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Costa E, Isgrò A, de Montalembert M, Leufkens HGM, Ware RE, De Franceschi L. Successes and pitfalls in orphan drug development for sickle cell disease. Blood Adv 2024; 8:2455-2465. [PMID: 38522095 PMCID: PMC11112610 DOI: 10.1182/bloodadvances.2023011730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 02/20/2024] [Accepted: 02/25/2024] [Indexed: 03/26/2024] Open
Abstract
ABSTRACT Sickle cell disease (SCD) is a hereditary red cell disorder with a large disease burden at a global level. In the United States and Europe, medicines may qualify for orphan designation (OD), a regulatory status that provides incentives to boost development. We evaluated the development of new therapies for SCD using data for OD granted in the United States and Europe over the last 2 decades (2000-2021). We analyzed their characteristics, pathophysiological targets, trends, and OD sponsors. We then investigated the approval outcomes, including the phase success rate and reasons for discontinuation across different variables. We identified 57 ODs for SCD: 43 (75.4%) small molecules, 32 (56.1%) for oral administration, and 36 (63.1%) for chronic use to prevent SCD complications. At the end of the study (2021), development of 34 of 57 ODs was completed. Four ODs were approved with a success rate of 11.8%. Products targeting upstream causative events of SCD pathophysiology had a 1.8 higher success rate compared with products targeting disease consequences. Large companies showed a fourfold higher success rate compared with small-medium enterprises. Failures in clinical development were mainly seen in phase 3 for a lack of efficacy on vaso-occlusive crisis as the primary study end point, likely related to variable definitions and heterogeneity of pain scoring and treatment. Both advances in SCD knowledge and regulatory incentives paved the way for new therapies for SCD. Our finding of high failure rates in late-stage clinical development signals the need for better early-stage predictive models, also in the context of meaningful clinical end points.
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Affiliation(s)
- Enrico Costa
- Division of Pharmacoepidemiology and Clinical Pharmacology, World Health Organization Collaborating Centre for Pharmaceutical Policy and Regulation, Utrecht University, Utrecht, The Netherlands
| | - Antonella Isgrò
- Centralized Procedures Office, Innovation and Pharmaceutical Strategy Division, Italian Medicines Agency, Rome, Italy
| | - Mariane de Montalembert
- Department of Pediatrics, Necker-Enfants Malades Hospital, Assistance Publique-Hopitaux de Paris Centre, Paris, France
| | - Hubert G. M. Leufkens
- Emeritus Professor Regulatory Science and Pharmaceutical Policy, Division of Pharmacoepidemiology and Clinical Pharmacoepidemiology, Utrecht University, Utrecht, The Netherlands
| | - Russell E. Ware
- Division of Hematology and Global Health Center, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
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2
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Nagose VB, Kodate PM, Kumbhalkar DT, Rathod SS, Nayak SP. Platelet Aggregation Studies and Coagulation Profile in Sickle Cell Disease in Symptomatic and Steady State Patients. Indian J Hematol Blood Transfus 2024; 40:281-288. [PMID: 38708151 PMCID: PMC11065820 DOI: 10.1007/s12288-023-01703-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 10/04/2023] [Indexed: 05/07/2024] Open
Abstract
To determine whether there is higher degree of platelet and/ or coagulation activation in sickle cell anaemia (SS) patients in complications and with clinical risk factors. A cross sectional study was conducted at a tertiary health care centre in central India with study groups: sickle cell disease (SCD): sickle cell anaemia (SS) and sickle cell trait (AS) consisting of 100 subjects each and controls (AA) with 40 subjects. Platelet aggregation (PA) with ADP, collagen and epinephrine, PT and aPTT were performed in all subjects and PA with ristocetin in ten candidates of each group. ANOVA and student's unpaired t test were used to compare PA and coagulation profile of the three groups with respect to age groups, gender, present diagnosis, history of complications, frequency of hospital admissions (high ≥ 3/year) and frequency of blood transfusion (high > 2/year). The max PA% with ADP was significantly less in SS patients in steady state, which was even lesser in those having symptoms, complications in past/ present, high-frequency hospital admission and > 2 blood transfusions per year subgroups, as compared to all other groups and subgroups, but not consistently with collagen and epinephrine. The max PA % with ristocetin was least in SS with complications. No statistically significant difference in PT and aPTT values among the various clinical risk subgroups and groups was found. SCD patients can be monitored by using PA with ADP for their timely and better management. PA with ADP, PT and aPTT should be added to the workup of these patients for improved prognostication.
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Affiliation(s)
- Vaishali B. Nagose
- Department of Pathology, Government Medical College and Hospital, Nagpur, India
- Department of Pathology, Government Medical College, Sindhudurg, India
| | - Purnima M. Kodate
- Department of Pathology, Government Medical College and Hospital, Nagpur, India
| | | | - Shivanand S. Rathod
- Department of Physiology, Dr Ulhas Patil Medical College and Hospital, Nagpur, India
| | - Suprita P. Nayak
- Department of Pathology, Government Medical College and Hospital, Nagpur, India
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3
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Ataga KI. The challenge of clinical end points in sickle cell disease. Blood 2023; 142:2047-2054. [PMID: 37890140 PMCID: PMC10733825 DOI: 10.1182/blood.2023021220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 10/05/2023] [Accepted: 10/08/2023] [Indexed: 10/29/2023] Open
Abstract
As most patients with sickle cell disease (SCD) do not have access to curative therapies, the availability of drug therapies that can modify disease severity remains highly desirable. Despite an increased understanding of the pathophysiology of SCD, only 4 drugs are approved by the US Food and Drugs Administration. Most drug trials in SCD have involved the use of acute pain episodes as the primary clinical end point. These studies have typically been to prevent or shorten the duration of such episodes. To date, no drug has received regulatory approval for shortening the duration of acute vaso-occlusive complications, likely highlighting the complex pathophysiology of acute pain episodes. Trials to prevent acute pain episodes have largely evaluated those episodes requiring health care use as a surrogate end point. However, with differences in culture and health care practices among countries, health care use may not reliably predict clinically important effects on acute pain episodes. This article discusses issues related to the use of health care use as the primary end point for prevention trials of acute pain episodes and highlights the importance of evaluating patient-reported outcomes as well as other SCD-related complications as outcome measures.
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Affiliation(s)
- Kenneth I. Ataga
- Center for Sickle Cell Disease, University of Tennessee Health Science Center, Memphis, TN
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4
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Rai P, Ataga KI. Using disease-modifying therapies in sickle cell disease. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2023; 2023:519-531. [PMID: 38066905 PMCID: PMC10727073 DOI: 10.1182/hematology.2023000485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
As curative therapy using allogeneic hematopoietic stem cell transplantation as well as gene therapy and gene editing remains inaccessible to most patients with sickle cell disease, the availability of drug therapies that are safe, efficacious, and affordable is highly desirable. Increasing progress is being made in developing drug therapies based on our understanding of disease pathophysiology. Four drugs, hydroxyurea, L-glutamine, crizanlizumab, and voxelotor, are currently approved by the US Food and Drug Administration, with multiple others at various stages of testing. With the limited efficacy of individual agents, combinations of agents will likely be required for optimal outcomes.
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Affiliation(s)
- Parul Rai
- Department of Hematology, St Jude Children's Research Hospital, Memphis, TN
| | - Kenneth I Ataga
- Center for Sickle Cell Disease, University of Tennessee Health Science Center, Memphis, TN
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5
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Chowdhury FA, Colussi N, Sharma M, Wood KC, Xu JZ, Freeman BA, Schopfer FJ, Straub AC. Fatty acid nitroalkenes - Multi-target agents for the treatment of sickle cell disease. Redox Biol 2023; 68:102941. [PMID: 37907055 PMCID: PMC10632539 DOI: 10.1016/j.redox.2023.102941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 09/27/2023] [Accepted: 10/18/2023] [Indexed: 11/02/2023] Open
Abstract
Sickle cell disease (SCD) is a hereditary hematological disease with high morbidity and mortality rates worldwide. Despite being monogenic, SCD patients display a plethora of disease-associated complications including anemia, oxidative stress, sterile inflammation, vaso-occlusive crisis-related pain, and vasculopathy, all of which contribute to multiorgan dysfunction and failure. Over the past decade, numerous small molecule drugs, biologics, and gene-based interventions have been evaluated; however, only four disease-modifying drug therapies are presently FDA approved. Barriers regarding effectiveness, accessibility, affordability, tolerance, and compliance of the current polypharmacy-based disease-management approaches are challenging. As such, there is an unmet pharmacological need for safer, more efficacious, and logistically accessible treatment options for SCD patients. Herein, we evaluate the potential of small molecule nitroalkenes such as nitro-fatty acid (NO2-FA) as a therapy for SCD. These agents are electrophilic and exert anti-inflammatory and tissue repair effects through an ability to transiently post-translationally bind to and modify transcription factors, pro-inflammatory enzymes and cell signaling mediators. Preclinical and clinical studies affirm safety of the drug class and a murine model of SCD reveals protection against inflammation, fibrosis, and vascular dysfunction. Despite protective cardiac, renal, pulmonary, and central nervous system effects of nitroalkenes, they have not previously been considered as therapy for SCD. We highlight the pathways targeted by this drug class, which can potentially prevent the end-organ damage associated with SCD and contrast their prospective therapeutic benefits for SCD as opposed to current polypharmacy approaches.
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Affiliation(s)
- Fabliha A Chowdhury
- Department of Pharmacology and Chemical Biology, University of Pittsburgh, Pittsburgh, PA, USA; Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - Nicole Colussi
- Department of Pharmacology and Chemical Biology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Malini Sharma
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Katherine C Wood
- Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - Julia Z Xu
- Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA, USA; Division of Hematology and Oncology, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Bruce A Freeman
- Department of Pharmacology and Chemical Biology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Francisco J Schopfer
- Department of Pharmacology and Chemical Biology, University of Pittsburgh, Pittsburgh, PA, USA; Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA, USA; Pittsburgh Liver Research Center (PLRC), University of Pittsburgh, Pittsburgh, PA, USA.
| | - Adam C Straub
- Department of Pharmacology and Chemical Biology, University of Pittsburgh, Pittsburgh, PA, USA; Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA, USA; Center for Microvascular Research, University of Pittsburgh, Pittsburgh, PA, USA.
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6
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Kuriri FA. Hope on the Horizon: New and Future Therapies for Sickle Cell Disease. J Clin Med 2023; 12:5692. [PMID: 37685759 PMCID: PMC10488840 DOI: 10.3390/jcm12175692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 08/16/2023] [Accepted: 08/28/2023] [Indexed: 09/10/2023] Open
Abstract
This article provides an overview of conventional, new, and future treatment options for sickle cell disease (SCD), a genetic disorder affecting the production of hemoglobin. Current treatments include hydroxyurea, a conventional SCD treatment that increases the levels of fetal hemoglobin, and new treatments such as voxelotor, a recently approved SCD treatment that selectively binds hemoglobin, preventing formation of sickled red blood cells. In addition to discussing the mechanisms of action of current SCD treatments, potential side effects are also discussed, highlighting the need for new treatments that can address the limitations of current treatments and improve the quality of life for people with SCD. Future treatments, such as gene therapy, are also explored as promising treatment options for SCD patients.
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Affiliation(s)
- Fahd A Kuriri
- Department of Clinical Laboratory Sciences, College of Applied Medical Sciences, Shaqra University, Shaqra, Riyadh 15572, Saudi Arabia
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7
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Piel FB, Rees DC, DeBaun MR, Nnodu O, Ranque B, Thompson AA, Ware RE, Abboud MR, Abraham A, Ambrose EE, Andemariam B, Colah R, Colombatti R, Conran N, Costa FF, Cronin RM, de Montalembert M, Elion J, Esrick E, Greenway AL, Idris IM, Issom DZ, Jain D, Jordan LC, Kaplan ZS, King AA, Lloyd-Puryear M, Oppong SA, Sharma A, Sung L, Tshilolo L, Wilkie DJ, Ohene-Frempong K. Defining global strategies to improve outcomes in sickle cell disease: a Lancet Haematology Commission. Lancet Haematol 2023; 10:e633-e686. [PMID: 37451304 DOI: 10.1016/s2352-3026(23)00096-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 03/31/2023] [Accepted: 04/12/2023] [Indexed: 07/18/2023]
Affiliation(s)
- Frédéric B Piel
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, UK.
