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Al Tabosh T, Al Tarrass M, Tourvieilhe L, Guilhem A, Dupuis-Girod S, Bailly S. Hereditary hemorrhagic telangiectasia: from signaling insights to therapeutic advances. J Clin Invest 2024; 134:e176379. [PMID: 38357927 PMCID: PMC10866657 DOI: 10.1172/jci176379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2024] Open
Abstract
Hereditary hemorrhagic telangiectsia (HHT) is an inherited vascular disorder with highly variable expressivity, affecting up to 1 in 5,000 individuals. This disease is characterized by small arteriovenous malformations (AVMs) in mucocutaneous areas (telangiectases) and larger visceral AVMs in the lungs, liver, and brain. HHT is caused by loss-of-function mutations in the BMP9-10/ENG/ALK1/SMAD4 signaling pathway. This Review presents up-to-date insights on this mutated signaling pathway and its crosstalk with proangiogenic pathways, in particular the VEGF pathway, that has allowed the repurposing of new drugs for HHT treatment. However, despite the substantial benefits of these new treatments in terms of alleviating symptom severity, this not-so-uncommon bleeding disorder still currently lacks any FDA- or European Medicines Agency-approved (EMA-approved) therapies.
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Affiliation(s)
- Tala Al Tabosh
- Biosanté Unit U1292, Grenoble Alpes University, INSERM, CEA, Grenoble, France
| | - Mohammad Al Tarrass
- Biosanté Unit U1292, Grenoble Alpes University, INSERM, CEA, Grenoble, France
| | - Laura Tourvieilhe
- Hospices Civils de Lyon, National HHT Reference Center and Genetics Department, Femme-Mère-Enfants Hospital, Bron, France
| | - Alexandre Guilhem
- Hospices Civils de Lyon, National HHT Reference Center and Genetics Department, Femme-Mère-Enfants Hospital, Bron, France
- TAI-IT Autoimmunité Unit RIGHT-UMR1098, Burgundy University, INSERM, EFS-BFC, Besancon, France
| | - Sophie Dupuis-Girod
- Biosanté Unit U1292, Grenoble Alpes University, INSERM, CEA, Grenoble, France
- Hospices Civils de Lyon, National HHT Reference Center and Genetics Department, Femme-Mère-Enfants Hospital, Bron, France
| | - Sabine Bailly
- Biosanté Unit U1292, Grenoble Alpes University, INSERM, CEA, Grenoble, France
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Yunus H, Amin S, Haq FU, Ali W, Hamid T, Ali W, Ullah B, Bai P. Case report: Diagnosis of hereditary hemorrhagic telangiectasia (Osler Weber Rendu Syndrome) in a 23-year-old male presented with anemia and thrombocytopenia and its response to bevacizumab. Front Med (Lausanne) 2022; 9:1001695. [PMID: 36262274 PMCID: PMC9575171 DOI: 10.3389/fmed.2022.1001695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Accepted: 09/12/2022] [Indexed: 11/22/2022] Open
Abstract
Osler Weber Rendu Syndrome (OWS) is characterized by the development of abnormally dilated blood vessels, which manifest as arteriovenous shunts (pulmonary, gastrointestinal, hepatic, and cerebral) and mucocutaneous telangiectasias (lips, tongue, and fingertips). It is an autosomal dominant disease with a defect in transforming growth factor beta superfamily genes. This defect results in increased angiogenesis and disruption of vessel wall integrity. The disease remains underreported, with occasional history of recurrent epistaxis, iron deficiency anemia, and gastrointestinal bleeding in moderate to severe cases. Diagnosis is based on clinical presentation and confirmed by genetic testing. Various local (nasal saline, air humidification, laser ablation, and electric cauterization for epistaxis and endoscopic Argon Plasma Coagulation-APC for active GI bleeding), surgical, and systemic (tranexamic acid and antiangiogenic agents like bevacizumab and thalidomide) treatment options are used depending upon disease severity. Here, we present a case with recurrent gastrointestinal bleeding refractory to endoscopic APC ablation and thalidomide and severe symptomatic anemia requiring multiple packed red cell transfusions. The patient was ultimately started on bevacizumab, to which he had a good response and has remained in remission for 8 months as of now. This case emphasizes the need to have a low threshold of suspicion to diagnose HHT and start targeted therapy like bevacizumab early on in moderate to severe cases of HHT rather than just relying on temporizing palliative measures like ablation, cauterization, and tranexamic acid.
