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Musallam KM, Sheth S, Cappellini MD, Forni GL, Maggio A, Taher AT. Anemia and iron overload as prognostic markers of outcomes in β-thalassemia. Expert Rev Hematol 2024; 17:631-642. [PMID: 39037857 DOI: 10.1080/17474086.2024.2383420] [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] [Received: 06/04/2024] [Accepted: 07/18/2024] [Indexed: 07/24/2024]
Abstract
INTRODUCTION Ineffective erythropoiesis and subsequent anemia as well as primary and secondary (transfusional) iron overload are key drivers for morbidity and mortality outcomes in patients with β-thalassemia. AREAS COVERED In this review, we highlight evidence from observational studies evaluating the association between measures of anemia and iron overload versus outcomes in both non-transfusion-dependent and transfusion-dependent forms of β-thalassemia. EXPERT OPINION Several prognostic thresholds have been identified with implications for patient management. These have also formed the basis for the design of novel therapy clinical trials by informing eligibility and target endpoints. Still, several data gaps persist in view of the challenge of assessing prospective long-term outcomes in a chronic disease. Pooling insights on the prognostic value of different measures of disease mechanism will be key to design future scoring systems that can help optimize patient management.
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Affiliation(s)
- Khaled M Musallam
- Center for Research on Rare Blood Disorders (CR-RBD), Burjeel Medical City, Abu Dhabi, United Arab Emirates
- Division of Hematology/Oncology, Department of Pediatrics, Weill Cornell Medicine, New York, NY, USA
| | - Sujit Sheth
- Division of Hematology/Oncology, Department of Pediatrics, Weill Cornell Medicine, New York, NY, USA
| | - Maria Domenica Cappellini
- Department of Clinical Sciences and Community, University of Milan, Ca' Granda Foundation IRCCS Maggiore Policlinico Hospital, Milan, Italy
| | | | - Aurelio Maggio
- Campus of Haematology Franco and Piera Cutino, AOOR Villa Sofia-V. Cervello, Palermo, Italy
| | - Ali T Taher
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
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Musallam KM, Taher AT, Kattamis A, Kuo KHM, Sheth S, Cappellini MD. Profile of Luspatercept in the Treatment of Anemia in Adults with Non-Transfusion-Dependent β-Thalassemia (NTDT): Design, Development and Potential Place in Therapy. Drug Des Devel Ther 2023; 17:1583-1591. [PMID: 37255740 PMCID: PMC10226484 DOI: 10.2147/dddt.s368584] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 05/20/2023] [Indexed: 06/01/2023] Open
Abstract
Over the past decade, evidence has been mounting on the detrimental clinical sequelae of untreated anemia in patients with non-transfusion-dependent β-thalassemia (NTDT). There are no pharmacologic agents that are specifically approved for the management of anemia in NTDT, and available options such as splenectomy, transfusion therapy, and hydroxyurea each come with their own shortcomings, especially for long-term use. Luspatercept is an erythroid maturation agent that has been evaluated in a Phase 2, randomized trial and showed a significant benefit in raising hemoglobin level by at least 1 g/dL in adults with NTDT and a baseline hemoglobin level ≤10 g/dL. These data led to luspatercept's approval by the European Commission for the treatment of anemia in adults with NTDT and presents the first evidence-based approach for a novel agent that is able to ameliorate anemia in this patient population.
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Affiliation(s)
- Khaled M Musallam
- Thalassemia Center, Burjeel Medical City, Abu Dhabi, United Arab Emirates
| | - Ali T Taher
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Antonis Kattamis
- First Department of Pediatrics, National and Kapodistrian University of Athens, Athens, Greece
| | - Kevin H M Kuo
- Division of Hematology, University of Toronto, Toronto, ON, Canada
| | - Sujit Sheth
- Division of Hematology and Oncology, Department of Pediatrics, Weill Cornell Medicine, New York, NY, USA
| | - Maria Domenica Cappellini
- Department of Clinical Sciences and Community, University of Milan, Ca’ Granda Foundation IRCCS Maggiore Policlinico Hospital, Milan, Italy
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Bou-Fakhredin R, Motta I, Cappellini MD, Taher AT. Clinical Complications and Their Management. Hematol Oncol Clin North Am 2023; 37:365-378. [PMID: 36907609 DOI: 10.1016/j.hoc.2022.12.007] [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: 03/12/2023]
Abstract
The diversity of disease-related complications among patients with β-thalassemia is complicated by the wide spectrum of genotypes and clinical risk factors. The authors herein present the different complications seen in patients with β-thalassemia, the pathophysiology underlying these complications and their management.