| | - David C Rees
- Department of Paediatric Haematology, King's College London, King's College Hospital, London, UK
| | - Michael R DeBaun
- Department of Pediatrics, Vanderbilt-Meharry Center of Excellence for Sickle Cell Disease, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Obiageli Nnodu
- Department of Haematology and Blood Transfusion, College of Health Sciences and Centre of Excellence for Sickle Cell Disease Research and Training, University of Abuja, Abuja, Nigeria
| | - Brigitte Ranque
- Department of Internal Medicine, Georges Pompidou European Hospital, Assistance Publique-Hopitaux de Paris Centre, University of Paris Cité, Paris, France
| | - Alexis A Thompson
- Division of Hematology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Russell E Ware
- Division of Hematology and Global Health Center, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Miguel R Abboud
- Department of Pediatrics and Adolescent Medicine, and Sickle Cell Program, American University of Beirut, Beirut, Lebanon
| | - Allistair Abraham
- Division of Blood and Marrow Transplantation, Children's National Hospital, Washington, DC, USA
| | - Emmanuela E Ambrose
- Department of Paediatrics and Child Health, Bugando Medical Centre, Mwanza, Tanzania
| | - Biree Andemariam
- New England Sickle Cell Institute, University of Connecticut Health, Connecticut, USA
| | - Roshan Colah
- Department of Haematogenetics, Indian Council of Medical Research National Institute of Immunohaematology, Mumbai, India
| | - Raffaella Colombatti
- Pediatric Oncology Hematology Unit, Department of Women's and Children's Health, University of Padua, Padua, Italy
| | - Nicola Conran
- Department of Clinical Medicine, School of Medical Sciences, Center of Hematology and Hemotherapy (Hemocentro), University of Campinas-UNICAMP, Campinas, Brazil
| | - Fernando F Costa
- Department of Clinical Medicine, School of Medical Sciences, Center of Hematology and Hemotherapy (Hemocentro), University of Campinas-UNICAMP, Campinas, Brazil
| | - Robert M Cronin
- Department of Internal Medicine, The Ohio State University, Columbus, OH, USA
| | - Mariane de Montalembert
- Department of Pediatrics, Necker-Enfants Malades Hospital, Assistance Publique-Hopitaux de Paris Centre, Paris, France
| | - Jacques Elion
- Paris Cité University and University of the Antilles, Inserm, BIGR, Paris, France
| | - Erica Esrick
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA, USA
| | - Anthea L Greenway
- Department Clinical Haematology, Royal Children's Hospital, Parkville and Department Haematology, Monash Health, Clayton, VIC, Australia
| | - Ibrahim M Idris
- Department of Hematology, Aminu Kano Teaching Hospital/Bayero University Kano, Kano, Nigeria
| | - David-Zacharie Issom
- Department of Business Information Systems, School of Management, HES-SO University of Applied Sciences and Arts of Western Switzerland, Geneva, Switzerland
| | - Dipty Jain
- Department of Paediatrics, Government Medical College, Nagpur, India
| | - Lori C Jordan
- Department of Pediatrics, Division of Pediatric Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Zane S Kaplan
- Department of Clinical Haematology, Monash Health and Monash University, Melbourne, VIC, Australia
| | - Allison A King
- Departments of Pediatrics and Internal Medicine, Divisions of Pediatric Hematology and Oncology and Hematology, Washington University School of Medicine, St Louis, MO, USA
| | - Michele Lloyd-Puryear
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Samuel A Oppong
- Department of Obstetrics and Gynecology, University of Ghana Medical School, Accra, Ghana
| | - Akshay Sharma
- Department of Bone Marrow Transplantation and Cellular Therapy, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Lillian Sung
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Leon Tshilolo
- Institute of Biomedical Research/CEFA Monkole Hospital Centre and Official University of Mbuji-Mayi, Mbuji-Mayi, Democratic Republic of the Congo
| | - Diana J Wilkie
- Department of Biobehavioral Nursing Science, College of Nursing, University of Florida, Gainesville, FL, USA
| | - Kwaku Ohene-Frempong
- Division of Hematology, Children's Hospital of Philadelphia, Pennsylvania, USA; Sickle Cell Foundation of Ghana, Kumasi, Ghana
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Ferraresi M, Panzieri DL, Leoni S, Cappellini MD, Kattamis A, Motta I. Therapeutic perspective for children and young adults living with thalassemia and sickle cell disease. Eur J Pediatr 2023:10.1007/s00431-023-04900-w. [PMID: 36997768 PMCID: PMC10257623 DOI: 10.1007/s00431-023-04900-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Revised: 02/17/2023] [Accepted: 02/23/2023] [Indexed: 04/01/2023]
Abstract
Hemoglobinopathies, including thalassemias and sickle cell disease, are the most common monogenic diseases worldwide, with estimated annual births of more than 330,000 affected infants. Hemoglobin disorders account for about 3.4% of deaths in children under 5 years of age. The distribution of these diseases is historically linked to current or previously malaria-endemic regions; however, immigration has led to a worldwide distribution of these diseases, making them a global health problem. During the last decade, new treatment approaches and novel therapies have been proposed, some of which have the potential to change the natural history of these disorders. Indeed, the first erythroid maturation agent, luspatercept, and gene therapy have been approved for beta-thalassemia adult patients. For sickle cell disease, molecules targeting vaso-occlusion and hemoglobin S polymerization include crizanlizumab, which has been approved for patients ≥ 16 years, voxelotor approved for patients ≥ 12 years, and L-glutamine for patients older than 5 years. Conclusion: We herein present the most recent advances and future perspectives in thalassemia and sickle cell disease treatment, including new drugs, gene therapy, and gene editing, and the current clinical trial status in the pediatric populations. What is Known: • Red blood cell transfusions, iron chelation therapy and hematopoietic stem cell transplantation have been the mainstay of treatment of thalassemia patients for decades. • For sickle cell disease, until 2005, treatment strategies were mostly the same as those for thalassemia, with the option of simple transfusion or exchange transfusion. In 2007, hydroxyurea was approved for patients ≥ 2 years old. What is New: • In 2019, gene therapy with betibeglogene autotemcel (LentiGlobin BB305) was approved for TDT patients ≥ 12 years old non β0/β0 without matched sibling donor. • Starting from 2017 several new drugs, such as L-glutamine (approved only by FDA), crizanlizumab (approved by FDA and EMA for patients ≥ 16 years), and lastly voxelotor (approved by FDA and EMA for patients ≥ 12 years old).
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Affiliation(s)
- Marta Ferraresi
- Unit of Medicine and Metabolic Disease, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, via F. Sforza, 35, 20122, Milan, Italy
- Università Degli Studi Di Milano, Milan, Italy
| | - Daniele Lello Panzieri
- Unit of Medicine and Metabolic Disease, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, via F. Sforza, 35, 20122, Milan, Italy
- Università Degli Studi Di Milano, Milan, Italy
| | - Simona Leoni
- Unit of Medicine and Metabolic Disease, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, via F. Sforza, 35, 20122, Milan, Italy
- Università Degli Studi Di Milano, Milan, Italy
| | - Maria Domenica Cappellini
- Unit of Medicine and Metabolic Disease, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, via F. Sforza, 35, 20122, Milan, Italy
- Department of Clinical Sciences and Community Health, Università Degli Studi Di Milano, Milan, Italy
| | - Antonis Kattamis
- Division of Pediatric Hematology-Oncology, First Department of Pediatrics, National and Kapodistrian University of Athens, Athens, Greece
| | - Irene Motta
- Unit of Medicine and Metabolic Disease, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, via F. Sforza, 35, 20122, Milan, Italy.
- Department of Clinical Sciences and Community Health, Università Degli Studi Di Milano, Milan, Italy.
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Tonin FS, Ginete C, Ferreira J, Delgadinho M, Santos B, Fernandez-Llimos F, Brito M. Efficacy and safety of pharmacological interventions for managing sickle cell disease complications in children and adolescents: Systematic review with network meta-analysis. Pediatr Blood Cancer 2023; 70:e30294. [PMID: 36916826 DOI: 10.1002/pbc.30294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 02/15/2023] [Accepted: 02/19/2023] [Indexed: 03/16/2023]
Abstract
This study aimed to synthesize the evidence on the effects of disease-modifying agents for managing sickle cell disease (SCD) in children and adolescents by means of a systematic review with network meta-analyses, surface under the cumulative ranking curve (SUCRA) and stochastic multicriteria acceptability analyses (SMAA) (CRD42022328471). Eightteen randomized controlled trials (hydroxyurea [n = 7], l-arginine [n = 3], antiplatelets [n = 2], immunotherapy/monoclonal antibodies [n = 2], sulfates [n = 2], docosahexaenoic acid [n = 1], niprisan [n = 1]) were analyzed. SUCRA and SMAA demonstrated that hydroxyurea at higher doses (30 mg/kg/day) or at fixed doses (20 mg/kg/day) and immunotherapy/monoclonal antibodies are more effective for preventing vaso-occlusive crisis (i.e., lower probabilities of incidence of this event; 14, 25, and 30%, respectively), acute chest syndrome (probabilities ranging from 8 to 30%), and needing of transfusions (11-31%), while l-arginine (100-200 mg/kg) and placebo were more prone to these events. Therapies were overall considered safe; however, antiplatelets and sulfates may lead to more severe adverse events. Although the evidence was graded as insufficient and weak, hydroxyurea remains the standard of care for this population, especially if a maximum tolerated dose schedule is considered.
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Affiliation(s)
- Fernanda S Tonin
- H&TRC - Health & Technology Research Center, ESTeSL - Escola Superior de Tecnologia da Saúde, Instituto Politécnico de Lisboa, Lisbon, Portugal
| | - Catarina Ginete
- H&TRC - Health & Technology Research Center, ESTeSL - Escola Superior de Tecnologia da Saúde, Instituto Politécnico de Lisboa, Lisbon, Portugal
| | - Joana Ferreira
- H&TRC - Health & Technology Research Center, ESTeSL - Escola Superior de Tecnologia da Saúde, Instituto Politécnico de Lisboa, Lisbon, Portugal
| | - Mariana Delgadinho
- H&TRC - Health & Technology Research Center, ESTeSL - Escola Superior de Tecnologia da Saúde, Instituto Politécnico de Lisboa, Lisbon, Portugal
| | - Brígida Santos
- Centro de Investigação em Saúde de Angola (CISA), Bengo, Angola.,Hospital Pediátrico David Bernardino (HPDB), Luanda, Angola
| | - Fernando Fernandez-Llimos
- CINTESIS@RISE, Laboratory of Pharmacology, Department of Drug Sciences, Faculty of Pharmacy, University of Porto, Porto, Portugal
| | - Miguel Brito
- H&TRC - Health & Technology Research Center, ESTeSL - Escola Superior de Tecnologia da Saúde, Instituto Politécnico de Lisboa, Lisbon, Portugal
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10
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Gibson JS, Rees DC. Emerging drug targets for sickle cell disease: shedding light on new knowledge and advances at the molecular level. Expert Opin Ther Targets 2023; 27:133-149. [PMID: 36803179 DOI: 10.1080/14728222.2023.2179484] [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: 02/22/2023]
Abstract
INTRODUCTION In sickle cell disease (SCD), a single amino acid substitution at β6 of the hemoglobin (Hb) chain replaces glutamate with valine, forming HbS instead of the normal adult HbA. Loss of a negative charge, and the conformational change in deoxygenated HbS molecules, enables formation of HbS polymers. These not only distort red cell morphology but also have other profound effects so that this simple etiology belies a complex pathogenesis with multiple complications. Although SCD represents a common severe inherited disorder with life-long consequences, approved treatments remain inadequate. Hydroxyurea is currently the most effective, with a handful of newer treatments, but there remains a real need for novel, efficacious therapies. AREAS COVERED This review summarizes important early events in pathogenesis to highlight key targets for novel treatments. EXPERT OPINION A thorough understanding of early events in pathogenesis closely associated with the presence of HbS is the logical starting point for identification of new targets rather than concentrating on more downstream effects. We discuss ways of reducing HbS levels, reducing the impact of HbS polymers, and of membrane events perturbing cell function, and suggest using the unique permeability of sickle cells to target drugs specifically into those more severely compromised.
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Affiliation(s)
- John S Gibson
- Department of Veterinary Medicine, University of Cambridge, Cambridge, UK
| | - David C Rees
- Department of Paediatric Haematology, King's College Hospital, London, UK
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11
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Chiang KC, Gupta A, Sundd P, Krishnamurti L. Thrombo-Inflammation in COVID-19 and Sickle Cell Disease: Two Faces of the Same Coin. Biomedicines 2023; 11:338. [PMID: 36830874 PMCID: PMC9953430 DOI: 10.3390/biomedicines11020338] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Revised: 01/12/2023] [Accepted: 01/15/2023] [Indexed: 01/26/2023] Open
Abstract
People with sickle cell disease (SCD) are at greater risk of severe illness and death from respiratory infections, including COVID-19, than people without SCD (Centers for Disease Control and Prevention, USA). Vaso-occlusive crises (VOC) in SCD and severe SARS-CoV-2 infection are both characterized by thrombo-inflammation mediated by endothelial injury, complement activation, inflammatory lipid storm, platelet activation, platelet-leukocyte adhesion, and activation of the coagulation cascade. Notably, lipid mediators, including thromboxane A2, significantly increase in severe COVID-19 and SCD. In addition, the release of thromboxane A2 from endothelial cells and macrophages stimulates platelets to release microvesicles, which are harbingers of multicellular adhesion and thrombo-inflammation. Currently, there are limited therapeutic strategies targeting platelet-neutrophil activation and thrombo-inflammation in either SCD or COVID-19 during acute crisis. However, due to many similarities between the pathobiology of thrombo-inflammation in SCD and COVID-19, therapies targeting one disease may likely be effective in the other. Therefore, the preclinical and clinical research spurred by the COVID-19 pandemic, including clinical trials of anti-thrombotic agents, are potentially applicable to VOC. Here, we first outline the parallels between SCD and COVID-19; second, review the role of lipid mediators in the pathogenesis of these diseases; and lastly, examine the therapeutic targets and potential treatments for the two diseases.