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Affiliation(s)
- Hamza Yunus
- Internal Medicine, Hayatabad Medical Complex, Peshawar, KPK, Pakistan,*Correspondence: Hamza Yunus,
| | - Said Amin
- Internal Medicine, Hayatabad Medical Complex, Peshawar, KPK, Pakistan
| | - Furqan Ul Haq
- Internal Medicine, Hayatabad Medical Complex, Peshawar, KPK, Pakistan
| | - Waqar Ali
- Internal Medicine, Mardan Medical Complex, Mardan, KPK, Pakistan
| | - Tanveer Hamid
- Internal Medicine, Sligo General Hospital, Sligo, Ireland
| | - Wajid Ali
- Internal Medicine, Hayatabad Medical Complex, Peshawar, KPK, Pakistan
| | - Basharat Ullah
- Pediatric Oncology, Shaukat Khanum Memorial Hospital and Research Centre, Peshawar, KPK, Pakistan
| | - Payal Bai
- Peoples University of Medical and Health Sciences (PUMHS), Nawabshah, Pakistan
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Hetts SW, Shieh JT, Ohliger MA, Conrad MB. Hereditary Hemorrhagic Telangiectasia: The Convergence of Genotype, Phenotype, and Imaging in Modern Diagnosis and Management of a Multisystem Disease. Radiology 2021; 300:17-30. [PMID: 33973836 DOI: 10.1148/radiol.2021203487] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant disease that manifests as vascular malformations in the brain, lung, liver, gastrointestinal tract, nasal mucosa, and skin. Diagnosis and management of HHT is guided in large part by imaging studies, making it a condition with which the radiology community needs familiarity. Proper screening and care lead to improved morbidity and mortality in patients with HHT. International guidelines were recently updated and form the basis for a detailed discussion of the role of imaging and image-guided therapy in HHT. © RSNA, 2021 Online supplemental material is available for this article.
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Affiliation(s)
- Steven W Hetts
- From the Department of Radiology and Biomedical Imaging (S.W.H., M.O., M.C.), HHT Center of Excellence (S.W.H., J.S., M.O., M.C.), and Department of -Pediatrics (J.S.), University of California San Francisco, 505 Parnassus Ave, L-351, San Francisco, CA 94143-0628
| | - Joseph T Shieh
- From the Department of Radiology and Biomedical Imaging (S.W.H., M.O., M.C.), HHT Center of Excellence (S.W.H., J.S., M.O., M.C.), and Department of -Pediatrics (J.S.), University of California San Francisco, 505 Parnassus Ave, L-351, San Francisco, CA 94143-0628
| | - Michael A Ohliger
- From the Department of Radiology and Biomedical Imaging (S.W.H., M.O., M.C.), HHT Center of Excellence (S.W.H., J.S., M.O., M.C.), and Department of -Pediatrics (J.S.), University of California San Francisco, 505 Parnassus Ave, L-351, San Francisco, CA 94143-0628
| | - Miles B Conrad
- From the Department of Radiology and Biomedical Imaging (S.W.H., M.O., M.C.), HHT Center of Excellence (S.W.H., J.S., M.O., M.C.), and Department of -Pediatrics (J.S.), University of California San Francisco, 505 Parnassus Ave, L-351, San Francisco, CA 94143-0628
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Olsen LB, Kjeldsen AD, Poulsen MK, Kjeldsen J, Fialla AD. High output cardiac failure in 3 patients with hereditary hemorrhagic telangiectasia and hepatic vascular malformations, evaluation of treatment. Orphanet J Rare Dis 2020; 15:334. [PMID: 33243256 PMCID: PMC7691053 DOI: 10.1186/s13023-020-01583-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 10/13/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This report addresses how patients with hereditary hemorrhagic telangiectasia (HHT) and high output cardiac failure (HOCF) due to hepatic vascular malformations, should be evaluated and could be treated. HHT is a genetic disorder, leading to vascular abnormalities with potentially serious clinical implications. In the liver, arteriovenous malformations occur in more than 70% of patients, but only about 8% present clinical symptoms such as HOCF with pulmonary hypertension and less commonly portal hypertension, biliary ischemia and hepatic encephalopathy. RESULTS Three female patients with HHT type 2 and HOCF caused by severe arteriovenous malformations in the liver are presented in this case series. The patients were seen at the HHT-Centre at Odense University Hospital. Treatment with either orthotopic liver transplantation (one patient) or bevacizumab (two patients) was initiated. All patients experienced marked symptom relief and objective improvement. New York Heart Association-class were improved, ascites, peripheral edema and hence diuretic treatment was markedly reduced or discontinued in all three patients. Bevacizumab also resulted in notable effects on epistaxis and anemia. CONCLUSION Our findings substantiate the importance of identification of symptomatic arteriovenous malformations in the liver in patients with HHT. Bevacizumab may possibly, as suggested in this case series and supported by previous case studies, postpone the time to orthotopic liver transplantation or even make it unnecessary. Bevacizumab represents a promising new treatment option, which should be investigated further in clinical trials.