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Affiliation(s)
- Rayan Bou-Fakhredin
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Irene Motta
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy; UOC General Medicine, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Maria Domenica Cappellini
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy; UOC General Medicine, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Ali T Taher
- Division of Hematology-Oncology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon.
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Abstract
Thalassemia is a disease with an extensive morbidity profile affecting almost every organ system. Renal involvement, once considered rare, is an underestimated and poorly studied complication that has been on the rise ever since medical advances granted patients longer life spans. Several studies and reports have emerged recently to shed light on the seriousness of this complication, although data is still lacking in terms of pathophysiology, diagnosis, prevention and treatment. In this review, we evaluate and compare renal involvement in the transfusion-dependent and independent variants of β-Thalassemia, highlighting the pathophysiology of kidney damage that involves iron overload, chronic anemia, and iron chelation therapy. An in-depth and focused review of the types of injuries incurred is also presented along with the diagnostic biomarkers accompanying each type of injury. Most research so far has focused on the transfusion-dependent thalassemia population being the group with most renal involvement, however recent reports have shown evidence of comparable, if not worse, involvement of the non-transfusion dependent population, sometimes leading to end-stage renal disease. As such, we try to shed light on distinct renal involvements in NTDT whenever available.
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Bou-Fakhredin R, Elias J, Taher AT. Iron Overload and Chelation Therapy in Hemoglobinopathies. THALASSEMIA REPORTS 2018. [DOI: 10.4081/thal.2018.7478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Iron overload (IOL) is highly prevalent among patients with hemoglobinopathies; both transfusion dependent thalassemia (TDT) and non-transfusion dependent thalassemia (NTDT). Whether IOL is secondary to regular transfusions like in TDT, or develops from increased intestinal absorption like in NTDT, it can cause significant morbidity and mortality. In TDT patients, iron accumulation in organ tissues is highly evident, and leads to organ toxicity and dysfunction. IOL in NTDT patients is cumulative with advancing age, and concern with secondary morbidity starts beyond the age of 10 years, as shown by the OPTIMAL CARE study. Several modalities are available for the diagnosis and monitoring of IOL. Serum ferritin (SF) assessment is widely available and heavily relied on in resource-poor countries. Non-invasive iron monitoring using MRI has become the gold standard to diagnose IOL. Three iron chelators are currently available for the treatment of IOL: deferoxamine (DFO) in subcutaneous or intravenous injection, oral deferiprone (DFP) in tablet or solution form, and oral deferasirox (DFX) in dispersible tablet (DT) and film-coated tablet (FCT). Today, the goal of ICT is to maintain safe levels of body iron at all times. Appropriate tailoring ICT with chelator choices and dose adjustment must be implemented in a timely manner. Clinical decision to initiate, adjust and stop ICT is based on SF, MRI-LIC and cardiac T2*. In this article, we review the mechanism of IOL in both TDT and NTDT, the pathophysiology behind it, its complications, and the different ways to assess and quantify it. We will also discuss the different ICT modalities available, and the emergence of novel therapies.
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Sleiman J, Tarhini A, Bou-Fakhredin R, Saliba AN, Cappellini MD, Taher AT. Non-Transfusion-Dependent Thalassemia: An Update on Complications and Management. Int J Mol Sci 2018; 19:E182. [PMID: 29316681 PMCID: PMC5796131 DOI: 10.3390/ijms19010182] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2017] [Revised: 01/05/2018] [Accepted: 01/06/2018] [Indexed: 12/16/2022] Open
Abstract
Patients with non-transfusion-dependent thalassemia (NTDT) experience many clinical complications despite their independence from frequent transfusions. Morbidities in NTDT stem from the interaction of multiple pathophysiological factors: ineffective erythropoiesis, iron overload (IOL), and hypercoagulability. Ineffective erythropoiesis and hemolysis are associated with chronic hypoxia and a hypercoagulable state. The latter are linked to a high prevalence of thromboembolic and cerebrovascular events, as well as leg ulcers and pulmonary hypertension. IOL in NTDT patients is a cumulative process that can lead to several iron-related morbidities in the liver (liver fibrosis), kidneys, endocrine glands (endocrinopathies), and vascular system (vascular disease). This review sheds light on the pathophysiology underlying morbidities associated with NTDT and summarizes the mainstays of treatment and some of the possible future therapeutic interventions.
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Affiliation(s)
- Joseph Sleiman
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut 11-0236, Lebanon.
| | - Ali Tarhini
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut 11-0236, Lebanon.
| | - Rayan Bou-Fakhredin
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut 11-0236, Lebanon.
| | - Antoine N Saliba
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA.
| | - Maria Domenica Cappellini
- Department of Medicine, Ca'Granda Foundation IRCCS, University of Milan, 20122 Milan, Italy.