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Affiliation(s)
| | - Ajay Gupta
- KARE Biosciences, Orange, CA 89128, USA
- Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, University of California Irvine (UCI) School of Medicine, Irvine, CA 92868, USA
| | - Prithu Sundd
- Vascular Medicine Institute and Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 15261, USA
| | - Lakshmanan Krishnamurti
- Division of Pediatric Hematology-Oncology, Yale School of Medicine, New Haven, CT 06510, USA
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Rai P, Desai PC, Ataga KI. The Evolving Landscape of Drug Therapies for Sickle Cell Disease. Hematol Oncol Clin North Am 2022; 36:1285-1312. [DOI: 10.1016/j.hoc.2022.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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13
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Ticagrelor vs placebo for the reduction of vaso-occlusive crises in pediatric sickle cell disease: the HESTIA3 study. Blood 2022; 140:1470-1481. [PMID: 35849650 PMCID: PMC9523370 DOI: 10.1182/blood.2021014095] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 05/24/2022] [Indexed: 11/28/2022] Open
Abstract
The phase 3 HESTIA3 study assessed the efficacy and safety of the reversible P2Y12 inhibitor ticagrelor vs placebo in preventing vaso-occlusive crises in pediatric patients with sickle cell disease (SCD). Patients aged 2 to 17 years were randomly assigned 1:1 to receive weight-based doses of ticagrelor or matching placebo. The primary end point was the rate of vaso-occlusive crises, a composite of painful crises and/or acute chest syndrome (ACS). Key secondary end points included number and duration of painful crises, number of ACS events, and number of vaso-occlusive crises requiring hospitalization or emergency department visits. Exploratory end points included the effect of ticagrelor on platelet activation. In total, 193 patients (ticagrelor, n = 101; placebo, n = 92) underwent randomization at 53 sites across 16 countries. The study was terminated 4 months before planned completion for lack of efficacy. Median ticagrelor exposure duration was 296.5 days. The primary end point was not met: estimated yearly incidence of vaso-occlusive crises was 2.74 in the ticagrelor group and 2.60 in the placebo group (rate ratio, 1.06; 95% confidence interval, 0.75-1.50; P = .7597). There was no evidence of efficacy for ticagrelor vs placebo across secondary end points. Median platelet inhibition with ticagrelor at 6 months was 34.9% predose and 55.7% at 2 hours' postdose. Nine patients (9%) in the ticagrelor group and eight patients (9%) in the placebo group had at least one bleeding event. In conclusion, no reduction of vaso-occlusive crises was seen with ticagrelor vs placebo in these pediatric patients with SCD. This trial was registered at www.clinicaltrials.gov as #NCT03615924.
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Ross JM, Forté S, Soulières D. Emerging drugs for the treatment of sickle cell disease: a review of phase II/III trials. Expert Opin Emerg Drugs 2022; 27:211-224. [PMID: 35912835 DOI: 10.1080/14728214.2022.2105835] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION The substitution of glutamic acid by valine on the ß-globin gene produces the hemoglobin S variant responsible for sickle cell disease (SCD), a disorder that affects millions of people worldwide and leads to acute and cumulative organ damage. Even though life expectancy has significantly improved where the best medical care is available, there are still few therapeutic options for SCD and those are limited by their availability, cost, and individual toxicities. AREAS COVERED This review summarizes the clinical data on current treatments for SCD and emerging therapies studied in the acute setting as well as potential disease-modifying agents, with an emphasis on the FDA-approved agents. EXPERT OPINION Hydroxyurea has been a gold standard for two decades, showing benefits in acute complications and overall survival in sickle cell anemia, although data is lacking for certain genotypes such as hemoglobin SC. As progress is made in our understanding of the pathophysiological networks characterizing SCD, numerous pathways appear to be targetable, with L-glutamine, Crizanlizumab and Voxelotor now approved by the FDA. Pursuing a multi-agent approach could alter the disease course in a more effective fashion and provide an alternative option to curative therapies, but longer clinical studies are needed.
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Affiliation(s)
- Jules M Ross
- Centre Universitaire de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Stéphanie Forté
- Centre Universitaire de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Denis Soulières
- Centre Universitaire de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
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15
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Zanfardino S, Mazziotto V, Bodas P. Black Americans' willingness to participate in pediatric sickle cell clinical trials: A retrospective, systematic review. Pediatr Blood Cancer 2022; 69:e29580. [PMID: 35188337 DOI: 10.1002/pbc.29580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 12/19/2021] [Accepted: 12/31/2021] [Indexed: 11/07/2022]
Abstract
Black individuals are underrepresented in randomized clinical trials (RCTs). Willingness to participate is a frequently cited explanation. However, the few studies that have investigated willingness to participate demonstrated no difference between Black individuals and other groups. We sought to measure willingness to participate by focusing on sickle cell disease (SCD), in which approximately 90% of affected individuals are Black. We conducted an analysis of 17 RCTs. A level of clarity was defined and correlated with each article's transparency in reporting patient enrollment data. Calculated measures of acceptance ranged from 32% to 93.5%. Calculated completion rates ranged from 58.8% to 100%. Weighted measures of acceptance and completion were 59.1% and 83.8%, respectively. Our study is limited by focusing solely on studies pertinent to SCD and only a minority of publications reviewed provided sufficient patient enrollment data. Yet, our results suggest that decreased willingness to participate does not account for underrepresentation of Black individuals.
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Affiliation(s)
- Sara Zanfardino
- Department of Hematology and Oncology at Akron Children's Hospital, Akron, Ohio, USA
| | - Volha Mazziotto
- Department of Hematology and Oncology at Akron Children's Hospital, Akron, Ohio, USA
| | - Prasad Bodas
- Department of Hematology and Oncology at Akron Children's Hospital, Akron, Ohio, USA
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16
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Extinguishing the fire in sickle cell anemia. Blood 2022; 139:2578-2580. [PMID: 35482344 DOI: 10.1182/blood.2022015910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 02/21/2022] [Indexed: 11/20/2022] Open
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17
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Strunk C, Tartaglione I, Piccone CM, Colombatti R, Andemariam B, Manwani D, Smith A, Haile H, Kim E, Wilson S, Asare EV, Rivers A, Farooq F, Urbonya R, Boruchov D, Boatemaa GD, Perrotta S, Ekem I, Sainati L, Rao S, Zempsky W, Sey F, Antwi-Boasiako C, Segbefia C, Inusa B, Campbell AD. Global geographic differences in healthcare utilization for sickle cell disease pain crises in the CASiRe cohort. Blood Cells Mol Dis 2021; 92:102612. [PMID: 34564050 DOI: 10.1016/j.bcmd.2021.102612] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 09/13/2021] [Accepted: 09/15/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Sickle cell disease (SCD) is characterized by frequent, unpredictable pain episodes and other vaso-occlusive crises (VOCs) leading to significant healthcare utilization. VOC frequency is often an endpoint in clinical trials investigating novel therapies for this devastating disease. PROCEDURE The Consortium for the Advancement of Sickle Cell Research (CASiRe) is an international collaboration investigating clinical severity in SCD using a validated questionnaire and medical chart review standardized across four countries (United States, United Kingdom, Italy and Ghana). RESULTS This study, focused on pain crisis incidence and healthcare utilization, included 868 patients, equally represented according to age and gender. HgbSS was the most common genotype. Patients from Ghana used the Emergency Room/Day Hospital for pain more frequently (annualized mean 2.01) than patients from other regions (annualized mean 1.56 U.S.; 1.09 U.K.; 0.02 Italy), while U.K. patients were hospitalized for pain more often (annualized mean: U.K. 2.98) than patients in other regions (annualized mean 1.98 U.S.; 1.18 Ghana; Italy 0.54). Italy's hospitalization rate for pain (annualized mean: 0.57) was nearly 20 times greater than its emergency room/day hospital only visits for pain (annualized mean: 0.03). When categorized by genotype and age, similar results were seen. CONCLUSIONS Geographic differences in pain crisis frequency and healthcare utilization may correlate with variable organization of healthcare systems among countries and should be considered regarding trial design, endpoints, and analysis of results when investigating novel agents for clinical benefit.
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Affiliation(s)
- Crawford Strunk
- Department of Pediatric Hematology/Oncology, ProMedica Russell J. Ebeid Children's Hospital, Toledo, OH, USA.
| | - Immacolata Tartaglione
- Department of Women, Child and General and Specialized Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Connie M Piccone
- Pediatric Hematology, Carle Foundation Hospital, Urbana, IL, USA
| | - Raffaella Colombatti
- Clinic of Pediatric Hematology Oncology, Department of Women's and Child Health, Azienda Ospedaliera-Università di Padova, Padova, Italy
| | - Biree Andemariam
- New England Sickle Cell Institute, Division of Hematology-Oncology, Neag Comprehensive Cancer Center, UCONN Health, University of Connecticut, Farmington, CT, USA
| | - Deepa Manwani
- Department of Pediatrics, Albert Einstein College of Medicine, Children's Hospital at Montefiore, Bronx, NY, USA
| | - Ashya Smith
- Division of Pediatric Hematology/Oncology, University of Michigan, Ann Arbor, MI, USA
| | - Haikel Haile
- Division of Pediatric Hematology/Oncology, University of Michigan, Ann Arbor, MI, USA
| | - Esther Kim
- Division of Pediatric Hematology/Oncology, University of Michigan, Ann Arbor, MI, USA
| | - Samuel Wilson
- Division of Pediatric Hematology/Oncology, University of Michigan, Ann Arbor, MI, USA
| | - Eugenia Vicky Asare
- Ghana Institute of Clinical Genetics, Korle Bu Teaching Hospital, Accra, Ghana
| | - Angela Rivers
- UCSF Benioff Children's Hospital Oakland, Oakland, CA, USA
| | - Fatimah Farooq
- Division of Pediatric Hematology/Oncology, University of Michigan, Ann Arbor, MI, USA
| | - Rebekah Urbonya
- Division of Pediatric Hematology/Oncology, University of Michigan, Ann Arbor, MI, USA
| | - Donna Boruchov
- Department of Child Health, Korle Bu Teaching Hospital, Accra, Ghana
| | - Gifty Dankwah Boatemaa
- Department of Physiology, University of Ghana Medical School, University of Ghana, Accra, Ghana
| | - Silverio Perrotta
- Department of Women, Child and General and Specialized Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Ivy Ekem
- Ghana Institute of Clinical Genetics, Korle Bu Teaching Hospital, Accra, Ghana
| | - Laura Sainati
- Clinic of Pediatric Hematology Oncology, Department of Women's and Child Health, Azienda Ospedaliera-Università di Padova, Padova, Italy
| | - Sudha Rao
- Department of Child Health, Korle Bu Teaching Hospital, Accra, Ghana
| | - William Zempsky
- Division of Pain and Palliative Care, Department of Pediatrics, University of Connecticut School of Medicine, Connecticut Children's Medical Center, Hartford, CT, USA
| | - Fredericka Sey
- Ghana Institute of Clinical Genetics, Korle Bu Teaching Hospital, Accra, Ghana
| | - Charles Antwi-Boasiako
- Department of Physiology, University of Ghana Medical School, University of Ghana, Accra, Ghana; Ghana Institute of Clinical Genetics, Korle Bu Teaching Hospital, Accra, Ghana
| | - Catherine Segbefia
- Department of Child Health, Korle Bu Teaching Hospital, Accra, Ghana; Department of Child Health, University of Ghana Medical School, University of Ghana, Accra, Ghana
| | - Baba Inusa
- Department of Pediatric Haematology, Evelina Children's Hospital, Guy's and St. Thomas NHS Trust, London, UK
| | - Andrew D Campbell
- Division of Pediatric Hematology/Oncology, University of Michigan, Ann Arbor, MI, USA; Department of Pediatrics, Divison of Hematology, Children's National Hospital, George Washington University School of Medicine Health Sciences, Washington, DC, USA
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18
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A polygenic score for acute vaso-occlusive pain in pediatric sickle cell disease. Blood Adv 2021; 5:2839-2851. [PMID: 34283174 DOI: 10.1182/bloodadvances.2021004634] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 04/05/2021] [Indexed: 12/12/2022] Open
Abstract
Individuals with monogenic disorders can experience variable phenotypes that are influenced by genetic variation. To investigate this in sickle cell disease (SCD), we performed whole-genome sequencing (WGS) of 722 individuals with hemoglobin HbSS or HbSβ0-thalassemia from Baylor College of Medicine and from the St. Jude Children's Research Hospital Sickle Cell Clinical Research and Intervention Program (SCCRIP) longitudinal cohort study. We developed pipelines to identify genetic variants that modulate sickle hemoglobin polymerization in red blood cells and combined these with pain-associated variants to build a polygenic score (PGS) for acute vaso-occlusive pain (VOP). Overall, we interrogated the α-thalassemia deletion -α3.7 and 133 candidate single-nucleotide polymorphisms (SNPs) across 66 genes for associations with VOP in 327 SCCRIP participants followed longitudinally over 6 years. Twenty-one SNPs in 9 loci were associated with VOP, including 3 (BCL11A, MYB, and the β-like globin gene cluster) that regulate erythrocyte fetal hemoglobin (HbF) levels and 6 (COMT, TBC1D1, KCNJ6, FAAH, NR3C1, and IL1A) that were associated previously with various pain syndromes. An unweighted PGS integrating all 21 SNPs was associated with the VOP event rate (estimate, 0.35; standard error, 0.04; P = 5.9 × 10-14) and VOP event occurrence (estimate, 0.42; standard error, 0.06; P = 4.1 × 10-13). These associations were stronger than those of any single locus. Our findings provide insights into the genetic modulation of VOP in children with SCD. More generally, we demonstrate the utility of WGS for investigating genetic contributions to the variable expression of SCD-associated morbidities.
