Hydroxyurea and periodicity in myeloproliferative disease

The highs and lows of cyclic thrombocytopenia

Cyclic thrombocytopenia (CTP) is characterized by periodic platelet oscillation with substantial amplitude. Most CTP cases have a thrombocytopenic background and are often misdiagnosed as immune thrombocytopenia with erratically effective treatment choices. CTP also occurs during hydroxyurea treatment in patients with myeloproliferative diseases. While the aetiology of CTP remains uncertain, here we evaluate historical, theoretical and clinical findings to provide a framework for understanding CTP pathophysiology. CTP retains the intrinsic oscillatory factors defined by the homeostatic regulation of platelet count, presenting as reciprocal platelet/thrombopoietin oscillations and stable oscillation periodicity. Moreover, CTP patients possess pathogenic factors destabilizing the platelet homeostatic system thereby creating opportunities for external perturbations to initiate and sustain the exaggerated platelet oscillations. Beyond humoral and cell-mediated autoimmunity, we propose recently uncovered germline and somatic genetic variants, such as those of MPL, STAT3 or DNMT3A, as pathogenic factors in thrombocytopenia-related CTP. Likewise, the JAK2 V617F or BCR::ABL1 translocation that drives underlying myeloproliferative diseases may also play a pathogenic role in hydroxyurea-induced CTP, where hydroxyurea treatment can serve as both a trigger and a pathogenic factor of platelet oscillation. Elucidating the pathogenic landscape of CTP provides an opportunity for targeted therapeutic approaches in the future.

Oscillatory haematopoiesis in adults with sickle cell disease treated with hydroxycarbamide

Hydroxycarbamide therapy has been associated with significant oscillations in peripheral blood counts from myeloid, lymphoid and erythroid lineages in patients with polycythaemia vera and chronic myeloid leukaemia. We retrospectively evaluated serial blood counts over an 8-year period from 44 adult patients with sickle cell disease receiving hydroxycarbamide. Platelet counts, leucocyte counts, haemoglobin values and reticulocyte counts, apportioned by hydroxycarbamide status, were analysed using a Lomb-Scargle periodogram algorithm. Significant periodicities were present in one or more counts in 38 patients receiving hydroxycarbamide for a mean duration of 4·81 years. Platelet and leucocyte counts oscillated in 56·8% and 52·3% of patients, respectively. These oscillations generally became detectable within days of initiating therapy. During hydroxycarbamide therapy, the predominant periods of oscillation were 27 ± 1 d for platelet counts and 15 ± 1 d for leucocyte counts. Despite an absolute decrease in leucocyte and platelet counts during hydroxycarbamide treatment, the amplitudes between nadirs and zeniths remained similar regardless of exposure. Our observations appear consistent with previously proposed models of cyclic haematopoiesis, and document that hydroxycarbamide-induced oscillations in blood counts are innocuous phenomena not limited to myeloproliferative disorders as described previously. We speculate the known cell cycle inhibitory properties of hydroxycarbamide may accentuate otherwise latent constitutive oscillatory haematopoiesis.

Hydroxycarbamide associated platelet count oscillations in a patient with polycythaemia vera. A case report and review of the literature

We describe an unusual case of oscillating platelet counts in a patient with polycythaemia vera. Following commencement of cytoreductive hydroxycarbamide therapy, episodes of thrombocytopenia were followed regularly by thrombocytosis. Platelet counts fluctuated periodically between approximately 200 and 800 x 109/l, with a 28 day cycle duration. Frequent adjustment of the hydroxycarbamide dose was not successful in preventing the oscillations in platelet count. In contrast, maintenance of a constant dose led to a gradual damping of the cycles and thus termination of the large oscillations. The case further implicates hydroxycarbamide as a potential cause of cyclic variations in platelet counts, and demonstrates that cessation of this drug is not always necessary in order to treat this phenomenon.

