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Al Tabosh T, Al Tarrass M, Tourvieilhe L, Guilhem A, Dupuis-Girod S, Bailly S. Hereditary hemorrhagic telangiectasia: from signaling insights to therapeutic advances. J Clin Invest 2024; 134:e176379. [PMID: 38357927 PMCID: PMC10866657 DOI: 10.1172/jci176379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2024] Open
Abstract
Hereditary hemorrhagic telangiectsia (HHT) is an inherited vascular disorder with highly variable expressivity, affecting up to 1 in 5,000 individuals. This disease is characterized by small arteriovenous malformations (AVMs) in mucocutaneous areas (telangiectases) and larger visceral AVMs in the lungs, liver, and brain. HHT is caused by loss-of-function mutations in the BMP9-10/ENG/ALK1/SMAD4 signaling pathway. This Review presents up-to-date insights on this mutated signaling pathway and its crosstalk with proangiogenic pathways, in particular the VEGF pathway, that has allowed the repurposing of new drugs for HHT treatment. However, despite the substantial benefits of these new treatments in terms of alleviating symptom severity, this not-so-uncommon bleeding disorder still currently lacks any FDA- or European Medicines Agency-approved (EMA-approved) therapies.
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Affiliation(s)
- Tala Al Tabosh
- Biosanté Unit U1292, Grenoble Alpes University, INSERM, CEA, Grenoble, France
| | - Mohammad Al Tarrass
- Biosanté Unit U1292, Grenoble Alpes University, INSERM, CEA, Grenoble, France
| | - Laura Tourvieilhe
- Hospices Civils de Lyon, National HHT Reference Center and Genetics Department, Femme-Mère-Enfants Hospital, Bron, France
| | - Alexandre Guilhem
- Hospices Civils de Lyon, National HHT Reference Center and Genetics Department, Femme-Mère-Enfants Hospital, Bron, France
- TAI-IT Autoimmunité Unit RIGHT-UMR1098, Burgundy University, INSERM, EFS-BFC, Besancon, France
| | - Sophie Dupuis-Girod
- Biosanté Unit U1292, Grenoble Alpes University, INSERM, CEA, Grenoble, France
- Hospices Civils de Lyon, National HHT Reference Center and Genetics Department, Femme-Mère-Enfants Hospital, Bron, France
| | - Sabine Bailly
- Biosanté Unit U1292, Grenoble Alpes University, INSERM, CEA, Grenoble, France
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Gong AJ, Garg T, Khalil A, Gowda PC, Mathai SC, Rowan NR, Merlo CA, Weiss CR. Health-Related Quality of Life Outcome Measures in Individuals With Hereditary Hemorrhagic Telangiectasia: A Scoping Review. Am J Rhinol Allergy 2024; 38:60-76. [PMID: 37855028 DOI: 10.1177/19458924231207123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2023]
Abstract
BACKGROUND Studies evaluating health-related quality of life (HRQOL) in patients with hereditary hemorrhagic telangiectasia (HHT) have expanded rapidly in the past decade. These studies have evaluated QOL aspects ranging from the general QOL for patients living with HHT to intervention-specific outcomes. However, few tools have been fully validated across the spectrum of disease manifestations and interventions in HHT. OBJECTIVE In this scoping review, we aim to map the literature on HHT-QOL metrics, identify gaps, inform future QOL research, and facilitate future metric development. METHODS We analyzed articles in English that assessed at least 1 measure of general HRQOL, including physical health, mental health, social health, or intervention-specific QOL in patients with HHT. Searches across 2 bibliographic databases (PubMed and Scopus) yielded 186 articles after duplicates were removed. Sixty-three studies met eligibility criteria: 22 prospective studies (34.9%), 20 retrospective studies (31.7%), 12 cross-sectional studies (17.5%), 6 randomized controlled trials or secondary analyses of a randomized controlled trials (9.5%), 2 qualitative studies (3.2%), and 1 case-control study (1.6%). Two additional studies-1 prospective and 1 cross-sectional study-were identified at the October 2022 14th International HHT Conference and included, making a total of 65 studies. RESULTS The 65 eligible studies used 30 QOL instruments. Twenty studies characterized baseline HRQOL, and 45 studies evaluated QOL before and after treatment. Of those 45 studies, 37 evaluated HRQOL before and after therapies targeting epistaxis and nasal symptoms, 4 targeted therapies for liver arteriovenous malformations and high-output heart failure, 3 evaluated therapies for both epistaxis and gastrointestinal bleeding, and 1 evaluated treatment targeting gastrointestinal bleeding alone. CONCLUSIONS Comparison of results across studies remains challenging given the heterogeneity in outcomes measures. Further development of HHT-specific patient-reported outcomes instruments that capture the global illness experience of HHT is needed.