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19
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Inati A, Al Alam C, El Ojaimi C, Hamad T, Kanakamedala H, Pilipovic V, Sabah R. Clinical Features and Outcome of Sickle Cell Disease in a Tertiary Center in Northern Lebanon: A Retrospective Cohort Study in a Local, Hospital-Associated Registry. Hemoglobin 2021; 45:80-86. [PMID: 33980108 DOI: 10.1080/03630269.2021.1904974] [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: 10/21/2022]
Abstract
Sickle cell disease affects more than 30 million people worldwide, including 0.1% of the population in Lebanon. It is characterized by unpredictable and painful vaso-occlusive crises (VOCs) that may lead to serious complications. This study describes the clinical burden of sickle cell disease in a cohort of patients treated at a comprehensive sickle cell disease referral center in Tripoli, Northern Lebanon. Patient demographics, clinical events, treatment, and survival were evaluated from a local, hospital-based registry of 334 sickle cell disease patients treated at the Nini Hospital, Tripoli, Lebanon, between 2009 and 2019. Mean age at sickle cell disease diagnosis and at first clinic visit was 2.9 and 8.5 years, respectively. Pain was the most common clinical event observed among all patients. Over the 10-year follow-up period, 15 (4.5%) patients died. Hydroxyurea (HU) and red blood cell (RBC) transfusions were the most commonly used therapies. One hundred and thirty-one (39.0%) patients were diagnosed with sickle cell disease at the Nini Hospital; the remaining patients were referred to and subsequently followed-up at the Nini Hospital. Eighty-seven (66.0%) Nini Hospital-diagnosed patients experienced a VOC. Seventy-four (85.0%) of these patients with a VOC event required HU during follow-up. Patients with a VOC required more RBC transfusions, cholecystectomy, and splenectomy than non-VOC patients. The high disease burden observed in this population of sickle cell disease patients illustrates a continued, unmet need to both prevent and manage VOC events and other sickle cell disease-associated complications.
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Affiliation(s)
- Adlette Inati
- School of Medicine, Lebanese American University, Byblos, Lebanon.,Department of Pediatrics, Nini Hospital, Tripoli, Lebanon
| | - Chadi Al Alam
- Department of Pediatrics, Nini Hospital, Tripoli, Lebanon
| | | | - Taghrid Hamad
- Department of Pediatrics, Nini Hospital, Tripoli, Lebanon
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20
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Duniva Inusa BP, Inati A, Maes P, Githanga J, Ogutu B, Abboud MR, Miano M, Cela E, Nduba V, Niazi M, Åstrand M, Persson K, Berggren A, Carlson G. Pharmacokinetics and safety of ticagrelor in infants and toddlers with sickle cell disease aged <24 months. Pediatr Blood Cancer 2021; 68:e28977. [PMID: 33629819 DOI: 10.1002/pbc.28977] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 01/14/2021] [Accepted: 01/30/2021] [Indexed: 11/07/2022]
Abstract
Inhibition of platelet activation may reduce vaso-occlusion rates in patients with sickle cell disease (SCD). In the HESTIA4 (NCT03492931) study, 21 children with SCD received a single oral dose of the antiplatelet agent ticagrelor (0.1 mg/kg <6 months; 0.2 mg/kg ≥6 to <24 months). All patients had measurable ticagrelor plasma concentrations. Ticagrelor and active metabolite (AR-C124910XX) exposure were comparable across all groups (<6 months, ≥6 to <12 months and ≥12 to <24 months). Ticagrelor was well tolerated. Palatability was generally acceptable. These data will be used to enable dose selection for further investigations of ticagrelor efficacy and safety in children with SCD.
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Affiliation(s)
| | - Adlette Inati
- Lebanese American University Byblos, and Rafic Hariri University Hospital, Beirut, Lebanon
| | | | - Jessie Githanga
- University of Nairobi/Gertrude's Children's Hospital, Nairobi, Kenya
| | | | - Miguel R Abboud
- American University of Beirut Medical Center, Beirut, Lebanon
| | - Maurizio Miano
- Haematology Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Elena Cela
- Hospital General Universitario Gregorio Marañon, Madrid, Spain
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21
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Morikis VA, Hernandez AA, Magnani JL, Sperandio M, Simon SI. Targeting Neutrophil Adhesive Events to Address Vaso-Occlusive Crisis in Sickle Cell Patients. Front Immunol 2021; 12:663886. [PMID: 33995392 PMCID: PMC8113856 DOI: 10.3389/fimmu.2021.663886] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 03/29/2021] [Indexed: 11/13/2022] Open
Abstract
Neutrophils are essential to protect the host against invading pathogens but can promote disease progression in sickle cell disease (SCD) by becoming adherent to inflamed microvascular networks in peripheral tissue throughout the body. During the inflammatory response, leukocytes extravasate from the bloodstream using selectin adhesion molecules and migrate to sites of tissue insult through activation of integrins that are essential for combating pathogens. However, during vaso-occlusion associated with SCD, neutrophils are activated during tethering and rolling on selectins upregulated on activated endothelium that line blood vessels. Recently, we reported that recognition of sLex on L-selectin by E-selectin during neutrophil rolling initiates shear force resistant catch-bonds that facilitate tethering to endothelium and activation of integrin bond clusters that anchor cells to the vessel wall. Evidence indicates that blocking this important signaling cascade prevents the congestion and ischemia in microvasculature that occurs from neutrophil capture of sickled red blood cells, which are normally deformable ellipses that flow easily through small blood vessels. Two recently completed clinical trials of therapies targeting selectins and their effect on neutrophil activation in small blood vessels reveal the importance of mechanoregulation that in health is an immune adaption facilitating rapid and proportional leukocyte adhesion, while sustaining tissue perfusion. We provide a timely perspective on the mechanism underlying vaso-occlusive crisis (VOC) with a focus on new drugs that target selectin mediated integrin adhesive bond formation.
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Affiliation(s)
- Vasilios A. Morikis
- Department of Biomedical Engineering, University of California-Davis, Davis, CA, United States
| | - Alfredo A. Hernandez
- Department of Biomedical Engineering, University of California-Davis, Davis, CA, United States
| | | | - Markus Sperandio
- Institute for Cardiovascular Physiology and Pathophysiology, Walter Brendel Center for Experimental Medicine Biomedical Center, Ludwig Maximilians University, Walter Brendel Center, Munich, Germany
| | - Scott I. Simon
- Department of Biomedical Engineering, University of California-Davis, Davis, CA, United States
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22
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Evaluation of Longitudinal Pain Study in Sickle Cell Disease (ELIPSIS) by patient-reported outcomes, actigraphy, and biomarkers. Blood 2021; 137:2010-2020. [PMID: 33067606 DOI: 10.1182/blood.2020006020] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 10/04/2020] [Indexed: 12/14/2022] Open
Abstract
Clinical trials in sickle cell disease (SCD) often focus on health care utilization for painful vaso-occlusive crises (VOCs). However, no objective, quantifiable pain biomarkers exist, pain is not specific to VOCs, health care utilization varies between patients, unreported at-home VOCs likely contribute to long-term outcomes, and patient-reported outcomes are seldom considered. This noninterventional, longitudinal, 6-month study aimed to develop tools to identify VOCs in SCD patients with or without health care utilization. Participants wore an actigraph device, tracking sleep and activity. Patients with SCD used an electronic patient-reported outcome (ePRO) tool to collect data on pain, medication, fatigue, and daily function. Patients self-reported when they experienced VOC pain (VOC day). Biomarkers were collected every 3 weeks (non-VOC). Self-reported VOCs triggered at-home or in-hospital blood collection. The study enrolled 37 participants with SCD; 35 completed the study. Participants reported 114 VOC events and 346 VOC days, of which 62.3% and 78.3%, respectively, were self-treated at home. The ePRO and actigraphy captured end points of pain, functionality, fatigue, activity, and sleep; each was significantly altered on VOC days compared with non-VOC days. Biomarkers collected at home or in the hospital on VOC days were significantly altered compared with non-VOC baseline values, including leukocyte-platelet aggregates, microfluidic-based blood cell adhesion, interleukin-6, C-reactive protein, interleukin-10, tumor necrosis factor-α, and thrombin-antithrombin. The Evaluation of Longitudinal Pain Study in Sickle Cell Disease (ELIPSIS) trial shows the feasibility of accurately monitoring out-of-hospital pain by using patient-reported VOC days as potential end points for clinical trials in SCD; it describes the changes in biomarkers and activity measured by actigraphy that may enable improved identification and assessment of VOCs.
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23
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Conran N, Embury SH. Sickle cell vaso-occlusion: The dialectic between red cells and white cells. Exp Biol Med (Maywood) 2021; 246:1458-1472. [PMID: 33794696 DOI: 10.1177/15353702211005392] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
The pathophysiology of sickle cell anemia, a hereditary hemoglobinopathy, has fascinated clinicians and scientists alike since its description over 100 years ago. A single gene mutation in the HBB gene results in the production of abnormal hemoglobin (Hb) S, whose polymerization when deoxygenated alters the physiochemical properties of red blood cells, in turn triggering pan-cellular activation and pathological mechanisms that include hemolysis, vaso-occlusion, and ischemia-reperfusion to result in the varied and severe complications of the disease. Now widely regarded as an inflammatory disease, in recent years attention has included the role of leukocytes in vaso-occlusive processes in view of the part that these cells play in innate immune processes, their inherent ability to adhere to the endothelium when activated, and their sheer physical and potentially obstructive size. Here, we consider the role of sickle red blood cell populations in elucidating the importance of adhesion vis-a-vis polymerization in vaso-occlusion, review the direct adhesion of sickle red cells to the endothelium in vaso-occlusive processes, and discuss how red cell- and leukocyte-centered mechanisms are not mutually exclusive. Given the initial clinical success of crizanlizumab, a specific anti-P selectin therapy, we suggest that it is appropriate to take a holistic approach to understanding and exploring the complexity of vaso-occlusive mechanisms and the adhesive roles of the varied cell types, including endothelial cells, platelets, leukocytes, and red blood cells.
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Affiliation(s)
- Nicola Conran
- Hematology Center, University of Campinas-UNICAMP, Barão Geraldo 13083-8, Campinas, SP, Brazil
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24
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Abstract
Introduction: The clinical manifestations of sickle cell disease (SCD) result from an inherited mutation in the beta-globin chain of hemoglobin (Hb) that causes Hb tetramers to polymerize when deoxygenated. The resulting erythrocyte deformation causes mechanical obstruction of blood flow by sickled cells, hemolysis, anemia and end-organ injury. While pain is the hallmark symptom of SCD, chronic organ injury as a result of anemia, inflammation and progressive vasculopathy play a major role in morbidity and mortality. Due to the complex pathophysiology of SCD, the need for an individualized, multi-modal pharmacologic approach is apparent. Until 2018, hydroxyurea was the only disease-modifying pharmacologic therapy approved for use in SCD. Since then, three new agents have been approved including voxelotor, the subject of this review.Areas covered: Published pre-clinical and clinical data are reviewed. Voxelotor is a first-in-class small-molecule agent that binds to Hb and increases oxygen affinity, preventing polymerization. Recent clinical trials have shown that it increases Hb concentration and reduces hemolysis in patients with SCD. This increase in Hb concentration may significantly impact morbidity and mortality from chronic organ injury.Expert opinion: The mechanism of action, published studies and current opinions on the clinical use of voxelotor in SCD are presented.
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Affiliation(s)
- Madhav Vissa
- Department of Pediatric Hematology/Oncology, UCSF Benioff Children's Hospital Oakland, Oakland, CA, USA
| | - Elliott Vichinsky
- Department of Pediatric Hematology/Oncology, UCSF Benioff Children's Hospital Oakland, Oakland, CA, USA
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25
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穆 志, 焦 富, 谢 凯. [Interpretation of the JCS/JSCS 2020 guideline on diagnosis and management of cardiovascular sequelae in Kawasaki disease]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2021; 23:213-220. [PMID: 33691912 PMCID: PMC7969191 DOI: 10.7499/j.issn.1008-8830.2010134] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 01/15/2021] [Indexed: 06/12/2023]
Abstract
Kawasaki disease is the main cause of acquired heart disease in children. The cardiovascular sequelae of Kawasaki disease, such as coronary artery lesion and giant coronary aneurysm, have a great impact on children's physical and mental health. The Japanese Circulatory Society and the Japanese Society of Cardiac Surgery jointly released the JCS/JSCS 2020 guideline on diagnosis and management of cardiovascular sequelae in Kawasaki disease in July, 2020, which systematically introduces the advances in the diagnosis and management of cardiovascular sequelae of Kawasaki disease. The article gives an interpretation in the severity evaluation of Kawasaki disease and diagnosis, treatment and long-term management of cardiovascular sequelae in the guideline.