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Affiliation(s)
- Lilian B Olsen
- HHT-Center Odense University Hospital, Part of VASCERN, Odense, Denmark
| | - Anette D Kjeldsen
- HHT-Center Odense University Hospital, Part of VASCERN, Odense, Denmark.,Department of Otorhinolaryngology Head and Neck Surgery, Odense, Denmark.,Institute of Clinical Research, Odense, Denmark
| | - Mikael K Poulsen
- HHT-Center Odense University Hospital, Part of VASCERN, Odense, Denmark.,Department of Cardiology, Odense University Hospital, Odense, Denmark.,Institute of Clinical Research, Odense, Denmark
| | - Jens Kjeldsen
- HHT-Center Odense University Hospital, Part of VASCERN, Odense, Denmark.,Department of Medical Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark.,Institute of Clinical Research, Odense, Denmark
| | - Annette D Fialla
- HHT-Center Odense University Hospital, Part of VASCERN, Odense, Denmark. .,Department of Medical Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark. .,Institute of Clinical Research, Odense, Denmark.
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Ternant D, Azzopardi N, Raoul W, Bejan-Angoulvant T, Paintaud G. Influence of Antigen Mass on the Pharmacokinetics of Therapeutic Antibodies in Humans. Clin Pharmacokinet 2020; 58:169-187. [PMID: 29802542 DOI: 10.1007/s40262-018-0680-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Therapeutic antibodies are increasingly used to treat various diseases, including neoplasms and chronic inflammatory diseases. Antibodies exhibit complex pharmacokinetic properties, notably owing to the influence of antigen mass, i.e. the amount of antigenic targets to which the monoclonal antibody binds specifically. This review focuses on the influence of antigen mass on the pharmacokinetics of therapeutic antibodies quantified by pharmacokinetic modelling in humans. Out of 159 pharmacokinetic studies, 85 reported an influence of antigen mass. This influence led to non-linear elimination decay in 50 publications, which was described using target-mediated drug disposition or derived models, as quasi-steady-state, irreversible binding and Michaelis-Menten models. In 35 publications, the pharmacokinetics was apparently linear and the influence of antigen mass was described as a covariate of pharmacokinetic parameters. If some reported covariates, such as the circulating antigen level or tumour size, are likely to be correlated to antigen mass, others, such as disease activity or disease type, may contain little information on the amount of antigenic targets. In some cases, antigen targets exist in different forms, notably in the circulation and expressed at the cell surface. The influence of antigen mass should be soundly described during the early clinical phases of drug development. To maximise therapeutic efficacy, sufficient antibody doses should be administered to ensure the saturation of antigen targets by therapeutic antibodies in all patients. If necessary, antigen mass should be taken into account in routine clinical practice.
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Affiliation(s)
- David Ternant
- Université de Tours, EA7501 GICC, Team PATCH, Tours, France. .,Department of Medical Pharmacology, CHRU de Tours, Tours University Hospital, 2 boulevard Tonnellé, 37044, Tours Cedex, France.
| | | | - William Raoul
- Université de Tours, EA7501 GICC, Team PATCH, Tours, France
| | - Theodora Bejan-Angoulvant
- Université de Tours, EA7501 GICC, Team PATCH, Tours, France.,Department of Medical Pharmacology, CHRU de Tours, Tours University Hospital, 2 boulevard Tonnellé, 37044, Tours Cedex, France
| | - Gilles Paintaud
- Université de Tours, EA7501 GICC, Team PATCH, Tours, France.,Department of Medical Pharmacology, CHRU de Tours, Tours University Hospital, 2 boulevard Tonnellé, 37044, Tours Cedex, France
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Viala M, Tosi D. [Determining the dose to be injected in the first clinical trials with monoclonal antibodies: not so easy!]. Med Sci (Paris) 2020; 35:1121-1129. [PMID: 31903926 DOI: 10.1051/medsci/2019209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Monoclonal antibodies are a therapeutic tool frequently used in oncology, as they allow the specific targeting of molecules expressed by cancer cells and, in most cases, induce minimal toxic effects on healthy tissues. Because monoclonal antibodies frequently lack significant toxicity and are not associated to a direct relationship between dose and effect, the methods of clinical development traditionally used for chemotherapy agents are scarcely useful for this class of drugs. In addition, no consensus exists on the definition of parameters different from toxicity that could assist the process of dose selection of monoclonal antibody in early clinical trials.