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Affiliation(s)
- Anna J Gong
- Division of Interventional Radiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Tushar Garg
- Division of Interventional Radiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Adham Khalil
- Division of Interventional Radiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Prateek C Gowda
- Division of Interventional Radiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Stephen C Mathai
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nicholas R Rowan
- Department of Otolaryngology-Head and Neck Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Christian A Merlo
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Clifford R Weiss
- Division of Interventional Radiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Anciaux M, Lebreton JP, Tonnerre D, Leclerc J, Dufour X, Carsuzaa F. Injection of cyanoacrylate glue for hereditary hemorrhagic telangiectasia. Int Forum Allergy Rhinol 2022; 12:1439-1441. [PMID: 35521750 DOI: 10.1002/alr.23017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 04/29/2022] [Accepted: 04/30/2022] [Indexed: 11/06/2022]
Affiliation(s)
- Maeva Anciaux
- Department of Head and Neck Surgery, University Hospital of Poitiers, Poitiers, France
| | - Jean-Pascal Lebreton
- Department of Head and Neck Surgery, University Hospital of Poitiers, Poitiers, France
| | - Denis Tonnerre
- Department of Head and Neck Surgery, University Hospital of Poitiers, Poitiers, France
| | - Justine Leclerc
- Department of Head and Neck Surgery, University Hospital of Poitiers, Poitiers, France
| | - Xavier Dufour
- Department of Head and Neck Surgery, University Hospital of Poitiers, Poitiers, France.,Laboratoire Inflammation, Tissus Epithéliaux et Cytokines (LITEC) - EA4331, University of Poitiers, Poitiers, France
| | - Florent Carsuzaa
- Department of Head and Neck Surgery, University Hospital of Poitiers, Poitiers, France.,Laboratoire Inflammation, Tissus Epithéliaux et Cytokines (LITEC) - EA4331, University of Poitiers, Poitiers, France
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Thiele B, Abdel-Aty Y, Marks L, Lal D, Marino M. Sclerotherapy for Hereditary Hemorrhagic Telangiectasia-Related Epistaxis: A Systematic Review. Ann Otol Rhinol Laryngol 2022; 132:82-90. [PMID: 35152768 DOI: 10.1177/00034894221078075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Hereditary hemorrhagic telangiectasia (HHT) is a common inherited condition characterized by mucosal telangiectasias, recurrent epistaxis, and arteriovenous malformations. HHT results in detriment to quality of life. Morbidity and mortality result from severe anemia. Conventional interventions for HHT-related epistaxis include nasal packing, diathermy, lasers, coblation, microdebridement, bevacizumab (topical and systemic), as well as septodermoplasty and nasal closure. Sclerotherapy has been recently described in the literature as a novel approach to HHT-related epistaxis. We hypothesize that sclerotherapy is an effective treatment for HHT-related epistaxis and improves upon the current standard of care for this disease. METHODS A systematic review was conducted to study sclerotherapy for treating HHT-related epistaxis. Ovid MEDLINE, Ovid EMBASE, Scopus, and Web of Science were searched. Articles were evaluated and excluded according to PRISMA guidelines and reviewed by 2 authors. Reported variables included number of injections, months of follow up, changes in Epistaxis Severity Score, previous treatments used to control epistaxis, and post-injection side effects. RESULTS Seven studies with a total of 196 patients met inclusion criteria. Three studies reported significant improvement as measured by the Epistaxis Severity Score scale. One reported improvement through subjective patient surveys and others used the Bergler-Sadick scale to measure frequency and intensity of epistaxis. All studies reported improvement in HHT-related epistaxis. The lack of uniform reporting measures however precluded formal meta-analysis. CONCLUSIONS Based on limited data, sclerotherapy appears to be effective for treating HHT-related epistaxis and offers promise for treating this recalcitrant condition. However, larger, prospective, multi-centered studies using universally validated instruments for epistaxis are needed to definitively evaluate outcomes from sclerotherapy.