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Affiliation(s)
- 志龙 穆
- 陕西省人民医院儿童病院/陕西省川崎病诊疗中心, 陕西西安 710068Children's Hospital of Shaanxi Provincial People's Hospital/Diagnosis and Treatment Center of Kawasaki Disease of Shaanxi Province, Xi'an 710068, China
| | - 富勇 焦
- 陕西省人民医院儿童病院/陕西省川崎病诊疗中心, 陕西西安 710068Children's Hospital of Shaanxi Provincial People's Hospital/Diagnosis and Treatment Center of Kawasaki Disease of Shaanxi Province, Xi'an 710068, China
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26
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Gyamfi J, Ojo T, Epou S, Diawara A, Dike L, Adenikinju D, Enechukwu S, Vieira D, Nnodu O, Ogedegbe G, Peprah E. Evidence-based interventions implemented in low-and middle-income countries for sickle cell disease management: A systematic review of randomized controlled trials. PLoS One 2021; 16:e0246700. [PMID: 33596221 PMCID: PMC7888630 DOI: 10.1371/journal.pone.0246700] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 01/22/2021] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Despite ~90% of sickle cell disease (SCD) occurring in low-and middle-income countries (LMICs), the vast majority of people are not receiving evidence-based interventions (EBIs) to reduce SCD-related adverse outcomes and mortality, and data on implementation research outcomes (IROs) and SCD is limited. This study aims to synthesize available data on EBIs for SCD and assess IROs. METHODS We conducted a systematic review of RCTs reporting on EBIs for SCD management implemented in LMICs. We identified articles from PubMed/Medline, Global Health, PubMed Central, Embase, Web of Science medical subject heading (MeSH and Emtree) and keywords, published from inception through February 23, 2020, and conducted an updated search through December 24, 2020. We provide intervention characteristics for each study, EBI impact on SCD, and evidence of reporting on IROs. MAIN RESULTS 29 RCTs were analyzed. EBIs identified included disease modifying agents, supportive care agents/analgesics, anti-malarials, systemic treatments, patient/ provider education, and nutritional supplements. Studies using disease modifying agents, nutritional supplements, and anti-malarials reported improvements in pain crisis, hospitalization, children's growth and reduction in severity and prevalence of malaria. Two studies reported on the sustainability of supplementary arginine, citrulline, and daily chloroquine and hydroxyurea for SCD patients. Only 13 studies (44.8%) provided descriptions that captured at least three of the eight IROs. There was limited reporting of acceptability, feasibility, fidelity, cost and sustainability. CONCLUSION EBIs are effective for SCD management in LMICs; however, measurement of IROs is scarce. Future research should focus on penetration of EBIs to inform evidence-based practice and sustainability in the context of LMICs. CLINICAL TRIAL REGISTRATION This review is registered in PROSPERO #CRD42020167289.
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Affiliation(s)
- Joyce Gyamfi
- Global Health Program, New York University School of Global Public Health, New York, New York, United States of America
| | - Temitope Ojo
- Department of Social and Behavioral Sciences, New York University School of Global Public Health, New York, New York, United States of America
| | - Sabrina Epou
- Global Health Program, New York University School of Global Public Health, New York, New York, United States of America
| | - Amy Diawara
- Global Health Program, New York University School of Global Public Health, New York, New York, United States of America
| | - Lotanna Dike
- Global Health Program, New York University School of Global Public Health, New York, New York, United States of America
| | - Deborah Adenikinju
- Global Health Program, New York University School of Global Public Health, New York, New York, United States of America
| | - Scholastica Enechukwu
- Global Health Program, New York University School of Global Public Health, New York, New York, United States of America
| | - Dorice Vieira
- New York University Health Sciences Library, New York, New York, United States of America
| | - Obiageli Nnodu
- Centre of Excellence for Sickle Cell Disease Research & Training (CESRTA), University of Abuja, Abuja, Nigeria
| | - Gbenga Ogedegbe
- Department of Population Health, New York University Medical Center, New York, New York, United States of America
| | - Emmanuel Peprah
- Global Health Program, New York University School of Global Public Health, New York, New York, United States of America
- Department of Social and Behavioral Sciences, New York University School of Global Public Health, New York, New York, United States of America
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27
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Campbell AD, Colombatti R, Andemariam B, Strunk C, Tartaglione I, Piccone CM, Manwani D, Asare EV, Boruchov D, Farooq F, Urbonya R, Boatemaa GD, Perrotta S, Sainati L, Rivers A, Rao S, Zempsky W, Sey F, Segbefia C, Inusa B, Antwi-Boasiako C. An Analysis of Racial and Ethnic Backgrounds Within the CASiRe International Cohort of Sickle Cell Disease Patients: Implications for Disease Phenotype and Clinical Research. J Racial Ethn Health Disparities 2021; 8:99-106. [PMID: 32418182 PMCID: PMC7669607 DOI: 10.1007/s40615-020-00762-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Revised: 04/06/2020] [Accepted: 04/13/2020] [Indexed: 12/13/2022]
Abstract
Millions are affected by sickle cell disease (SCD) worldwide with the greatest burden in sub-Saharan Africa. While its origin lies historically within the malaria belt, ongoing changes in migration patterns have shifted the burden of disease resulting in a global public health concern. We created the Consortium for the Advancement of Sickle Cell Research (CASiRe) to understand the different phenotypes of SCD across 4 countries (USA, UK, Italy, and Ghana). Here, we report the multi-generational ethnic and racial background of 877 SCD patients recruited in Ghana (n = 365, 41.6%), the USA (n = 254, 29%), Italy (n = 81, 9.2%), and the UK (n = 177, 20.2%). West Africa (including Benin Gulf) (N = 556, 63.4%) was the most common geographic region of origin, followed by North America (N = 184, 21%), Caribbean (N = 51, 5.8%), Europe (N = 27, 3.1%), Central Africa (N = 24, 2.7%), and West Africa (excluding Benin Gulf) (N = 21, 2.4%). SCD patients in Europe were primarily West African (73%), European (10%), Caribbean (8%), and Central African (8%). In the USA, patients were largely African American (71%), Caribbean (13%), or West African (10%). Most subjects identified themselves as Black or African American; the European cohort had the largest group of Caucasian SCD patients (8%), including 21% of the Italian patients. This is the first report of a comprehensive analysis of ethnicity within an international, transcontinental group of SCD patients. The diverse ethnic backgrounds observed in our cohort raises the possibility that genetic and environmental heterogeneity within each SCD population subgroup can affect the clinical phenotype and research outcomes.
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Affiliation(s)
- Andrew D Campbell
- Division of Pediatric Hematology/Oncology, University of Michigan, Ann Arbor, MI, USA.
- Center for Cancer and Blood Disorders, Children's National Medical Center, Washington, DC, USA.
| | - Raffaella Colombatti
- Clinic of Pediatric Hematology Oncology, Department of Women's and Child Health, Azienda Ospedaliera-Università di Padova, Padova, Italy
| | - Biree Andemariam
- Division of Hematology-Oncology, New England Sickle Cell Institute, Neag Comprehensive Cancer Center, UCONN Health, University of Connecticut, Farmington, CT, USA
| | - Crawford Strunk
- ProMedica Russell J. Ebeid Children's Hospital, Toledo, OH, USA
| | - Immacolata Tartaglione
- Department of Women, Child and General and Specialized Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Connie M Piccone
- Pediatric Hematology/Oncology, Rainbow Babies and Children's Hospital, Cleveland, OH, USA
| | - Deepa Manwani
- Department of Pediatrics, Albert Einstein College of Medicine, Children's Hospital at Montefiore, Bronx, NY, USA
| | - Eugenia Vicky Asare
- Ghana Institute of Clinical Genetics, Korle Bu Teaching Hospital, Accra, Ghana
- Department of Hematology, Korle-Bu Teaching Hospital, Accra, Ghana
| | - Donna Boruchov
- Department of Pediatrics, Connecticut Children's Medical Center, Hartford, CT, USA
| | - Fatimah Farooq
- Division of Pediatric Hematology/Oncology, University of Michigan, Ann Arbor, MI, USA
| | - Rebekah Urbonya
- Division of Pediatric Hematology/Oncology, University of Michigan, Ann Arbor, MI, USA
| | | | - Silverio Perrotta
- Department of Women, Child and General and Specialized Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Laura Sainati
- Clinic of Pediatric Hematology Oncology, Department of Women's and Child Health, Azienda Ospedaliera-Università di Padova, Padova, Italy
| | - Angela Rivers
- Division of Pediatric Hematology/Oncology, University of Illinois-Chicago, Chicago, IL, USA
| | - Sudha Rao
- Department of Child Health, Korle Bu Teaching Hospital, Accra, Ghana
| | - William Zempsky
- Department of Pediatrics, Connecticut Children's Medical Center, Hartford, CT, USA
| | - Fredericka Sey
- Ghana Institute of Clinical Genetics, Korle Bu Teaching Hospital, Accra, Ghana
| | | | - Baba Inusa
- Department of Pediatric Haematology, Evelina Children's Hospital, Guy's and St. Thomas NHS Trust, London, UK
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28
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Ali MA, Ahmad A, Chaudry H, Aiman W, Aamir S, Anwar MY, Khan A. Efficacy and safety of recently approved drugs for sickle cell disease: a review of clinical trials. Exp Hematol 2020; 92:11-18.e1. [PMID: 32841705 PMCID: PMC7442900 DOI: 10.1016/j.exphem.2020.08.008] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 08/04/2020] [Accepted: 08/19/2020] [Indexed: 02/08/2023]
Abstract
Sickle cell disease is prevalent in several parts of the world. Most hospitalizations of these patients are related to pain crisis episodes. Moreover, levels of hemoglobin are lower in sickle cell disease patients as compared with the general population. Complications related to sickle cell disease are managed with blood transfusions, hydroxyurea, and opioids. Despite these therapies, patients with sickle cell disease experience multiple pain crisis episodes leading to hospitalizations and end-organ damage. The US Food and Drug Administration has approved three new drugs-L-glutamine, voxelotor, and crizanlizumab-for the prophylaxis and treatment of complications related to sickle cell disease. This review was aimed at assessing the efficacy and safety of recently approved drugs for the treatment of sickle cell disease. A comprehensive search was made on PubMed and clinicaltrials.gov to look for clinical trials reporting the efficacy and safety of recently approved drugs for sickle cell disease. Based on the results of clinical trials, L-glutamine, voxelotor, and crizanlizumab were well tolerated by sickle cell disease patients. L-Glutamine and crizanlizumab reduced the number of sickle cell crisis episodes, while voxelotor improved the level of hemoglobin in sickle cell disease patients. These drugs were effective alone and in combination with hydroxyurea.
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Affiliation(s)
| | - Asrar Ahmad
- Internal Medicine, Abington Hospital-Jefferson Health, Abington, PA.
| | - Hafsa Chaudry
- Internal Medicine, King Edward Medical University, Lahore, Pakistan
| | - Wajeeha Aiman
- Internal Medicine, Nishtar Medical University, Multan, Pakistan
| | - Sobia Aamir
- Internal Medicine, The Children's Hospital and The Institute of Child Health, Lahore, Pakistan
| | | | - Anam Khan
- Internal Medicine, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, India
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29
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Li J, Jeong SY, Xiong B, Tseng A, Mahon AB, Isaacman S, Gordeuk VR, Cho J. Repurposing pyridoxamine for therapeutic intervention of intravascular cell-cell interactions in mouse models of sickle cell disease. Haematologica 2020; 105:2407-2419. [PMID: 33054081 PMCID: PMC7556679 DOI: 10.3324/haematol.2019.226720] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 10/29/2019] [Indexed: 12/25/2022] Open
Abstract
Adherent neutrophils on vascular endothelium positively contribute to cell-cell aggregation and vaso-occlusion in sickle cell disease. In the present study, we demonstrated that pyridoxamine, a derivative of vitamin B6, might be a therapeutic agent to alleviate intravascular cell-cell aggregation in sickle cell disease. Using real-time intravital microscopy, we found that one oral administration of pyridoxamine dose-dependently increased the rolling influx of neutrophils and reduced neutrophil adhesion to endothelial cells in cremaster microvessels of sickle cell disease mice challenged with hypoxia-reoxygenation. Short-term treatment also mitigated neutrophil-endothelial cell and neutrophil-platelet interactions in the microvessels and improved the survival of sickle cell disease mice challenged with tumor necrosis factor-α. The inhibitory effects of pyridoxamine on intravascular cell-cell interactions were potentiated by co-treatment with hydroxyurea. We observed that long-term (5.5 months) oral treatment with pyridoxamine significantly diminished the adhesive function of neutrophils and platelets and down-regulated the expression of E-selectin and intercellular adhesion molecule-1 on the vascular endothelium in tumor necrosis factor-α-challenged sickle cell disease mice. Ex vivo studies revealed that the surface amount of αMβ2 integrin was significantly decreased in stimulated neutrophils isolated from sickle cell disease mice treated with pyridoxamine-containing water. Studies using platelets and neutrophils from sickle cell disease mice and patients suggested that treatment with pyridoxamine reduced the activation state of platelets and neutrophils. These results suggest that pyridoxamine may be a novel therapeutic and a supplement to hydroxyurea to prevent and treat vaco-occlusion events in sickle cell disease.
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Affiliation(s)
- Jing Li
- Department of Pharmacology, University of Illinois at Chicago College of Medicine, Chicago, IL, USA
| | - Si-Yeon Jeong
- Department of Pharmacology, University of Illinois at Chicago College of Medicine, Chicago, IL, USA
| | - Bei Xiong
- Department of Pharmacology, University of Illinois at Chicago College of Medicine, Chicago, IL, USA
- Department of Hematology, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, P.R. China
| | - Alan Tseng
- Department of Pharmacology, University of Illinois at Chicago College of Medicine, Chicago, IL, USA
| | | | | | - Victor R. Gordeuk
- Section of Hematology/Oncology, University of Illinois at Chicago College of Medicine, Chicago, IL, USA
- Comprehensive Sickle Cell Center, University of Illinois at Chicago College of Medicine, Chicago, IL, USA
| | - Jaehyung Cho
- Department of Pharmacology, University of Illinois at Chicago College of Medicine, Chicago, IL, USA
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30
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Shet AS, Lizarralde-Iragorri MA, Naik RP. The molecular basis for the prothrombotic state in sickle cell disease. Haematologica 2020; 105:2368-2379. [PMID: 33054077 PMCID: PMC7556662 DOI: 10.3324/haematol.2019.239350] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 07/22/2020] [Indexed: 12/15/2022] Open
Abstract
The genetic and molecular basis of sickle cell disease (SCD) has long since been characterized but the pathophysiological basis is not entirely defined. How a red cell hemolytic disorder initiates inflammation, endothelial dysfunction, coagulation activation and eventually leads to vascular thrombosis, is yet to be elucidated. Recent evidence has demonstrated a high frequency of unprovoked/recurrent venous thromboembolism (VTE) in SCD, with an increased risk of mortality among patients with a history of VTE. Here, we thoroughly review the molecular basis for the prothrombotic state in SCD, specifically highlighting emerging evidence for activation of overlapping inflammation and coagulation pathways, that predispose to venous thromboembolism. We share perspectives in managing venous thrombosis in SCD, highlighting innovative therapies with the potential to influence the clinical course of disease and reduce thrombotic risk, while maintaining an acceptable safety profile.