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Affiliation(s)
- Marie Viala
- Unité d'Essais de Phase Précoce (UEPP), Institut du Cancer de Montpellier (ICM), Montpellier, France
| | - Diego Tosi
- Unité d'Essais de Phase Précoce (UEPP), Institut du Cancer de Montpellier (ICM), Montpellier, France - Institut de Recherche en Cancérologie de Montpellier (IRCM), Inserm U1194, Montpellier, France
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7
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Multimodality Management of Complex Periorbital Venolymphatic Malformations. Ophthalmic Plast Reconstr Surg 2019; 35:387-398. [DOI: 10.1097/iop.0000000000001294] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Faughnan ME, Gossage JR, Chakinala MM, Oh SP, Kasthuri R, Hughes CCW, McWilliams JP, Parambil JG, Vozoris N, Donaldson J, Paul G, Berry P, Sprecher DL. Pazopanib may reduce bleeding in hereditary hemorrhagic telangiectasia. Angiogenesis 2018; 22:145-155. [PMID: 30191360 PMCID: PMC6510884 DOI: 10.1007/s10456-018-9646-1] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 08/14/2018] [Indexed: 12/22/2022]
Abstract
Pazopanib (Votrient) is an orally administered tyrosine kinase inhibitor that blocks VEGF receptors potentially serving as anti-angiogenic treatment for hereditary hemorrhagic telangiectasia (HHT). We report a prospective, multi-center, open-label, dose-escalating study [50 mg, 100 mg, 200 mg, and 400 mg], designed as a proof-of-concept study to demonstrate efficacy of pazopanib on HHT-related bleeding, and to measure safety. Patients, recruited at 5 HHT Centers, required ≥ 2 Curacao criteria AND [anemia OR severe epistaxis with iron deficiency]. Co-primary outcomes, hemoglobin (Hgb) and epistaxis severity, were measured during and after treatment, and compared to baseline. Safety monitoring occurred every 1.5 weeks. Seven patients were treated with 50 mg pazopanib daily. Six/seven showed at least 50% decrease in epistaxis duration relative to baseline at some point during study; 3 showed at least 50% decrease in duration during Weeks 11 and 12. Six patients showed a decrease in ESS of > 0.71 (MID) relative to baseline at some point during study; 3/6 showed a sustained improvement. Four patients showed > 2 gm improvement in Hgb relative to baseline at one or more points during study. Health-related QOL scores improved on all SF-36 domains at Week 6 and/or Week 12, except general health (unchanged). There were 19 adverse events (AE) including one severe AE (elevated LFTs, withdrawn from dosing at 43 days); with no serious AE. In conclusion, we observed an improvement in Hgb and/or epistaxis in all treated patients. This occurred at a dose much lower than typically used for oncologic indications, with no serious AE. Further studies of pazopanib efficacy are warranted.
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Affiliation(s)
- Marie E Faughnan
- Toronto HHT Program, Division of Respirology, Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada.
- Li Ka Shing Knowledge Institute of St. Michaels Hospital, 30 Bond St, Toronto, ON, M5B-1W8, Canada.