Hydroxyurea increases eNOS protein levels through inhibition of proteasome activity

Recent reports have identified the proteasome as the primary degradation pathway for inducible, neuronal and endothelial nitric oxide synthase (NOS). We have demonstrated that hydroxyurea increased nitric oxide (NO) production in endothelial cells through phosphorylation of eNOS as a short-term effect. We find now that NO production in endothelial cells is dose-dependently stimulated by hydroxyurea, as well as both specific and non-specific proteasome inhibitors, as a long term effect. Prolonged treatment of primary human umbilical vein endothelial cells (HUVEC) with hydroxyurea was found to increase eNOS protein levels without an effect on eNOS mRNA levels, suggesting posttranscriptional control. We observed that the inhibitors of proteasomes that we tested also increased eNOS protein levels in HUVEC. In a proteasome assay, we showed that hydroxyurea inhibited protein degradation in a dose-dependent manner, in both purified 20S proteasome and HUVEC lysates. The NO production induced by hydroxyurea in endothelial cells appears to be mediated by long term posttranscriptional augmentation in eNOS levels via inhibition of the proteasome activity.

Prolonged perturbation of the oscillations of hepatoma Fao cell proliferation by a single small dose of methotrexate

The proliferation rate of various cell types in vitro, including hepatoma Fao cells, displays aperiodic oscillations. The frequency of these oscillations is about one every 3-5 weeks, and there are variations in cell functions and polarity. Topological analysis has showed that these oscillations in growth rate are determined, and presumably chaotic. One characteristic of complex chaotic systems is that their dynamics can be persistently modified by a small external perturbation. We show that treatment with a single small dose of the anticancer drug methotrexate causes long-term stable alteration of the oscillatory dynamics of Fao cell proliferation. The oscillations of growth rate are shifted, and their mean level decreased according to a fractal pattern.

Anagrelide: a decade of clinical experience with its use for the treatment of primary thrombocythaemia

Primary thrombocythaemia (PT) is the most frequent among the rare chronic myeloproliferative disorders. Life expectancy is determined by thromboembolic and haemorrhagic complications, which can be prevented by cytoreductive therapy. For a long time, hydroxyurea has been considered as the therapeutic gold standard. However, hydroxyurea treatment is not lineage-specific, may not be tolerated because of adverse effects (skin, gastrointestinal tract) and is leukaemogenic when sequentially used with other DNA-targeting drugs. Hence, anagrelide was welcomed in 1988 when it was first described as being efficient at normalising elevated platelet counts, specific for megakaryocytes and non-mutagenic. Since then, anagrelide has been approved in the US and Canada (Agrylin), Shire Pharmaceuticals) as well as in Austria and other countries of the EU (Thromboreductin), AOP Orphan Pharmaceuticals). Clinical Phase III trials (PT1 and ANAHYDRET) are underway to directly compare the efficacy and safety of anagrelide and hydroxyurea.

Deterministic dynamics control oscillations of bone marrow cell proliferation

OBJECTIVE

The production of blood cells in vivo, both normal and tumoral, displays oscillatory dynamics. Many cells in long-term cultures also show large amplitude oscillations of proliferative rate. Therefore we examined the proliferation dynamics of mouse bone marrow cells (MBM) and their clonogenic progenitor production (BMP), in order to characterize these dynamics.

METHODS

Five Dexter-type cultures of MBM cells and their clonogenic BMP production were examined for up to seven-months periods of time. The recorded time series exhibited a complex pattern of oscillations with variable amplitudes. We previously reported a method that allowed analysis of such nonlinear dynamics of hepatoma cell proliferation. We applied this method, based on the two-dimensional recurrent representation of data, to analyze the fluctuations of bone marrow cells proliferation.

RESULTS

The proliferation rate of mouse bone marrow cells shows large amplitude oscillations every 2 to 3 weeks. Mathematical analysis revealed a deterministic mechanism that controls all proliferation local maxima of MBM cells. Dynamics for progenitor production resembled that of parental cells. This reflects a predominant negative feedback on bone marrow cell proliferation.

CONCLUSION

These dynamics were opposite of that previously described for hepatoma cells where the dominant control is applied to the local minima (troughs of proliferation). Therefore, the complex system of cell proliferation is controlled by a bipolar mechanism, with a predominant dampening command depending on the cell type. We propose that the dominant dampening control of local maxima in bone marrow cells protects the stock of stem cells.