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Affiliation(s)
- Arun S. Shet
- Laboratory of Sickle Thrombosis and Vascular Biology, National Heart, Lung, and Blood Institute, NIH, Bethesda
| | | | - Rakhi P. Naik
- Division of Hematology, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
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31
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Conran N, De Paula EV. Thromboinflammatory mechanisms in sickle cell disease - challenging the hemostatic balance. Haematologica 2020; 105:2380-2390. [PMID: 33054078 PMCID: PMC7556678 DOI: 10.3324/haematol.2019.239343] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 04/19/2020] [Indexed: 11/11/2022] Open
Abstract
Sickle cell disease (SCD) is an inherited hemoglobinopathy that is caused by the presence of abnormal hemoglobin S (HbS) in red blood cells, leading to alterations in red cell properties and shape, as the result of HbS dexoygenation and subsequent polymerization. SCD pathophysiology is characterized by chronic inflammatory processes, triggered by hemolytic and vaso-occlusive events, which lead to the varied complications, organ damage and elevated mortality seen in individuals with the disease. In association with activation of the endothelium and leukocytes, hemostatic alterations and thrombotic events are well-documented in SCD. Here we discuss the role for inflammatory pathways in modulating coagulation and inducing platelet activation in SCD, due to tissue factor activation, adhesion molecule expression, inflammatory mediator production and the induction of innate immune responses, amongst other mechanisms. Thromboinflammatory pathways may play a significant role in some of the major complications of SCD, such as stroke, venous thromboembolism and possibly acute chest syndrome, besides exacerbating the chronic inflammation and cellular interactions that trigger vaso-occlusion, ischemia-reperfusion processes, and eventually organ damage.
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Affiliation(s)
- Nicola Conran
- Hematology Center, University of Campinas, UNICAMP, Cidade Universitária, Campinas-SP, Brazil
| | - Erich V. De Paula
- Hematology Center, University of Campinas, UNICAMP, Cidade Universitária, Campinas-SP, Brazil
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32
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Osunkwo I, Manwani D, Kanter J. Current and novel therapies for the prevention of vaso-occlusive crisis in sickle cell disease. Ther Adv Hematol 2020; 11:2040620720955000. [PMID: 33062233 PMCID: PMC7534097 DOI: 10.1177/2040620720955000] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 08/10/2020] [Indexed: 12/28/2022] Open
Abstract
Individuals with sickle cell disease (SCD) are living further into adulthood in high-resource countries. However, despite increased quantity of life, recurrent, acute painful episodes cause significant morbidity for affected individuals. These SCD-related painful episodes, also referred to as vaso-occlusive crises (VOCs), have multifactorial causes, and they often occur as a result of multicellular aggregation and vascular adherence of red blood cells, neutrophils, and platelets, leading to recurrent and unpredictable occlusion of the microcirculation. In addition to severe pain, long-term complications of vaso-occlusion may include damage to muscle and/or bone, in addition to vital organs such as the liver, spleen, kidneys, and brain. Severe pain associated with VOCs also has a substantial detrimental impact on quality of life for individuals with SCD, and is associated with increased health care utilization, financial hardship, and impairments in education and vocation attainment. Previous treatments have targeted primarily SCD symptom management, or were broad nontargeted therapies, and include oral or parenteral hydration, analgesics (including opioids), nonsteroidal anti-inflammatory agents, and various other types of nonpharmacologic pain management strategies to treat the pain associated with VOC. With increased understanding of the pathophysiology of VOCs, there are several new potential therapies that specifically target the pathologic process of vaso-occlusion. These new therapies may reduce cell adhesion and inflammation, leading to decreased incidence of VOCs and prevention of end-organ damage. In this review, we consider the benefits and limitations of current treatments to reduce the occurrence of VOCs in individuals with SCD and the potential impact of emerging treatments on future disease management.
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Affiliation(s)
- Ifeyinwa Osunkwo
- Non-Malignant Hematology Section, The Levine Cancer Institute and Atrium Health, Charlotte, NC, USA
| | - Deepa Manwani
- Division of Pediatric Hematology and Oncology, The Children's Hospital at Montefiore, Albert Einstein College of Medicine, New York, NY, USA
| | - Julie Kanter
- Division of Hematology and Oncology, University of Alabama Birmingham, 1720 2nd Avenue S, NP 2510, Birmingham, AL 35294, USA
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33
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Ribeiro-Filho J, Yahouédéhou SCMA, Pitanga TN, Santana SS, Adorno EV, Barbosa CG, Ferreira JRD, Pina ETG, Neres JSDS, Leite IPR, Lyra IM, Goncalves MS. An evaluation of ticagrelor for the treatment of sickle cell anemia. Expert Rev Hematol 2020; 13:1047-1055. [PMID: 32972255 DOI: 10.1080/17474086.2020.1817736] [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: 10/23/2022]
Abstract
INTRODUCTION Ticagrelor is an antiplatelet agent approved for the treatment of patients with an acute coronary syndrome or a history of myocardial infarction. Considering the evidence demonstrating that ticagrelor-mediated inhibition of platelet activation and aggregation have beneficial effects in the treatment of thrombotic conditions, clinical studies have been conducted to evaluate the use of this drug for the treatment of sickle cell disease (SCD), demonstrating satisfactory tolerability and safety. AREAS COVERED Clinical investigation has characterized the pharmacokinetic and pharmacodynamical profile, as well as the efficacy and safety of ticagrelor to prevent painful vaso-occlusive crisis (painful episodes and acute chest syndrome) in SCD patients. EXPERT OPINION While phase 1 and 2 clinical trials demonstrated satisfactory tolerability and safety, the conclusion of phase 3 clinical trials is crucial to prove the efficacy of ticagrelor as a therapeutic option for the treatment of SCD. Thus, it is expected that ticagrelor, especially in combination with other drugs, will improve the clinical profile and quality of life of patients with SCD.
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Affiliation(s)
- Jaime Ribeiro-Filho
- Laboratóriode Investigaçãoem Genéticae Hematologia Translacional, Instituto Gonçalo Moniz , Salvador, Bahia, Brasil
| | - Sètondji Cocou Modeste Alexandre Yahouédéhou
- Laboratóriode Investigaçãoem Genéticae Hematologia Translacional, Instituto Gonçalo Moniz , Salvador, Bahia, Brasil.,Laboratório de Pesquisa em Anemia, Departamento de Análises Clínicas, Faculdade de Farmácia, Universidade Federal da Bahia , Salvador, Bahia, Brasil
| | - Thassila Nogueira Pitanga
- Laboratóriode Investigaçãoem Genéticae Hematologia Translacional, Instituto Gonçalo Moniz , Salvador, Bahia, Brasil.,Faculdade de Biomedicina, Universidade Católica de Salvador , Salvador, Bahia, Brasil
| | - Sânzio Silva Santana
- Laboratóriode Investigaçãoem Genéticae Hematologia Translacional, Instituto Gonçalo Moniz , Salvador, Bahia, Brasil.,Faculdade de Biomedicina, Universidade Católica de Salvador , Salvador, Bahia, Brasil
| | - Elisângela Vitória Adorno
- Laboratório de Pesquisa em Anemia, Departamento de Análises Clínicas, Faculdade de Farmácia, Universidade Federal da Bahia , Salvador, Bahia, Brasil
| | - Cynara Gomes Barbosa
- Laboratório de Pesquisa em Anemia, Departamento de Análises Clínicas, Faculdade de Farmácia, Universidade Federal da Bahia , Salvador, Bahia, Brasil
| | - Júnia Raquel Dutra Ferreira
- Laboratório de Pesquisa em Anemia, Departamento de Análises Clínicas, Faculdade de Farmácia, Universidade Federal da Bahia , Salvador, Bahia, Brasil
| | - Eugênia Terra Granado Pina
- Laboratóriode Investigaçãoem Genéticae Hematologia Translacional, Instituto Gonçalo Moniz , Salvador, Bahia, Brasil
| | | | - Ivana Paula Ribeiro Leite
- Complexo Hospitalar Universitário Professor Edgard Santos, Universidade Federal da Bahia , Salvador, Bahia, Brasil
| | - Isa Menezes Lyra
- Complexo Hospitalar Universitário Professor Edgard Santos, Universidade Federal da Bahia , Salvador, Bahia, Brasil.,Ambulatório, Fundação de Hematologia e Hemoterapia da Bahia , Salvador, Bahia, Brasil.,Curso de Medicina, Escola de Ciências da Saúde e Bem-Estar, Universidade Salvador , Salvador, Bahia, Brasil
| | - Marilda Souza Goncalves
- Laboratóriode Investigaçãoem Genéticae Hematologia Translacional, Instituto Gonçalo Moniz , Salvador, Bahia, Brasil.,Laboratório de Pesquisa em Anemia, Departamento de Análises Clínicas, Faculdade de Farmácia, Universidade Federal da Bahia , Salvador, Bahia, Brasil
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34
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Role of the coagulation system in the pathogenesis of sickle cell disease. Blood Adv 2020; 3:3170-3180. [PMID: 31648337 DOI: 10.1182/bloodadvances.2019000193] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2019] [Accepted: 09/16/2019] [Indexed: 01/12/2023] Open
Abstract
Sickle cell disease (SCD) is an inherited monogenic red blood cell disorder affecting millions worldwide. SCD causes vascular occlusions, chronic hemolytic anemia, and cumulative organ damage such as nephropathy, pulmonary hypertension, pathologic heart remodeling, and liver necrosis. Coagulation system activation, a conspicuous feature of SCD that causes chronic inflammation, is an important component of SCD pathophysiology. The key coagulation factor, thrombin (factor IIa [FIIa]), is both a central protease in hemostasis and thrombosis and a key modifier of inflammation. Pharmacologic or genetic reduction of circulating prothrombin in Berkeley sickle mice significantly improves survival, ameliorates vascular inflammation, and results in markedly reduced end-organ damage. Accordingly, factors both upstream and downstream of thrombin, such as the tissue factor-FX complex, fibrinogen, platelets, von Willebrand factor, FXII, high-molecular-weight kininogen, etc, also play important roles in SCD pathogenesis. In this review, we discuss the various aspects of coagulation system activation and their roles in the pathophysiology of SCD.
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35
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Abstract
Sickle cell disease (SCD) afflicts millions of people worldwide but is referred to as an orphan disease in the United States. Over the past several decades, there has been an increasing understanding of the pathophysiology of SCD and its complications. While most individuals with SCD in resource-rich countries survive into adulthood, the life expectancy of patients with SCD remains substantially shorter than for the general African-American population. SCD can be cured using hematopoietic stem cell transplantation and possibly gene therapy, but these treatment approaches are not available to most patients, the majority of whom reside in low- and middle-income countries. Until relatively recently, only one drug, hydroxyurea, was approved by the US Food and Drug Administration to ameliorate disease severity. Multiple other drugs (L-glutamine, crizanlizumab, and voxelotor) have recently been approved for the treatment of SCD, with several others at various stages of clinical testing. The availability of multiple agents to treat SCD raises questions related to the choice of appropriate drug therapy, combination of multiple agents, and affordability of recently approved products. The enthusiasm for new drug development provides opportunities to involve patients in low- and middle-income nations in the testing of potentially disease-modifying therapies and has the potential to contribute to capacity building in these environments. Demonstration that these agents, alone or in combination, can prevent or decrease end-organ damage would provide additional evidence for the role of drug therapies in improving outcomes in SCD.
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Affiliation(s)
- Parul Rai
- Department of Hematology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Kenneth I. Ataga
- Center for Sickle Cell Disease, University of Tennessee Health Science Center, Memphis, TN, USA
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Salinas Cisneros G, Thein SL. Recent Advances in the Treatment of Sickle Cell Disease. Front Physiol 2020; 11:435. [PMID: 32508672 PMCID: PMC7252227 DOI: 10.3389/fphys.2020.00435] [Citation(s) in RCA: 90] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 04/08/2020] [Indexed: 12/31/2022] Open
Abstract
Sickle cell anemia (SCA) was first described in the Western literature more than 100 years ago. Elucidation of its molecular basis prompted numerous biochemical and genetic studies that have contributed to a better understanding of its pathophysiology. Unfortunately, the translation of such knowledge into developing treatments has been disproportionately slow and elusive. In the last 10 years, discovery of BCL11A, a major γ-globin gene repressor, has led to a better understanding of the switch from fetal to adult hemoglobin and a resurgence of efforts on exploring pharmacological and genetic/genomic approaches for reactivating fetal hemoglobin as possible therapeutic options. Alongside therapeutic reactivation of fetal hemoglobin, further understanding of stem cell transplantation and mixed chimerism as well as gene editing, and genomics have yielded very encouraging outcomes. Other advances have contributed to the FDA approval of three new medications in 2017 and 2019 for management of sickle cell disease, with several other drugs currently under development. In this review, we will focus on the most important advances in the last decade.