| | - James R Gossage
- Division of Pulmonary and Critical Care Medicine, Augusta University, Augusta, GA, USA
| | - Murali M Chakinala
- Division of Pulmonary and Critical Care Medicine, Washington University, St. Louis, MO, USA
| | - S Paul Oh
- Barrow Aneurysm & AVM Research Center, Barrow Neurological Institute/Dignity Health, Phoenix, AZ, USA
| | - Raj Kasthuri
- Division of Hematology and Oncology, Department of Medicine, UNC School of Medicine, Chapel Hill, NC, USA
| | - Christopher C W Hughes
- Department of Molecular Biology & Biochemistry, and Department of Biomedical Engineering, University of California Irvine, Irvine, CA, USA
| | - Justin P McWilliams
- Division of Interventional Radiology, Department of Radiology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | | | - Nicholas Vozoris
- Toronto HHT Program, Division of Respirology, Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute of St. Michaels Hospital, 30 Bond St, Toronto, ON, M5B-1W8, Canada
| | | | | | - Pamela Berry
- Patient Reported Outcomes, Janssen Global Services, LLC, Horsham, PA, USA
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Viala M, Vinches M, Alexandre M, Mollevi C, Durigova A, Hayaoui N, Homicsko K, Cuenant A, Gongora C, Gianni L, Tosi D. Strategies for clinical development of monoclonal antibodies beyond first-in-human trials: tested doses and rationale for dose selection. Br J Cancer 2018; 118:679-697. [PMID: 29438365 PMCID: PMC5846071 DOI: 10.1038/bjc.2017.473] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Revised: 11/29/2017] [Accepted: 11/30/2017] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Our previous survey on first-in-human trials (FIHT) of monoclonal antibodies (mAbs) showed that, due to their limited toxicity, the recommended phase II dose (RP2D) was only tentatively defined. METHODS We identified, by MEDLINE search, articles on single-agent trials of mAbs with an FIHT included in our previous survey. For each mAb, we examined tested dose(s) and dose selection rationale in non-FIHTs (NFIHTs). We also assessed the correlation between doses tested in the registration trials (RTs) of all FDA-approved mAbs and the corresponding FIHT results. RESULTS In the 37 dose-escalation NFIHTs, the RP2D indication was still poorly defined. In phase II-III NFIHTs (n=103 on 37 mAbs), the FIHT RP2D was the only dose tested for five mAbs. For 16 mAbs, only doses different from the FIHT RP2D or the maximum administered dose (MAD) were tested and the dose selection rationale infrequently indicated. In the 60 RTs on 27 FDA-approved mAbs with available FIHT, the FIHT RP2D was tested only for two mAbs, and RT doses were much lower than the FIHT MAD. CONCLUSIONS The rationale beyond dose selection in phase II and III trials of mAbs is often unclear in published articles and not based on FIHT data.
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Affiliation(s)
- Marie Viala
- Institut du Cancer de Montpellier, Montpellier, France
| | - Marie Vinches
- Institut du Cancer de Montpellier, Montpellier, France
| | | | | | | | - Nadia Hayaoui
- Institut du Cancer de Montpellier, Montpellier, France
| | | | - Alice Cuenant
- Institut du Cancer de Montpellier, Montpellier, France
| | - Céline Gongora
- Institut de Recherche en Cancérologie de Montpellier, Inserm U1194, Montpellier, France
| | - Luca Gianni
- San Raffaele – Scientific Institute, Milan, Italy
| | - Diego Tosi
- Institut du Cancer de Montpellier, Montpellier, France
- Institut de Recherche en Cancérologie de Montpellier, Inserm U1194, Montpellier, France
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Steineger J, Osnes T, Heimdal K, Dheyauldeen S. Long-term experience with intranasal bevacizumab therapy. Laryngoscope 2018; 128:2237-2244. [DOI: 10.1002/lary.27147] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Revised: 01/11/2018] [Accepted: 01/25/2018] [Indexed: 11/09/2022]
Affiliation(s)
| | - Terje Osnes
- Department of Otorhinolaryngology-Head and Neck Surgery
- Institute of Clinical Medicine, Medical Faculty; University of Oslo; Oslo Norway
| | - Ketil Heimdal
- Division of Head and Neck and Reconstructive Surgery, Department of Medical Genetics
- Center for Rare Diagnosis; Oslo University Hospital; Rikshospitalet Oslo Norway
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Guilhem A, Fargeton AE, Simon AC, Duffau P, Harle JR, Lavigne C, Carette MF, Bletry O, Kaminsky P, Leguy V, Lerolle N, Roux D, Lambert M, Chinet T, Bonnet D, Dupuis-Girod S, Rivière S. Intra-venous bevacizumab in hereditary hemorrhagic telangiectasia (HHT): A retrospective study of 46 patients. PLoS One 2017; 12:e0188943. [PMID: 29190827 PMCID: PMC5708634 DOI: 10.1371/journal.pone.0188943] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Accepted: 11/15/2017] [Indexed: 12/25/2022] Open
Abstract
Background Bevacizumab, an anti-VEGF monoclonal antibody, has recently emerged as a new option for severe forms of hereditary hemorrhagic telangiectasia (HHT). Its utilization in this orphan disease has rapidly spread despite the lack of randomized trials and international guidelines. The objective of this study is to report the main clinical data (baseline characteristics, dose schedule, efficacy, adverse events and deaths) of HHT patients treated by intravenous bevacizumab in France. Methods Retrospective observational study of HHT patients treated with bevacizumab for a severe form of the disease in the 14 centers of the French HHT network. Results Forty-six patients (median age: 68 years) were treated between March 2009 and May 2015. Ten patients were treated for high output cardiac failure, 20 patients for severe hemorrhages and 16 for both indications. The standard protocol (6 infusions of 5mg/kg every 2 weeks) was initially used in 89% of the cases but diverse strategies were subsequently applied. A clinical improvement was noted by the referent physician for 74% of the patients with a median effect’s duration of 6 months. Wound healing complications led to 2 amputations. Arthralgia/arthritis and arterial hypertension occurred in 5 patients each. One third of the patients were dead at the time of the final update, coherently with age and the poor prognosis of these highly symptomatic patients. Conclusion Intravenous bevacizumab seems to provide a clinical benefice in severe HHT patients. Precautions concerning wound healing and vascular pathologies must be respected. Prospective double blinded versus placebo trials are needed.
