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Paul A, Thomson VS, Refaat M, Al-Rawahi B, Taher A, Nadar SK. Cardiac involvement in beta-thalassaemia: current treatment strategies. Postgrad Med 2019; 131:261-267. [DOI: 10.1080/00325481.2019.1608071] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Amal Paul
- Department of Cardiology, Christian Medical college and Hospital, Vellore, India
| | - Viji S Thomson
- Department of Cardiology, Christian Medical college and Hospital, Vellore, India
| | - Marwan Refaat
- Departments of: Internal Medicine, Biochemistry & Molecular Genetics, American University of Beirut Medical Center, Beirut, Lebanon
| | - Bader Al-Rawahi
- Department of Hematology, Sultan Qaboos University Hospital, Muscat Oman
| | - Ali Taher
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Sunil K Nadar
- Department of Medicine, Sultan Qaboos University Hospital, Muscat, Oman
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Du Y, Long Z, Chen M, Han B, Hou B, Feng F. Observational Monitoring of Patients with Aplastic Anemia and Low/Intermediate-1 Risk of Myelodysplastic Syndromes Complicated with Iron Overload. Acta Haematol 2017; 138:119-128. [PMID: 28866669 DOI: 10.1159/000479422] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Accepted: 07/10/2017] [Indexed: 01/19/2023]
Abstract
BACKGROUND This study focuses on the iron overload (IOL) of patients with transfused aplastic anemia (AA) or a low/intermediate-1 risk of myelodysplastic syndrome (MDS). METHODS Ninety-two AA or MDS patients with IOL were prospectively recruited. Clinical data were collected every 6 months, and organ magnetic resonance imaging T2* values were collected annually. Patients with IOL were chelated. RESULTS Serum ferritin was correlated with liver T2* and pancreatic T2* in the AA and MDS groups. Transfusion amounts were correlated with serum ferritin values, liver T2*, and pancreatic T2* in the AA group. At the 6-month and 1-year evaluations, patients with sufficient chelation experienced significant decreases in serum ferritin, and those with decreased serum ferritin experienced an obvious increase in hemoglobin. At their 1-year-follow-up, patients with adequate chelation showed significant increases in hepatic T2*, cardiac T2*, and left ventricular ejection fraction (LVEF). Patients with decreased serum ferritin (including those without chelation) experienced an increase in hemoglobin, hepatic T2*, cardiac T2*, and LVEF. CONCLUSION The transfusion amount was more reliable at predicting IOL in patients with AA than in those with MDS. Adequate iron chelation can decrease serum ferritin levels and may improve hepatic T2*, cardiac T2*, and LVEF levels. A decrease in serum ferritin, even in the absence of chelation, may also benefit patients.
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Affiliation(s)
- Yali Du
- Department of Hematology, Chinese Academy of Medical Sciences, Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
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Aydinok Y, Kattamis A, Cappellini MD, El-Beshlawy A, Origa R, Elalfy M, Kilinç Y, Perrotta S, Karakas Z, Viprakasit V, Habr D, Constantinovici N, Shen J, Porter JB. Effects of deferasirox-deferoxamine on myocardial and liver iron in patients with severe transfusional iron overload. Blood 2015; 125:3868-77. [PMID: 25934475 PMCID: PMC4490296 DOI: 10.1182/blood-2014-07-586677] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Accepted: 04/17/2015] [Indexed: 01/19/2023] Open
Abstract
Deferasirox (DFX) monotherapy is effective for reducing myocardial and liver iron concentrations (LIC), although some patients may require intensive chelation for a limited duration. HYPERION, an open-label single-arm prospective phase 2 study, evaluated combination DFX-deferoxamine (DFO) in patients with severe transfusional myocardial siderosis (myocardial [m] T2* 5-<10 ms; left ventricular ejection fraction [LVEF] ≥56%) followed by optional switch to DFX monotherapy when achieving mT2* >10 ms. Mean dose was 30.5 mg/kg per day DFX and 36.3 mg/kg per day DFO on a 5-day regimen. Geometric mean mT2* ratios (Gmeanmonth12/24/Gmeanbaseline) were 1.09 and 1.30, respectively, increasing from 7.2 ms at baseline (n = 60) to 7.7 ms at 12 (n = 52) and 9.5 ms at 24 months (n = 36). Patients (17 of 60; 28.3%) achieved mT2* ≥10 ms and ≥10% increase from baseline at month 24; 15 switched to monotherapy during the study based on favorable mT2*. LIC decreased substantially from a baseline of 33.4 to 12.8 mg Fe/g dry weight at month 24 (-52%). LVEF remained stable with no new arrhythmias/cardiac failure. Five patients discontinued with mT2* <5 ms and 1 died (suspected central nervous system infection). Safety was consistent with established monotherapies. Results show clinically meaningful improvements in mT2* in about one-third of patients remaining on treatment at month 24, alongside rapid decreases in LIC in this heavily iron-overloaded, difficult-to-treat population. Combination therapy may be useful when rapid LIC reduction is required, regardless of myocardial iron overload. This trial was registered at www.clinicaltrials.gov as #NCT01254227.