- Department of Clinical Science and Community, University of Milan, 20122 Milan, Italy.
| | - Ali T Taher
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut 11-0236, Lebanon.
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Saliba AN, Taher AT. Morbidities in non-transfusion-dependent thalassemia. Ann N Y Acad Sci 2016; 1368:82-94. [DOI: 10.1111/nyas.13083] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Revised: 04/06/2016] [Accepted: 04/07/2016] [Indexed: 01/19/2023]
Affiliation(s)
- Antoine N. Saliba
- Department of Medicine; Indiana University School of Medicine; Indianapolis Indiana
| | - Ali T. Taher
- Department of Internal Medicine; American University of Beirut Medical Center; Beirut Lebanon
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Cappellini MD, Porter JB, Musallam KM, Kattamis A, Viprakasit V, Galanello R, Taher AT. Development of a new disease severity scoring system for patients with non-transfusion-dependent thalassemia. Eur J Intern Med 2016; 28:91-6. [PMID: 26545830 DOI: 10.1016/j.ejim.2015.10.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Revised: 10/05/2015] [Accepted: 10/09/2015] [Indexed: 01/28/2023]
Abstract
BACKGROUND Patients with non-transfusion-dependent thalassemia (NTDT) present with a spectrum of disease severities. Since there are multiple pathophysiologies in such patients, tailoring treatment remains essential. Therefore, one simple, reliable tool would be beneficial to assess disease severity and tailor therapy, particularly for internal medicine specialists who may treat a variety of NTDT patients with a multitude of complications. This would allow for standardization of assessments leading to timely interventions and prevention of complications. METHODS A working group of NTDT experts was formed to develop a new disease severity scoring system for adult and pediatric patients with NTDT, based on parameters considered to be most pertinent in defining disease severity. RESULTS 20 parameters were selected for inclusion in the disease severity scoring system. An additional six parameters, largely related to growth and development, were selected specifically for pediatric patients (≤ 16 years of age). Consensus of expert opinion was used to establish the selected methods of assessment for each parameter, based on feasibility and availability of technology, cost containment, and avoidance of patient risk. CONCLUSION We propose that this new disease severity scoring system for adult and pediatric NTDT patients could be developed into a practical tool for widespread clinical use.
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Affiliation(s)
| | | | - Khaled M Musallam
- Universita di Milano, Ca Granda Foundation IRCCS, Milan, Italy; American University of Beirut, Beirut, Lebanon
| | - Antonis Kattamis
- First Department of Pediatrics, University of Athens, Athens, Greece
| | - Vip Viprakasit
- Department of Pediatrics and Thalassemia Center, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Renzo Galanello
- Ospedale Regionale Microcitemie, Dipartimento Scienze Biomediche e Biotechnologie, Università di Cagliari, Cagliari, Italy
| | - Ali T Taher
- American University of Beirut, Beirut, Lebanon
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Harb AR, Saliba AN, Taher AT. Non-Transfusion Dependent Thalassemia: Translating Evidence to Guidelines. THALASSEMIA REPORTS 2014. [DOI: 10.4081/thal.2014.4863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
The thalassemias are a group of inherited disorders of hemoglobin synthesis characterized by various degrees of defective production of the α- or β-globin chains of adult hemoglobin A. Non-transfusion- dependent thalassemia (NTDT) includes a group of thalassemia patients who do not require regular RBC transfusions for survival, but may require occasional transfusions due to infection or pregnancy or may require more regular transfusions later in life due to splenomegaly or other complications. Due to the rising phenomenon of global migration, this previously well-localized entity is currently spreading more and more worldwide reaching Northern America and Northern Europe. The clinical picture of NTDT is governed by the severity of the ineffective erythropoiesis and the chronic hemolytic anemia, which, in turn, lead to iron overload, hypercoagulability, and an array of clinical complications involving almost every organ system. Patients with NTDT suffer from complications that are distinct from those encountered in patients with transfusion- dependent thalassemia (TDT) in addition to the complications shared by both TDT and NTDT. As a consequence, patients with NTDT deserve a care specifically tailored to their needs. In the care of patients with NTDT, aiming at a standardized yet personalized care is not an easy task especially that NTDT patients lie on a heterogeneous spectrum with a wide variability in their clinical presentation and response to therapy. Therefore, guidelines emerge as a necessity to answer the specific needs of NTDT patients and the clinicians caring for them. In this article, we summarize the complications most commonly associated with NTDT and the recommendations of the guidelines for the management of patients with NTDT, based on the best available evidence.
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