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Affiliation(s)
- Alexandre Guilhem
- Médecine Interne - Maladies Multi-Organiques, Hôpital Saint Eloi, Montpellier, France
- * E-mail:
| | - Anne-Emmanuelle Fargeton
- Service de Génétique - Centre de Référence National Maladie de Rendu-Osler, Hôpital Femme-Mère-Enfant, Bron, France
| | | | - Pierre Duffau
- Service de Médecine Interne et Immunologie Clinique, Hôpital Saint-André, Bordeaux, France
| | - Jean-Robert Harle
- Département de Médecine Interne, Hôpital de la Timone, Marseille, France
| | - Christian Lavigne
- Médecine Interne et Maladies Vasculaires, CHU d’Angers, Angers, France
| | | | - Olivier Bletry
- Service de Médecine Interne, Hôpital Foch, Suresnes, France
| | - Pierre Kaminsky
- Service de Médecine Interne, Hôpital de Brabois, Vandoeuvre-lès-Nancy, France
| | - Vanessa Leguy
- Service de Médecine Interne et Immunologie Clinique, Hôpital François Mitterrand, Dijon, France
| | | | | | - Marc Lambert
- Service de Médecine Interne, Hôpital Huriez, Lille, France
| | - Thierry Chinet
- Service de Pneumologie, Hôpital Ambroise Paré, Boulogne-Billancourt, France
| | - Delphine Bonnet
- Service de Médecine Interne du Pôle digestif, CHU Purpan, Toulouse, France
| | - Sophie Dupuis-Girod
- Service de Génétique - Centre de Référence National Maladie de Rendu-Osler, Hôpital Femme-Mère-Enfant, Bron, France
| | - Sophie Rivière
- Médecine Interne - Maladies Multi-Organiques, Hôpital Saint Eloi, Montpellier, France
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Abstract
Correct organization of the vascular tree requires the balanced activities of several signaling pathways that regulate tubulogenesis and vascular branching, elongation, and pruning. When this balance is lost, the vessels can be malformed and fragile, and they can lose arteriovenous differentiation. In this review, we concentrate on the transforming growth factor (TGF)-β/bone morphogenetic protein (BMP) pathway, which is one of the most important and complex signaling systems in vascular development. Inactivation of these pathways can lead to altered vascular organization in the embryo. In addition, many vascular malformations are related to deregulation of TGF-β/BMP signaling. Here, we focus on two of the most studied vascular malformations that are induced by deregulation of TGF-β/BMP signaling: hereditary hemorrhagic telangiectasia (HHT) and cerebral cavernous malformation (CCM). The first of these is related to loss-of-function mutation of the TGF-β/BMP receptor complex and the second to increased signaling sensitivity to TGF-β/BMP. In this review, we discuss the potential therapeutic targets against these vascular malformations identified so far, as well as their basis in general mechanisms of vascular development and stability.
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Affiliation(s)
- Sara I Cunha
- From the Department of Immunology, Genetics, and Pathology, Uppsala University, Sweden (S.I.C., P.U.M., E.D.); FIRC Institute of Molecular Oncology, Milan, Italy (E.D., M.G.L.); and Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy (M.G.L.)
| | - Peetra U Magnusson
- From the Department of Immunology, Genetics, and Pathology, Uppsala University, Sweden (S.I.C., P.U.M., E.D.); FIRC Institute of Molecular Oncology, Milan, Italy (E.D., M.G.L.); and Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy (M.G.L.)
| | - Elisabetta Dejana
- From the Department of Immunology, Genetics, and Pathology, Uppsala University, Sweden (S.I.C., P.U.M., E.D.); FIRC Institute of Molecular Oncology, Milan, Italy (E.D., M.G.L.); and Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy (M.G.L.).
| | - Maria Grazia Lampugnani
- From the Department of Immunology, Genetics, and Pathology, Uppsala University, Sweden (S.I.C., P.U.M., E.D.); FIRC Institute of Molecular Oncology, Milan, Italy (E.D., M.G.L.); and Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy (M.G.L.)