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Affiliation(s)
- Gabriel Salinas Cisneros
- Sickle Cell Branch, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD, United States.,Division of Hematology and Oncology, Children's National Medical Center, Washington, DC, United States
| | - Swee L Thein
- Sickle Cell Branch, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD, United States
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Abstract
INTRODUCTION In sickle cell disease (SCD), hemoglobin S (HbS) red blood cells (RBCs) are characteristically deformed and inflexible. Often breaking down in the circulation, they exhibit increased adhesive properties with the endothelium and activated neutrophils and platelets, increasing the risk of occlusion of the microcirculation. SCD is categorized into two sub-phenotypes: hyperhemolytic, associated with priapism, leg ulcers, pulmonary hypertension, and stroke, and high hemoglobin/viscosity, which may promote vaso-occlusion-associated pain, acute chest syndrome, and osteonecrosis. AREAS COVERED The sub-phenotypes are not completely distinct. Hemolysis may trigger vaso-occlusion, contributing to vascular complications. Targeting P-selectin, a key mediator of cross-talk between hyperhemolysis and vaso-occlusion, may be beneficial for vascular and vaso-occlusion-associated complications. English-language articles from PubMed on the topic of SCD and vaso-occlusive crises (VOCs) were reviewed from 1 January 2000 to 1 January 2019 using the search terms 'sickle cell disease,' 'vaso-occlusive crises,' and 'selectin.' EXPERT OPINION Besides targeting P-selectin, other strategies to counter VOCs and RBC sickling are being pursued. These include platelet inhibition to counter aggregation, intercellular adhesion, and thrombosis during VOCs; gene therapy to correct the homozygous missense mutation in the β-globin gene, causing polymerization of HbS; L-glutamine, possibly reducing oxidative stress in sickled RBCs; and fetal hemoglobin inducers.
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Affiliation(s)
- Solomon F Ofori-Acquah
- Department of Medicine, University of Pittsburgh , Pittsburgh, USA.,School of Biomedical and Allied Health Sciences, College of Health Sciences, University of Ghana , Accra, Ghana.,West African Genetic Medicine Centre (WAGMC), College of Health Sciences, University of Ghana , Accra, Ghana
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Abstract
Despite sickle cell disease (SCD) being the most common and severe inherited condition worldwide, therapeutic options are limited. To date, hydroxyurea remains the main treatment option in SCD. However, in the last decade the numbers of interventional clinical trials focussing on therapies for SCD have increased significantly. Many new drugs with various pharmacological targets have emerged and, although the majority have failed to show benefit in clinical trials, some have produced encouraging results. It seems probable that more drugs will soon become available for the treatment of SCD. Furthermore, promising clinical trials with improved outcomes have recently changed the perspective of curative therapies in SCD. Nevertheless, the application of novel therapeutic agents and potential curative treatments will most likely be limited to high-income countries and, thus, will remain unavailable for the majority of people with SCD in the foreseeable future.
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Affiliation(s)
- Amina Nardo-Marino
- Centre for Haemoglobinopathies, Department of Haematology, Herlev and Gentofte Hospital, University of Copenhagen, Herlev, Denmark
| | - Valentine Brousse
- Sickle Cell Disease Reference Center, Department of General Pediatrics and Pediatric Infectious Diseases, Necker-Enfants Malades Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - David Rees
- Department of Haematological Medicine, King's College London, King's College Hospital, London, UK
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Farooq F, Mogayzel PJ, Lanzkron S, Haywood C, Strouse JJ. Comparison of US Federal and Foundation Funding of Research for Sickle Cell Disease and Cystic Fibrosis and Factors Associated With Research Productivity. JAMA Netw Open 2020; 3:e201737. [PMID: 32219405 DOI: 10.1001/jamanetworkopen.2020.1737] [Citation(s) in RCA: 80] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
IMPORTANCE Sickle cell disease (SCD) and cystic fibrosis (CF) are severe autosomal recessive disorders associated with intermittent disease exacerbations that require hospitalizations, progressive chronic organ injury, and substantial premature mortality. Research funding is a limited resource and may contribute to health care disparities, especially for rare diseases that disproportionally affect economically disadvantaged groups. OBJECTIVE To compare disease-specific funding between SCD and CF and the association between funding and research productivity. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study examined federal and foundation funding, publications indexed in PubMed, clinical trials registered in ClinicalTrials.gov, and new drug approvals from January 1, 2008, to December 31, 2018, in an estimated US population of approximately 90 000 individuals with SCD and approximately 30 000 individuals with CF. MAIN OUTCOMES AND MEASURES Federal and foundation funding, publications indexed in PubMed, clinical trial registrations, and new drug approvals. RESULTS From 2008 through 2018, federal funding was greater per person with CF compared with SCD (mean [SD], $2807 [$175] vs $812 [$147]; P < .001). Foundation expenditures were greater for CF than for SCD (mean [SD], $7690 [$3974] vs $102 [$13.7]; P < .001). Significantly more research articles (mean [SD], 1594 [225] vs 926 [157]; P < .001) and US Food and Drug Administration drug approvals (4 vs 1) were found for CF compared with SCD, but the total number of clinical trials was similar (mean [SD], 27.3 [6.9] vs 23.8 [6.3]; P = .22). CONCLUSIONS AND RELEVANCE The findings show that disparities in funding between SCD and CF may be associated with decreased research productivity and novel drug development for SCD. Increased federal and foundation funding is needed for SCD and other diseases that disproportionately affect economically disadvantaged groups to address health care disparities.
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Affiliation(s)
- Faheem Farooq
- Deparment of Pediatrics and Medicine, Stony Brook University Hospital, Stony Brook, New York
| | - Peter J Mogayzel
- Division of Pediatric Pulmonology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sophie Lanzkron
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Carlton Haywood
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Berman Institute of Bioethics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - John J Strouse
- Division of Hematology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina
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Tubman VN. Mother knows best: The caregiver's perspective on clinical trials for sickle cell disease highlights the challenges of providing care in Africa. Pediatr Blood Cancer 2020; 67:e28054. [PMID: 31724295 DOI: 10.1002/pbc.28054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 10/08/2019] [Indexed: 11/09/2022]
Affiliation(s)
- Venée N Tubman
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas.,Texas Children's Cancer and Hematology Centers, Houston, Texas
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Allali S, Maciel TT, Hermine O, de Montalembert M. Innate immune cells, major protagonists of sickle cell disease pathophysiology. Haematologica 2020; 105:273-283. [PMID: 31919091 PMCID: PMC7012475 DOI: 10.3324/haematol.2019.229989] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 09/26/2019] [Indexed: 12/30/2022] Open
Abstract
Sickle cell disease (SCD), considered the most common monogenic disease worldwide, is a severe hemoglobin disorder. Although the genetic and molecular bases have long been characterized, the pathophysiology remains incompletely elucidated and therapeutic options are limited. It has been increasingly suggested that innate immune cells, including monocytes, neutrophils, invariant natural killer T cells, platelets and mast cells, have a role in promoting inflammation, adhesion and pain in SCD. Here we provide a thorough review of the involvement of these novel, major protagonists in SCD pathophysiology, highlighting recent evidence for innovative therapeutic perspectives.
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Affiliation(s)
- Slimane Allali
- Department of General Pediatrics and Pediatric Infectious Diseases, Reference Center for Sickle Cell Disease, Necker Hospital for Sick Children, Assistance Publique - Hôpitaux de Paris (AP-HP), Paris Descartes University, Paris .,Laboratory of Cellular and Molecular Mechanisms of Hematological Disorders and Therapeutical Implications, Paris Descartes - Sorbonne Paris Cite University, Imagine Institute, Inserm U1163, Paris.,Laboratory of Excellence GR-Ex, Paris
| | - Thiago Trovati Maciel
- Laboratory of Cellular and Molecular Mechanisms of Hematological Disorders and Therapeutical Implications, Paris Descartes - Sorbonne Paris Cite University, Imagine Institute, Inserm U1163, Paris.,Laboratory of Excellence GR-Ex, Paris
| | - Olivier Hermine
- Laboratory of Cellular and Molecular Mechanisms of Hematological Disorders and Therapeutical Implications, Paris Descartes - Sorbonne Paris Cite University, Imagine Institute, Inserm U1163, Paris.,Laboratory of Excellence GR-Ex, Paris.,Department of Hematology, Necker Hospital for Sick Children, AP-HP, Paris Descartes University, Paris, France
| | - Mariane de Montalembert
- Department of General Pediatrics and Pediatric Infectious Diseases, Reference Center for Sickle Cell Disease, Necker Hospital for Sick Children, Assistance Publique - Hôpitaux de Paris (AP-HP), Paris Descartes University, Paris .,Laboratory of Excellence GR-Ex, Paris
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Dolatkhah R, Dastgiri S. Blood transfusions for treating acute chest syndrome in people with sickle cell disease. Cochrane Database Syst Rev 2020; 1:CD007843. [PMID: 31942751 PMCID: PMC6984655 DOI: 10.1002/14651858.cd007843.pub4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Sickle cell disease is an inherited autosomal recessive blood condition and is one of the most prevalent genetic blood diseases worldwide. Acute chest syndrome is a frequent complication of sickle cell disease, as well as a major cause of morbidity and the greatest single cause of mortality in children with sickle cell disease. Standard treatment may include intravenous hydration, oxygen as treatment for hypoxia, antibiotics to treat the infectious cause and blood transfusions may be given. This is an update of a Cochrane Review first published in 2010 and updated in 2016. OBJECTIVES To assess the effectiveness of blood transfusions, simple and exchange, for treating acute chest syndrome by comparing improvement in symptoms and clinical outcomes against standard care. SEARCH METHODS We searched The Cochrane Cystic Fibrosis and Genetic Disorders Group's Haemoglobinopathies Trials Register, which comprises references identified from comprehensive electronic database searches and handsearching of relevant journals and abstract books of conference proceedings. Date of the most recent search: 30 May 2019. SELECTION CRITERIA Randomised controlled trials and quasi-randomised controlled trials comparing either simple or exchange transfusion versus standard care (no transfusion) in people with sickle cell disease suffering from acute chest syndrome. DATA COLLECTION AND ANALYSIS Both authors independently selected trials and assessed the risk of bias, no data could be extracted. MAIN RESULTS One trial was eligible for inclusion in the review. While in the multicentre trial 237 people were enrolled (169 SCC, 42 SC, 15 Sβ⁰-thalassaemia, 11Sβ+-thalassaemia); the majority were recruited to an observational arm and only ten participants met the inclusion criteria for randomisation. Of these, four were randomised to the transfusion arm and received a single transfusion of 7 to 13 mL/kg packed red blood cells, and six were randomised to standard care. None of the four participants who received packed red blood cells developed acute chest syndrome, while 33% (two participants) developed acute chest syndrome in standard care arm. No data for any pre-defined outcomes were available. AUTHORS' CONCLUSIONS We found only one very small randomised controlled trial; this is not enough to make any reliable conclusion to support the use of blood transfusion. Whilst there appears to be some indication that chronic blood transfusion may play a roll in reducing the incidence of acute chest syndrome in people with sickle cell disease and albeit offering transfusions may be a widely accepted clinical practice, there is currently no reliable evidence to support or refute the perceived benefits of these as treatment options; very limited information about any of the potential harms associated with these interventions or indeed guidance that can be used to aid clinical decision making. Clinicians should therefore base any treatment decisions on a combination of; their clinical experience, individual circumstances and the unique characteristics and preferences of adequately informed people with sickle cell disease who are suffering with acute chest syndrome. This review highlights the need of further high quality research to provide reliable evidence for the effectiveness of these interventions for the relief of the symptoms of acute chest syndrome in people with sickle cell disease.
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Affiliation(s)
- Roya Dolatkhah
- Tabriz University of Medical SciencesLiver and Gastrointestinal Diseases Research CenterTabrizIran
| | - Saeed Dastgiri
- Tabriz University of Medical SciencesTabriz Health Services Management Research CenterTabrizIran5166615739
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Ballas SK. The Evolving Pharmacotherapeutic Landscape for the Treatment of Sickle Cell Disease. Mediterr J Hematol Infect Dis 2020; 12:e2020010. [PMID: 31934320 PMCID: PMC6951351 DOI: 10.4084/mjhid.2020.010] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 12/17/2019] [Indexed: 01/02/2023] Open
Abstract
Sickle cell disease (SCD) is an extremely heterogeneous disease that has been associated with global morbidity and early mortality. More effective and inexpensive therapies are needed. During the last five years, the landscape of the pharmacotherapy of SCD has changed dramatically. Currently, 54 drugs have been used or under consideration to use for the treatment of SCD. These fall into 3 categories: the first category includes the four drugs (Hydroxyurea, L-Glutamine, Crizanlizumab tmca and Voxelotor) that have been approved by the United States Food and Drug Administration (FDA) based on successful clinical trials. The second category includes 22 drugs that failed, discontinued or terminated for now and the third category includes 28 drugs that are actively being considered for the treatment of SCD. Crizanlizumab and Voxelotor are included in the first and third categories because they have been used in more than one trial. New therapies targeting multiple pathways in the complex pathophysiology of SCD have been achieved or are under continued investigation. The emerging trend seems to be the use of multimodal drugs (i.e. drugs that have different mechanisms of action) to treat SCD similar to the use of multiple chemotherapeutic agents to treat cancer.
