira
- Service of Hemotherapy and Hemostasis, Hospital Clínic, Barcelona, Spain.
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Meerpohl JJ, Antes G, Rücker G, Fleeman N, Motschall E, Niemeyer CM, Bassler D. Deferasirox for managing iron overload in people with myelodysplastic syndrome. Cochrane Database Syst Rev 2010:CD007461. [PMID: 21069694 DOI: 10.1002/14651858.cd007461.pub2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND The myelodysplastic syndrome (MDS) comprises a diverse group of haematopoietic stem cell disorders. Due to symptomatic anaemia most patients require supportive therapy including repeated red blood cell (RBC) transfusions. In combination with increased iron absorption, this contributes to the accumulation of iron resulting in secondary iron overload and the risk of organ dysfunction and reduced life expectancy. Since the human body has no natural means of getting rid of excess iron, iron chelation therapy is usually recommended. However, whether the new oral chelator deferasirox leads to relevant benefit is unclear. OBJECTIVES To assess the effectiveness and safety of oral deferasirox in people with myelodysplastic syndrome and iron overload. SEARCH STRATEGY We searched MEDLINE, EMBASE, The Cochrane Library, Biosis Previews, Web of Science, Derwent Drug File, XTOXLINE and three trial registries: Current Controlled Trials: www.controlled-trials.com, ClinicalTrials.gov: www.clinicaltrials.gov, ICTRP: www.who.int./ictrp/en/. Most recent searches of these databases: June 2010. SELECTION CRITERIA Randomised controlled trials comparing deferasirox with no therapy/placebo or with another iron chelating treatment schedule. DATA COLLECTION AND ANALYSIS No studies eligible for inclusion in this review were identified. MAIN RESULTS No studies were included in this review. However, we identified one ongoing study comparing deferasirox with deferoxamine. AUTHORS' CONCLUSIONS We planned to report evidence from randomised clinical trials evaluating the effectiveness of deferasirox compared to either placebo/no treatment or other chelating regimens such as deferoxamine in people with myelodysplastic syndrome. However, no completed randomised trials addressing this question could be identified.One ongoing randomised study comparing deferasirox with placebo was identified and preliminary data will hopefully be available soon. These results will be important to inform physicians and patients on the advantages and disadvantages of this treatment option.
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Affiliation(s)
- Joerg J Meerpohl
- German Cochrane Centre, Institute of Medical Biometry & Medical Informatics and Pediatric Hematology & Oncology, Center for Pediatrics & Adolescent Medicine, University Medical Center Freiburg, Berliner Allee 29, Freiburg, Germany, 79110
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Affiliation(s)
- Ayalew Tefferi
- Division of Hematology, Mayo Clinic, Rochester, MN 55905, USA.
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Gattermann N, Rachmilewitz EA. Iron overload in MDS-pathophysiology, diagnosis, and complications. Ann Hematol 2010; 90:1-10. [PMID: 20938663 DOI: 10.1007/s00277-010-1091-1] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2010] [Accepted: 09/22/2010] [Indexed: 12/17/2022]
Abstract
Many patients with myelodysplastic syndromes (MDS) become dependent on blood transfusions and develop transfusional iron overload, which is exacerbated by increased absorption of dietary iron in response to ineffective erythropoiesis. However, it is uncertain whether there is an association among iron accumulation, clinical complications, and decreased likelihood of survival in MDS patients. Here, we discuss our current understanding of the effects of transfusion dependency and iron overload in MDS, indicate our knowledge gaps, and suggest that particular emphasis should be placed on further characterizing the role of redox-active forms of labile iron, which may be as important as the total iron burden.
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Affiliation(s)
- Norbert Gattermann
- Department of Hematology, Oncology and Clinical Immunology, Heinrich-Heine-University, Mooren Str. 5, 40225, Düsseldorf, Germany.
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Rose C, Brechignac S, Vassilief D, Pascal L, Stamatoullas A, Guerci A, Larbaa D, Dreyfus F, Beyne-Rauzy O, Chaury MP, Roy L, Cheze S, Morel P, Fenaux P. Does iron chelation therapy improve survival in regularly transfused lower risk MDS patients? A multicenter study by the GFM. Leuk Res 2010; 34:864-70. [PMID: 20129667 DOI: 10.1016/j.leukres.2009.12.004] [Citation(s) in RCA: 149] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2009] [Revised: 12/12/2009] [Accepted: 12/12/2009] [Indexed: 11/16/2022]
Affiliation(s)
- Christian Rose
- Service d'Onco-Hématologie, Hôpital Saint Vincent de Paul, Université Catholique de Lille, Lille, France
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Iron chelation therapy in myelodysplastic syndromes. Adv Hematol 2010; 2010:756289. [PMID: 20672005 PMCID: PMC2905902 DOI: 10.1155/2010/756289] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2009] [Revised: 01/18/2010] [Accepted: 04/20/2010] [Indexed: 01/19/2023] Open
Abstract
Myelodysplastic syndromes (MDS) are a heterogeneous disorder of the hematopoietic stem cells, frequently characterized by anemia and transfusion dependency. In low-risk patients, transfusion dependency can be long lasting, leading to iron overload. Iron chelation therapy may be a therapeutic option for these patients, especially since the approval of oral iron chelators, which are easier to use and better accepted by the patients. The usefulness of iron chelation in MDS patients is still under debate, mainly because of the lack of solid prospective clinical trials that should take place in the future. This review aims to summarize what is currently known about the incidence and clinical consequences of iron overload in MDS patients and the state-of the-art of iron chelation therapy in this setting. We also give an overview of clinical guidelines for chelation in MDS published to date and some perspectives for the future.
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Tefferi A. ASH 2009 meeting report-Top 10 clinically oriented abstracts in myeloproliferative neoplasms. Am J Hematol 2010. [DOI: 10.1002/ajh.21620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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50
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