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13
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Kovacs-Sipos E, Holzmann D, Scherer T, Soyka MB. Nintedanib as a novel treatment option in hereditary haemorrhagic telangiectasia. BMJ Case Rep 2017; 2017:bcr-2017-219393. [PMID: 28652319 DOI: 10.1136/bcr-2017-219393] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 70-year-old patient with known hereditary haemorrhagictelangiectasia (HHT) was seen regularly in our outpatient clinic. He underwent multiple therapeutical interventions, including both surgical and medical, for the treatment of recurrent epistaxis without sustained success. Due to a concurrent diagnosis of idiopathic pulmonary fibrosis, treatment with the tyrosine kinase inhibitor nintedanib was initiated, after which point the patient reported a dramatic and unanticipated improvement in his epistaxis and skin telangiectasia. On the basis of this case report, we propose that nintedanib may be a potential treatment option for refractory epistaxis in HHT.
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Affiliation(s)
- Evelin Kovacs-Sipos
- Department of ENT Head and Neck Surgery, University Hospital Zurich, Zurich, Switzerland
| | - David Holzmann
- Department of ENT Head and Neck Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Thomas Scherer
- Pulmonary Center, Hirslanden Klinik, Zurich, Switzerland
| | - Michael B Soyka
- Department of ENT Head and Neck Surgery, University Hospital Zurich, Zurich, Switzerland
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14
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Bertoli LF, Lee PL, Lallone L, Barton JC. Intravenous Bevacizumab Therapy in a Patient with Hereditary Hemorrhagic Telangiectasia, ENG E137K, Alcoholic Cirrhosis, and Portal Hypertension. Case Rep Gastroenterol 2017. [PMID: 28626375 PMCID: PMC5471789 DOI: 10.1159/000475748] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Intravenous bevacizumab decreased mucosal bleeding in some patients with hereditary hemorrhagic telangiectasia (HHT). We treated a 47-year-old male who had HHT, severe epistaxis, and gastrointestinal bleeding, alcoholic cirrhosis, and portal hypertension with intravenous bevacizumab 2.5 mg/kg every 2 weeks. We tabulated these measures weekly during weeks 1–33 (no bevacizumab); 34–57 (bevacizumab); and 58–97 (no bevacizumab): hemoglobin (Hb) levels; platelet counts; units of transfused packed erythrocytes (PRBC units); and quantities of iron infused as iron dextran to support erythropoiesis. We performed univariate and multivariable analyses. We sequenced his ENG and ACVRL1 genes. Epistaxis and melena decreased markedly during bevacizumab treatment. He reported no adverse effects due to bevacizumab. Mean weekly Hb levels were significantly higher and mean weekly PRBC units and quantities of intravenous iron were significantly lower during bevacizumab treatment. We performed a multiple regression on weekly Hb levels using these independent variables: bevacizumab treatment (dichotomous); weekly platelet counts; weekly PRBC units; and weekly quantities of intravenous iron. There was 1 positive association: (bevacizumab treatment; p = 0.0046) and 1 negative association (PRBC units; p = 0.0004). This patient had the novel ENG mutation E137K (exon 4; c.409G→A). Intravenous bevacizumab treatment 2.5 mg/kg every 2 weeks for 24 weeks was well-tolerated by a patient with HHT due to ENG E137K and was associated with higher weekly Hb levels and fewer weekly PRBC units.
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Affiliation(s)
- Luigi F Bertoli
- Department of Medicine, Brookwood Medical Center, Birmingham, Alabama, USA.,Brookwood Biomedical, Birmingham, Alabama, USA
| | - Pauline L Lee
- Department of Molecular and Experimental Medicine, The Scripps Research Institute, La Jolla, California, USA
| | | | - James C Barton
- Department of Medicine, Brookwood Medical Center, Birmingham, Alabama, USA.,Southern Iron Disorders Center, Birmingham, Alabama, USA.,Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
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15
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Moulinet T, Maunoury V, Hatron PY. Intractable anemia due to extensive refractory angiodysplasia of the small intestine stabilized by an anti-angiogenic agent. Presse Med 2017; 46:331-332. [PMID: 28062159 DOI: 10.1016/j.lpm.2016.11.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Revised: 10/11/2016] [Accepted: 11/21/2016] [Indexed: 11/29/2022] Open
Affiliation(s)
- Thomas Moulinet
- University Hospital of Lille, Nord de France, 59000 Lille, France
| | - Vincent Maunoury
- University Hospital of Lille, Nord de France, 59000 Lille, France.