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Affiliation(s)
- Yesim Aydinok
- Department of Pediatric Hematology, Ege University Hospital, Izmir, Turkey
| | - Antonis Kattamis
- First Department of Pediatrics, University of Athens, Athens, Greece
| | - M Domenica Cappellini
- Universitá di Milano, Ca Granda Foundation Istituto Di Ricovero e Cura a Carattere Scientifico (IRCCS), Milan, Italy
| | - Amal El-Beshlawy
- Department of Hematology, Pediatric Hospital, Cairo University, Cairo, Egypt
| | - Raffaella Origa
- Ospedale Regionale per le Microcitemie, University of Cagliari, Cagliari, Italy
| | - Mohsen Elalfy
- Thalassemia Center, Children's Hospital, Ain Shams University, Cairo, Egypt
| | | | - Silverio Perrotta
- Department of Woman, Child and of General and Specialist Surgery, I°Policlinico II°Università di Napoli, Naples, Italy
| | - Zeynep Karakas
- Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Vip Viprakasit
- Department of Pediatrics and Thalassemia Center, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Dany Habr
- Novartis Pharmaceuticals, East Hanover, NJ
| | | | - Junwu Shen
- Novartis Pharmaceuticals, East Hanover, NJ
| | - John B Porter
- Department of Hematology, UCL Cancer Institute, University College London, London, United Kingdom
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Aydinok Y, Porter JB, Piga A, Elalfy M, El-Beshlawy A, Kilinç Y, Viprakasit V, Yesilipek A, Habr D, Quebe-Fehling E, Pennell DJ. Prevalence and distribution of iron overload in patients with transfusion-dependent anemias differs across geographic regions: results from the CORDELIA study. Eur J Haematol 2015; 95:244-53. [PMID: 25418187 DOI: 10.1111/ejh.12487] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/14/2014] [Indexed: 01/22/2023]
Abstract
OBJECTIVES The randomized comparison of deferasirox to deferoxamine for myocardial iron removal in patients with transfusion-dependent anemias (CORDELIA) gave the opportunity to assess relative prevalence and body distribution of iron overload in screened patients. METHODS Patients aged ≥ 10 yr with transfusion-dependent anemias from 11 countries were screened. Data were summarized descriptively, overall and across regions. RESULTS Among 925 patients (99.1% with β-thalassemia major; 98.5% receiving prior chelation; mean age 19.2 yr), 36.7% had myocardial iron overload (myocardial T2* ≤ 20 ms), 12.1% had low left ventricular ejection fraction. Liver iron concentration (LIC) (mean 25.8 mg Fe/g dw) and serum ferritin (median 3702 ng/mL) were high. Fewer patients in the Middle East (ME; 28.5%) had myocardial T2* ≤ 20 ms vs. patients in the West (45.9%) and Far East (FE, 40.9%). Patients in the West had highest myocardial iron burden, but lowest LIC (26.9% with LIC < 7 mg Fe/g dw) and serum ferritin. Among patients with normal myocardial iron, a higher proportion of patients from the ME and FE had LIC ≥ 15 than < 7 mg Fe/g dw (ME, 56.7% vs. 17.2%; FE, 78.6% vs. 7.8%, respectively), a trend which was less evident in the West (44.6% vs. 33.9%, respectively). Transfusion and chelation practices differed between regions. CONCLUSIONS Evidence of substantial myocardial and liver iron burden across regions revealed a need for optimization of effective, convenient iron chelation regimens. Significant regional variation exists in myocardial and liver iron loading that are not well explained; improved understanding of factors contributing to differences in body iron distribution may be of clinical benefit.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Dany Habr
- Novartis Pharmaceuticals, East Hanover, NJ, USA
| | | | - Dudley J Pennell
- NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, London, UK
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Lu MY, Peng SSF, Chang HH, Yang YL, Chen CA, Jou ST, Lin DT, Lin KH. Cardiac iron measurement and iron chelation therapy in patients with β thalassaemia major: experience from Taiwan. Transfus Med 2013; 23:100-7. [PMID: 23448138 DOI: 10.1111/tme.12014] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2012] [Revised: 10/23/2012] [Accepted: 01/15/2013] [Indexed: 11/29/2022]
Affiliation(s)
| | - S. S. F. Peng
- Department of Imaging Medicine; National Taiwan University Hospital and College of Medicine; Taipei; Taiwan
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Ladis V, Karagiorga-Lagana M, Tsatra I, Chouliaras G. Thirty-year experience in preventing haemoglobinopathies in Greece: achievements and potentials for optimisation. Eur J Haematol 2013; 90:313-22. [DOI: 10.1111/ejh.12076] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/11/2013] [Indexed: 11/29/2022]
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Delaporta P, Kattamis A, Apostolakou F, Boiu S, Bartzeliotou A, Tsoukas E, Papassotiriou I. Correlation of NT-proBNP levels and cardiac iron concentration in patients with transfusion-dependent thalassemia major. Blood Cells Mol Dis 2013; 50:20-4. [DOI: 10.1016/j.bcmd.2012.09.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2012] [Revised: 08/30/2012] [Accepted: 08/31/2012] [Indexed: 01/12/2023]