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Affiliation(s)
| | | | - Lisa Marks
- Library Services, Mayo Clinic, Phoenix, AZ, USA
| | - Devyani Lal
- Department of Otolaryngology, Mayo Clinic, Phoenix, AZ, USA
| | - Michael Marino
- Department of Otolaryngology, Mayo Clinic, Phoenix, AZ, USA
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Khanwalkar AR, Rathor A, Read AK, Ma Y, Hwang PH. Randomized controlled double-blinded clinical trial of the effect of bevacizumab injection in the management of epistaxis in HHT patients undergoing surgical cauterization. Int Forum Allergy Rhinol 2022; 12:1034-1042. [PMID: 34989143 DOI: 10.1002/alr.22961] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 12/09/2021] [Accepted: 12/27/2021] [Indexed: 11/10/2022]
Abstract
INTRODUCTION Given its role in the disease pathophysiology, inhibition of VEGF-mediated angiogenesis has received attention as a potential strategy to reduce epistaxis associated with hereditary hemorrhagic telangiectasia (HHT). This study evaluates the efficacy of a submucosal injection of bevacizumab, a VEGF-inhibitor, in reducing the severity of epistaxis and improving quality of life when given at the time of operative electrocautery. METHODS This randomized, double-blinded placebo-controlled trial was conducted at a single institution from 2014 to 2019. Patients scheduled to undergo operative bipolar electrocautery of nasal telangiectasias were randomized to receive a submucosal injection of saline or bevacizumab at time of surgery. Surveys to assess epistaxis severity and quality-of-life (QOL), including the Epistaxis Severity Score (ESS) and Short Form 12 (SF-12), were administered preoperatively and at 1, 2, 4, and 6 months postoperatively. The minimal clinically important difference (MCID) of the ESS instrument is reported to be 0.71. RESULTS Of 39 patients enrolled, 37 (94.9%) completed the study. The saline group demonstrated reduced ESS versus baseline at 1 (-1.2, p = 0.01) and 4 (-1.2, p = 0.05) months post-procedure. The bevacizumab group demonstrated reduced ESS versus baseline at 1 (-2.3, p<0.001), 2 (-2.3, p<0.001), 4 (-2.0, p = 0.003), and 6 (-1.3, p = 0.05) months post-procedure. The additive benefit of bevacizumab over saline exceeded the MCID at 1, 2, and 4 months but the difference was not statistically significant. CONCLUSION The addition of a single treatment of submucosal bevacizumab may be associated with additional clinically meaningful benefit for up to 4 months when compared to electrocautery alone. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Ashoke R Khanwalkar
- Department of Otolaryngology - Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Aakanksha Rathor
- Department of Otolaryngology - Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Amelia K Read
- Department of Otolaryngology - Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Yifei Ma
- Department of Otolaryngology - Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Peter H Hwang
- Department of Otolaryngology - Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, CA, USA
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Marcos S, Botella LM, Albiñana V, Arbia A, de Rosales AM. Sclerotherapy on Demand with Polidocanol to Treat HHT Nosebleeds. J Clin Med 2021; 10:jcm10173845. [PMID: 34501293 PMCID: PMC8432129 DOI: 10.3390/jcm10173845] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 08/12/2021] [Accepted: 08/24/2021] [Indexed: 01/22/2023] Open
Abstract
Epistaxis is the most prevalent clinical symptom in Hereditary Haemorrhagic Telangiectasia (HHT), causing anaemia and decreasing the quality of life (QOL). Since 2013, in Hospital Universitario Fundación Alcorcón, more than 150 HHT patients have been treated by nose sclerotherapy on demand. This study shows the results of 105 patients treated with sclerotherapy between 2017 and 2019. HHT-ESS (epistaxis severity score) was used to measure the severity and frequency of epistaxis. QOL was determined before and after treatment by EuroQol-5D (EQ-5D) and the visual analogue scale (VAS) on the health condition. According to HHT-ESS before treatment, 22 patients presented mild, 35 moderate, and 47 severe epistaxes. Sclerotherapy significantly decreased the frequency and severity of epistaxis, with a significant drop of HHT-ESS in 4.6 points, from 6.23 ± 2.3 to 1.64 ± 1.6. Furthermore, the QOL significantly improved, the EQ-5D scale raised from 0.7 ± 0.26 pre- to 0.92 ± 0.16 post-treatment (p < 0.05). Additionally, VAS mean value showed a significant increase from 4.38 ± 2.4 to 8.35 ± 1.2. The QOL improvement was correlated with the ESS decrease. In conclusion, this study shows that on-demand sclerotherapy at the office significantly reduces HHT epistaxis as well as improved the patients' QOL.
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Affiliation(s)
- Sol Marcos
- Otorrhinolaringology Department, Hospital Universitario Fundación Alcorcón, 28922 Madrid, Spain;
- Correspondence:
| | - Luisa María Botella
- CIBER Rare Diseases Unit 707, Centro de Investigaciones Biológicas Margarita Salas, CSIC, 28040 Madrid, Spain; (L.M.B.); (V.A.)
| | - Virginia Albiñana
- CIBER Rare Diseases Unit 707, Centro de Investigaciones Biológicas Margarita Salas, CSIC, 28040 Madrid, Spain; (L.M.B.); (V.A.)
| | - Agustina Arbia
- Otorrhinolaringology Department, Hospital Universitario Fundación Alcorcón, 28922 Madrid, Spain;
| | - Anna María de Rosales
- Pharmaceutical Department, Hospital Universitario Fundación Alcorcón, 28922 Madrid, Spain;
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