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16
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Robaina Cabrera DM, Verde González MP, Tarazona Chocano B, Amado Fernández C, Zarrabeitia Puente R. Telangiectasia hemorrágica hereditaria: enfermedad de Rendu-Osler-Weber. ACTA ACUST UNITED AC 2016. [DOI: 10.1016/j.fmc.2016.01.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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17
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Morrell NW, Bloch DB, ten Dijke P, Goumans MJTH, Hata A, Smith J, Yu PB, Bloch KD. Targeting BMP signalling in cardiovascular disease and anaemia. Nat Rev Cardiol 2016; 13:106-20. [PMID: 26461965 PMCID: PMC4886232 DOI: 10.1038/nrcardio.2015.156] [Citation(s) in RCA: 159] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Bone morphogenetic proteins (BMPs) and their receptors, known to be essential regulators of embryonic patterning and organogenesis, are also critical for the regulation of cardiovascular structure and function. In addition to their contributions to syndromic disorders including heart and vascular development, BMP signalling is increasingly recognized for its influence on endocrine-like functions in postnatal cardiovascular and metabolic homeostasis. In this Review, we discuss several critical and novel aspects of BMP signalling in cardiovascular health and disease, which highlight the cell-specific and context-specific nature of BMP signalling. Based on advancing knowledge of the physiological roles and regulation of BMP signalling, we indicate opportunities for therapeutic intervention in a range of cardiovascular conditions including atherosclerosis and pulmonary arterial hypertension, as well as for anaemia of inflammation. Depending on the context and the repertoire of ligands and receptors involved in specific disease processes, the selective inhibition or enhancement of signalling via particular BMP ligands (such as in atherosclerosis and pulmonary arterial hypertension, respectively) might be beneficial. The development of selective small molecule antagonists of BMP receptors, and the identification of ligands selective for BMP receptor complexes expressed in the vasculature provide the most immediate opportunities for new therapies.
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Affiliation(s)
- Nicholas W Morrell
- Department of Medicine, University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Hills Road, Cambridge CB2 0QQ, UK
| | - Donald B Bloch
- Center for Immunology and Inflammatory Diseases, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, 149 13th Street, Charlestown, MA 02129, USA
| | - Peter ten Dijke
- Department of Molecular Cell Biology and Cancer Genomics Centre Netherlands, Leiden University Medicine Centre, Albinusdreef 2, 2333 ZA Leiden, Netherlands
| | - Marie-Jose T H Goumans
- Department of Molecular Cell Biology and Cancer Genomics Centre Netherlands, Leiden University Medicine Centre, Albinusdreef 2, 2333 ZA Leiden, Netherlands
| | - Akiko Hata
- Cardiovascular Research Institute, University of California, 500 Parnassus Avenue, San Francisco, CA 94143, USA
| | - Jim Smith
- MRC National Institute for Medical Research, The Ridgeway, Mill Hill, London NW7 1AA, UK
| | - Paul B Yu
- Department of Medicine, Cardiovascular Division, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Kenneth D Bloch
- Anaesthesia Centre for Critical Care Research, Department of Anaesthesia, Critical Care and Pain Medicine, 55 Fruit Street, Boston, MA 02114, USA
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18
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Blei F. Update December 2015. Lymphat Res Biol 2015. [DOI: 10.1089/lrb.2015.29044.fb] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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19
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Brinjikji W, Iyer VN, Sorenson T, Lanzino G. Cerebrovascular Manifestations of Hereditary Hemorrhagic Telangiectasia. Stroke 2015; 46:3329-37. [PMID: 26405205 DOI: 10.1161/strokeaha.115.010984] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Accepted: 08/28/2015] [Indexed: 11/16/2022]
Affiliation(s)
- Waleed Brinjikji
- From the Departments of Radiology (W.B.), Pulmonary and Critical Care Medicine (V.N.I.), and Neurosurgery (T.S., G.L.), Mayo Clinic, Rochester, MN.
| | - Vivek N Iyer
- From the Departments of Radiology (W.B.), Pulmonary and Critical Care Medicine (V.N.I.), and Neurosurgery (T.S., G.L.), Mayo Clinic, Rochester, MN
| | - Thomas Sorenson
- From the Departments of Radiology (W.B.), Pulmonary and Critical Care Medicine (V.N.I.), and Neurosurgery (T.S., G.L.), Mayo Clinic, Rochester, MN
| | - Giuseppe Lanzino
- From the Departments of Radiology (W.B.), Pulmonary and Critical Care Medicine (V.N.I.), and Neurosurgery (T.S., G.L.), Mayo Clinic, Rochester, MN
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