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Affiliation(s)
- Samir K Ballas
- Cardeza Foundation for Hematologic Research, Department of Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
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44
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Ansari J, Gavins FNE. Ischemia-Reperfusion Injury in Sickle Cell Disease: From Basics to Therapeutics. THE AMERICAN JOURNAL OF PATHOLOGY 2019; 189:706-718. [PMID: 30904156 DOI: 10.1016/j.ajpath.2018.12.012] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 11/17/2018] [Accepted: 12/07/2018] [Indexed: 12/17/2022]
Abstract
Sickle cell disease (SCD) is one of the most common hereditary hemoglobinopathies worldwide, affecting almost 400,000 newborns globally each year. It is characterized by chronic hemolytic anemia and endothelial dysfunction, resulting in a constant state of disruption of the vascular system and leading to recurrent episodes of ischemia-reperfusion injury (I/RI) to multiple organ systems. I/RI is a fundamental vascular pathobiological paradigm and contributes to morbidity and mortality in a wide range of conditions, including myocardial infarction, stroke, acute kidney injury, and transplantation. I/RI is characterized by an initial restriction of blood supply to an organ, which can lead to ischemia, followed by the subsequent restoration of perfusion and concomitant reoxygenation. Recent advances in the pathophysiology of SCD have led to an understanding that many of the consequences of this disease can be explained by mechanisms associated with I/RI. The following review focuses on the evolving pathobiology of SCD, how various complications of SCD can be attributed to I/RI, and the role of timely therapeutic intervention(s) based on targeting mediators or pathways that influence I/R insult.
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Affiliation(s)
- Junaid Ansari
- Department of Molecular & Cellular Physiology, Louisiana State University Health Sciences Center Shreveport, Shreveport, Louisiana
| | - Felicity N E Gavins
- Department of Molecular & Cellular Physiology, Louisiana State University Health Sciences Center Shreveport, Shreveport, Louisiana.
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45
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El-Amin N, Nietert P, Kanter J. International Differences in Outpatient Pain Management: A Survey of Sickle Cell Disease. J Clin Med 2019; 8:jcm8122136. [PMID: 31817043 PMCID: PMC6947541 DOI: 10.3390/jcm8122136] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Revised: 11/22/2019] [Accepted: 11/29/2019] [Indexed: 01/17/2023] Open
Abstract
Vaso-occlusive pain crises are the hallmark of sickle cell disease (SCD) and the primary reason for health care utilization. Both national and international guidelines recommend aggressive intravenous opioids, intravenous fluids and anti-inflammatory therapy as the mainstay of treatment for acute SCD pain. However, many vaso-occlusive crises are managed at home with oral medication and supportive care. There are no guidelines on home medication management of SCD-related pain, likely due to the lack of well-defined endpoints for acute events and the lack of funding for already approved pain medications. Amplifying this issue is the growing concern for opioid abuse and misuse in the United States (US) and internationally. This study aimed to evaluate differences in opioid prescribing practices among providers treating SCD in the US and internationally. A survey was disseminated electronically to known providers using a combination of purposive and snowball sampling strategy. There were 127 responses and 17 countries represented. US providers were more likely to prescribe opioids (p < 0.001) and were more likely to be “very comfortable” prescribing opioids than non-US prescribers (p < 0.001). US providers also tended to prescribe more tablets per patient of stronger opioids than non-US physicians. US physicians were more likely to be concerned that patients were abusing opioids than non-US physicians (32% vs. 27%, p < 0.05). There are significant variations in how different parts of the world manage pain in the outpatient setting for SCD. Identifying optimal home pain management strategies is necessary to improve care and long-term outcomes in SCD.
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Affiliation(s)
- Nadirah El-Amin
- Department of Pediatric Hematology-Oncology, Virginia Commonwealth University, Richmond, VA 23219, USA;
| | - Paul Nietert
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC 29425, USA;
| | - Julie Kanter
- Department of Medicine, University of Alabama, Birmingham, AL 35233, USA
- Correspondence:
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46
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Inusa BPD, Colombatti R, Rees DC, Heeney MM, Hoppe CC, Ogutu B, Hassab HM, Zhou C, Yao S, Brown PB, Heath LE, Jakubowski JA, Abboud MR. Geographic Differences in Phenotype and Treatment of Children with Sickle Cell Anemia from the Multinational DOVE Study. J Clin Med 2019; 8:jcm8112009. [PMID: 31744266 PMCID: PMC6912763 DOI: 10.3390/jcm8112009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Revised: 11/07/2019] [Accepted: 11/10/2019] [Indexed: 11/30/2022] Open
Abstract
Background: DOVE (Determining Effects of Platelet Inhibition on Vaso-Occlusive Events) was a Phase 3, randomized, double-blind, placebo-controlled study conducted in children with sickle cell anemia at 51 sites in 13 countries across four continents. Procedure: Data from DOVE were assessed for regional differences in subject phenotype and treatment. Demographics, baseline clinical and laboratory data, hydroxyurea (HU) use, vaso-occlusive crisis (VOCs; composite endpoint of painful crisis or acute chest syndrome (ACS)), serious adverse events (SAEs), hospitalization, and treatments were compared across the Americas, Europe, North Africa/Middle East, and Sub-Saharan Africa (SSA). Results: Race, body mass index, and blood pressures differed by region. Pre-enrollment VOCs were highest in the Americas. For subjects not on HU, baseline hemoglobin was lowest in SSA; reticulocyte count was lowest in the Americas. Within SSA, Kenya subjects presented higher baseline hemolysis. Painful crisis was the most common SAE, followed by ACS in the Americas and infections in other regions. VOC rate and percentage of VOC hospitalizations were highest in Europe. Regardless of region, most VOCs were treated with analgesics; approximately half were treated with intravenous fluids. The proportion of VOC-related transfusions was greatest in Europe. Lengths of hospital stay were similar across regions. Conclusions: Overall differences in SAEs and hospitalization for VOCs may be due to cultural diversities, resource utilization, disease severity, or a combination of factors. These data are of importance for the planning of future trials in SCA in a multinational setting.
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Affiliation(s)
- Baba Psalm Duniya Inusa
- Evelina Children’s Hospital, and Guy’s and St. Thomas’ Hospital, London SE1 7EH, UK
- Women and Children’s Health, Faculty of Life Sciences & Medicine, King’s College, London SE1 7EH, UK
- Correspondence: ; Tel.: +44-791-959-7783; Fax: +44-207-188-4612
| | - Raffaella Colombatti
- Clinic of Pediatric Hematology-Oncology, Azienda Ospedaliera-University of Padua, Padua 35129, Italy;
| | - David C. Rees
- Department of Paediatric Haematology, King’s College London, King’s College Hospital, Denmark Hill, London SE5 8RZ, UK;
| | - Matthew M. Heeney
- Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Boston, MA 02115, USA;
| | - Carolyn C. Hoppe
- UCSF Benioff Children’s Hospital Oakland, Oakland, CA 94609, USA;
| | - Bernhards Ogutu
- U.S. Army Medical Research Unit-Kenya, Centre for Clinical Research, Kenya Medical Research Institute, Kisumu 00200, Kenya;
| | - Hoda M. Hassab
- Pediatric Department and Clinical Research Center, Faculty of Medicine, Alexandria University, Alexandria 21500, Egypt;
| | - Chunmei Zhou
- Eli Lilly and Company, Indianapolis, IN 46285, USA; (C.Z.); (S.Y.); (P.B.B.); (L.E.H.); (J.A.J.)
| | - Suqin Yao
- Eli Lilly and Company, Indianapolis, IN 46285, USA; (C.Z.); (S.Y.); (P.B.B.); (L.E.H.); (J.A.J.)
| | - Patricia B. Brown
- Eli Lilly and Company, Indianapolis, IN 46285, USA; (C.Z.); (S.Y.); (P.B.B.); (L.E.H.); (J.A.J.)
| | - Lori E. Heath
- Eli Lilly and Company, Indianapolis, IN 46285, USA; (C.Z.); (S.Y.); (P.B.B.); (L.E.H.); (J.A.J.)
| | - Joseph A. Jakubowski
- Eli Lilly and Company, Indianapolis, IN 46285, USA; (C.Z.); (S.Y.); (P.B.B.); (L.E.H.); (J.A.J.)
| | - Miguel R. Abboud
- Department of Pediatrics and Adolescent Medicine, American University of Beirut, Beirut 11-0236, Lebanon;
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Kanter J, Lanzkron S. Innovations in Targeted Anti-Adhesion Treatment for Sickle Cell Disease. Clin Pharmacol Ther 2019; 107:140-146. [PMID: 31617585 DOI: 10.1002/cpt.1682] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 10/13/2019] [Indexed: 02/02/2023]
Abstract
Sickle cell disease (SCD) is an inherited hemoglobinopathy that leads to significant lifetime morbidity and early mortality. An enhanced understanding of the complex pathophysiology of the disease has elucidated novel therapeutic targets for which new therapies are in development. In order to increase the therapeutic landscape, it has been important to identify the blood vessel and more specifically the endothelium as the target organ in this complex disease. Through this lens, we present a review of new anti-adhesion therapies for SCD in development. The long-term promise of multimodal therapies for SCD is finally on the horizon.
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Affiliation(s)
- Julie Kanter
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Sophie Lanzkron
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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48
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Heeney MM, Abboud MR, Amilon C, Andersson M, Githanga J, Inusa B, Kanter J, Leonsson-Zachrisson M, Michelson AD, Berggren AR. Ticagrelor versus placebo for the reduction of vaso-occlusive crises in pediatric sickle cell disease: Rationale and design of a randomized, double-blind, parallel-group, multicenter phase 3 study (HESTIA3). Contemp Clin Trials 2019; 85:105835. [DOI: 10.1016/j.cct.2019.105835] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 08/19/2019] [Accepted: 08/20/2019] [Indexed: 02/08/2023]
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The platelet NLRP3 inflammasome is upregulated in sickle cell disease via HMGB1/TLR4 and Bruton tyrosine kinase. Blood Adv 2019; 2:2672-2680. [PMID: 30333099 DOI: 10.1182/bloodadvances.2018021709] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 09/17/2018] [Indexed: 01/01/2023] Open
Abstract
A key inflammatory mechanism recently identified in platelets involves the Nod-like receptor nucleotide-binding domain leucine-rich repeat containing protein 3 (NLRP3) and Bruton tyrosine kinase (BTK), which control activation of caspase-1 within inflammasome complexes. We investigated platelet caspase-1 activity in the context of sickle cell disease (SCD) directly in platelets isolated from SCD patients (n = 24) and indirectly by incubating platelets from healthy subjects with plasma obtained from SCD patients (n = 20), both in steady state and during an acute pain crisis (paired samples). The platelet NLRP3 inflammasome was upregulated in SCD patients under steady state conditions compared with healthy controls, and it was further upregulated when patients experienced an acute pain crisis. The results were consistent with indirect platelet assays, in which SCD plasma increased caspase-1 activity of platelets from healthy subjects in an NLRP3-dependent fashion. The damage-associated molecular pattern molecule high-mobility group box 1 (HMGB1) was elevated in plasma of SCD subjects compared with healthy controls and correlated with caspase-1 activity in platelets. Pharmacological or antibody-mediated inhibition of HMGB1, Toll-like receptor 4, and BTK interfered with sickle plasma-induced platelet caspase-1 activation. In Townes SCD mice, caspase-1 activity and aggregation of circulating platelets were elevated, which was suppressed by IV injection of an NLRP3 inhibitor and the BTK inhibitor ibrutinib. Activation of the platelet NLRP3 inflammasome in SCD may have diagnostic and therapeutic implications.
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50
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Carden MA, Little J. Emerging disease-modifying therapies for sickle cell disease. Haematologica 2019; 104:1710-1719. [PMID: 31413089 PMCID: PMC6717563 DOI: 10.3324/haematol.2018.207357] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 07/10/2019] [Indexed: 12/20/2022] Open
Abstract
Sickle cell disease afflicts millions of people worldwide and approximately 100,000 Americans. Complications are myriad and arise as a result of complex pathological pathways ‘downstream’ to a point mutation in DNA, and include red blood cell membrane damage, inflammation, chronic hemolytic anemia with episodic vaso-occlusion, ischemia and pain, and ultimately risk of cumulative organ damage with reduced lifespan of affected individuals. The National Heart, Lung, and Blood Institute’s 2014 evidence-based guideline for sickle cell disease management states that additional research is needed before investigational curative therapies will be widely available to most patients with sickle cell disease. To date, sickle cell disease has been cured by hematopoietic stem cell transplantation in approximately 1,000 people, most of whom were children, and significantly ameliorated by gene therapy in a handful of subjects who have only limited follow-up thus far. During a timespan in which over 20 agents were approved for the treatment of cystic fibrosis by the Food and Drug Administration, similar approval was granted for only two drugs for sickle cell disease (hydroxyurea and L-glutamine) despite the higher prevalence of sickle cell disease. This trajectory appears to be changing, as the lack of multimodal agent therapy in sickle cell disease has spurred engagement among many in academia and industry who, in the last decade, have developed new drugs poised to prevent complications and alleviate suffering. Identified therapeutic strategies include fetal hemoglobin induction, inhibition of intracellular HbS polymerization, inhibition of oxidant stress and inflammation, and perturbation of the activation of the endothelium and other blood components (e.g. platelets, white blood cells, coagulation proteins) involved in the pathophysiology of sickle cell disease. In this article, we present a crash-course review of disease-modifying approaches (minus hematopoietic stem cell transplant and gene therapy) for patients with sickle cell disease currently, or recently, tested in clinical trials in the era following approval of hydroxyurea.
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Affiliation(s)
- Marcus A Carden
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, University of North Carolina Chapel Hill School of Medicine.,Department of Medicine, Division of Hematology, University of North Carolina Chapel Hill School of Medicine, Chapel Hill, NC, USA
| | - Jane Little
- Department of Medicine, Division of Hematology, University of North Carolina Chapel Hill School of Medicine, Chapel Hill, NC, USA
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