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Cardiac iron removal and functional cardiac improvement by different iron chelation regimens in thalassemia major patients. Ann Hematol 2012; 91:1443-9. [PMID: 22572843 DOI: 10.1007/s00277-012-1480-8] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2012] [Accepted: 04/21/2012] [Indexed: 10/28/2022]
Abstract
Heart failure due to myocardial iron overload remains the leading cause of morbidity and mortality in adult thalassemia major (TM) patients. We evaluated the removal of cardiac iron and the changes of cardiac function by different iron chelation in TM patients by T2* cardiac magnetic resonance (CMR). Sixty-seven TM patients (27 males/40 females; mean age, 35 ± 6 years) on different chelation regimens underwent T2* CMR at baseline (t (0)), after 6-14 months (t (1)) and after 32 ± 7 months (t (2)). Patients were divided in four groups according to chelation treatment: group A (deferasirox), group B (deferoxamine), group C (combined treatment, deferoxamine plus deferiprone) and group D (deferiprone alone). Myocardial T2* at t (0) was <10 ms in 8 patients, between 10 and 20 ms in 22 patients and ≥ 20 ms in 37 patients. Progressive changes in T2* were observed at t (1) and t (2). Ten patients (10/36, 27.8 %) in group A, three patients (3/15, 20 %) in group B and three patients (3/12, 25 %) in group C moved from an abnormal T2* to normal values. We observed an improvement of left ventricular ejection fraction and a reduction of end-systolic and end-diastolic left ventricular volumes only in patients in group A with baseline cardiac T2* between 10 and 20 ms. Rigorous compliance to any chelation therapy at proper doses significantly improve myocardial T2*. Treatment with deferasirox significantly improves left ventricular function. Combination therapy seems to ameliorate cardiac T2* in a shorter period of time in severe siderosis.
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Pennell DJ, Carpenter JP, Roughton M, Cabantchik ZI. On improvement in ejection fraction with iron chelation in thalassemia major and the risk of future heart failure. J Cardiovasc Magn Reson 2011; 13:45. [PMID: 21910880 PMCID: PMC3180261 DOI: 10.1186/1532-429x-13-45] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2011] [Accepted: 09/12/2011] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Trials of iron chelator regimens have increased the treatment options for cardiac siderosis in beta-thalassemia major (TM) patients. Treatment effects with improved left ventricular (LV) ejection fraction (EF) have been observed in patients without overt heart failure, but it is unclear whether these changes are clinically meaningful. METHODS This retrospective study of a UK database of TM patients modelled the change in EF between serial scans measured by cardiovascular magnetic resonance (CMR) to the relative risk (RR) of future development of heart failure over 1 year. Patients were divided into 2 strata by baseline LVEF of 56-62% (below normal for TM) and 63-70% (lower half of the normal range for TM). RESULTS A total of 315 patients with 754 CMR scans were analyzed. A 1% absolute increase in EF from baseline was associated with a statistically significant reduction in the risk of future development of heart failure for both the lower EF stratum (EF 56-62%, RR 0.818, p < 0.001) and the higher EF stratum (EF 63-70%, RR 0.893 p = 0.001). CONCLUSION These data show that during treatment with iron chelators for cardiac siderosis, small increases in LVEF in TM patients are associated with a significantly reduced risk of the development of heart failure. Thus the iron chelator induced improvements in LVEF of 2.6% to 3.1% that have been observed in randomized controlled trials, are associated with risk reductions of 25.5% to 46.4% for the development of heart failure over 12 months, which is clinically meaningful. In cardiac iron overload, heart mitochondrial dysfunction and its relief by iron chelation may underlie the changes in LV function.
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Affiliation(s)
- DJ Pennell
- Cardiovascular Magnetic Resonance Unit, Royal Brompton Hospital, London UK
- National Heart and Lung Institute, Imperial College, London UK
| | - JP Carpenter
- Cardiovascular Magnetic Resonance Unit, Royal Brompton Hospital, London UK
- National Heart and Lung Institute, Imperial College, London UK
| | - M Roughton
- Department of Statistics, University College London, UK
| | - ZI Cabantchik
- Life Sciences Institute, Hebrew University of Jerusalem, Safra Campus-Givat Ram, Jerusalem, Israel
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